PFAS alters placental arterial vasculature in term human placentae: A prospective pregnancy cohort study

INTRODUCTION

Perfluoroalkyl substances (PFAS) are synthetic chemicals used in industrial and consumer goods that are widely detected in human populations and are associated with adverse health outcomes, including perinatal health risks and child health. One mechanism of influence may be the impact of PFAS exposure on placental structure and function.

OBJECTIVES

The objective of this study is to investigate the relationship between maternal prenatal exposure to PFAS and measures of placental vascularization, and to assess whether changes in vascularization play a role in mediating the impact of PFAS on birth outcomes.

METHODS

Using data from a prospective cohort study, we examined associations between second trimester PFAS (individually and as mixtures using Bayesian kernel machine regression) and placental arterial vasculature in term placentae (N = 158); secondarily we evaluated the degree to which alterations in placental arterial vasculature explained associations between PFAS exposure and birth outcomes. Placental arterial vasculature features were collected from arterial tracings of each placental image.

RESULTS

In both linear regression and mixture models, natural log-transformed perfluorooctanoic acid concentrations were negatively associated with surface vasculature, indexed by the mean distance from arterial end point to perimeter (β = -0.23, 95% CI: -0.41, -0.041); additionally, maximum arterial tortuosity was negatively associated with placental weight (β = -0.19, 95% CI: -0.34, -0.051). There were no reliable differences in effect by fetal sex.

DISCUSSION

The findings provide some of the first evidence of PFAS exposure shaping a key measure of placental vascular function, which may underlie the impact of PFAS on perinatal and child health risks.

Risks of obstructive genitourinary birth defects in relation to trihalomethane and haloacetic acid exposures: expanding disinfection byproduct mixtures analyses using relative potency factors

BACKGROUND

Some disinfection byproducts (DBPs) are teratogens based on toxicological evidence. Conventional use of predominant DBPs as proxies for complex mixtures may result in decreased ability to detect associations in epidemiological studies.

OBJECTIVE

We assessed risks of obstructive genitourinary birth defects (OGDs) in relation to 12 DBP mixtures and 13 individual component DBPs.

METHODS

We designed a nested registry-based case-control study (210 OGD cases; 2100 controls) in Massachusetts towns with complete quarterly 1999-2004 data on four trihalomethanes (THMs) and five haloacetic acids (HAAs). We estimated temporally-weighted average DBP exposures for the first trimester of pregnancy. We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for OGD in relation to individual DBPs, unweighted mixtures, and weighted mixtures based on THM/HAA relative potency factors (RPF) from animal toxicology data for full-litter resorption, eye defects, and neural tube defects.

RESULTS

We detected elevated aORs for OGDs for the highest of bromodichloromethane (aOR = 1.75; 95% CI: 1.15-2.65), dibromochloromethane (aOR = 1.71; 95% CI: 1.15-2.54), bromodichloroacetic acid (aOR = 1.56; 95%CI: 0.97-2.51), chlorodibromoacetic acid (aOR = 1.97, 95% CI: 1.23-3.15), and tribromoacetic acid (aOR = 1.90; 95%CI: 1.20-3.03). Across unweighted mixture sums, the highest aORs were for the sum of three brominated THMs (aOR = 1.74; 95% CI: 1.15-2.64), the sum of six brominated HAAs (aOR = 1.43; 95% CI: 0.89-2.31), and the sum of nine brominated DBPs (aOR = 1.80; 95% CI: 1.05-3.10). Comparing eight RPF-weighted to unweighted mixtures, the largest aOR differences were for two HAA metrics, which both were higher with RPF weighting; other metrics had reduced or minimally changed ORs in RPF-weighted models.

Assessment of personal care product use and perceptions of use in a sample of US adults affiliated with a university in the Northeast

Evidence supports unequal burdens of chemical exposures from personal care products (PCPs) among some groups, namely femme-identifying and racial and ethnic minorities. In this study, we implemented an online questionnaire to assess PCP purchasing and usage behaviors and perceptions of use among a sample of US adults recruited at a Northeastern university. We collected PCP use across seven product categories (hair, beauty, skincare, perfumes/colognes, feminine hygiene, oral care, other), and behaviors, attitudes, and perceptions of use and safety across sociodemographic factors to evaluate relationships between sociodemographic factors and the total number of products used within the prior 24-48 h using multivariable models. We also summarized participants' perceptions and attitudes. Among 591 adults (20.0% Asian American/Pacific Islander [AAPI], 5.9% Hispanic, 9.6% non-Hispanic Black [NHB], 54.6% non-Hispanic White [NHW], and 9.9% multiracial or other), the average number of PCPs used within the prior 24-48 h was 15.6 ± 7.7. PCP use was greater among females than males (19.0 vs. 7.9, P < 0.01) and varied by race and ethnicity among females. Relative to NHWs, AAPI females used fewer hair products (2.5 vs. 3.1) and more feminine hygiene products (1.5 vs. 1.1), NHB females used more hair products (3.8 vs. 3.1), perfumes (1.0 vs. 0.6), oral care (2.3 vs. 1.9), and feminine hygiene products (1.8 vs. 1.1), and multiracial or other females used more oral care (2.2 vs. 1.9) and feminine hygiene products (1.5 vs. 1.1) (P-values <0.05). Generally, study participants reported moderate concern about exposures and health effects from using PCPs, with few differences by gender, race, and ethnicity. These findings add to the extant literature on PCP use across sociodemographic characteristics. Improving the understanding of patterns of use for specific products and their chemical ingredients is critical for developing interventions to reduce these exposures, especially in vulnerable groups with an unequal burden of exposure.

Associations between area-level arsenic exposure and adverse birth outcomes: An Echo-wide cohort analysis

BACKGROUND

Drinking water is a common source of exposure to inorganic arsenic. In the US, the Safe Drinking Water Act (SDWA) was enacted to protect consumers from exposure to contaminants, including arsenic, in public water systems (PWS). The reproductive effects of preconception and prenatal arsenic exposure in regions with low to moderate arsenic concentrations are not well understood.

OBJECTIVES

This study examined associations between preconception and prenatal exposure to arsenic violations in water, measured via residence in a county with an arsenic violation in a regulated PWS during pregnancy, and five birth outcomes: birth weight, gestational age at birth, preterm birth, small for gestational age (SGA), and large for gestational age (LGA).

METHODS

Data for arsenic violations in PWS, defined as concentrations exceeding 10 parts per billion, were obtained from the Safe Drinking Water Information System. Participants of the Environmental influences on Child Health Outcomes Cohort Study were matched to arsenic violations by time and location based on residential history data. Multivariable, mixed effects regression models were used to assess the relationship between preconception and prenatal exposure to arsenic violations in drinking water and birth outcomes.

RESULTS

Compared to unexposed infants, continuous exposure to arsenic from three months prior to conception through birth was associated with 88.8 g higher mean birth weight (95% CI: 8.2, 169.5), after adjusting for individual-level confounders. No statistically significant associations were observed between any preconception or prenatal violations exposure and gestational age at birth, preterm birth, SGA, or LGA.

CONCLUSIONS

Our study did not identify associations between preconception and prenatal arsenic exposure, defined by drinking water exceedances, and adverse birth outcomes. Exposure to arsenic violations in drinking water was associated with higher birth weight. Future studies would benefit from more precise geodata of water system service areas, direct household drinking water measurements, and exposure biomarkers.

Associations between neighborhood stress and maternal sex steroid hormones in pregnancy

BACKGROUND

Neighborhood stressors (e.g., crime and deprivation) have been associated with adverse pregnancy outcomes including preterm birth and low birth weight. A potential mechanism is disruption of maternal endocrine pathways. While stress hormones (e.g., cortisol) have received much attention, other relevant hormones, including sex steroids, have been overlooked.

METHODS

Pregnant women in the Understanding Pregnancy Signals and Infant Development (UPSIDE) study contributed biospecimens, questionnaires, and medical record data (n = 262). In each trimester, maternal serum total testosterone [TT], estrone, estradiol, and estriol were measured using LC/MS-MS and serum free testosterone was measured by equilibrium dialysis. In the third trimester, participants reported on neighborhood stress over the last year through the validated City Stress Inventory. We examined two subscales: 11-item neighborhood disorder (e.g., vacant buildings, crime) and 7-item exposure to violence (personal experiences of violence). Composite scores were calculated and examined categorically (quartile (Q) for neighborhood disorder and any/none for exposure to violence). We fitted linear mixed models examining associations between neighborhood stressors and sex steroid hormones across pregnancy as well as trimester-specific linear regression models, all adjusting for confounders. Secondarily, we stratified by fetal sex. Results are presented as percentage change (∆%) and 95% confidence interval (CI) in hormones.

