Associations Between Primary Residence and Mental Health in Global Marginalized Populations

Scholars suggest that marginalized people in non-urban areas experience higher distress levels and fewer psychosocial resources than in urban areas. Researchers have yet to test whether precise proximity to urban centers is associated with mental health for marginalized populations. We recruited 1733 people who reported living in 45 different countries. Participants entered their home locations and completed measures of anxiety, depression, social support, and resilience. Regression and thematic analyses were used to determine what role distance from legislative and urban centers may play in mental health when marginalized people were disaggregated. Greater distance from legislative center predicted higher anxiety and resilience. Greater distance from urban center also predicted more resilience. Thematic analyses yielded five categories (e.g., safety, connection) that further illustrated the impact of geographic location on health. Implications for community mental health are discussed including the need to better understand and further expand resilience in rural areas.

A phase I trial evaluating the effects of plerixafor, G-CSF, and azacitidine for the treatment of myelodysplastic syndromes

Interactions between the bone marrow microenvironment and MDS tumor clones play a role in pathogenesis and response to treatment. We hypothesized G-CSF and plerixafor may enhance sensitivity to azacitidine in MDS. Twenty-eight patients with MDS were treated with plerixafor, G-CSF and azacitidine with a standard 3 + 3 design. Subjects received G-CSF 10 mcg/kg D1-D8, plerixafor D4-D8, and azacitidine 75 mg/m² D4-D8, but the trial was amended to reduce G-CSF dose to 5 mcg/kg for 5 days after 2 patients had significant leukocytosis. Plerixafor was dose escalated to 560 mcg/kg/day without dose limiting toxicity. Two complete responses and 6 marrow responses were seen for an overall response rate (ORR) of 36% in evaluable patients, and ORR of 53% in patients receiving the triplet. Evidence of mobilization correlated with a higher ORR, 60% vs. 17%. Plerixafor, G-CSF and azacitidine appears tolerable when given over 5 days and has encouraging response rates.KEY POINTSPlerixafor and G-CSF can be safely combined with azacitidine for 5 days in patients with MDS.The overall response rate of 53% for evaluable patients with this regimen is higher than expected and more responses were seen in patients with blast mobilization.

Perfluoroalkyl substances and lipid profile in exposed pregnant women in the Veneto Region, Italy

Background

Perfluoroalkyl substances (PFASs) are persistent and widespread environmental pollutants. Residents of a large area of the Veneto Region (North-Eastern Italy) were exposed to high concentrations of PFASs through drinking water from the late-1970s to 2013. PFASs have been consistently associated with raised serum lipids, but only few studies have been conducted among pregnant women, and none has stratified analyses by trimesters of gestation. Our main objective was to evaluate the association between perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) levels and lipid profiles in high-exposed pregnant women.

Methods

A cross-sectional analysis was conducted in 319 pregnant women (age 14-48 years) recruited in the Regional health surveillance program. Serum PFASs were measured by HPLC-MS/MS. Non-fasting serum total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) were measured by enzymatic assays in automated analysers, and low-density lipoprotein cholesterol (LDL-C) was calculated. The associations between ln-transformed PFASs (and categorized into quartiles) and lipids were assessed using generalized additive models. Analyses were adjusted for potential confounders and stratified according to pregnancy trimester.

Results

In the first trimester, plasma concentrations of both PFOA and PFOS were positively associated with TC. However in the third trimester PFOA levels were instead inversely significantly associated with TC and LDL-C levels. Overall, both PFOA and PFOS were positively associated with HDL-C, and PFOA negatively with LDL-C.

Conclusions

In a small highly exposed population of pregnant women, the associations between PFASs concentrations and lipid profile were modified by trimester of gestation. Patterns late in pregnancy were different to the positive associations with LDL-C generally found. Differential transfer and bioaccumulation of lipids and PFAS in the placenta across gestation might explain our findings.

Key messages

This study provides evidence of different patterns of PFAS associations with lipids in pregnant women across the trimesters of gestation. The different patterns of association from general population studies sheds light on the role of fetal nutrition during pregnancy affecting both lipids and PFAS in serum.

Perfluoroalkyl substances and blood pressure in exposed young population in the Veneto Region, Italy

Background

Residents in a large area of the Veneto Region (North-Eastern Italy) were exposed to perfluoroalkyl substances (PFASs) via drinking water. Studies on the association between PFASs and blood pressure (BP) levels are limited and results are inconsistent. Using cross-sectional data from the Regional health surveillance program, we aimed to quantify the associations between PFAS serum concentrations and blood pressure and hypertension prevalence.

