Phytoremediation of Lead-Contaminated Soil in the Westside of Atlanta, GA

Phytoremediation has been explored as a cost-effective method to remediate soil Pb contamination. A greenhouse study was conducted to evaluate the efficacy of Vigna unguiculata, Brassica pekinensis, Gomphrena globose, and Helianthus annuus for removing and immobilizing Pb in soil collected from the Westside Lead Superfund site in Atlanta. Plants were cultivated in sampled soil with a Pb concentration of 515 ± 10 mg/kg for 60 days. Soils growing H. annuus were additionally treated with ethylenediaminetetraacetic acid (EDTA) (0.1 g/kg) or compost (20% soil blend) to assess their capabilities for enhancing phytoremediation. Mean post-phytoremediation Pb concentrations in the four plant species were 23.5, 25.7, 50.0, and 58.1 mg/kg dry weight (DW), respectively, and were substantially higher than 1.55 mg/kg DW in respective plant species grown in control soils with no Pb contamination. The highest Pb concentration, translocation factor, and biomass were found in V. unguiculate among four species without soil amendments. H. annuus treated with EDTA and compost resulted in a significant increase in the total Pb uptake and larger biomass compared to non-treated plants, respectively. Although this study found that V. unguiculata was the best candidate for Pb accumulation and immobilization among four species, soil remediation was limited to 54 mg/kg in a growing season. We find that it is critically important to perform phytostabilization in a secure manner, since Pb bioavailability of edible plant parts implies the potential risk associated with their unintentional consumption. Efficiently and effectively remediating Pb-contaminated soils in a low-cost manner needs to be further studied.

The association between 2,4-D and serum testosterone levels: NHANES 2013-2014

BACKGROUND

Previous studies have investigated associations between herbicides such as 2,4-Dichlorophenoxyacetic acid (2,4-D) and dyshormonogenesis, specifically low testosterone, in human, rodent, and cell models, but results have been conflicting and inconclusive.

METHODS

Using data from a cross-sectional study of 456 adult men in the 2013-2014 NHANES survey cycle, we examined the relationship between urinary concentrations of 2,4-D and serum testosterone levels.

RESULTS

Multivariable regression models adjusting for potential confounders revealed a significant, negative association between urinary 2,4-D and mean serum testosterone among U.S. adult males (β =  - 11.4 ng/dL, p = 0.02). Multivariable logistic regression models using a cutoff defining abnormally low testosterone (i.e., serum testosterone < 300 ng/dL) revealed no significant associations between 2,4-D and the odds of low testosterone.

CONCLUSION

These findings expand on previous literature implicating a role for 2,4-D in the etiology of low testosterone and dyshormonogenesis. Future studies are warranted to corroborate these findings, determine clinical significance, and to investigate the proposed potential biological mechanisms underlying this association.

Prediction of 90-day mortality after surgery for colorectal cancer using standardized nationwide quality-assurance data

Background

Personalized risk assessment provides opportunities for tailoring treatment, optimizing healthcare resources and improving outcome. The aim of this study was to develop a 90-day mortality-risk prediction model for identification of high- and low-risk patients undergoing surgery for colorectal cancer.

Methods

This was a nationwide cohort study using records from the Danish Colorectal Cancer Group database that included all patients undergoing surgery for colorectal cancer between 1 January 2004 and 31 December 2015. A least absolute shrinkage and selection operator logistic regression prediction model was developed using 121 pre- and intraoperative variables and internally validated in a hold-out test data set. The accuracy of the model was assessed in terms of discrimination and calibration.

Results

In total, 49 607 patients were registered in the database. After exclusion of 16 680 individuals, 32 927 patients were included in the analysis. Overall, 1754 (5.3 per cent) deaths were recorded. Targeting high-risk individuals, the model identified 5.5 per cent of all patients facing a risk of 90-day mortality exceeding 35 per cent, corresponding to a 6.7 times greater risk than the average population. Targeting low-risk individuals, the model identified 20.9 per cent of patients facing a risk less than 0.3 per cent, corresponding to a 17.7 times lower risk compared with the average population. The model exhibited discriminatory power with an area under the receiver operating characteristics curve of 85.3 per cent (95 per cent c.i. 83.6 to 87.0) and excellent calibration with a Brier score of 0.04 and 32 per cent average precision.

Conclusion

Pre- and intraoperative data, as captured in national health registries, can be used to predict 90-day mortality accurately after colorectal cancer surgery.

Accuracy of an automated knowledge base for identifying drug adverse reactions

INTRODUCTION

Drug safety researchers seek to know the degree of certainty with which a particular drug is associated with an adverse drug reaction. There are different sources of information used in pharmacovigilance to identify, evaluate, and disseminate medical product safety evidence including spontaneous reports, published peer-reviewed literature, and product labels. Automated data processing and classification using these evidence sources can greatly reduce the manual curation currently required to develop reference sets of positive and negative controls (i.e. drugs that cause adverse drug events and those that do not) to be used in drug safety research.

METHODS

In this paper we explore a method for automatically aggregating disparate sources of information together into a single repository, developing a predictive model to classify drug-adverse event relationships, and applying those predictions to a real world problem of identifying negative controls for statistical method calibration.

RESULTS

Our results showed high predictive accuracy for the models combining all available evidence, with an area under the receiver-operator curve of ⩾0.92 when tested on three manually generated lists of drugs and conditions that are known to either have or not have an association with an adverse drug event.

CONCLUSIONS

Results from a pilot implementation of the method suggests that it is feasible to develop a scalable alternative to the time-and-resource-intensive, manual curation exercise previously applied to develop reference sets of positive and negative controls to be used in drug safety research.

Similarity-based modeling applied to signal detection in pharmacovigilance

One of the main objectives in pharmacovigilance is the detection of adverse drug events (ADEs) through mining of healthcare databases, such as electronic health records or administrative claims data. Although different approaches have been shown to be of great value, research is still focusing on the enhancement of signal detection to gain efficiency in further assessment and follow-up. We applied similarity-based modeling techniques, using 2D and 3D molecular structure, ADE, target, and ATC (anatomical therapeutic chemical) similarity measures, to the candidate associations selected previously in a medication-wide association study for four ADE outcomes. Our results showed an improvement in the precision when we ranked the subset of ADE candidates using similarity scorings. This method is simple, useful to strengthen or prioritize signals generated from healthcare databases, and facilitates ADE detection through the identification of the most similar drugs for which ADE information is available.

