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Martin KV, Sucharew H, Dietrich KN, Parsons PJ, Palmer CD, Wright R, Amarasiriwardena C, Smith DR, Haynes EN. Co-exposure to manganese and lead and pediatric neurocognition in East Liverpool, Ohio. Environ Res 2021; 202:111644. [PMID: 34246641 PMCID: PMC8578304 DOI: 10.1016/j.envres.2021.111644] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 05/09/2023]
Abstract
Exposure to metal mixtures may lead to health impacts greater than the effects associated with singular exposures. Two common childhood environmental exposures, manganese (Mn) and lead (Pb), are associated with similar adverse neurodevelopmental effects; however, the effects surrounding concurrent exposure to both metals remain unclear. We study the impact of joint exposure to Mn and Pb on cognitive performance in school-aged children participating in the Communities Actively Researching Exposure Study (CARES) based in East Liverpool, Ohio. Blood Pb levels were measured for each child (geometric mean (GM) = 1.13 μg/dL, range 0.30 μg/dL - 6.64 μg/dL). Mn was measured in participant blood, hair, and toenails with GMs of 10.1 μg/L, 360 ng/g, 0.974 μg/g, respectively. Trained team members administered the Wechsler Intelligence Scale for Children-IV (WISC-IV) to assess intelligence quotient (IQ). The WISC-IV provides scores for Full Scale IQ, Perceptual Reasoning, Processing Speed, Working Memory, and Verbal Comprehension. Interactions between blood Pb and all Mn biomarkers were tested in linear models adjusted for child sex, household income, and serum cotinine. Separate regression models were run for each of the Mn biomarkers. The cohort was comprised of 106 children with a mean age of 8.4 years. Interactions between blood Pb and hair Mn were significant (p < 0.05) for four out of the five IQ domains. The effect of blood Pb on IQ was more pronounced at higher levels of hair and toenail Mn. No significant associations were observed when characterizing the main effect of Mn using blood. Uncovering the health impacts associated with exposure mixtures is critical to understanding the impact of real-life conditions. Our findings suggest that joint exposure to Mn and Pb may produce heightened neurocognitive impacts even at blood Pb levels below the CDC reference concentration of 5 μg/dL.
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Affiliation(s)
- Kaitlin Vollet Martin
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA.
| | - Heidi Sucharew
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kim N Dietrich
- Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Patrick J Parsons
- Wadsworth Center, New York State Department of Health, Albany, NY, USA; Department of Environmental Health Sciences, School of Public Health, University of Albany, Rensselaer, NY, USA
| | - Christopher D Palmer
- Wadsworth Center, New York State Department of Health, Albany, NY, USA; Department of Environmental Health Sciences, School of Public Health, University of Albany, Rensselaer, NY, USA
| | - Robert Wright
- Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Donald R Smith
- Microbiology and Environmental Toxicology, University of California, Santa Cruz, CA, USA
| | - Erin N Haynes
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
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Goldman RH, Zajac L, Geller RJ, Miller MD. Developing and implementing core competencies in children's environmental health for students, trainees and healthcare providers: a narrative review. BMC Med Educ 2021; 21:503. [PMID: 34560874 PMCID: PMC8464086 DOI: 10.1186/s12909-021-02921-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/01/2021] [Indexed: 05/29/2023]
Abstract
Knowledge of the health impacts of environmental exposures (such as pollution disasters, poor air quality, water contamination, climate change) on children's health has dramatically increased in the past 40 years. The World Health Organization (WHO) estimated that 23% of all deaths worldwide were attributable to the environment, and 26% of deaths in children less than 5 years old could be prevented with removal of environmental risks factors. Yet, little has permeated medical education, leaving pediatric providers ill equipped to address these issues. To address this gap, members from the Pediatric Environmental Health Specialty Units, a United States nationwide network of academically affiliated experts who have created numerous environmental health educational materials and programs, have identified fifteen core environmental health (EH) competencies needed by health care providers to enable them to effectively address environmental health concerns. These competencies can serve as the foundation for the development and implementation of relevant educational programs. The core EH competencies are based upon these foundational elements: 1) Definition of "children's environmental health" that describes how environmental exposures (positive and negative) in early life influence the health and development in childhood and across the entire human life span 2) Children are not "little adults" and so have unique vulnerabilities to environmental hazards; 3) Environmental health inequities exist, causing some children to have a disproportionate amount of unhealthy exposures and consequently a greater risk of adverse effects; 4) Climate change will translate to numerous adverse health effects that will particularly affect children worldwide. In this article, the authors describe the core environmental health competencies and provide resources, online tools, strategies, and examples targeted to all levels of training and practice to better enable leaders and educators to bring this important content to the forefront.