RESULTS

Most participants (73%) reported one or more exposures to neighborhood disorder; 22% reported any exposure to violence. In adjusted models, neighborhood disorder was associated with higher TT across pregnancy (Q2: %∆= 37.3, 95%CI: 13.2, 66.5; Q3: %∆= 22.2, 95%CI: 1.2, 47.5; and Q4: %∆= 25.7, 95%CI: 1.6, 55.3), with the strongest associations observed in the third trimester (Q2: %∆= 38.0, 95%CI: 10.6, 72.1; Q3: %∆= 29.2, 95%CI: 4.4, 59.9; and Q4: %∆=33.4, 95%CI: 4.9, 69.6). In stratified models, neighborhood disorder was associated with higher TT among women carrying male fetuses (%∆ range: 48.2-84.8). Exposure to violence was not associated with any hormones.

CONCLUSION

Neighborhood disorder is associated with higher maternal testosterone levels, which may have implications for maternal and child health. Additional research is needed to understand the mechanisms by which neighborhood stress impacts endocrine physiology.

Per- and polyfluoroalkyl substances, gestational weight gain, postpartum weight retention and body composition in the UPSIDE cohort

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) are synthetic chemicals found in drinking water and consumer products, resulting in ubiquitous human exposure. PFAS have been linked to endocrine disruption and altered weight gain across the lifespan. A limited and inconsistent body of research suggests PFAS may impact gestational weight gain (GWG) and postpartum body mass index (BMI), which are important predictors of overall infant and maternal health, respectively.

METHODS

In the Understanding Pregnancy Signals and Infant Development (UPSIDE/UPSIDE-MOMs) study (n = 243; Rochester, NY), we examined second trimester serum PFAS (PFOS: perfluorooctanesulfonic acid, PFOA: perfluorooctanoic acid, PFNA: perfluorononanoic acid, PFHxS: perfluorohexanesulfonic acid, PFDA: perfluorodecanoic acid) in relation to GWG (kg, and weekly rate of gain) and in the postpartum, weight retention (PPWR (kg) and total body fat percentage (measured by bioelectrical impedance)). We fit multivariable linear regression models examining these outcomes in relation to log-transformed PFAS in the whole cohort as well as stratified by maternal pre-pregnancy BMI (< 25 vs. =  > 25 kg/m2), adjusting for demographics and lifestyle factors. We used weighted quantile sum regression to find the combined influence of the 5 PFAS on GWG, PPWR, and body fat percentage.

RESULTS

PFOA and PFHxS were inversely associated with total GWG (PFOA: ß = -1.54 kg, 95%CI: -2.79, -0.30; rate ß = -0.05 kg/week, 95%CI: -0.09, -0.01; PFHxS: ß = -1.59 kg, 95%CI: -3.39, 0.21; rate ß = -0.05 kg/week, 95%CI: -0.11, 0.01) and PPWR at 6 and 12 months (PFOA 6 months: ß = -2.39 kg, 95%CI: -4.17, -0.61; 12 months: ß = -4.02 kg, 95%CI: -6.58, -1.46; PFHxS 6 months: ß = -2.94 kg, 95%CI: -5.52, -0.35; 12 months: ß = -5.13 kg, 95%CI: -8.34, -1.93). PFOA was additionally associated with lower body fat percentage at 6 and 12 months (ß = -1.75, 95%CI: -3.17, -0.32; ß = -1.64, 95%CI: -3.43, 0.16, respectively) with stronger associations observed in participants with higher pre-pregnancy BMI. The PFAS mixture was inversely associated with weight retention at 12 months (ß = -2.030, 95%CI: -3.486, -0.573) amongst all participants.

CONCLUSION

PFAS, in particular PFOA and PFHxS, in pregnancy are associated with altered patterns of GWG and postpartum adiposity with potential implications for fetal development and long-term maternal cardiometabolic health.

A comparison of four liquid chromatography-mass spectrometry platforms for the analysis of zeranols in urine

Targeted biomonitoring studies quantifying the concentration of zeranols in biological matrices have focused on liquid chromatography interfaced to mass spectrometry (LC-MS). The MS platform for measurement, quadrupole, time-of-flight (ToF), ion trap, etc., is often chosen based on either sensitivity or selectivity. An instrument performance comparison of the benefits and limitations using matrix-matched standards containing 6 zeranols on 4 MS instruments, 2 low-resolution (linear ion traps), and 2 high-resolution (Orbitrap and ToF) was undertaken to identify the best measurement platform for multiple biomonitoring projects characterizing the endocrine disruptive properties of zeranols. Analytical figures of merit were calculated for each analyte to compare instrument performance across platforms. The calibration curves had correlation coefficients r = 0.989 ± 0.012 for all analytes and LODs and LOQs were ranked for sensitivity: Orbitrap > LTQ > LTQXL > G1 (V mode) > G1 (W mode). The Orbitrap had the smallest measured variation (lowest %CV), while the G1 had the highest. Instrumental selectivity was calculated using full width at half maximum (FWHM) and as expected, the low-resolution instruments had the broadest spectrometric peaks, concealing coeluting peaks under the same mass window as the analyte. Multiple peaks from concomitant ions, unresolved at low resolution (within a unit mass window), were present but did not match the exact mass predicted for the analyte. For example, the high-resolution platforms were able to differentiate between a concomitant peak at 319.1915 from the analyte at 319.1551, included in low-resolution quantitative analyses demonstrating the need to consider coeluting interfering ions in biomonitoring studies. Finally, a validated method using the Orbitrap was applied to human urine samples from a pilot cohort study.

Prenatal Cadmium Exposure and Maternal Sex Steroid Hormone Concentrations across Pregnancy

Cadmium exposure has been associated with adverse perinatal outcomes. One possible mechanism is endocrine disruption. Studies of non-pregnant adults suggest that cadmium impacts androgen production; here, we examined these associations during pregnancy. Participants in the Understanding Pregnancy Signals and Infant Development (UPSIDE) cohort provided biospecimens and questionnaire data in each trimester (n = 272). We quantified urinary cadmium, serum total testosterone (TT), estrone, estradiol, and estriol and serum free testosterone (fT). In adjusted longitudinal models, we examined sex steroid concentrations across pregnancy in relation to specific gravity-adjusted, ln-transformed cadmium concentrations. Additionally, we examined trimester-specific associations and stratified models by fetal sex. Results are presented as percent change (%∆) in hormone concentrations. In longitudinal models, higher cadmium concentrations were associated with lower fT across pregnancy (%∆ = -5.19, 95%CI: -8.33, -1.93), with no differences in other hormones observed. In trimester-specific models, higher cadmium concentrations were associated with lower TT in trimester 2 (%∆ = -15.26, 95%CI: -25.15, -4.06) and lower fT in trimester 3 (%∆ = -14.35, 95%CI: -19.75, -8.59). Associations with TT were stronger in pregnancies carrying female fetuses. Maternal cadmium exposure may be associated with reduced testosterone in pregnancy. Additional work is necessary to understand how alterations in gestational testosterone activity may impact pregnancy and child health.

Optimized extraction and analysis methods using liquid chromatography-tandem mass spectrometry for zearalenone and metabolites in human placental tissue

Zearalenone and its metabolites, a group of endocrine disrupting mycotoxins, have been linked to adverse reproductive health effects. They cross the placental barrier, potentially reaching the fetus. In this study, we adapted and optimized our protocol previously used for urine, to measure these mycotoxins in human placentas. We combined a supported liquid extraction step using Chem Elut cartridges with solid phase extraction on Discovery® DSC-NH2 tubes. The optimized extraction efficiencies were between 68 and 80% for all metabolites. Analysis was performed by UHPLC-HRMS using a Betasil™ Phenyl-Hexyl column eluted with a gradient of acetonitrile-methanol-water. The chromatography method separated all analytes in under 15 min. Validation experiments confirmed the method's sensitivity, with LODs ranging from 0.0055 to 0.011 pg/mg tissue. The method was linear over a range of 0.0025-1.5 pg/mg tissue with R2 values ≥ 0.994. Precision and accuracy calculations ranged from 4.7-7.9% and 0.6-6.7% respectively. The method was then successfully applied to a subset of placenta samples (n = 25) collected from an ongoing prospective birth cohort. Interestingly, 92% of the samples contained at least one measurable zearalenone metabolite, providing initial indication of potentially widespread exposure during pregnancy.