Cooking fuel type, household ventilation, and the risk of acute lower respiratory illness in urban Bangladeshi children: a longitudinal study

Acute lower respiratory illnesses (ALRI) are the leading cause of death among children <5 years. Studies have found that biomass cooking fuels are an important risk factor for ALRI. However, few studies have evaluated the influence of natural household ventilation indicators on ALRI. The purpose of this study was to assess the association between cooking fuel, natural household ventilation, and ALRI. During October 17, 2004-September 30, 2005, children <5 years living in a low-income neighborhood of Dhaka, Bangladesh, were assessed weekly for ALRI and surveyed quarterly about biomass fuel use, electric fan ownership, and natural household ventilation (windows, ventilation grates, and presence of a gap between the wall and ceiling). Bivariate and multivariate analyses were performed using generalized estimating equations. Six thousand and seventy-nine children <5 years enrolled during the study period (99% participation) experienced 1291 ALRI. In the multivariate model, ≥2 windows [OR = 0.75, 95% CI = (0.58, 0.96)], ventilation grates [OR = 0.80, 95% CI = (0.65, 0.98)], and not owning an electric fan [OR = 1.50, 95% CI = (1.21, 1.88)] were associated with ALRI; gap presence and using biomass fuels were not associated with ALRI. Structural factors that might improve household air circulation and exchange were associated with decreased ALRI risk. Improved natural ventilation might reduce ALRI among children in low-income families.

PRACTICAL IMPLICATIONS

The World Health Organization has stated that controlling pneumonia is a priority for achieving the fourth Millennium Development Goal, which calls for a two-third reduction in mortality of children <5 years old compared to the 1990 baseline. Our study represents an important finding of a modifiable risk factor that might decrease the burden of respiratory illness among children living in Bangladesh and other low-income settings similar to our study site. We found that the existence of at least two windows in the child's sleeping room was associated with a 25% decreased ALRI risk. Increasing available natural ventilation within the household in similar settings has the potential to reduce childhood mortality because of acute lower respiratory illnesses.

Temporal patterns of activities potentially related to pesticide exposure

Longitudinal information on human activity patterns is required to perform reliable assessments of chronic exposure to pesticides in nonoccupational settings. As part of a longitudinal, multimedia exposure survey in Maryland, USA, we collected 2521 person-days of information on the frequency of five activities that are potentially important to pesticide exposure in residential settings: preparation of pesticides; application of pesticides; contact with soil on the skin; contact with grass on the skin; and contact with carpet. Logistic regression was used to evaluate the data for variability by time of year, day of week, and several demographic factors. Eight percent of the population reported preparing pesticides on at least one occasion over the year, while 24% of the population applied pesticides at least once. The majority of the population reported contact with soil (68%), grass (72%), and carpet (64%) over the course of a year. Skin contact with soil and grass was found to occur approximately twice as frequently (p<0.001) in spring and summer periods than in fall and winter periods. Similarly, contact with soil and grass was about 50% (p<0.05) more likely to occur on weekend days than on weekdays. These results indicate that short-term measurements (e.g., 1-day or 1-week) of these activities for an individual may not be equivalent to long-term average patterns. We also found that selected demographic characteristics were significant predictors of several of these activities. Thus, some demographic characteristics may be useful in categorizing exposure although it is unlikely that a single short-term measurement will suffice to describe annual average activity or multiple short-term activity periods.

A longitudinal investigation of aggregate oral intake of copper

Four-day composite solid food and beverage duplicate plates and 1-L samples of drinking water were collected from a stratified random sample of 80 individuals as part of the National Human Exposure Assessment Survey in Maryland. The media were obtained from each participant in up to six equally spaced sampling cycles over a year and analyzed for copper by inductively coupled plasma mass spectrometry. Copper concentrations (microg/kg) and consumption rates (kg/d) of solid food, beverage and drinking water were used to derive average daily aggregate oral intake of copper (microg/d). The mean aggregate copper intake of 263 measurements obtained from 68 people was 923.2 +/- 685.6 microg/d (mean +/- SD). Intake through solid food accounted for the majority of aggregate daily intake of copper contributing 87% on average. According to results from mixed model analysis of variance procedures, the mean log-transformed average daily copper intake in each medium except beverage exhibited significant (P < 0.05) variability among sampling cycles. Between-person variability accounted for 50% of the total variance in aggregate copper intake. As measured by the coefficient of variation, distributions of copper intake consisting of one observation per individual were more variable than the distribution consisting of the long-term average intake for each person. These results suggest that estimates of the fraction of a population at risk from chronic copper deficiency or excess copper intake can be overestimated if based upon short-term measures of copper intake. In addition, these results indicate that longitudinal information is required for accurate assessment of aggregate oral intake of copper for an individual.

Dietary exposure to chlorpyrifos and levels of 3,5,6-trichloro-2-pyridinol in urine

Information on associations between chlorpyrifos residues in food and personal exposure to chlorpyrifos would be valuable for evaluating the relationship between personal exposure and possible health effects. We used food consumption records, chlorpyrifos levels in duplicate plates, and measures of 3,5,6-trichloro-2-pyridinol (TCPy) in urine obtained from human volunteers in the National Human Exposure Assessment Survey in Maryland (NHEXAS-MD) to evaluate a food consumption-chemical residue model for estimating dietary intake of chlorpyrifos. Model inputs were the NHEXAS-MD food consumption records and chlorpyrifos residues in specific foods measured in the U.S. Food and Drug Administration Total Diet Study (TDS) market baskets from 1993 to 1997. The estimated mean and standard deviation of chlorpyrifos concentration (microg/kg) in duplicate plates (n=203) were within 20% and 50%, respectively, of the corresponding parameters of measured chlorpyrifos levels. However, predicted and measured concentrations in the 78 duplicate plates with detectable levels of chlorpyrifos were not significantly associated according to Spearman correlation analysis (r=0.04, p=0.7667) and linear regression (p=0.2726). Measured and estimated chlorpyrifos intakes for observations with non-zero values for each intake measure (n=71) were moderately associated on a rank (Spearman's r=0.24, p=0.0462) and linear basis (regression r(2)=0.07, p=0.0242). Measured intakes of chlorpyrifos from food and urinary TCPy were significantly correlated in rank order (n=87, Spearman's r=0.30, p=0.0041) and linear (n=87, Pearson's r=0.22, p=0.0409) analyses. Correlation coefficients between estimated intake of chlorpyrifos from food and TCPy were significantly different from zero (n=87; Spearman's r=0.22, p=0.0393; Pearson's r=0.21, p=0.0479). Comparing mean measured chlorpyrifos intake from food (0.46 microg/day) to mean estimated TCPy excretion via urine (6.3 microg/day), dietary intake of chlorpyrifos accounted for approximately 7% of TCPy in this population. These findings suggest the food consumption-chemical residue model can yield reasonably accurate estimates of the population distribution of dietary chlorpyrifos intake, but has little ability to predict dietary exposure for individuals; and that intake of chlorpyrifos from food is a minor contributor to TCPy in urine.