Methods

The study included 16,224 individuals aged 20-39 years. Pregnant women (n = 327), participants with self-reported diagnosis or under treatment (n = 296) or with missing information on the selected covariates (n = 114) were excluded, leaving 15,487 subjects. Hypertension (HYP) was defined as any self-reported diagnosis, use of antihypertensive drugs, or raised systolic/diastolic blood pressure (SBP)≥140, DBP ≥90 mmHg). Serum PFASs were measured by HPLC-MS. Generalized additive models were used to investigate the relation between each PFAS (perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA)) ln transformed and by decile, and SBP, DBP, HYP, adjusted for potential confounders.

Results

Both SBP and DBP increased significantly with an increase in the ln-transformed serum PFASs concentration in a monotonic way. The predicted increase in SBP and DBP were 1.62 (95% CI = 0.69, 2.55), 1.64 mmHg (95% CI = 0.96, 2.31) from lowest to highest decile of PFOA. The associations were stronger for SBP in men and DBP in women. One unit increase in each ln-PFAS was positively associated with an increased odds of HYP in men: PFOA OR = 1.07 (1.01-1.14), PFOS OR = 1.18 (1.05-1.32), PFHxS OR = 1.11 (1.03-1.19), PFNA OR = 1.19 (1.01-1.41).

Conclusions

Our findings suggest that exposure to PFAS is associated with increased blood pressure and thus may contribute as a risk factor for the development of cardiovascular diseases.

Key messages

Serum PFASs were associated with raised systolic blood pressure in men and diastolic blood pressure in women in a large highly exposed young adult population. Serum PFASs were associated with raised prevalence of hypertension in men.

Use of public water supply fluoride concentration as an indicator of population exposure to fluoride in England 1995-2015

Public health monitoring of Community Water Fluoridation (CWF) schemes requires estimates of exposure to fluoride in public water supplies (PWS). We aimed to use routine data to estimate population exposure to PWS-fluoride in England and to determine whether PWS-fluoride exposure from 2005 to 2015 could be used as a proxy for exposure for 1995-2004, when fluoride concentration data that could be linked to population health data were unavailable. We calculated annual mean water supply zone PWS-fluoride concentrations from monitoring data for 1995-2015, stratified by fluoridation scheme-flagging. We allocated annual 2005-2015 mean PWS-fluoride concentrations to small area boundaries to describe population exposure within five concentration categories (< 0.1 to ≥ 0.7 mg/L). We compared zone-level 1995-2004 and 2005-2015 mean PWS-fluoride concentrations using Spearman correlation. Most (72%) of the population received PWS with < 0.2 mg/L fluoride and 10% with ≥ 0.7 mg/L. Fluoride concentrations in 1995-2004 and 2005-2015 were similar (median 0.11 mg/L (lower quartile-upper quartile (LQ-UQ) 0.06-0.17) and 0.11 mg/L (LQ-UQ 0.07-0.17), respectively) and highly correlated (coefficient 0.93) if un-fluoridated but differed (1995-2004 median 0.78 mg/L (LQ-UQ 0.59-0.92); 2005-2015 0.84 mg/L (LQ-UQ 0.72-0.95)) and correlated weakly (coefficient 0.31) if fluoridated. Fluoride concentrations in 2005-2015 approximate those in 1995-2004 but with a greater risk of misclassification in fluoridation schemes.

Surface wipe and bulk sampling of household dust: arsenic exposure in Cornwall, UK

Dust elemental levels can be expressed as concentrations (bulk samples) or surface loadings (wipe samples). Wipe sampling has not been widely adopted for elements other than lead (Pb). In this study, 433 wipe samples from 130 households in south west England - a region of widespread, natural and anthropogenic arsenic contamination linked with previous mining activities-were analysed to (i) quantify loadings of arsenic (As); (ii) assess the quality of wipe data using QA/QC criteria; (iii) estimate, using published ingestion rates, human exposure to As in dust using loadings and concentrations from 97 bulk samples and (iv) comparatively assess the performance of wipe and bulk sampling using associations with As biomonitoring data (urine, toenails and hair). Good QC performance was observed for wipes: strong agreement between field duplicates, non-detectable contamination of field blank wipes and good reference material recoveries. Arsenic loadings exceeded an existing urban background benchmark in 67 (52%) households. No exceedances of tolerable daily As intake were observed for adult exposure estimates but infant estimates exceeded for 1 household. Infant estimates calculated using bulk concentrations resulted in 4 (3%) exceedances. Neither wipe nor bulk As metrics were sufficiently better predictors of As in biospecimens. Sampling strategies, analytical protocols, exposure metrics and assessment criteria require refinement to validate dust sampling methodologies.