Protective role of the placental efflux transporter BCRP/ABCG2 in the relationship between prenatal cadmium exposure, placenta weight, and size at birth

BACKGROUND AND AIM

Placental efflux transporter proteins, such as BCRP, reduce the placental and fetal toxicity of environmental contaminants but have received little attention in perinatal environmental epidemiology. Here, we evaluate the potential protective role of BCRP following prenatal exposure to cadmium, a metal that preferentially accumulates in the placenta and adversely impacts fetal growth. We hypothesized that individuals with a reduced function polymorphism in ABCG2, the gene encoding BCRP, would be most vulnerable to the adverse impacts of prenatal cadmium exposure, notably, smaller placental and fetal size.

METHODS

We measured cadmium in maternal urine samples at each trimester and in term placentas from UPSIDE-ECHO study participants (NY, USA; n = 269). We fit adjusted multivariable linear regression and generalized estimating equation models to examine log-transformed urinary and placental cadmium concentrations in relation to birthweight, birth length, placental weight, and fetoplacental weight ratio (FPR) and stratified models by ABCG2 Q141K (C421A) genotype.

RESULTS

Overall 17% of participants expressed the reduced-function ABCG2 C421A variant (AA or AC). Placental cadmium concentrations were inversely associated with placental weight (β = -19.55; 95%CI: -37.06, -2.04) and trended towards higher FPR (β = 0.25; 95%CI: -0.01, 0.52) with stronger associations in 421A variant infants. Notably, higher placental cadmium concentrations in 421A variant infants were associated with reduced placental weight (β = -49.42; 95%CI: 98.87, 0.03), and higher FPR (β = 0.85, 95%CI: 0.18, 1.52), while higher urinary cadmium concentration was associated with longer birth length (β = 0.98; 95%CI: 0.37, 1.59), lower ponderal index (β = -0.09; 95%CI: 0.15, -0.03), and higher FPR (β = 0.42; 95%CI: 0.14, 0.71).

CONCLUSIONS

Infants with reduced function ABCG2 polymorphisms may be particularly vulnerable to the developmental toxicity of cadmium as well as other xenobiotics that are BCRP substrates. Additional work examining the influence of placental transporters in environmental epidemiology cohorts is warranted.

Prenatal perfluoroalkyl substances exposure and maternal sex steroid hormones across pregnancy

BACKGROUND

Poly- and perfluoroalkyl substances (PFAS) are ubiquitous and persistent environmental contaminants that may act as endocrine disruptors in utero, but the specific endocrine pathways are unknown.

OBJECTIVE

We examined associations between maternal serum PFAS and sex steroid hormones at three time points during pregnancy.

METHODS

Pregnant women participating in the Understanding Pregnancy Signals and Infant Development (UPSIDE) study contributed biospecimens, questionnaire, and medical record data in each trimester (n = 285). PFAS (including perfluorooctanoic acid (PFOA), perfluorooctanesulfonic acid (PFOS), perfluorohexane sulfonic acid (PFHxS), perfluorononanoic acid (PFNA) and perfluorodecanoic acid (PFDA)) were analyzed in second-trimester serum samples by high-performance liquid chromatography and tandem mass spectrometry (LC-MS/MS). Total testosterone [TT], free testosterone [fT], estrone [E1], estradiol [E2], and estriol [E3]) were measured by LC-MS/MS in serum samples from each trimester. Linear mixed models with random intercepts were used to examine associations between log-transformed PFAS concentrations and hormone levels, adjusting for covariates, and stratifying by fetal sex. Results are presented as the mean percentage difference (Δ%) in hormone levels per ln-unit increase in PFAS concentration.

RESULTS

In adjusted models, PFHxS was associated with higher TT (%Δ = 20.0, 95%CI: 1.7, 41.6), particularly among women carrying male fetuses (%Δ = 15.3, 95%CI: 1.2, 30.7); this association strengthened as the pregnancy progressed. PFNA (%Δ = 7.9, 95%CI: 3.4, 12.5) and PFDA (%Δ = 7.2, 95%CI: 4.9, 9.7) were associated with higher fT, with associations again observed only in women carrying male fetuses. PFHxS was associated with higher levels of E2 and E3 in women carrying female fetuses (%Δ = 13.2, 95%CI: 0.5, 29.1; %Δ = 17.9, 95%CI: 3.2, 34.8, respectively). No associations were observed for PFOS and PFOA.

CONCLUSION

PFHxS, PFNA, and PFDA may disrupt androgenic and estrogenic pathways in pregnancy in a sex-dependent manner.

Connect: Cultivating Academic-Community Partnerships to Address Our Communities' Complex Needs During Public Health Crises

BACKGROUND

Black and Latino communities have been disproportionately impacted by coronavirus disease 2019 and we sought to understand perceptions and attitudes in four heavily impacted New Jersey counties to develop and evaluate engagement strategies to enhance access to testing.

OBJECTIVE

To establish a successful academic/community partnership team during a public health emergency by building upon longstanding relationships and using principles from community engaged research.

METHODS

We present a case study illustrating multiple levels of engagement, showing how we successfully aligned expectations, developed a commitment of cooperation, and implemented a research study, with community-based and health care organizations at the center of community engagement and recruitment.

LESSONS LEARNED

This paper describes successful approaches to relationship building including information sharing and feedback to foster reciprocity, diverse dissemination strategies to enhance engagement, and intergenerational interaction to ensure sustainability.

CONCLUSIONS

This model demonstrates how academic/community partnerships can work together during public health emergencies to develop sustainable relationships.

Phenols, Parabens, Phthalates and Puberty: a Systematic Review of Synthetic Chemicals Commonly Found in Personal Care Products and Girls' Pubertal Development

PURPOSE OF REVIEW

Exposure to endocrine disrupting chemicals through personal care products (PCPs) is widespread and may disrupt hormone-sensitive endpoints, such as timing of puberty. Given the well-documented (and ongoing) decline in age at menarche in many populations, we conducted a systematic review of the epidemiological literature on exposure to chemicals commonly found in PCPs (including certain phthalates, phenols, and parabens) in relation to girls' pubertal development.

RECENT FINDINGS

The preponderance of research on this topic has examined phthalate exposures with the strongest evidence indicating that prenatal monoethyl phthalate (MEP) concentrations may be associated with slightly earlier timing of puberty, including age at menarche. Findings examining peri-pubertal phthalate exposures and pubertal outcomes were less consistent as were studies of prenatal and peri-pubertal phenol exposures. Very few studies had examined parabens in relation to girls' pubertal development. Common study limitations included potential exposure misclassification related to use of spot samples and/or mistimed biomarker assessment with respect to the outcomes. The role of body size as a mediator in these relationships remains unresolved. Overall, evidence of associations between chemical exposures in PCPs and girls' pubertal development was conflicting. When associations were observed, effect sizes were small. Nevertheless, given the many environmental, social, and behavioral factors in the modern environment that may act synergistically to accelerate timing of puberty, even marginal changes may be cause for concern, with implications for cancer risk, mental health, and cardiometabolic disease in later life.

Community- Versus Health Care Organization-Based Approaches to Expanding At-Home COVID-19 Testing in Black and Latino Communities, New Jersey, 2021

At-home COVID-19 testing offers convenience and safety advantages. We evaluated at-home testing in Black and Latino communities through an intervention comparing community-based organization (CBO) and health care organization (HCO) outreach. From May through December 2021, 1100 participants were recruited, 94% through CBOs. The odds of COVID-19 test requests and completions were significantly higher in the HCO arm. The results showed disparities in test requests and completions related to age, race, language, insurance, comorbidities, and pandemic-related challenges. Despite the popularity of at-home testing, barriers exist in underresourced communities. (Am J Public Health. 2022;112(S9):S918-S922. https://doi.org/10.2105/AJPH.2022.306989).

Phthalate Exposures and Placental Health in Animal Models and Humans: A Systematic Review

Phthalates are ubiquitous compounds known to leach from the plastic products that contain them. Due to their endocrine-disrupting properties, a wide range of studies have elucidated their effects on reproduction, metabolism, neurodevelopment, and growth. Additionally, their impacts during pregnancy and on the developing fetus have been extensively studied. Most recently, there has been interest in the impacts of phthalates on the placenta, a transient major endocrine organ critical to maintenance of the uterine environment and fetal development. Phthalate-induced changes in placental structure and function may have significant impacts on the course of pregnancy and ultimately, child health. Prior reviews have described the literature on phthalates and placental health; however to date, there has been no comprehensive, systematic review on this topic. Here, we review 35 papers (24 human and 11 animal studies) and summarize phthalate exposures in relation to an extensive set of placental measures. Phthalate-related alterations were reported for placental morphology, hormone production, vascularization, histopathology, and gene/protein expression. The most consistent changes were observed in vascular and morphologic endpoints, including cell composition. These changes have implications for pregnancy complications such as preterm birth and intrauterine growth restriction as well as potential ramifications for children's health. This comprehensive review of the literature, including common sources of bias, will inform the future work in this rapidly expanding field.