Longitudinal investigation of dietary exposure to selected pesticides

Between September 1995 and September 1996, 4-day composite duplicate plate samples (379 solid food samples and 303 beverage samples) were obtained from a stratified random sample of 75 individuals in Maryland and analyzed for the presence of 10 pesticides. Samples were collected in each of six approximately equally spaced cycles as part of a larger pilot investigation of longitudinal exposure to pesticides and other elements. Chlorpyrifos was detected in 38.3% of the solid food samples, malathion in 75.2%, and p,p'-DDE in 21.4%. Other pesticides were detected in less than 10% of the solid food samples. Pesticide residues were not detected in duplicate beverage samples. In solid food samples, the mean concentration of chlorpyrifos was 0.7 (SD 1.7) microg/kg, 1.8 (2.1) for malathion, and 0.2 (0.6) for p,p'-DDE. The detection rate and mean concentration of chlorpyrifos, malathion, and p,p'-DDE varied by a factor of 2-3 among sampling cycles and significantly according to results from several statistical analyses. Co-occurrence of chlorpyrifos and malathion in solid food samples was found relatively frequently and also varied with time. Pesticides were detected in food samples with greatest frequency in spring and summer months and with lowest frequency in winter months. These results support the hypothesis that 4-day average exposure to chlorpyrifos and malathion varies over time for this population mean and for individual members of the population and that correlation between exposures to these two organophosphate pesticides can occur. The measurements of pesticide levels in duplicate plate samples presented here can be used to evaluate and set parameters for dietary exposure models.

Analysis of dietary intake of selected metals in the NHEXAS-Maryland investigation

As part of a large pilot investigation of multimedia exposure to several classes of environmental contaminants, the National Human Exposure Assessment Survey (NHEXAS)-Maryland study, we collected 388 semiquantitative food checklists and duplicate diet solid food samples, analyzed for arsenic, cadmium, chromium, and lead concentrations, from 80 individuals in Maryland in 1995-1996 in a repeated measures design. Here we explore several methods to infer foods most strongly associated with concentrations of these metals observed in the duplicate diet in our data set. We employed two techniques in which logarithmically transformed metal concentrations in the duplicate diet were regressed on individual food item consumption using algorithms designed to identify the foods most associated with the observed duplicate diet concentrations. We also employed an alternative strategy in which foods to be used as independent variables in regression were selected using data collected in national food consumption and residue surveys, with regression procedures proceeding with the selected foods in a similar manner. The concordance of foods selected as major predictors among these three techniques is noteworthy and is discussed. Finally, the Dietary Exposure Potential Model (DEPM) was used with the Dietary Checklist data to predict duplicate diet concentrations within our sample. A comparison between the predicted values and those observed gave R(2) values of 0.180, 0.206, and 0.076 for As, Cd, and Pb, respectively (p < 0.0001 in all cases). We discuss the significance of these observations and the implications for dietary-exposure-based risk analysis and dietary intake epidemiology.

Interim results of the study of particulates and health in Atlanta (SOPHIA)

Substantial evidence supports an association of particulate matter (PM) with cardiorespiratory illnesses, but little is known regarding characteristics of PM that might contribute to this association and the mechanisms of action. The Atlanta superstation sponsored by the Electric Power Research Institute as part of the Aerosol Research and Inhalation Epidemiology Study (ARIES) study is monitoring chemical composition of ambient particles by size fraction, as well as a comprehensive suite of other pollutants, at a site in downtown Atlanta during the 25-month period, August 1, 1998-August 31, 2000. Our investigative team is making use of this unique resource in several morbidity studies, called the "Study of Particulates and Health in Atlanta (SOPHIA)". The study includes the following components: (1) a time series investigation of emergency department (ED) visits for the period during which the superstation is operating; (2) a time series investigation of ED visits during the 5 years prior to implementation of the superstation; and (3) a study of arrhythmic events in patients equipped with automatic implantable cardioverter defibrillators (AICDs) for the period January 1, 1993-August 31, 2000. Thirty-three of 39 Atlanta area EDs are participating in the ED studies, comprising over a million annual ED visits. In this paper, we present initial analyses of data from 18 of the 33 participating EDs. The preliminary data set includes 1,662,713 ED visits during the pre-superstation time period and 559,480 visits during the superstation time period. Visits for four case groupings--asthma, chronic obstructive pulmonary disease (COPD), dysrhythmia, and all cardiovascular diseases (CVDs) combined--have been assessed relative to daily air quality indices, controlling for long-term temporal trends and meteorologic variables, using general linear models, generalized estimating equations and generalized additive models. Single-pollutant models predicting case visitation rates using moving averages of 0-, 1-, and 2-day lagged air quality variables were run. For the pre-superstation period, PM10 (24-h), ozone (8-h), SO2 (1-h), NO2 (1-h) and CO (1-h) were studied. For the first 12 months of superstation operation, the following air quality variables of a priori interest were available: ozone (8-h), NO2 (1-h), SO2 (1-h), CO (1-h), and 24-h measurements of PM10, coarse PM (PM 2.5-10 microm), PM2.5, polar VOCs, 10-100 nm particulate count and surface area, and in the PM2.5 fraction: sulfates, acidity, water-soluble metals, organic matter (OM), and elemental carbon (EC). During the pre-superstation time period, statistically significant, positive associations were observed for adult asthma with ozone, and for COPD with ozone, NO2 and PM10. During the superstation time period, the following statistically significant, positive associations were observed: dysrhythmia with CO, coarse PM, and PM2.5 EC; and all CVDs with CO, PM2.5 EC and PM2.5 OM. While covariation of many of the air quality indices limits the informativeness of this analysis, the study provides one of the first assessments of PM components in relation to ED visits.