Variability in the chemistry of private drinking water supplies and the impact of domestic treatment systems on water quality

Tap water from 497 properties using private water supplies, in an area of metalliferous and arsenic mineralisation (Cornwall, UK), was measured to assess the extent of compliance with chemical drinking water quality standards, and how this is influenced by householder water treatment decisions. The proportion of analyses exceeding water quality standards were high, with 65 % of tap water samples exceeding one or more chemical standards. The highest exceedances for health-based standards were nitrate (11 %) and arsenic (5 %). Arsenic had a maximum observed concentration of 440 µg/L. Exceedances were also high for pH (47 %), manganese (12 %) and aluminium (7 %), for which standards are set primarily on aesthetic grounds. However, the highest observed concentrations of manganese and aluminium also exceeded relevant health-based guidelines. Significant reductions in concentrations of aluminium, cadmium, copper, lead and/or nickel were found in tap waters where households were successfully treating low-pH groundwaters, and similar adventitious results were found for arsenic and nickel where treatment was installed for iron and/or manganese removal, and successful treatment specifically to decrease tap water arsenic concentrations was observed at two properties where it was installed. However, 31 % of samples where pH treatment was reported had pH < 6.5 (the minimum value in the drinking water regulations), suggesting widespread problems with system maintenance. Other examples of ineffectual treatment are seen in failed responses post-treatment, including for nitrate. This demonstrates that even where the tap waters are considered to be treated, they may still fail one or more drinking water quality standards. We find that the degree of drinking water standard exceedances warrant further work to understand environmental controls and the location of high concentrations. We also found that residents were more willing to accept drinking water with high metal (iron and manganese) concentrations than international guidelines assume. These findings point to the need for regulators to reinforce the guidance on drinking water quality standards to private water supply users, and the benefits to long-term health of complying with these, even in areas where treated mains water is widely available.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Foreign Medical Teams in support of the Ebola outbreak: a UK military model of pre-deployment training and assurance

We discuss the training methodology developed and utilised to prepare UK military medical teams to establish an Ebola Treatment Centre in Sierra Leone. We highlight the process of identifying and mitigating nosocomial risk in the Pre-Deployment Training process, encompassing the challenges of developing, training and assuring a capability at pace, which deployed to deliver high quality clinical care to patients with Ebola Virus Disease.

Phase II Study of Propylene Glycol-Free Melphalan Combined with Carmustine, Etoposide, and Cytarabine for Myeloablative Conditioning in Lymphoma Patients Undergoing Autologous Stem Cell Transplantation

The lyophilized formulation of melphalan has several limitations based on its marginal solubility, limited stability after reconstitution, and the requirement to reconstitute it in propylene glycol (PG). PG-free melphalan (Evomela; Spectrum Pharmaceuticals, Irvine CA) overcomes these limitations by using the solubilizing agent Captisol (Ligand Pharmaceuticals, Inc., LaJolla CA) to improve the stability of the reconstituted melphalan and avoid the potential toxicities of PG. This phase II study investigated the safety and efficacy of high-dose PG-free melphalan when included in the carmustine, etoposide, and cytarabine (BEAM) regimen for adult patients with non-Hodgkin lymphoma (NHL) or Hodgkin lymphoma (HL). Carmustine, etoposide, and cytarabine were given at standard doses on day -6 through day -3. PG-free melphalan, 140 mg/m², was infused over 30 minutes on day -2. The primary endpoint was toxicity. Fifty patients (33 NHL/17 HL) completed BEAM with PG-free melphalan and stem cell infusion. The most common grades 3 to 4 nonhematologic toxicities were neutropenic fever (68%), infections (36%), and electrolyte abnormalities. Forty-one patients (82%) had oral mucositis, which was mostly grades 1 to 2 (6% grade 3). Moderate or severe gastrointestinal toxicities were uncommon. There were no treatment-related deaths. Forty-nine patients (98%) had neutrophil and platelet engraftment at a median of 10 and 19 days, respectively. At response assessment at 60 to 100 days after autologous stem cell transplantation, 42 patients (82%) were in complete remission, 2 in partial remission, and 6 had progressive disease. Progression-free survival at 1 year was 70%. These results demonstrate that PG-free melphalan can be used in place of the standard, lyophilized formulation of melphalan in the BEAM regimen for lymphoma patients undergoing autologous stem cell transplantation. It has a safety profile that compares favorably with standard lyophilized melphalan, and the engraftment rate and response rates were consistent with expectations.