Personal care products: Demographic characteristics and maternal hormones in pregnant women from Puerto Rico

Personal care products (PCPs) refer to a wide variety of items commonly characterized as health or beauty products. PCPs contain a number of ingredients, often including a wide range of endocrine disrupting chemicals such as phthalates and parabens. The present study examines the association between self-reported PCP use and prenatal sex-steroids and thyroid hormones levels in women from Puerto Rico. We recruited pregnant women (n = 1070) through the Puerto Rico PROTECT Cohort and collected blood, demographic and pregnancy-related data at recruitment and subsequent visits. PCP use in the 48-h preceding the blood sample was collected through self-reported questionnaires. Nine hormones (corticotropin-releasing hormone [CRH], sex-hormone binding globulin [SHBG], estriol [E3], progesterone, testosterone, thyroid-stimulating hormone [TSH], total triiodothyronine [T3], total thyroxine [T4], and free thyroxine [fT4]) were measured in maternal serum samples at two points during pregnancy. Linear mixed models with random intercepts were used to examine associations between PCP use and serum hormone levels. Use of cosmetics significantly increased with age, household income and education level (p < 0.01). Use of hair products, such as hair dyes and bleach, relaxers, and mousse, was associated with lower levels of all sex steroid hormones compared to non-use: SHBG (%Δ = -7.1, 95%CI: -12.4,-1.8), E3 (%Δ = -23.2, 95%CI: -32.2,-13.0), progesterone (%Δ = -21.5, 95%CI: -29.4,-12.9) and testosterone (%Δ = -21.5, 95%CI: -33.1,-7.8) adjusted for maternal age, education and pre-pregnancy body mass index. Our findings suggest that household income and education level influence PCP use among pregnant women in this study. Use of certain hair products was associated with lower concentrations of sex steroid hormones. Although there are limitations to questionnaire data, characterizing PCP use is inexpensive and may represent exposure from multiple classes of chemicals, including chemicals that may not specifically appear on product labels and/or have not been tested for endocrine disrupting potential, making it a useful complement to chemical biomarker data.

Experiences of Black and Latinx health care workers in support roles during the COVID-19 pandemic: A qualitative study

Black and Latinx individuals, and in particular women, comprise an essential health care workforce often serving in support roles such as nursing assistants and dietary service staff. Compared to physicians and nurses, they are underpaid and potentially undervalued, yet play a critical role in health systems. This study examined the impact of the coronavirus disease 2019 (COVID-19) pandemic from the perspective of Black and Latinx health care workers in support roles (referred to here as HCWs). From December 2020 to February 2021, we conducted 2 group interviews (n = 9, 1 group in English and 1 group in Spanish language) and 8 individual interviews (1 in Spanish and 7 in English) with HCWs. Participants were members of a high-risk workforce as well as of communities that suffered disproportionately during the pandemic. Overall, they described disruptive changes in responsibilities and roles at work. These disruptions were intensified by the constant fear of contracting COVID-19 themselves and infecting their family members. HCWs with direct patient care responsibilities reported reduced opportunities for personal connection with patients. Perspectives on vaccines reportedly changed over time, and were influenced by peers' vaccination and information from trusted sources. The pandemic has exposed the stress endured by an essential workforce that plays a critical role in healthcare. As such, healthcare systems need to dedicate resources to improve the work conditions for this marginalized workforce including offering resources that support resilience. Overall working conditions and, wages must be largely improved to ensure their wellbeing and retain them in their roles to manage the next public health emergency. The role of HCWs serving as ambassadors to provide accurate information on COVID-19 and vaccination among their coworkers and communities also warrants further study.

Black and Latinx Community Perspectives on COVID-19 Mitigation Behaviors, Testing, and Vaccines

IMPORTANCE

Black and Latinx communities have been disproportionately affected by the COVID-19 pandemic, yet little work has sought to understand their perspectives.

OBJECTIVE

To explore the experiences of Black and Latinx communities during the pandemic to better understand their perspectives on COVID-19 mitigation behaviors (eg, mask wearing), testing, and vaccines.

DESIGN, SETTING, AND PARTICIPANTS

In this community-engaged qualitative study conducted with 18 community-based organizations and 4 health care organizations between November 19, 2020, and February 5, 2021, in New Jersey counties severely affected by the pandemic, group and individual interviews were used to purposively sample 111 Black and Latinx individuals. A total of 13 group interviews were organized by race/ethnicity and language: 4 English-speaking groups with Black participants (n = 34), 3 Spanish-speaking groups with Latinx participants (n = 24), and 4 English-speaking groups with Black and Latinx participants (n = 36). To understand the views of health care workers from these communities, 2 additional groups (n = 9) were convened and supplemented with individual interviews.

MAIN OUTCOMES AND MEASURES

Description of Black and Latinx participants' experiences during the COVID-19 pandemic and their perspectives on mitigation behaviors, testing, and vaccines.

RESULTS

The study included 111 participants (87 women [78.4%]; median age, 43 years [range, 18-93 years]). Participants described the devastating effects of the pandemic on themselves, loved ones, and their community. Their experiences were marked by fear, illness, loss, and separation. These experiences motivated intense information seeking, mitigation behaviors, and testing. Nevertheless, vaccine skepticism was high across all groups. Participants did not trust the vaccine development process and wanted clearer information. Black participants expressed that they did not want to be subjects of experiments.

CONCLUSIONS AND RELEVANCE

The remaining unknowns about new vaccines need to be acknowledged and described for Black and Latinx communities to make informed decisions. Ultimately, scientists and public officials need to work transparently to address unanswered questions and work collaboratively with trusted community leaders and health professionals to foster partnered approaches, rather than focusing on marketing campaigns, to eliminate vaccine skepticism.

Determining the efficacy of low-dose oral benzodiazepine administration and use of wide-bore magnet in assisting claustrophobic patients to undergo MRI brain examination

PURPOSE

Claustrophobia remains a challenging barrier for a significant number of patients to successfully complete a Magnetic Resonance Imaging (MRI) examination. While use of wide-bore machines and pre-exam administration of a low-dose benzodiazepine are commonly employed, there is little published research to determine which modality is the most efficacious based on the patient's specific degree of claustrophobia. This retrospective case-control study examines the efficacy of using a low-dose oral benzodiazepine and wide-bore magnet to successfully aid the claustrophobic patient in completing an MRI Brain examination.

METHODS

3966 non-contrast MRI brain examinations were considered for this study. The sample was filtered to include only patients who were older than 18 years of age, not currently experiencing symptoms which may hinder MRI examination, and did not undergo any additional MR studies at the time of their exam, resulting in a final sample of 2358 examinations for analysis. Patients were then sub-divided based on severity of claustrophobia and analyzed using logistic regression analysis.

RESULTS

Use of wide-bore magnet increased odds of successfully completing the MRI Brain examination in mild, moderately, and severely claustrophobic patients (OR: 1.79, 95% CI: 1.17-2.75). The administration of pre-examination low-dose oral benzodiazepine increased odds of successfully completing the MRI Brain examination in severely claustrophobic patients (OR: 6.21, 95% CI: 1.63-19.28).

CONCLUSION

Use of a wide-bore magnet is effective in assisting mild, moderately, and severely claustrophobic patients in completing an MRI Brain exam. However, the efficacy of low-dose oral benzodiazepine is limited to severely claustrophobic patients.