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Affiliation(s)
- Rose Hannah Goldman
- Department of Medicine, Cambridge Health Alliance, Cambridge Massachusetts, Cambridge Hospital, Macht Center 427, Cambridge, MA, 02139, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Lauren Zajac
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Robert J Geller
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Mark D Miller
- Division of Occupational and Environmental Medicine, Department of Medicine, University of California, California, San Francisco, USA
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Morales Ramos F, Herrera MT, Zajac L, Sheffield P. Children's environmental health and disaster resilience in Puerto Rico and the U.S. Virgin Islands. Appl Nurs Res 2021;:151482. [PMID: 34602323 DOI: 10.1016/j.apnr.2021.151482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/17/2021] [Accepted: 08/03/2021] [Indexed: 11/21/2022]
Abstract
The environment plays a significant role in the global burden of disease for children. Climate-related disasters such as the 2017 Atlantic hurricane season are increasingly contributing to this burden. United Nations designated Small Island Developing States (SIDS) like Puerto Rico and the U.S. Virgin Islands are particularly at risk due to environmental health hazards caused by natural disasters, and health care structure vulnerabilities. United Nations' Sustainable Development Goals (UN SDG), specifically UN SDG 3, 13 and 17, focus on climate impacts via promotion of health preparedness and building partnerships between different sectors of society, respectively. The Pediatric Environmental Health Specialty Unit's (PEHSU) work is consistent with these most notably via the delivery of environmental health services along with training nurses, doctors, and other health professionals, formation of partnerships and linking resources. Therefore, training a diverse array of health professionals and linking these groups to relevant community resources is of utmost importance and has the potential to enhance the effective management and early prevention of top environmental health (EH) risks. Nursing is identified as a key health sector to engage for this initiative. This article describes the work of the Federal Region 2 PEHSU in Puerto Rico and the U.S. Virgin Islands that supports health professionals' knowledge building, development of environmental health services, and promotion of wide scale access to such services for children and families. The PEHSU's work is consistent with these most notably with regards to the delivery of environmental health services in pediatrics.
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Murray CJ, Olson AL, Palmer EL, Yang Q, Amos CI, Johnson DJ, Karagas MR. Private well water testing promotion in pediatric preventive care: A randomized intervention study. Prev Med Rep 2020; 20:101209. [PMID: 33072497 PMCID: PMC7548982 DOI: 10.1016/j.pmedr.2020.101209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 11/16/2022] Open
Abstract
Over 43 million U.S. residents rely on private unregulated wells for their drinking water, raising public health concerns, particularly in regions like northern New England where widespread groundwater arsenic contamination is now recognized. Children are particularly vulnerable to adverse health effects from arsenic exposure. Despite AAP Guidelines, approaches to engage pediatric clinicians in promoting private well testing have not been previously described. We sought to determine the most effective practice approaches to achieve successful well water testing in routine pediatric care. 12 primary care clinics were block randomized to one of four study arms. Two intervention variables were assessed: (1) test results access (parent only vs. parent and clinic) and (2) follow up approaches (yes/no). Parents of children under 12 months using a private well were eligible. Prepaid water tests were provided. Primary outcome was parental water test completion. Eleven clinics successfully implemented processes identifying well users. 240 testing kits were dispensed. Completion rates averaged 29% (range 10 to 61%). The study arm with both clinic results access and staff follow up system was 2.3 times more likely to achieve test completion than other arms (95% CI 1.12-4.86, p = .03). Kit distribution by clinicians versus nursing staff, irrespective of study arm, had 2.4 times greater completion (95% CI 1.13-5.11, p = .02). Systematic drinking water source screening can be improved in pediatric care. Higher testing completion was found in practices randomized to reminders and structured follow up versus single visit discussion, but clinician involvement was the most predictive factor.