Phase I study of azacitidine following donor lymphocyte infusion for relapsed acute myeloid leukemia post allogeneic stem cell transplantation

Donor lymphocyte infusion (DLI) without prophylactic immunosuppression has been used for relapsed AML after allogeneic stem cell transplant (allo-SCT). However DLI is associated with an increased incidence of acute Graft vs. Host Disease (aGVHD). In mice, administration of azacitidine (AzaC) on days 4, 6, 8, and 10 post DLI increases regulatory T cell (Treg) numbers and prevents GVHD without hindering Graft vs. Leukemia (GVL). Based on these findings, we conducted a phase 1 study of AzaC post DLI for AML relapse post allo-SCT. AzaC was administered on days 4, 6, 8 and 10 post-DLI. Dose escalation was done using a 3+3 design with three AzaC dose levels: 30mg/m(2) (level -1), 45mg/m(2) (level 1) and 75mg/m(2) (level 2). Three patients were treated in the 45mg/m(2) dose level and 5 patients were treated in the 75mg/m(2) dose level; no DLTs or grade 3-5 treatment related toxicities were observed. After a median follow-up of 5.2 months, no patients developed grade III-IV aGVHD and no patients died of aGVHD. Six out of 8 patients in the treatment group responded to treatment including two cytogenetic complete remissions, one hematologic complete remission, and three complete remissions with incomplete count recovery. In conclusion, administration of AzaC early post DLI is well tolerated and can potentially prevent GVHD after DLI. Further studies are required to evaluate the effect of azacitidine early post DLI on GVHD and GVL.

Prolonged exposure to arsenic in UK private water supplies: toenail, hair and drinking water concentrations

Chronic exposure to arsenic (As) in drinking water is an established cause of cancer and other adverse health effects. Arsenic concentrations >10 μg L(-1) were previously measured in 5% of private water supplies (PWS) in Cornwall, UK. The present study investigated prolongued exposure to As by measuring biomarkers in hair and toenail samples from 212 volunteers and repeated measurements of As in drinking water from 127 households served by PWS. Strong positive Pearson correlations (rp = 0.95) indicated stability of water As concentrations over the time period investigated (up to 31 months). Drinking water As concentrations were positively correlated with toenail (rp = 0.53) and hair (rp = 0.38) As concentrations - indicative of prolonged exposure. Analysis of washing procedure solutions provided strong evidence of the effective removal of exogenous As from toenail samples. Significantly higher As concentrations were measured in hair samples from males and smokers and As concentrations in toenails were negatively associated with age. A positive association between seafood consumption and toenail As and a negative association between home-grown vegetable consumption and hair As was observed for volunteers exposed to <1 As μg L(-1) in drinking water. These findings have important implications regarding the interpretation of toenail and hair biomarkers. Substantial variation in biomarker As concentrations remained unaccounted for, with soil and dust exposure as possible explanations.

Formulating and improving care while mitigating risk in a military Ebola virus disease treatment unit

This paper describes the development of the UK military's Ebola Virus Disease Treatment Unit (EVD TU) that was deployed to Sierra Leone as part of the UK response to the West African Ebola virus disease (EVD) epidemic in 2014 and 2015. It highlights specific challenges faced within this unique Field Hospital environment. The military EVD TU was initially established to provide confidence to international healthcare workers coming to Sierra Leone to assist in the international response to the EVD epidemic and formed a key part of the action plan by the UK's Department for International Development. It was designed and staffed to provide a high level of care to those admitted with suspected or confirmed EVD and was prepared to admit the first patient within 6 weeks of the original activation order by the Ministry of Defence. This article outlines the main hazards perceived at the outset of the operation and the methods used to mitigate the risk to the healthcare workers at the EVD TU. The article examines the mechanisms that enabled the hospital to respond positively to challenges that emerged during the deployment, while simultaneously reducing the risk to the healthcare workers involved in care delivery.

Urinary arsenic profiles reveal exposures to inorganic arsenic from private drinking water supplies in Cornwall, UK

Private water supplies (PWS) in Cornwall, South West England exceeded the current WHO guidance value and UK prescribed concentration or value (PCV) for arsenic of 10 μg/L in 5% of properties surveyed (n = 497). In this follow-up study, the first of its kind in the UK, volunteers (n = 207) from 127 households who used their PWS for drinking, provided urine and drinking water samples for total As determination by inductively coupled plasma mass spectrometry (ICP-MS) and urinary As speciation by high performance liquid chromatography ICP-MS (HPLC-ICP-MS). Arsenic concentrations exceeding 10 μg/L were found in the PWS of 10% of the volunteers. Unadjusted total urinary As concentrations were poorly correlated (Spearman's ρ = 0.36 (P < 0.001)) with PWS As largely due to the use of spot urine samples and the dominance of arsenobetaine (AB) from seafood sources. However, the osmolality adjusted sum, U-As(IMM), of urinary inorganic As species, arsenite (As(III)) and arsenate (As(V)), and their metabolites, methylarsonate (MA) and dimethylarsinate (DMA), was found to strongly correlate (Spearman's ρ: 0.62 (P < 0.001)) with PWS As, indicating private water supplies as the dominant source of inorganic As exposure in the study population of PWS users.