Impact of Fusarium-Derived Mycoestrogens on Female Reproduction: A Systematic Review

Contamination of the world’s food supply and animal feed with mycotoxins is a growing concern as global temperatures rise and promote the growth of fungus. Zearalenone (ZEN), an estrogenic mycotoxin produced by Fusarium fungi, is a common contaminant of cereal grains and has also been detected at lower levels in meat, milk, and spices. ZEN’s synthetic derivative, zeranol, is used as a growth promoter in United States (US) and Canadian beef production. Experimental research suggests that ZEN and zeranol disrupt the endocrine and reproductive systems, leading to infertility, polycystic ovarian syndrome-like phenotypes, pregnancy loss, and low birth weight. With widespread human dietary exposure and growing experimental evidence of endocrine-disrupting properties, a comprehensive review of the impact of ZEN, zeranol, and their metabolites on the female reproductive system is warranted. The objective of this systematic review was to summarize the in vitro, in vivo, and epidemiological literature and evaluate the potential impact of ZEN, zeranol, and their metabolites (commonly referred to as mycoestrogens) on female reproductive outcomes. We conducted a systematic review (PROSPERO registration CRD42020166469) of the literature (2000–2020) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The data sources were primary literature published in English obtained from searching PubMed, Web of Science, and Scopus. The ToxR tool was applied to assess risk of bias. In vitro and in vivo studies (n = 104) were identified and, overall, evidence consistently supported adverse effects of mycoestrogens on physiological processes, organs, and tissues associated with female reproduction. In non-pregnant animals, mycoestrogens alter follicular profiles in the ovary, disrupt estrus cycling, and increase myometrium thickness. Furthermore, during pregnancy, mycoestrogen exposure contributes to placental hemorrhage, stillbirth, and impaired fetal growth. No epidemiological studies fitting the inclusion criteria were identified.

Association of biomarkers of exposure to metals and metalloids with maternal hormones in pregnant women from Puerto Rico

BACKGROUND

Metal(loid)s have been associated to adverse birth outcomes in experimental and epidemiological studies, but the underlying mechanism(s) are not well understood. Endocrine disruption may be a mechanism by which the metal(loid)s impact birth outcomes.

METHODS

Pregnant women were recruited through the Puerto Rico Testsite for Exploring Contamination Threats (PROTECT). Urine, blood, demographic and pregnancy-related data were collected at recruitment and subsequent visits. Sixteen metal(loid)s were analyzed in urine and blood samples, while nine maternal hormones (corticotropin-releasing hormone (CRH), sex-hormone binding globulin (SHBG), estriol (E3), progesterone, testosterone, thyroid-stimulating hormone (TSH), total triiodothyronine (T3), total thyroxine (T4), and free thyroxine (fT4)) were measured in serum samples from 815 singleton pregnancies. Linear mixed models with random intercepts were used to examine associations between metal(loid)s in blood and urine with hormone concentrations.

RESULTS

Arsenic blood concentrations were significantly associated with increased levels in CRH (%Δ: 23.0, 95%CI: 8.4-39.6) and decreased levels in testosterone (%Δ: ^-16.3, 95%CI: ^-26.2-^-5.1). Cobalt, manganese, and lead blood concentrations were associated with small increases in SHBG (%Δ range: 3.3-4.2), E3 (%Δ range: 3.9-8.7) and progesterone (%Δ range: 4.1-6.3) levels, respectively. Nickel blood concentration was inversely associated with testosterone levels (%Δ ^-13.3, 95%CI: ^-18.7-^-7.6). Significant interactions were detected for the association between nickel and study visit in relation to CRH (p < 0.02) and testosterone levels (p < 0.01).

CONCLUSION

Our analysis suggests that metal(loid)s may act as endocrine disruptors by altering prenatal hormone levels. This disruption may depend on specific windows of exposure during pregnancy. Additionally, some essential metal(loid)s such as managense and cobalt may be contributors to adverse maternal and fetal outcomes. The study of metal(loid)s as endocrine disruptors is in the early stages of epidemiological research and future studies are needed to further investigate these associations.

Combined Impacts of Prenatal Environmental Exposures and Psychosocial Stress on Offspring Health: Air Pollution and Metals

PURPOSE OF REVIEW

Pregnant women and their offspring are vulnerable to the adverse effects of environmental and psychosocial stressors, individually and in combination. Here, we review the literature on how air pollution and metal exposures may interact with structural and individual-level stressors (including poverty and stressful life events) to impact perinatal and child outcomes.

RECENT FINDINGS

The adverse associations between air pollution and metal exposures and adverse infant and child health outcomes are often exacerbated by co-exposure to psychosocial stressors. Although studies vary by geography, study population, pollutants, stressors, and outcomes considered, the effects of environmental exposures and psychosocial stressors on early health outcomes are sometimes stronger when considered in combination than individually. Environmental and psychosocial stressors are often examined separately, even though their co-occurrence is widespread. The evidence that combined associations are often stronger raises critical issues around environmental justice and protection of vulnerable populations.

Factors Associated With Receipt of Partial Nephrectomy or Minimally Invasive Surgery for Patients With Clinical T1a and T1b Renal Masses: Implications for Regionalization of Care

PURPOSE

To identify factors associated with receipt of partial nephrectomy (PN) and minimally invasive surgery (MIS) in patients with clinical T1 renal cell carcinoma (RCC) using the National Cancer Data Base (NCDB).

METHODS

We queried the NCDB from 2010 to 2014 identifying patients treated surgically for cT1a-bN0M0 RCC. Logistic regression was used to examine associations between socioeconomic, clinical, and treatment factors, and receipt of MIS or PN within the T1 patient population.

RESULTS

Our cohort included 69,694 patients (cT1a, n = 44,043; cT1b, n = 25,651). For cT1a tumors, 70% of patients received PN and 65% underwent MIS. For cT1b tumors, 32% of patients received PN and 62% underwent MIS. cT1a and cT1b patients with household income < $62,000, without private insurance, and treated outside academic centers were less likely to receive MIS or PN. cT1a patients traveling > 31 miles were more likely to undergo MIS. For both cT1a/b, the farther a patient traveled for treatment, the more likely a PN was performed.

CONCLUSION

Data showed an increase in utilization of MIS and PN from 2010 to 2014. However, patients in the lowest socioeconomic groups were less likely to travel and were more likely to receive more invasive treatments. On the basis of these findings, additional research is needed into how regionalization of RCC surgery affects treatment disparities.

Impact of pathologic lymph node-positive renal cell carcinoma on survival in patients without metastasis: Evidence in support of expanding the definition of stage IV kidney cancer

BACKGROUND

Stage III renal cell carcinoma (RCC) encompasses both lymph node-positive (pT1-3N1M0) and lymph node-negative (pT3N0M0) disease. However, prior institutional studies have indicated that among patients with stage III disease, those with lymph node disease have worse oncologic outcomes and experience survival that is similar to that of patients with American Joint Committee on Cancer (AJCC) stage IV disease. The objective of the current study was to validate these findings using a large, nationally representative sample of patients with kidney cancer.

METHODS

Patients with AJCC stage III or stage IV RCC were identified using the National Cancer Data Base (NCDB). Patients were categorized as having lymph node-positive stage III (pT1-3N1M0), lymph node-negative stage III (pT3N0M0), or stage IV metastatic (pT1-3 N0M1) disease. Cox proportional hazards models compared outcomes while adjusting for comorbidities. Kaplan-Meier estimates illustrated relative survival when comparing staging groups.

RESULTS

A total of 8988 patients met the inclusion criteria, with 6587 patients classified as having lymph node-negative stage III disease, 2218 as having lymph node-positive stage III disease, and 183 as having stage IV disease. Superior survival was noted among patients with lymph node-negative stage III disease, but similar survival was noted between patients with lymph node-positive stage III and stage IV RCC, with 5-year survival rates of 61.9% (95% confidence interval [95% CI], 60.3%-63.4%), 22.7% (95% CI, 20.6%-24.9%), and 15.6% (95% CI, 11.1%-23.8%), respectively.

CONCLUSIONS

Current RCC staging systems group pT1-3N1M0 and pT3N0M0 disease as stage III disease. However, the results of the current validation study suggest the need for further stratification and even placement of patients with pT1-3N1M0 disease into the stage IV category. Staging that accurately reflects oncologic prognosis may help clinicians better counsel and select patients who might derive the most benefit from lymphadenectomy, adjuvant systemic therapy, more rigorous imaging surveillance, and clinical trial participation.

Association of Combined Modality Therapy vs Chemotherapy Alone With Overall Survival in Early-Stage Pediatric Hodgkin Lymphoma

Importance

To date, there is no well-defined standard of care for early-stage pediatric Hodgkin lymphoma (HL), which may include chemotherapy alone or combined modality therapy (CMT) with chemotherapy followed by radiotherapy. Although the use of radiotherapy in pediatric HL is decreasing, this strategy remains controversial.

Objective

To examine the use of CMT in pediatric HL and its association with improved overall survival using data from a large cancer registry.