Neurological effects of environmental exposure to arsenic in dust and soil among humans

Persons living in a small town in Georgia, USA, were studied because of known environmental exposure to arsenic-containing dust. To assess the effects of this exposure on the nervous system, a cross-sectional epidemiological study was performed. The health outcome assessments of the study were based on a priori selected clinical examination results and quantitative electrophysiologic and behavioral outcome measures. Because the primary goal was to identify cases of peripheral neuropathy, a clinically relevant case definition, based on results of these outcomes was created. Historical exposure reconstructions were performed on a subset of the exposed subjects for whom such information was available. Of the 238 persons enrolled in the study, 133 were classified as non-exposed (i.e., did not reside in the area of known exposure) and 105 were classified as exposed (i.e., did reside in the area of known exposure). Following exclusions of persons with occupational exposure to neurotoxicants, pre-existing conditions associated with peripheral nerve impairment, or age below 18 years, 118 unexposed subjects and 85 exposed subjects were available for inclusion in the analyses of peripheral nerve outcomes. A total of 4 (3.4%) of the unexposed subjects and 13 (15.3%) of the exposed subjects met the case definitions for peripheral neuropathy (OR=5.1; p=0.004). Comparison of three exposure groups (none, low, high) did not yield statistically significant differences. Statistically significant exposure group differences were observed on quantitative tests of standing steadiness, vibrotactile threshold and tremor intensity but not for nerve conduction measures. These results demonstrate a strong association between community arsenic containing dust exposure and peripheral neuropathy among participants in this investigation.

Longitudinal investigation of exposure to arsenic, cadmium, and lead in drinking water

Arsenic, cadmium, and lead have been associated with various forms of cancer, nephrotoxicity, central nervous system effects, and cardiovascular disease in humans. Drinking water is a well-recognized pathway of exposure to these metals. To improve understanding of the temporal dimension of exposure to As, Cd, and Pb in drinking water, we obtained 381 samples of tap and/or tap/filtered water and self-reported rates of drinking water consumption from 73 members of a stratified random sample in Maryland. Data were collected at approximately 2-month intervals from September 1995 through September 1996. Concentrations of As (range < 0.2-13.8 microg/L) and Pb (< 0.1-13.4 microg/L) were within the ranges reported for the United States, as were the rates of drinking water consumption (median < 0.1-4.1 L/day). Cd was present at a detectable level in only 8.1% of the water samples. Mean log-transformed concentrations and exposures for As and Pb varied significantly among sampling cycles and among respondents, as did rates of drinking water consumption, according to a generalized linear model that accounted for potential correlation among repeated measures from the same respondent. We used the intraclass correlation coefficient of reliability to attribute the total variance observed for each exposure metric to between-person and within-person variability. Between-person variability was estimated to account for 67, 81, and 55% of the total variance in drinking water consumption, As exposure (micrograms per day), and Pb exposure (micrograms per day), respectively. We discuss these results with respect to their implications for future exposure assessment research, quantitative risk assessment, and environmental epidemiology.

Air quality and pediatric emergency room visits for asthma in Atlanta, Georgia, USA

Pediatric emergency room visits for asthma were studied in relation to air quality indices in a spatio-temporal investigation of approximately 130,000 visits (approximately 6,000 for asthma) to the major emergency care centers in Atlanta, Georgia, during the summers of 1993-1995. Generalized estimating equations, logistic regression, and Bayesian models were fitted to the data. In logistic regression models comparing estimated exposures of asthma cases with those of the nonasthma patients, controlling for temporal and demographic covariates and using residential zip code to link patients to spatially resolved ozone levels, the estimated relative risk per 20 parts per billion (ppb) increase in the maximum 8-hour ozone level was 1.04 (p < 0.05). The estimated relative risk for particulate matter less than or equal to 10 microm in aerodynamic diameter (PM10) was 1.04 per 15 microg/m3 (p < 0.05). Exposure-response trends (p < 0.01) were observed for ozone (>100 ppb vs. <50 ppb: odds ratio = 1.23, p = 0.003) and PM10 (>60 microg/m3 vs. <20 microg/m3: odds ratio = 1.26, p = 0.004). In models with ozone and PM10, both terms became nonsignificant because of collinearity of the variables (r= 0.75). The other analytical approaches yielded consistent findings. This study supports accumulating evidence regarding the relation of air pollution to childhood asthma exacerbation.

Longitudinal investigation of exposure to arsenic, cadmium, chromium and lead via beverage consumption

Semi-quantitative food checklists and duplicate beverage samples were collected from up to 80 individuals in Maryland in 1995-1996 in as many as six approximately equally spaced sampling cycles as part of a pilot longitudinal exposure investigation. The duplicate beverage samples were homogenized and analyzed for arsenic (As), cadmium (Cd), chromium (Cr) and lead (Pb) using inductively coupled plasma mass spectrometry (ICP-MS). Metal concentrations (microg/kg) and weights of the duplicate beverage samples (kg/day) were used to derive average daily exposure (microg/day) for each metal. Mixed models and generalized linear models were used to evaluate temporal and population variability of the beverage consumption rates, the log-transformed metal concentrations in the beverage samples, and the associated exposures. The mean number of beverage servings consumed per day was 3.4 (SD 1.9). The temporal variability of the total beverage consumption rates was found to be significant (p = 0.0476). As, Cd, Cr, and Pb were present at quantifiable levels in 93.5, 76.0, 93.5, and 96.7% of the beverage samples, respectively. The mean concentration in the samples was 2.0 (SD 4.4) microg/kg for As, 0.9 (1.6) for Cd, 29.2 (138.5) for Cr, and 2.0 (2.4) for Pb. The mean log-transformed concentrations for As, Cr and Pb and exposure for As varied by as much as a factor of 3 across sampling cycles and were statistically significantly different (p<0.05). Concentrations and exposures of all four metals varied significantly among participants. These findings are discussed with respect to the data collection methods, results from comparable studies, and implications for exposure and risk assessment.