Root biomass production in populations of six rooted macrophytes in response to Cu exposure: intra-specific variability versus constitutive-like tolerance

Intra-specific variability of root biomass production (RP) of six rooted macrophytes, i.e. Juncus effusus, Phragmites australis, Schoenoplectus lacustris, Typha latifolia, Phalaris arundinacea, and Iris pseudacorus grown from clones, in response to Cu exposure was investigated. Root biomass production varied widely for all these macrophytes in control conditions (0.08 μM) according to the sampling site. Root biomass production of T. latifolia and I. pseudacorus in the 2.5-25 μM Cu range depended on the sampling location but not on the Cu dose in the growth medium. For P. australis, J. effusus, S. lacustris, and P. arundinacea, an intra-specific variability of RP depending on both the sampling location and the Cu-dose was evidenced. This intra-specific variability of RP depending on the sampling location and of Cu-tolerance for these last four species suggests that Cu constitutive tolerance for all rooted macrophytes is not a species-wide trait but it exhibits variability for some species.

Escherichia coli contamination and health aspects of soil and tomatoes (Solanum lycopersicum L.) subsurface drip irrigated with on-site treated domestic wastewater

Faecal contamination of soil and tomatoes irrigated by sprinkler as well as surface and subsurface drip irrigation with treated domestic wastewater were compared in 2007 and 2008 at experimental sites in Crete and Italy. Wastewater was treated by Membrane Bio Reactor (MBR) technology, gravel filtration or UV-treatment before used for irrigation. Irrigation water, soil and tomato samples were collected during two cropping seasons and enumerated for the faecal indicator bacterium Escherichia coli and helminth eggs. The study found elevated levels of E. coli in irrigation water (mean: Italy 1753 cell forming unit (cfu) per 100 ml and Crete 488 cfu per 100 ml) and low concentrations of E. coli in soil (mean: Italy 95 cfu g(-1) and Crete 33 cfu g(-1)). Only two out of 84 tomato samples in Crete contained E. coli (mean: 2700 cfu g(-1)) while tomatoes from Italy were free of E. coli. No helminth eggs were found in the irrigation water or on the tomatoes from Crete. Two tomato samples out of 36 from Italy were contaminated by helminth eggs (mean: 0.18 eggs g(-1)) and had been irrigated with treated wastewater and tap water, respectively. Pulsed Field Gel Electrophoresis DNA fingerprints of E. coli collected during 2008 showed no identical pattern between water and soil isolates which indicates contribution from other environmental sources with E. coli, e.g. wildlife. A quantitative microbial risk assessment (QMRA) model with Monte Carlo simulations adopted by the World Health Organization (WHO) found the use of tap water and treated wastewater to be associated with risks that exceed permissible limits as proposed by the WHO (1.0 × 10(-3) disease risk per person per year) for the accidental ingestion of irrigated soil by farmers (Crete: 0.67 pppy and Italy: 1.0 pppy). The QMRA found that the consumption of tomatoes in Italy was deemed to be safe while permissible limits were exceeded in Crete (1.0 pppy). Overall the quality of tomatoes was safe for human consumption since the disease risk found on Crete was based on only two contaminated tomato samples. It is a fundamental limitation of the WHO QMRA model that it is not based on actual pathogen numbers, but rather on numbers of E. coli converted to estimated pathogen numbers, since it is widely accepted that there is poor correlation between E. coli and viral and parasite pathogens. Our findings also stress the importance of the external environment, typically wildlife, as sources of faecal contamination.