Design, Setting, and Participants

This observational cohort study used data from the National Cancer Database to evaluate clinical features and survival outcomes among 5657 pediatric patients (age, 0.1-21 years) who received a diagnosis of stage I or II HL in the United States from January 1, 2004, to December 31, 2015. Statistical analysis was conducted from May 1 to November 1, 2018.

Exposures

Patients received definitive treatment with chemotherapy or CMT, defined as chemotherapy followed by radiotherapy.

Main Outcomes and Measures

Kaplan-Meier survival curves were used to examine overall survival. The association between CMT use, covariables, and overall survival was assessed in multivariable Cox proportional hazards regression models. Use of radiotherapy was assessed over time.

Results

Among the 11 546 pediatric patients with HL in the National Cancer Database, 5657 patients (3004 females, 2596 males, and 57 missing information on sex; mean [SD] age, 17.1 [3.6] years) with stage I or II classic HL were analyzed. Of these patients, 2845 (50.3%) received CMT; use of CMT vs chemotherapy alone was associated with younger age (<16 years, 1102 of 2845 [38.7%] vs 856 of 2812 [30.4%]; P < .001), male sex (1369 of 2845 [48.1%] vs 1227 of 2812 [43.6%]; P < .001), stage II disease (2467 of 2845 [86.7%] vs 2376 of 2812 [84.5%]; P = .02), and private health insurance (2065 of 2845 [72.6%] vs 1949 of 2812 [69.3%]; P = .002). The 5-year overall survival was 94.5% (confidence limits, 93.8%, 95.8%) for patients who received chemotherapy alone and 97.3% (confidence limits, 96.4%, 97.9%) for those who received CMT, which remained significant in the intention-to-treat analysis and multivariate analysis (adjusted hazard ratio for CMT, 0.57; 95% CI, 0.42-0.78; P < .001). In the sensitivity analysis, the low-risk cohort (stage I-IIA) and adolescent and young adult patients had the greatest benefit from CMT (adjusted hazard ratio, 0.47; 95% CI, 0.40-0.56; P < .001). The use of CMT decreased by 24.8% from 2004 to 2015 (from 59.7% [271 of 454] to 34.9% [153 of 438]).

Conclusions and Relevance

In this study, pediatric patients with early-stage HL receiving CMT experienced improved overall survival 5 years after treatment. There is a nationwide decrease in the use of CMT, perhaps reflecting the bias of ongoing clinical trials designed to avoid consolidation radiotherapy. This study represents the largest data set to date examining the role of CMT in pediatric HL.

Accuracy of clinical nodal staging and factors associated with receipt of lymph node dissection at the time of surgery for nonmetastatic renal cell carcinoma

INTRODUCTION

The benefit of lymph node dissection (LND) in renal cell carcinoma (RCC) remains poorly defined. Despite this uncertainty, the American Urological Association (AUA) guideline on localized renal cancer recommends that LND be performed for staging purposes when there is suspicion of regional lymphadenopathy on imaging. Using the National Cancer Database (NCDB), we sought to determine how much of a departure the new AUA guideline is from current practice. We hypothesized that practice patterns would reflect the "Expert Opinion" recommendation and that patients who are clinical lymph node (cLN) positive would receive a LND more often than those who are cLN negative. Additionally, we sought to determine factors that would trigger a LND as well the accuracy of clinical staging by examining the relationship between cLN and pathologic lymph node (pLN) status of patients who received a LND.

MATERIALS AND METHODS

The NCDB was queried for patients with nonmetastatic RCC who underwent partial nephrectomy or nephrectomy from 2010 to 2014. Patient sociodemographic and clinical characteristics were extracted. Frequency distributions were calculated for patients with both cLN and pLN status available. Of patients who received a LND, sensitivity, specificity, and positive/negative predictive values (PPV/NPV) of cLN status for pLN positivity were calculated. Logistic regression models were used to examine association between clinical and socioeconomic factors and receipt of LND. Propensity score matching was used in sensitivity analyses to examine potential for reporting bias in NCDB data.

RESULTS

We identified 110,963 patients who underwent surgery for RCC, of whom 11,867 (11%) had LND performed at the time of surgery. cLN and pLN information were available in 11,300 patients, of which 1,725 were preoperatively staged as having positive cLN. More LNDs were performed per year for patients who were cLN negative than cLN positive. Of patients who received a LND, the majority of patients were cLN negative across all clinical T (cT) stages. Multivariable analysis showed that all patients who had care at an academic/research institution (odds ratio [OR]: 1.58, 95% confidence interval [CI]: 1.43-1.74) and had to travel >12.5 to 31.0 miles and >31.0 miles to a treatment center (OR: 1.08, 95%CI: 1.01-1.15 and OR: 1.28, 95%CI: 1.20-1.36, respectively) were more likely to get a LND. As cT stage increased from cT2-4, the risk of LND increased (OR range: 4.7-7.90, respectively). Patients who were cLN positive were more likely to receive a LND at the time of surgery (OR: 18.68, 95%CI: 16.62-21.00). Of the patients who received a LND, clinical staging was more specific than sensitive.

CONCLUSION

More patients received a LND who were cLN negative compared to patients who were cLN positive. Patients who were cLN positive were more likely to receive a LND. Treatment center type, distance to treatment center, cT stage, and cLN positivity were factors associated with LND receipt.

Urinary mycoestrogens and age and height at menarche in New Jersey girls

BACKGROUND

Despite evidence of the endocrine disrupting properties of zearalenone (ZEN) and alpha-zearalanol (zeranol, α-ZAL), they have been minimally studied in human populations. In previous cross-sectional analyses, we demonstrated that 9-10 years old girls with detectable urinary ZEN were of shorter stature and less likely to have reached the onset of breast development than girls with undetectable urinary ZEN. The aim of this study was to examine baseline concentrations of ZEN, (α-ZAL), and their phase-1 metabolites in relation to subsequent growth and timing of menarche using 10 years of longitudinal data.

METHODS

Urine samples were collected from participants in the Jersey Girl Study at age 9-10 (n = 163). Unconjugated ZEN, (α-ZAL), and their metabolites were analyzed using high performance liquid chromatography and tandem mass spectrometry. Information on height, weight, and pubertal development was collected at a baseline visit with annual follow-up by mail thereafter. Cox regression was used to evaluate time to menarche in relation to baseline ZEN, (α-ZAL), and total mycoestrogen exposure. Z-scores for height and weight were used in mixed models to assess growth.

RESULTS

Mycoestrogens were detectable in urine in 78.5% of the girls (median ZEN: 1.02 ng/ml, range 0-22.3). Girls with detectable urinary concentrations of (α-ZAL) and total mycoestrogens (sum of ZEN, (α-ZAL) and their metabolites) at baseline were significantly shorter at menarche than girls with levels below detection (p = 0.04). ZEN and total mycoestrogen concentrations were inversely associated with height- and weight-z-scores at menarche (adjusted β = - 0.18, 95% CI: -0.29, - 0.08, and adjusted β = - 0.10, 95% CI: -0.21, 0.01, respectively).

CONCLUSION

This study supports and extends our previous results suggesting that exposure to ZEN, (α-ZAL), and their metabolites is associated with slower growth and pubertal development in adolescent girls.

Water metal contaminants in a potentially mineral-deficient population of Haiti

This study aimed to characterize metal contaminant concentrations and assess temporal and spatial variability in the main drinking water sources of Cap-Haïtien, Haiti. Water sources from five communities were sampled in two seasons, June (2014) and October (2014), and analysed for a suite of metals. A geographic information system was used to examine the spatial distribution of sampling points. Metal concentrations were below the US Environmental Protection Agency (USEPA) primary drinking water standards. Mean manganese concentrations were comparatively higher in wells (254.5 µg/L), exceeding the USEPA secondary drinking water standard (50 µg/L). Higher mean Mg/Ca and Ba/Ca ratios (range 2.3-3.4) may indicate different interactions between seawater and groundwater throughout the year. Although metal concentrations were within the limits of the USEPA drinking water standards, emerging contaminants, such as manganese, showed concentrations in excess of recommended limits. These metals may interact with background nutritional status with potential implications for growth and development.

Trends and outcomes of lymphadenectomy for nonmetastatic renal cell carcinoma: A propensity score-weighted analysis of the National Cancer Database

PURPOSE

Lymph node (LN) involvement in renal cell carcinoma (RCC) is associated with a poor prognosis. While lymph node dissection (LND) may provide diagnostic information, its therapeutic benefit remains controversial. Thus, the aim of our study is to analyze survival outcomes after LND for nonmetastatic RCC and to characterize contemporary practice patterns.