Measurement variability associated with KXRF bone lead measurement in young adults

In vivo bone lead measurement using K X-ray fluorescence (KXRF) has been used to estimate long-term lead exposure, especially in adults. Relatively few studies have been conducted on young subjects with this technique. To explore the measurement variability of KXRF bone lead measurements in young subjects, the tibiae of two male cadavers from Boston, Massachusetts, 17 and 20 years of age, were obtained for repeated bone lead measurements. Bone lead concentrations were measured using a grid of nine locations, 1 cm apart, centered at the midpoint of the tibia. Each location was sampled using five 60-min measurements. Measured concentrations ranged from < 0 to 11.8 microg Pb/g bone mineral across a tibia with mean concentrations for the midpoint locations of 0.8 microg Pb/g bone mineral SD = 2.5 and 2.0 microg Pb/g bone mineral (SD = 1.9) for the left and right legs of the younger subject and 3.6 microg Pb/g bone mineral (SD = 2.6) and 6.0 microg Pb/g bone mineral (SD = 3.3) for the left and right legs of the older subject. Although bone lead concentrations did not vary significantly by measurement location in an individual leg, reported measurement uncertainty increased significantly at locations that were 1 cm from the center of the tibia horizontally (p < 0.0001). Symmetry in bone lead concentration between legs was observed for the 17-year-old subject. Potential asymmetry between the left and right legs was suggested for the 20-year-old subject (p = 0.06). These data describe the degree of variability that may be associated with bone lead measurements of young subjects with low bone lead concentrations using a standard spot-source KXRF instrument. Because of the importance of conducting additional research on adolescent lead toxicity, further improvements to the precision of KXRF measurement are needed.

Temporal variability of microenvironmental time budgets in Maryland

Information on human time-activity patterns is often required to interpret environmental exposure data fully and to implement exposure assessment models. Data on short-term time-activity patterns for individuals, such as 1-day measurements, are relatively abundant. The reliability of such data for use in chronic exposure (e.g., 1 or more years) assessments performed for evaluation of health risks is not well understood. As part of the NHEXAS-Maryland investigation, daily time budget data for seven microenvironments were collected from 80 people during as many as six 1-week Cycles over a 12-month period. The data were summarized and analyzed statistically by sampling Cycle, day of week, and individual to characterize long-term average microenvironmental time budgets and to identify their determinants. Median times spent in transit, indoors at home, outside at home, indoors at work or school, outdoors at work or school, indoors at other locations, and outdoors at other locations were found to vary significantly, although not substantively in many cases, by time of year (i.e., Cycle), by day of week, and by individuals. Time budgets for most of the microenvironments also exhibited significant variability by gender, age group, education level, annual household income, and work status. The results indicate that short-term (e.g., 1-day) measures of microenvironmental time budgets for individuals are unlikely to be representative of their long-term patterns. Thus, health risk or epidemiological assessments performed for a population mean or specific quantile may be relatively insensitive to when time budget data were collected. However, the accuracy of such assessments performed for individuals is likely to be greatly improved by collection of time budget data from numerous points in time.

A longitudinal investigation of selected pesticide metabolites in urine

As part of a longitudinal investigation of environmental exposures to selected chemical contaminants, concentrations of the pesticide metabolites 1-naphthol (INAP), 3,5,6-trichloro-2-pyridinol (TCPY), malathion dicarboxylic acid (MDA), and atrazine mercapturate (AM) were measured in repeated samples obtained from 80 individuals in Maryland during 1995-1996. Up to six urine samples were collected from each individual at intervals of approximately 8 weeks over a 1-year period (i.e., one sample per participant in each of six cycles). INAP (median=4.2 microg/l and 3.3 microg/g creatinine) and TCPY (median=5.3 microg/l and 4.6. microg/g creatinine) were present in over 80% of the samples, while MDA and AM were detected infrequently (6.6% and <1% of samples, respectively). Geometric mean (GM) concentrations of INAP in urine did not vary significantly among sampling cycles. In contrast, GM concentrations of TCPY were significantly greater in samples collected during the spring and summer of 1996 than in the preceding fall and winter. Repeated measurements of INAP and TCPY from the same individual over time were highly variable. The average range of INAP and TCPY concentrations from the same individual were approximately 200% and 50% greater than the respective population mean levels. Geometric mean (GM) TCPY concentrations differed significantly between Caucasian (n=42, GM=5.7 microg/g creatinine) and African-American (n=11, GM=4.0 microg/g) participants and among education levels, but were not significantly different among groups classified by gender, age, or household income. In future research, environmental measurements of the parent compounds and questionnaire data collected concurrently with the biomarker data will be used to characterize the determinants of variability in the urinary pesticide metabolite levels.

A longitudinal investigation of solid-food based dietary exposure to selected elements

As part of a longitudinal investigation of environmental exposures to selected chemical contaminants, the National Human Exposure Assessment Survey (NHEXAS), food consumption and duplicate diet samples were obtained in each of six sampling cycles from up to 80 individuals in Maryland during 1995-1996. Duplicate diet samples were weighed and analyzed for arsenic, cadmium, chromium and lead and were used to derive average daily intakes of each element. Mean log-transformed concentrations of arsenic and cadmium in duplicate diet samples and derived intakes of chromium were found to vary significantly among sampling cycles. Repeated observations of dietary exposure metrics from the same individual over time were highly variable. The results suggest that distributions of dietary exposure to arsenic and cadmium do vary for a population within a 1-year period, while those for chromium and lead do not. This may result in single measurements of exposure being sufficient to characterize population variability for these latter two elements. However, even for those elements not displaying statistically significant temporal variability for the population, a single dietary exposure measurement may still not be sufficient to characterize accurately chronic dietary exposure levels for individuals.

Relations between individual and neighborhood-based measures of socioeconomic position and bone lead concentrations among community-exposed men: the Normative Aging Study

To examine the association between lead exposure and both individual and geographic area indicators of socioeconomic position, the authors measured tibia lead concentration, a biomarker of cumulative lead exposure, using K x-ray fluorescence in a cross-sectional survey of 538 white males aged 50-92 years who were healthy when enrolled in the Normative Aging Study (Boston, Massachusetts) in the 1960s. Data on individual risk factors, education, occupation, and income were collected by questionnaire. Using subjects' residential addresses at the time of the tibia lead measurements, the authors obtained geographic area-specific measures of education, social class, and poverty by linking records to 1990 US Census block group data. In multivariate linear regression analysis controlling for age and cumulative smoking, tibia lead concentrations were 10.39 microg/g (95% confidence interval (CI) 7.80-12.97) higher in men who did not graduate from high school than in men with > or =4 years of college. Among the former men (non-high school graduates), living in an undereducated area was associated with a 9.28 microg/g (95% CI 1.59-16.97) increase in tibia lead level compared with living in a non-undereducated area; among the latter men (college graduates), no difference existed by residential area education (beta = 0.72, 95% CI -5.35 to 6.78). The authors conclude that the influence of individual socioeconomic position on cumulative lead exposure is modified by geographic area conditions.