Effect of lipids on insect cell growth and expression of recombinant proteins in serum-free medium

The lipid emulsion components of a serum-free insect cell medium were varied and evaluated for effects on cell growth and recombinant protein expression. The growth of High-Five(TM) cells was significantly affected by polyol Pluronic F-68 and Tween-80, but not by lipids. Pluronic was essential for cell growth, while Tween-80 was required to achieve maximum cell densities. A dose response effect was observed for Tween-80 with optimal cell growth at a concentration of 25 mg/l. Cholesterol had a minor effect on cell growth, but was essential for the expression of recombinant proteins. The expression of β-galactosidase (β-gal) was directly affected by cholesterol with optimal expression at a concentration of 5.4 mg/l. Vitamin E, important as an antioxidant to stabilize lipids, did not directly affect recombinant protein expression. Although lipids were not required for cell growth, the presence of lipids were required during the cell growth phase in order to achieve efficient infection with baculovirus. These studies help to define the important components, and range of concentrations, for lipid emulsions which can effectively replace serum in insect cell culture.

Cancer morbidity in British military veterans included in chemical warfare agent experiments at Porton Down: cohort study

OBJECTIVE

To determine cancer morbidity in members of the armed forces who took part in tests of chemical warfare agents from 1941 to 1989.

DESIGN

Historical cohort study, with cohort members followed up to December 2004.

DATA SOURCE

Archive of UK government research facility at Porton Down, UK military personnel records, and national death and cancer records.

PARTICIPANTS

All veterans included in the cohort study of mortality, excluding those known to have died or been lost to follow-up before 1 January 1971 when the UK cancer registration system commenced: 17,013 male members of the UK armed forces who took part in tests (Porton Down veterans) and a similar group of 16,520 men who did not (non-Porton Down veterans).

MAIN OUTCOME MEASURES

Cancer morbidity in each group of veterans; rate ratios, with 95% confidence intervals, adjusted for age group and calendar period.

RESULTS

3457 cancers were reported in the Porton Down veterans compared with 3380 cancers in the non-Porton Down veterans. While overall cancer morbidity was the same in both groups (rate ratio 1.00, 95% confidence interval 0.95 to 1.05), Porton Down veterans had higher rates of ill defined malignant neoplasms (1.12, 1.02 to 1.22), in situ neoplasms (1.45, 1.06 to 2.00), and those of uncertain or unknown behaviour (1.32, 1.01 to 1.73).

CONCLUSION

Overall cancer morbidity in Porton Down veterans was no different from that in non-Porton Down veterans.

Mortality in British military participants in human experimental research into chemical warfare agents at Porton Down: cohort study

OBJECTIVE

To investigate any long term effects on mortality in participants in experimental research related to chemical warfare agents from 1941 to 1989.

DESIGN

Historical cohort study. Data sources Archive of UK government research facility at Porton Down, UK military personnel records, and national death and cancer records. Participants 18,276 male members of the UK armed forces who had spent one or more short periods (median 4 days between first and last test) at Porton Down and a comparison group of 17,600 non-Porton Down veterans followed to 31 December 2004.

MAIN OUTCOME MEASURES

Mortality rate ratio of Porton Down compared with non-Porton Down veterans and standardised mortality ratio of each veteran group compared with the general population. Both ratios adjusted for age group and calendar period.

RESULTS

Porton Down veterans were similar to non-Porton Down veterans in year of enlistment (median 1951) but had longer military service (median 6.2 v 5.0 years). After a median follow-up of 43 years, 40% (7306) of Porton Down and 39% (6900) of non-Porton Down veterans had died. All cause mortality was slightly greater in Porton Down veterans (rate ratio 1.06, 95% confidence interval 1.03 to 1.10, P<0.001), more so for deaths outside the UK (1.26, 1.09 to 1.46). Of 12 cause specific groups examined, rate ratios in Porton Down veterans were increased for deaths attributed to infectious and parasitic (1.57, 1.07 to 2.29), genitourinary (1.46, 1.04 to 2.04), circulatory (1.07, 1.01 to 1.12), and external (non-medical) (1.17, 1.00 to 1.37) causes and decreased for deaths attributed to in situ, benign, and unspecified neoplasms (0.60, 0.37 to 0.99). There was no clear relation between type of chemical exposure and cause specific mortality. The mortality in both groups of veterans was lower than that in the general population (standardised mortality ratio 0.88, 0.85 to 0.90; 0.82, 0.80 to 0.84).

CONCLUSIONS

Mortality was slightly higher in Porton Down than non-Porton Down veterans. With lack of information on other important factors, such as smoking or service overseas, it is not possible to attribute the small excess mortality to chemical exposures at Porton Down.

Exposure to indoor mould and children's respiratory health in the PATY study

BACKGROUND

Living in a damp or mouldy home reportedly damages children's respiratory health, yet mould appears not to be a prominent risk factor in the public's perception. Analyses of data on over 58,000 children from the Pollution and the Young (PATY) study are presented. In this collaboration, researchers from 12 cross-sectional studies pooled their data to assess the effects of air quality on a spectrum of children's respiratory disorders.