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Affiliation(s)
- Carolyn J. Murray
- Children’s Environmental Health and Disease Prevention Research Center at Dartmouth, Dartmouth Geisel School of Medicine, 1 Medical Center Drive, Lebanon, NH 03756, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, 74 College Street, Hanover, NH 03755, USA
| | - Ardis L. Olson
- Dartmouth CO-OP Primary Care Research Network, Dartmouth Geisel School of Medicine, 46 Centerra Parkway, Lebanon, NH 03766, USA
| | - Ellen L. Palmer
- Department of Biomedical Data Science, Dartmouth Geisel School of Medicine, 1 Medical Center Drive, Lebanon, NH 03756, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Qian Yang
- Department of Biomedical Data Science, Dartmouth Geisel School of Medicine, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Christopher I. Amos
- Department of Biomedical Data Science, Dartmouth Geisel School of Medicine, 1 Medical Center Drive, Lebanon, NH 03756, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Deborah J. Johnson
- Dartmouth CO-OP Primary Care Research Network, Dartmouth Geisel School of Medicine, 46 Centerra Parkway, Lebanon, NH 03766, USA
| | - Margaret R. Karagas
- Children’s Environmental Health and Disease Prevention Research Center at Dartmouth, Dartmouth Geisel School of Medicine, 1 Medical Center Drive, Lebanon, NH 03756, USA
- Department of Epidemiology, Dartmouth Geisel School of Medicine, 1 Medical Center Drive, Lebanon, NH 03756, USA
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Wong KH, Allen A, Durrani TS. Evaluating Effectiveness of Online Learning Modules in Pediatric Environmental Health Education. J Med Toxicol 2020; 16:269-275. [PMID: 31873854 PMCID: PMC7320078 DOI: 10.1007/s13181-019-00746-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/16/2019] [Accepted: 10/24/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Content and training about pediatric environmental health are lacking in healthcare professionals' education. In an initiative to improve pediatric environmental health education, the Pediatric Environmental Health Specialty Unit (PEHSU) program offers free, interactive, web-based ("eLearning") modules on environmental health topics. The aim of this study is to determine the effectiveness of PEHSU eLearning modules in increasing knowledge about pediatric and reproductive environmental health. METHODS This is a retrospective analysis of 994 users who had completed at least one of the 12 PEHSU eLearning modules and its associated pre-test and post-test scores between March 2016 and November 2018. Users who completed modules between March 2016 and April 2018 received a 6-month follow-up survey to assess the impact of the knowledge gained on their clinical practice. RESULTS A wide range of clinical professionals and nonclinical professionals utilized and completed the PEHSU eLearning modules. For all users, post-test scores were significantly higher than pre-test scores, with an increase of 30.55% ± 22.37 (paired t-test, p < 0.0001), after completion of eLearning modules. CONCLUSION PEHSU eLearning modules are effective at increasing environmental health knowledge of clinical and nonclinical professionals. Further studies are needed to determine long-term knowledge retention and clinical impact.
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Affiliation(s)
- Katelyn H Wong
- School of Medicine, University of Connecticut, 263 Farmington Ave, Farmington, CT, 06032, USA
| | - Amanda Allen
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Timur S Durrani
- School of Medicine, University of California San Francisco, 1600 Divisadero St, San Francisco, CA, 94115, USA.
- Division of OEM, ZSFG, Western States Pediatric Environmental Health Specialty Unit, Box 0843, San Francisco, CA, 94143-0843, USA.
- California Poison Control System - San Francisco Division, Box 1369, San Francisco, CA, 94143-1369, USA.
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