Urine vanadium concentrations in workers overhauling an oil-fired boiler

Since fuel oil ash contains vanadium (V), the measurement of urinary levels of V may provide a biological marker in workers exposed to fuel oil ash. The usefulness of urine V samples as a biological monitoring tool ultimately depends on determining the appropriate time of sampling relative to when exposure occurs. Twenty boilermakers were studied during the overhaul of a large oil-fired boiler. A total of 117 urine samples were collected, 65 start-of-shift (S-O-S) and 52 end-of-shift (E-O-S) samples. Air V exposures were estimated with personal sampling devices and work history diaries. Air V concentrations ranged from 0.36 to 32.19 micrograms V/m3, with a mean +/- SD of 19.1 +/- 10.7, and a median of 18.5. On the first day of work on the overhaul, the V urine levels at the E-O-S (mean +/- SD were 1.53 +/- 0.53, median was 1.52 mg V/g creatinine) were significantly higher than those at the S-O-S (0.87 +/- 0.32, median was 0.83), P = 0.004. However, the V concentrations of the S-O-S urine samples on the last Monday of the study were not significantly different from the S-O-S urine levels on the previous Saturday, a time interval of about 38 hr between the end of exposure and sample collection. The Spearman correlation coefficient (r) between the S-O-S urine V and the workplace concentration of V dust during the previous day was r = 0.35. In summary, the results suggest a rapid initial clearance of V (elevating the E-O-S V concentration on the first day of work relative to the S-O-S concentration), followed by a slow clearance that is not complete 38 hr after the end of exposure, as evidenced by the Monday morning urine V concentrations. The Spearman correlations suggest that the S-O-S urine is preferred to the E-O-S urine for across-shift biological monitoring of V exposure.

In vivo bone lead measurement in suburban teenagers

OBJECTIVE

Bone represents a biologically active long-term storage site for lead, and bone lead data on teenagers are limited. Therefore, this study was designed to identify the distribution of bone lead in a teenage population and to explore the environmental and demographic factors associated with bone lead concentrations in young, nonoccupationally exposed subjects.

DESIGN

A cross-sectional study of bone lead levels in high school students.

PARTICIPANTS

A total of 168 students at a suburban Boston high school. Subjects (90 boys, 78 girls) ranged in age from 13.5 to 19 years and included 40% nonwhite minorities. Of the 168 subjects, 45 lived in homes constructed before 1960. None of the participants reported a history of lead poisoning.

OUTCOME MEASURES

Tibial bone lead concentrations were measured in vivo for 60 minutes using K x-ray fluorescence. Lead exposure information was obtained by self-administered questionnaire.

RESULTS

Point estimates of bone lead levels ranged from -7.15 to 14.23 microg lead/g bone mineral (microg/g), (mean, 4.0 microg/g; standard deviation, 4.4 microg/g). The reported measurement uncertainties accompanying each of the point estimates ranged from 2.56 to 9.01 microg/g (mean, 3.9 microg/g; standard deviation, 1.0 microg/g). Bone lead levels were not associated with the demographic factors of age, sex, or race. Additionally, current home conditions (housing age, traffic level) were not predictive of bone lead levels, even though these factors were predictive of in-home lead concentrations.

CONCLUSIONS

These results demonstrate that although bone lead levels are measurable in this age group, the common predictors of blood and bone lead concentrations are not explanatory for bone lead levels.

Validation of a self-administered lead exposure questionnaire among suburban teenagers

Teenagers represent a unique population in which to evaluate lead exposure. A self-administered questionnaire was developed to evaluate the current and historic lead exposures of teenagers. This work evaluates the exposure questionnaire for both its ability to predict lead exposure and the accuracy of the teenage respondents. Subjects received the survey at school and were instructed to get assistance from their parents in questionnaire completion. Environmental samples (dust, soil, and water) were collected from 30 suburban Boston homes to evaluate the questionnaire's predictiveness. To evaluate the accuracy of subjects' responses, independent information about housing was obtained. The questionnaire was effective in identifying predictors of dust and soil lead levels, but not for water lead levels. Fine dust lead loading (< 150 microns) varied significantly among the six housing age categories (pre-1940, 1940-1949, 1950-1959, 1960-1969, 1970-1979, and > 1979) and traffic levels. Fine dust lead concentrations varied significantly with decade of housing construction. Mean soil lead levels varied significantly among housing age categories, traffic levels, and exterior construction materials. For the important predictors, there was excellent agreement between the teenagers' self-report and confirmatory information. For housing age categories, the observed agreement was 69%; for traffic level, the observed agreement was 88%. These results illustrate that questionnaires continue to be useful in evaluating home lead levels even in suburban homes and that teenagers are accurate respondents.

Dietary exposures to selected metals and pesticides

Average daily dietary exposures to 11 contaminants were estimated for approximately 120,000 U.S. adults by combining data on annual diet, as measured by a food frequency questionnaire, with contaminant residue data for table-ready foods that were collected as part of the annual U.S. Food and Drug Administration Total Diet Study. The contaminants included in the analysis were four heavy metals (arsenic, cadmium, lead, mercury), three organophosphate pesticides (chlorpyrifos, diazinon, malathion), and four organochlorine pesticides (dieldrin, p,p'-DDE, lindane, heptachlor epoxide). Dietary exposures to these contaminants were highly variable among individuals, spanning two to three orders of magnitude. Intraindividual exposures to the metals, organophosphates, and organochlorines were estimated to be strongly correlated; Pearson's correlation coefficients ranged from 0.28 for lindane:dieldrin to 0.84 for lead:mercury. For some of the compounds (e.g., arsenic and dieldrin), a substantial fraction of the population was estimated to have dietary intakes in excess of health-based standards established by the EPA. Before use for risk assessment or epidemiologic purposes, however, the validity of the exposure estimates must be evaluated by comparison with biological indicators of chronic exposure. Because of their low detection rate in table-ready foods, the estimated distributions of exposures for dieldrin, p,p'-DDE, heptachlor epoxide, lindane, diazinon, and chlorpyrifos were found to be sensitive to assumed values for nondetect samples. Reliable estimates of the population distribution of dietary exposures to most other contaminants cannot be made currently, due to their low rate of detection in table-ready foods. Monitoring programs that use more sensitive study designs and population-based assessments for other subpopulations should be a priority for future research.