METHOD

Original studies were conducted in Russia, North America and 10 countries in Eastern and Western Europe. Pooled analyses were restricted to children aged 6-12 years. Associations between visible mould reported in the household and a spectrum of eight respiratory and allergic symptoms were estimated within each study. Logistic regressions were used, controlling for individual risk factors and for study area. Heterogeneity between study-specific results and mean effects (allowing for heterogeneity) were estimated using meta-analysis.

RESULTS

Visible mould was reported by 13.9% of respondents in Russia, increasing to 39.1% in North America. Positive associations between exposure to mould and children's respiratory health were seen with considerable consistency across studies and across outcomes. Confounder-adjusted combined ORs ranged from 1.30 (95% CI 1.22 to 1.39) for "nocturnal cough" to 1.50 (1.31 to 1.73) for "morning cough". Evidence of stronger effects in more crowded households was statistically significant for only asthma and sensitivity to inhaled allergens. No consistent interactions between mould and age, sex or parental smoking were found.

CONCLUSION

Indoor mould exposure was consistently associated with adverse respiratory health outcomes in children living in these diverse countries.

Exposure to indoor mould and children's respiratory health in the PATY study

BACKGROUND

Living in a damp or mouldy home reportedly damages children's respiratory health, yet mould appears not to be a prominent risk factor in the public's perception. Analyses of data on over 58,000 children from the Pollution and the Young (PATY) study are presented. In this collaboration, researchers from 12 cross-sectional studies pooled their data to assess the effects of air quality on a spectrum of children's respiratory disorders.

METHOD

Original studies were conducted in Russia, North America and 10 countries in Eastern and Western Europe. Pooled analyses were restricted to children aged 6-12 years. Associations between visible mould reported in the household and a spectrum of eight respiratory and allergic symptoms were estimated within each study. Logistic regressions were used, controlling for individual risk factors and for study area. Heterogeneity between study-specific results and mean effects (allowing for heterogeneity) were estimated using meta-analysis.

RESULTS

Visible mould was reported by 13.9% of respondents in Russia, increasing to 39.1% in North America. Positive associations between exposure to mould and children's respiratory health were seen with considerable consistency across studies and across outcomes. Confounder-adjusted combined ORs ranged from 1.30 (95% CI 1.22 to 1.39) for "nocturnal cough" to 1.50 (1.31 to 1.73) for "morning cough". Evidence of stronger effects in more crowded households was statistically significant for only asthma and sensitivity to inhaled allergens. No consistent interactions between mould and age, sex or parental smoking were found.

CONCLUSION

Indoor mould exposure was consistently associated with adverse respiratory health outcomes in children living in these diverse countries.

Reconstructing Exposures from the UK Chemical Warfare Agent Human Research Programme

The UK government has carried out a research programme studying military capability under conditions of chemical warfare at a facility at Porton Down, Wiltshire, since World War I. In 2001 the Ministry of Defence commissioned a cohort study to investigate the long-term health effects on military veterans of their participation in this programme. We assessed the availability and quality of exposure assessment data held in the archive at Porton Down for the purpose of this study. This involved looking in detail at exposure data in a sample of 150 veterans and undertaking a general review of all available records held in the archive. These sources suggested that the Porton Down records were largely complete and included sufficient identifying information for linkage with service personnel data and with national mortality and cancer registration records. Servicemen usually had multiple tests so data were most readily available in a test-wise format, allowing subsequent aggregation of tests by individual. The name of the chemical used in each test could be determined for most tests and most of the named chemicals could be categorized into major groups for epidemiological analyses. For the major groups (vesicants and nerve agents), quantitative data were available on exposure and on acute toxicity. Standardization will be required of the several different units which were used. Based on this study, exposure assessment for the cohort study of Porton Down veterans will involve abstraction of the name of the chemical used in each test, with quantitative data on exposure and acute toxicity for vesicants and nerve agents. Our results here show that experimental records at Porton Down offer a unique and valuable resource for reconstructing the chemical exposures used in this research programme. The resulting cohort study has the potential to provide information which will assist in understanding the long-term health impact of chemical warfare agent exposure on these veterans.

NO2 and children's respiratory symptoms in the PATY study

OBJECTIVES

NO2)is a major urban air pollutant. Previously reported associations between ambient NO2)and children's respiratory health have been inconsistent, and independent effects of correlated pollutants hard to assess. The authors examined effects of NO2 on a spectrum of 11 respiratory symptoms, controlling for PM10 and SO2, using a large pooled dataset.