MATERIALS AND METHODS

The National Cancer Database was queried for patients with nonmetastatic RCC who underwent either partial or radical nephrectomy from 2010 to 2014. A total of 11,867 underwent surgery and LND. Chi-square tests were used to examine differences in patient demographics. To minimize selection bias, propensity score matching (PSM) was used to select one control for each LND case (n = 19,500). Cox regression analyses were conducted to examine overall survival (OS) in patients who received LND compared to those who did not.

RESULTS

Of all patients undergoing LND for RCC (n = 11,867), 5%, 23%, 31%, 47% were performed for tumors of clinical T stage 1, 2, 3, and 4, respectively. Proportions of LND have not significantly changed from 2010 to 2014. No significant improvement in median OS for patients undergoing LND compared to no LND was shown (34.7 vs. 34.9 months, respectively; P = 0.98). Similarly, no significant improvement in median OS was found for clinically LN positive patients undergoing LND compared to no LND (P = 0.90). On Cox regression analysis, LND dissection was not associated with an OS benefit (hazard ratio: 1.00; 95% confidence interval 0.97 to 1.04).

CONCLUSIONS

Among all RCC patients, LNDs are often performed for low stage disease, suggesting a potential overutilization of LND. No OS benefit was seen in any subgroup of patients undergoing LND. Further investigation is needed to determine which patient populations may benefit most from LND.

Exposure to disinfectant by-products and the risk of stillbirth in Massachusetts

OBJECTIVES

We examined stillbirths in relation to disinfection by-product (DBP) exposures including chloroform, bromodichloromethane (BDCM), dibromochloromethane, bromoform, trichloroacetic acid, dichloroacetic acid (DCAA), monobromoacetic acid and summary DBP measures (trihalomethanes (THM4), haloacetic acids (HAA5), THMBr (brominated trihalomethanes) and DBP9 (sum of THM4 and HAA5)).

METHODS

We randomly selected 10 controls for each of the 2460 stillbirth cases with complete quarterly 1997-2004 THM4 and HAA5 town-level drinking water data. Adjusted (aORs) were calculated based on weight-averaged second-trimester DBP exposures.

RESULTS

We detected statistically significant associations for stillbirths and the upper DCAA quartiles (aOR range: 1.50-1.71). We also found positive associations for the upper four HAA5 quintiles and different stillbirth cause of death categories that were examined including unexplained stillbirth (aOR range: 1.24-1.72), compression of umbilical cord (aOR range: 1.08-1.94), prematurity (aOR range: 1.37-2.88), placental separation and haemorrhage (aOR range: 1.44-2.01) and asphyxia/hypoxia (aOR range: 1.52-1.97). Additionally, we found positive associations between stillbirths and chloroform exposure (aOR range: 1.29 - 1.36) and unexplained stillbirths and BDCM exposure (aOR range: 1.51 - 1.78). We saw no evidence of exposure-response relationships for any categorical DBP metrics.

CONCLUSIONS

Consistent with some previous studies, we found associations between stillbirths and chloroform and unexplained stillbirth and BDCM exposures. These findings strengthen existing evidence of prenatal THM exposures increasing the risk of stillbirth. Additionally, we saw statistically significant associations between DCAA and stillbirth. Future research should examine cause-specific stillbirths in relation to narrower critical windows and additional DBP exposure metrics beyond trihalomethanes and haloacetic acids.

Perceived Benefits of Participation and Risks of Soil Contamination in St. Louis Urban Community Gardens

Community gardens are credited for promoting health within neighborhoods, by increasing healthy food intake and exercise frequency. These benefits, however, are potentially undermined as urban soils are often contaminated from industrial legacies. The purpose of this study was to examine the perceived benefits of participation and risks of soil contamination within urban community gardens, and factors associated with soil contamination concerns. Ninety-three gardeners were interviewed across 20 community gardens in St. Louis, Missouri between June and August 2015. Surveys included questions on demographics, gardening practices, and perceptions of community gardening. Multilevel logistic models assessed how gardener demographics, gardening practices, and garden characteristics were associated with soil contamination concerns. Common perceived benefits of community gardening were community building (68.8%), healthy and fresh food (35.5%), and gardening education (18.3%). Most gardeners (62.4%) were not concerned about soil contamination, but nearly half (48.4%) stated concerns about heavy metals. Black race was significantly associated with soil contamination concerns (OR 5.47, 95% CI 1.00-30.15, p = .04). Community gardens offer numerous social and health benefits. Although most gardeners were not concerned about soil contamination, black gardeners were more likely to have concerns. Garden leaders should provide resources to gardeners to learn about soil contamination and methods to manage their risk, particularly in minority neighborhoods.

Safety of differential radiation dosing in lymph node positive necks treated with IMRT

PURPOSE

When treating head and neck squamous cell carcinoma (HNSCC) with intensity modulated radiation therapy (IMRT), it is common to use several dose levels for a lymph node positive neck: full dose (66-70 Gy) to gross cancer, intermediate dose (59-63 Gy) to higher risk neck regions, and standard dose (50-54 Gy) to lower risk neck regions. There is no consensus regarding how much of the neck should receive intermediate versus standard dose, however.

METHODS AND MATERIALS

HNSCC patients treated with IMRT were identified from 2 academic medical centers between 2004 and 2016. Intermediate dose was restricted to a region of the neck 2 cm above and below the most superior and inferior involved lymph nodes; standard dose was delivered to more distal neck regions. Descriptive statistics were calculated for demographics and clinical characteristics as well as proportions for failures 2 years after treatment. Failure outside the intermediate dose region was determined by calculating confidence intervals from a modification of the Poisson distribution.

RESULTS

Of the 57 necks included in this study, 17.5% experienced disease recurrence in the neck within 2 years of completing treatment. All failures were within the 2-cm margin above or below the most superior and inferior involved nodes; there were no failures outside this 2-cm margin (95% confidence interval, 0-7.7).

CONCLUSIONS

The results of this study support the feasibility of treating only the neck adjacent to gross neck disease to an intermediate dose, and treating the remainder of the neck to a lower, standard dose. Although these results are encouraging, additional study of this treatment paradigm is warranted.

Disinfection By-Product Exposures and the Risk of Specific Cardiac Birth Defects

BACKGROUND

Epidemiological studies suggest that women exposed to disinfection by-products (DBPs) have an increased risk of delivering babies with cardiovascular defects (CVDs).

OBJECTIVE

We examined nine CVDs in relation to categorical DBP exposures including bromoform, chloroform, dibromochloromethane (DBCM), bromodichloromethane (BDCM), monobromoacetic acid (MBAA), dichloroacetic acid (DCAA), trichloroacetic acid (TCAA), and summary DBP measures (HAA5, THMBr, THM4, and DBP9).

METHODS

We calculated adjusted odds ratios (aORs) in a case-control study of birth defects in Massachusetts with complete quarterly 1999-2004 trihalomethane (THM) and haloacetic acid (HAA) data. We randomly matched 10 controls each to 904 CVD cases based on week of conception. Weight-averaged aggregate first-trimester DBP exposures were assigned to individuals based on residence at birth.

RESULTS

We detected associations for tetralogy of Fallot and the upper exposure categories for TCAA, DCAA, and HAA5 (aOR range, 3.34-6.51) including positive exposure-response relationships for DCAA and HAA5. aORs consistent in magnitude were detected between atrial septal defects and bromoform (aOR = 1.56; 95% CI: 1.01, 2.43), as well as DBCM, chloroform, and THM4 (aOR range, 1.26-1.67). Ventricular septal defects (VSDs) were associated with the highest bromoform (aOR = 1.85; 95% CI: 1.20, 2.83), MBAA (aOR = 1.81; 95% CI: 0.85, 3.84), and DBCM (aOR = 1.54; 95% CI: 1.00, 2.37) exposure categories.

CONCLUSIONS

To our knowledge, this is the first birth defect study to develop multi-DBP adjusted regression models as well as the first CVD study to evaluate HAA exposures and the second to evaluate bromoform exposures. Our findings, therefore, inform exposure specificity for the consistent associations previously reported between THM4 and CVDs including VSDs. Citation: Wright JM, Evans A, Kaufman JA, Rivera-Núñez Z, Narotsky MG. 2017. Disinfection by-product exposures and the risk of specific cardiac birth defects. Environ Health Perspect 125:269-277; http://dx.doi.org/10.1289/EHP103.