Dietary exposures to selected metals and pesticides

Average daily dietary exposures to 11 contaminants were estimated for approximately 120,000 U.S. adults by combining data on annual diet, as measured by a food frequency questionnaire, with contaminant residue data for table-ready foods that were collected as part of the annual U.S. Food and Drug Administration Total Diet Study. The contaminants included in the analysis were four heavy metals (arsenic, cadmium, lead, mercury), three organophosphate pesticides (chlorpyrifos, diazinon, malathion), and four organochlorine pesticides (dieldrin, p,p'-DDE, lindane, heptachlor epoxide). Dietary exposures to these contaminants were highly variable among individuals, spanning two to three orders of magnitude. Intraindividual exposures to the metals, organophosphates, and organochlorines were estimated to be strongly correlated; Pearson's correlation coefficients ranged from 0.28 for lindane:dieldrin to 0.84 for lead:mercury. For some of the compounds (e.g., arsenic and dieldrin), a substantial fraction of the population was estimated to have dietary intakes in excess of health-based standards established by the EPA. Before use for risk assessment or epidemiologic purposes, however, the validity of the exposure estimates must be evaluated by comparison with biological indicators of chronic exposure. Because of their low detection rate in table-ready foods, the estimated distributions of exposures for dieldrin, p,p'-DDE, heptachlor epoxide, lindane, diazinon, and chlorpyrifos were found to be sensitive to assumed values for nondetect samples. Reliable estimates of the population distribution of dietary exposures to most other contaminants cannot be made currently, due to their low rate of detection in table-ready foods. Monitoring programs that use more sensitive study designs and population-based assessments for other subpopulations should be a priority for future research.

Measurement of organic acids, aldehydes, and ketones in residential environments and their relation to ozone

Ozone and several polar volatile organic compounds (VOCs) including organic acids and carbonyls (aldehydes and ketones) were measured over an approximately 24 hour period in four residences during the winter of 1993 and in nine residences during the summer of 1993. All residences were in the greater Boston, Massachusetts area. The relation of the polar VOCs to the ozone concentration was examined. Indoor carbonyl concentrations were similar between the summer and winter, with the total mean winter concentration being 31.7 ppb and the total mean summer concentration being 36.6 ppb. However, the average air exchange rate was 0.9 hr-1 during the winter and 2.6 hr-1 during the summer. Therefore, the estimated carbonyl emission rates were significantly higher during the summer. Indoor organic acid concentrations were about twice as high during the summer as during the winter. For formic acid, the indoor winter mean was 9.8 ppb, and the summer indoor mean was 17.8 ppb. For acetic acid, the indoor winter mean was 15.5 ppb, and the summer indoor mean was 28.7 ppb. The concentrations of the polar VOCs were found to be significantly correlated with one another. Also, the emission rates of the polar VOCs were found to be correlated with both the environmental variables such as temperature and relative humidity and the ozone removal rate; however, it was difficult to apportion the relative effects of the environmental variables and the ozone removal.

Estimating long-term exposures from short-term measurements

Many health problems are related to chronic exposure of individuals to pollutants in the environment. The level of exposure of a specified population is typically represented by the mean level of exposure of the population, the variation in exposure between individuals within the population, and levels of exposure for selected percentiles of the population, such as the 50th and 98th percentiles. However, the day-to-day level of exposure for individuals varies, and direct measurement of total exposure for long periods of time is impractical. The problem is to estimate the quantities listed above using incomplete sampling of the time period of interest. This paper looks at the effect of using estimates of long-term exposure for individuals on estimating the exposure distribution of the population. A simple and apparently robust estimate for the upper percentiles of the exposure distribution is proposed. Problems related to estimating an individual's long-term exposure, including sample size, are also discussed. The length of time defined as long-term in this paper is one year; however, the results are generalizable to any period of time desired.

A population-based exposure model for benzene

A model of daily-average inhalation exposures and total-absorbed doses of benzene to members of large populations was developed as part of a series of multimedia exposure and absorbed dose models. The benzene exposure and dose model is based upon probabilistic rather than sequential simulation of time-activity patterns, a simpler approach to modeling personal benzene exposures than other existing models. An important innovation of the benzene model is the incorporation of an anthropometric module for generating correlated exposure factors used to estimate absorbed doses occurring from inhalation, ingestion, and dermal absorption of benzene. A preliminary validation exercise indicates that the benzene model produces reasonable estimates of the distribution of benzene personal air concentrations expected for a large population. Uncertainty about specific percentiles of the predicted distributions of personal air concentrations was found to be dominated by uncertainty about microenvironmental benzene concentrations rather than time-activity patterns, and uncertainty about total absorbed doses was dominated by a lack of knowledge about the true absorption coefficient for benzene in the lung rather than knowledge gaps about microenvironmental concentrations or intake rates. The results of this modeling effort have implications for environmental control decisions, including evaluation of source control options, characterization of population and individual risk, and allocation of resources for future studies.

Validation of K-XRF bone lead measurement in young adults

K-X-ray fluorescence (K-XRF) is a useful tool for assessing environmental exposure to lead in occupationally exposed individuals and older adults. This study explores the possibility of using this technique on young adults with low environmental lead exposure. Twenty-three college students, aged 18-21 years, were recruited for 2 hr of bone lead measurement. Bone lead measurements were taken from the mid-shaft tibia for periods of 30 or 60 min. In the analysis, 30-min measurements were combined so that each subject had the equivalent of two 60-min measurements. The average concentration of two bone lead measurements in this population ranged from -1.5 to 8.2 micrograms Pb/g bone mineral, with a mean of 3.0 micrograms Pb/g bone mineral. In a one sample t-test, this mean was significantly different from 0 (p < 0.0001). A linear trend with age was detected despite the small age range of our population. By doubling the sampling time, the reported measurement uncertainty decreased by a factor of 1.5, resulting in uncertainty estimates below the mean bone lead estimates. Power calculations using the observed variance estimates suggest that with 80% power, differences in bone lead concentration of 2-3 micrograms Pb/g bone mineral can be identified in groups of 100 or smaller. Due to the large within-person variation in young adults, K-XRF may not yet be a useful diagnostic tool for individual subjects, but it may be of great use to environmental scientists trying to characterize long-term lead exposure and dose in the general population or specific subpopulations.