METHODS

Cross sectional studies were conducted in Russia, Austria, Italy, Switzerland, and the Netherlands, during 1993-99, contributing in total 23 955 children. Study-specific odds ratios for associations with ambient NO2 are estimated using logistic regressions with area-level random effects. Heterogeneity between study-specific results, and mean estimates (allowing for heterogeneity) are calculated.

RESULTS

Long term average NO2 concentrations were unrelated to prevalences of bronchitis or asthma. Associations were found for sensitivity to inhaled allergens and allergy to pets, with mean odds ratios around 1.14 per 10 microg/m3 NO2. SO2 had little confounding effect, but an initial association between NO2 and morning cough was reduced after controlling for PM10. Associations with reported allergy were not reduced by adjustment for the other pollutants. Odds ratios for allergic symptoms tended to be higher for the 9-12 year old children compared with the 6-8 year old children.

CONCLUSIONS

Evidence for associations between NO2 and respiratory symptoms was robust only for inhalation allergies. NO2 most likely is acting as an indicator of traffic related air pollutants, though its direct effect cannot be ruled out. This remains important, as policies to reduce traffic related air pollution will not result in rapid reductions.

Parental education and children's respiratory and allergic symptoms in the Pollution and the Young (PATY) study

Inequalities in health between socio-economic groups are a major public health concern. The current authors studied associations between parental socio-economic status (SES) and children's respiratory and allergic symptoms in 13 diverse countries, including the Russian Federation, North America (Canada and the USA), and countries across Eastern and Western Europe. Data of 57,000 children aged 6-12 yrs, originating from eight cross-sectional studies, were analysed. SES was defined by parental education. Respiratory and allergic symptoms were defined by parental questionnaire reports. Multiple logistic regressions showed that low parental education was associated with a decreased risk of inhalant allergy and itchy rash in school children. Furthermore, low parental education was associated with an increased prevalence of wheeze and nocturnal dry cough. No clear association was found between parental education and prevalence of doctor-diagnosed asthma and bronchitis. Part of the difference between socio-economic groups with regard to their children's symptoms was explained by established risk factors, such as parental allergy, smoking during pregnancy, pet ownership, crowding, mould/moisture in the home, use of gas for cooking, and air pollution (particulate matter with a diameter of <10 microm). However, differences remained after adjusting for these variables. Children's health was associated with parental education. The association could not fully be explained by established risk factors.

Discovery of potent, nonsystemic apical sodium-codependent bile acid transporter inhibitors (Part 1)

Elevated plasma levels of low-density lipoprotein (LDL) cholesterol are a major risk factor for atherosclerosis leading to coronary artery disease (CAD), which remains the main cause of mortality in Western society. We believe that by preventing the reabsorption of bile acids, a minimally absorbed apical sodium-codependent bile acid transporter (ASBT) inhibitor would lower the serum cholesterol without the potential systemic side effects of an absorbed drug. A series of novel benzothiepines (3R,3R'-2,3,4,5-tetrahydro-5-aryl-1-benzothiepin-4-ol 1,1-dioxides) were synthesized and tested for their ability to inhibit the apical sodium dependent bile acid transport (ASBT)-mediated uptake of [(14)C]taurocholate (TC) in H14 cells. A 3R,4R,5R/3S,4S,5S racemate was found to have greater potency than the other three possible racemates. Addition of electron-donating groups such as a dimethylamino substituent at the 7 position greatly enhanced potency, and incorporation of a long-chain quaternary ammonium substituent on the 5-phenyl ring was useful in minimizing systemic exposure of this locally active ASBT inhibitor while also increasing water solubility and maintaining potency. The reported results describe the synthesis and SAR development of this benzothiepine class of ASBT inhibitors resulting in an 6000-fold improvement in ASBT inhibition with desired minimal systemic exposure of this locally acting drug candidate.

Discovery of Potent, Nonsystemic Apical Sodium-Codependent Bile Acid Transporter Inhibitors (Part 2)

In the preceding paper several compounds were reported as potent apical sodium-codependent bile acid transporter (ASBT) inhibitors. Since the primary site for active bile acid reabsorption is via ASBT, which is localized on the luminal surface of the distal ileum, we reasoned that a nonsystemic inhibitor would be desirable to minimize or eliminate potential systemic side effects of an absorbed drug. To ensure bioequivalency and product stability, it was also essential that we identify a nonhygroscopic inhibitor in its most stable crystalline form. A series of benzothiepines were prepared to refine the structure-activity relationship of the substituted phenyl ring at the 5-position of benzothiepine ring and to identify potent, crystalline, nonhygroscopic, and efficacious ASBT inhibitors with low systemic exposure.