Spatial variation of disinfection by-product concentrations: exposure assessment implications

The use of public water system (PWS) average trihalomethane (THM) and haloacetic acid (HAA) concentrations as surrogates of "personal" exposures in epidemiological studies of disinfection by-products (DBPs) may result in exposure misclassification bias from various sources of measurement error including intra-system variation of DBPs. Using 2000-2004 data from 107 PWSs in Massachusetts, we assessed two approaches for characterizing DBP spatial variability by identifying PWSs with low spatial variability (LSV) and examining differences in LSV across DBP groups and by type of source water and primary disinfectant. We also used spatial differences to examine the association between THM concentrations and indices of social disadvantage; however, we found no correlations or statistically significant differences based on the available data. We observed similar patterns for the percentage of quarterly sampling dates with LSV across different types of source water for all DBPs but not across disinfectants. We found there was little overlap between sites classified as having LSV across different DBP groups. In the main analysis, we found moderate correlations between both approaches (φ(THM4) = 0.55; φ(BrTHM) = 0.64; φ(HAA5) = 0.67); although Method 1 (based on concentration differences between samples) may be better suited for identifying PWSs for inclusion in epidemiological studies because it is more easily adapted to study-specific exposure gradients than Method 2 (based on categorical exposure percentiles). These data reinforce the need to consider different exposure assessment approaches when examining the spatial variation of multiple DBP surrogates as they can represent different DBP mixtures.

Comparison of trihalomethanes in tap water and blood: a case study in the United States

BACKGROUND

Epidemiological studies have used various measures to characterize trihalomethane (THM) exposures, but the relationship of these indicators to exposure biomarkers remains unclear.

OBJECTIVES

We examined temporal and spatial variability in baseline blood THM concentrations and assessed the relationship between these concentrations and several exposure indicators (tap water concentration, water-use activities, multiroute exposure metrics).

METHODS

We measured water-use activity and THM concentrations in blood and residential tap water from 150 postpartum women from three U.S. locations.

RESULTS

Blood ΣTHM [sum of chloroform (TCM), bromodichloromethane (BDCM), dibromo-chloromethane (DBCM), and bromoform (TBM)] concentrations varied by site and season. As expected based on variable tap water concentrations and toxicokinetic properties, the proportion of brominated species (BDCM, DBCM, and TBM) in blood varied by site (site 1, 24%; site 2, 29%; site 3, 57%) but varied less markedly than in tap water (site 1, 35%; site 2, 75%; site 3, 68%). The blood-water ΣTHM Spearman rank correlation coefficient was 0.36, with correlations higher for individual brominated species (BDCM, 0.62; DBCM, 0.53; TBM, 0.54) than for TCM (0.37). Noningestion water activities contributed more to the total exposure metric than did ingestion, but tap water THM concentrations were more predictive of blood THM levels than were metrics that incorporated water use.

CONCLUSIONS

Spatial and temporal variability in THM concentrations was greater in water than in blood. We found consistent blood-water correlations across season and site for BDCM and DBCM, and multivariate regression results suggest that water THM concentrations may be an adequate surro-gate for baseline blood levels.

Urinary arsenic species, toenail arsenic, and arsenic intake estimates in a Michigan population with low levels of arsenic in drinking water

The large disparity between arsenic concentrations in drinking water and urine remains unexplained. This study aims to evaluate predictors of urinary arsenic in a population exposed to low concentrations (≤50 μg/l) of arsenic in drinking water. Urine and drinking water samples were collected from a subsample (n=343) of a population enrolled in a bladder cancer case-control study in southeastern Michigan. Total arsenic in water and arsenic species in urine were determined using ICP-MS: arsenobetaine (AsB), arsenite (As[III]), arsenate (As[V]), methylarsenic acid (MMA[V]), and dimethylarsenic acid (DMA[V]). The sum of As[III], As[V], MMA[V], and DMA[V] was denoted as SumAs. Dietary information was obtained through a self-reported food intake questionnaire. Log(10)-transformed drinking water arsenic concentration at home was a significant (P<0.0001) predictor of SumAs (R(2)=0.18). Associations improved (R(2)=0.29, P<0.0001) when individuals with less than 1 μg/l of arsenic in drinking water were removed and further improved when analyses were applied to individuals who consumed amounts of home drinking water above the median volume (R(2)=0.40, P<0.0001). A separate analysis indicated that AsB and DMA[V] were significantly correlated with fish and shellfish consumption, which may suggest that seafood intake influences DMA[V] excretion. The Spearman correlation between arsenic concentration in toenails and SumAs was 0.36 and between arsenic concentration in toenails and arsenic concentration in water was 0.42. Results show that arsenic exposure from drinking water consumption is an important determinant of urinary arsenic concentrations, even in a population exposed to relatively low levels of arsenic in drinking water, and suggest that seafood intake may influence urinary DMA[V] concentrations.

Low-level determination of six arsenic species in urine by High Performance Liquid Chromatography-Inductively Coupled Plasma-Mass Spectrometry (HPLC-ICP-MS)

Many methods that have been used to speciate arsenic metabolites in urine are unable to adequately resolve the chromatographic peaks for arsenite (As[iii]) and arsenobetaine (AsB). We present a High Performance Liquid Chromatography-Inductively Coupled Plasma-Mass Spectrometry (HPLC-ICP-MS) method that has been optimized to reliably measure the following six arsenic species in human urine: As[iii], arsenate (As[v]), monomethylarsonous acid (MMA[iii]), monomethylarsonic acid (MMA[v]), dimethylarsinic acid (DMA[v]) and AsB. The method was evaluated with regards to changes in mobile phase, accuracy and precision. The ability to quantify the six species in a given sample depended on the low detection limits of the method-0.06 μg L^-1 for AsB, 0.11 μg L^-1 for As[iii], 0.08 μg L^-1 for DMA[v], 0.12 μg L^-1 for MMA[v] and 0.15 μg L^-1 for As[v]. The procedure was used to measure the six arsenic species in urine samples from 387 individuals in southeast Michigan who are chronically exposed to slightly elevated levels of arsenic in their drinking water. The DMA[v] was detected in 99.2% of samples, AsB in 98.2%, MMA[v] in 73.4%, As[iii] in 45.0%, and As[v] in 27.1%. No MMA[iii] was detected even in samples analyzed within 6 hours after collection. The results raise some doubt as to whether MMA[iii] is a significant metabolite in urine of people exposed to arsenic concentrations below 20 μg L^-1 in their drinking water.

Temporal variability in trihalomethane and haloacetic acid concentrations in Massachusetts public drinking water systems

Previous epidemiological studies in Massachusetts have reported a risk of adverse health outcomes in relation to disinfection by-product (DBP) exposures. Measurement error due to the use of indirect exposure surrogates can lead to misclassification bias in epidemiological studies; therefore, it is important to characterize exposure variability in these populations to assess the potential for exposure misclassification. We used 19,944 trihalomethane (THM) samples and 9291 haloacetic acid (HAA) samples collected in 201 public water systems (PWSs) in Massachusetts to examine temporal variability under different drinking water sources and disinfection types. Annual and seasonal variability was also examined in 46 PWSs with complete quarterly THM4 (i.e., the sum of 4 individual THMs) data from 1995 to 2004 and 19 PWSs with complete HAA5 (i.e., the sum of 5 individual HAAs) data from 2001 to 2004. The quarterly ratio of THM4 and HAA5 and correlations between THM4, HAA5 and individual DBP species were examined to determine the adequacy of using different exposure surrogates in epidemiological studies. Individual PWSs were used to examine monthly variability in relation to quarterly averages. Based on all available matched samples (n=9003) from 1995 to 2004 data, we found a correlation of 0.52 for THM4 and HAA5. The correlation was stronger among the 62 ground water systems (r(s)=0.62) compared to the 81 surface water (r(s)=0.45) and 40 mixed water (r(s)=0.39) systems. Mean THM4 levels were fairly stable over the 10-year study period for 46 PWSs including 39 PWSs that did not change disinfection. Large reductions (∼40 μg/L) in mean THM4 data were found among seven systems that switched from chlorination to alternative disinfectants. As expected, the highest mean THM4 values were detected for Quarter 3, while the lowest values were found in Quarter 1. The highest HAA5 values were detected in Quarters 2 and 3 and the lowest was found in Quarter 4. Data from four systems showed mean differences up to 66 μg/L (67% change) in successive months and by 46 μg/L compared to quarterly mean concentrations. Although longer-term disinfection by-product temporality may be minimal in this study population, the use of monthly average concentrations for exposure assessment may be needed for some PWSs to minimize misclassification of narrow critical periods of exposure in epidemiological studies.