Personal exposure to nitrogen dioxide in the Los Angeles Basin

A large scale study of human exposure to nitrogen dioxide (NO2) was conducted in the Los Angeles Basin, the only metropolitan area in the United States that exceeds the NO2 NAAQS. Data are available for a population representative sample of 482 households and 682 individuals. Personal exposures, as well as indoor and outdoor home levels, were monitored using passive time-integrating filter badges. Monitoring extended over a one-year period (May 1987 to May 1988), with each individual providing two consecutive days of data. Information was also collected on activity patterns, household and personal characteristics, and spatial and temporal variables. This paper describes the study design, summarizes the sample characteristics and representativeness, and presents the distribution of personal, indoor, and outdoor NO2 concentrations recorded by the monitors. Over the entire sample, median personal and outdoor levels were 35 ppb; median indoor levels were 24 ppb. Personal exposures for those in homes with gas ranges with pilot lights average 10 ppb greater than those with electric ranges, and 4 ppb greater than those with gas ranges without pilot lights. Forty percent of the variation in indoor concentrations is explained by outdoor levels; 59 percent of the variation in personal exposures is explained by indoor levels; and 48 percent of the variation in personal exposures is explained by outdoor levels.

Indoor/outdoor measurements of volatile organic compounds in the Kanawha Valley of West Virginia

The Kanawha Valley region of West Virginia which is comprised of Charleston and surrounding communities is the center of a heavily industrialized area known for its chemical manufacturing. As part of a larger study designed to investigate the impact of the chemical industry on human exposures to volatile organic compounds (VOC), a study of the relationship between indoor and outdoor concentrations was conducted. Thirty-five homes were selected for monitoring from among volunteers; approximately ten in each of three distinct population-industry centers and four outside the Valley to act as controls. Monitoring was performed using passive, badge samplers with a three-week monitoring period. Two separate questionnaires were administered: one for characterization of the residence; and one to characterize source use during monitoring. Participants were also asked to keep a record of their activities with respect to in-home, outdoors and other indoor environments. Analysis of the samplers was performed by solvent extraction followed by gas chromatography using a flame-ionization detector. Results suggest that indoor VOC concentrations are higher than outdoor concentrations. Additionally, certain ventilation-related parameters were identified that afforded some predictive power for indoor concentrations. No statistically significant differences between regions were identified.

Exposures to acidic aerosols

Ambient monitoring of acid aerosols in four U.S. cities and in a rural region of southern Ontario clearly show distinct periods of strong acidity. Measurements made in Kingston, TN, and Steubenville, OH, resulted in 24-hr H+ ion concentrations exceeding 100 nmole/m3 more than 10 times during summer months. Periods of elevated acidic aerosols occur less frequently in winter months. The H+ determined during episodic conditions in southern Ontario indicates that respiratory tract deposition can exceed the effects level reported in clinical studies. Observed 12-hr H+ concentrations exceeded 550 nmole/m3 (approximately 27 micrograms/m3 H2SO4). The maximum estimated 1-hr concentration exceeded 1500 nmole/m3 for H+ ions. At these concentrations, an active child might receive more than 2000 nmole of H+ ion in 12 hr and in excess of 900 nmole during the hour when H2SO4 exceeded 50 micrograms/m3.

Cost-effective drug regimen review program for home health care patients

A prospective longitudinal study of a home health agency-based drug regimen review program was completed. A consultant pharmacist working collaboratively with home health nurses and physicians reduced medication utilization and costs to homebound patients. Within a 12 month period, medication utilization in 840 homebound patients was reduced by 27%. Projected total net medication cost saving per annum was $183,379.20 (e.g., $218.31 per patient reviewed). Implementation of similar drug regimen review programs in home-health agencies could improve patient care, prevent adverse drug reactions, and achieve cost-effective medication utilization.

Lead levels in the hair of bipolar patients and normal controls

The analysis of hair samples taken from ten symptomatic bipolar patients and from ten normal controls matched for age, sex and race suggest that a relatively high body burden of lead may be associated with episodes of bipolar illness.

Estimated distributions of personal exposure to respirable particles

A method of estimating distributions of exposure to respirable particles is presented. Using pollutant monitoring data from outdoors and indoors, time-activity data and a time-weighted exposure model, means and variances for exposure distributions are generated. Variances are estimated using Gauss' law of error propagation. The model is calibrated using data from a personal monitoring study. Estimated distributions of exposure to respirable particles for children in six cities living in homes with and without smokers are presented. The implications of these estimates for air pollution epidemiology and needs for further research are discussed.

The effect of erythromycin on theophylline pharmacokinetics in chronic bronchitis

We examined theophylline pharmacokinetics for changes caused by the addition of erythromycin in patients with chronic bronchitis and obstructive pulmonary disease. Twelve hospitalized patients were randomized in a crossover fashion to receive aminophylline and either erythromycin or placebo. After the eighth dose, plasma was analyzed for theophylline, using the enzyme-mediated immunoassay technique. A 6-h urine collection was analyzed for theophylline metabolites, using high-pressure liquid chromatography. Erythromycin significantly decreased mean theophylline clearance by 22% from 4.9 L/min to 3.87 L/min (p less than 0.05). Mean peak theophylline levels increased 28% from 11.9 micrograms/ml to 15.3 micrograms/ml (p = 0.05). No change in urine theophylline metabolites was found. Patients with chronic bronchitis and obstructive pulmonary disease who begin erythromycin while receiving a preexisting therapeutic theophylline regimen experience a significant elevation of theophylline concentration, which predisposes to theophylline toxicity. For those patients with theophylline levels at the higher end of the therapeutic range (15 to 20 micrograms/ml), we recommend an initial 25% reduction in theophylline dosage when erythromycin is added. Serum theophylline levels should be monitored for further refinement of dosage.

Steady state urinary excretion of theophylline and its metabolites in the presence of erythromycin

The effect of erythromycin on the quantitative pattern of urinary excretion of theophylline and its known metabolites at steady state in eight human subjects was examined. The percent of dose excreted of the various compounds in the absence and presence of the antibiotic were as follows: theophylline, 9.3% vs. 16.3%; 1, 3-dimethyluric acid, 51.9% vs. 59.6%; 3-methylxanthine, 11.9% vs. 13.0%; and 1-methyluric acid, 27.3% vs. 31.6%. These results show that erythromycin did not influence the metabolism of theophylline under the experimental protocol employed.

Economic justification of pharmacist involement in patient medication consultation

The financial savings experienced by patients as a result of pharmacists' efforts in a discharge medication interview program were evaluated. The study involved 1,000 patients discharged from the surgery service of a university hospital. Pharmacists worked with physicians and patients in reducing the cost of medications by: (1) substituting less expensive drugs when possible, (2) relabeling bedside medication, (3) securing third party coverage for eligible patients, and (4) recommending purchase of non-prescription drugs over the counter. Savings of nearly +1,700 were realized on 517 out of 1,832 prescriptions; this was equal to +9.13 of savings to the patient per hour of pharmacist consultation time.