Application and demonstration of meso-activity exposure factors to advance estimates of incidental soil ingestion among agricultural workers

BACKGROUND

Soil is an understudied and underregulated pathway of chemical exposure, particularly for agricultural workers who cultivate food in soils. Little is known about how agricultural workers spend their time and how they may contact soil while growing food. Exposure factors are behavioral and environmental variables used in exposure estimation.

OBJECTIVES

Our study aimed to derive exposure factors describing how growers engage in different tasks and use those factors to advance the use of time-activity data to estimate soil ingestion exposures among agricultural workers.

METHODS

We administered a meso-activity-based, season-specific soil contact activity questionnaire to 38 fruit and vegetable growers. We asked growers to estimate the frequency and duration of six meso-activities and describe how they completed them. We used questionnaire data to derive exposure factors and estimate empirical and simulated exposures to a hypothetical contaminant in soil via incidental ingestion using daily, hourly, and hourly-task-specific ingestion rates.

RESULTS

We generated exposure factors characterizing the frequency and duration of six meso-activities by season, and self-reported soil contact, glove use, and handwashing practices by meso-activity and season. Seasonal average daily doses (ADDs) were similar across all three forms of ingestion rates. No consistent patterns regarding task-specific contributions to seasonal or annual ADDs were observed.

A qualitative characterization of meso-activity factors to estimate soil exposure for agricultural workers

BACKGROUND

Agricultural workers' exposure to soil contaminants is not well characterized. Activity pattern data are a useful exposure assessment tool to estimate extent of soil contact, though existing data do not sufficiently capture the range and magnitude of soil contact in the agricultural context.

OBJECTIVE

We introduce meso-activity, or specific tasks, to improve traditional activity pattern methodology. We propose a conceptual framework to organize the factors that may modify soil exposure and impact soil contact estimates within each meso-activity in agriculture. We build upon models from the US EPA to demonstrate an application of this framework to dose estimation.

METHODS

We conducted in-depth interviews with sixteen fruit and vegetable growers in Maryland to characterize factors that influence soil exposure in agriculture. For illustrative purposes, we demonstrate the application of the framework to translate our qualitative data into quantitative estimates of soil contact using US EPA models for ingestion and dermal exposure.

RESULTS

Growers discussed six tasks, or meso-activities, involving interaction with soil and described ten factors that may impact the frequency, duration and intensity of soil contact. We organized these factors into four categories (i.e., Environmental, Activity, Timing and Receptor; EAT-R) and developed a framework to improve agricultural exposure estimation and guide future research. Using information from the interviews, we estimated average daily doses for several agricultural exposure scenarios. We demonstrated how the integration of EAT-R qualitative factors into quantitative tools for exposure assessment produce more rigorous estimates of exposure that better capture the true variability in agricultural work.

SIGNIFICANCE

Our study demonstrates how a meso-activity-centered framework can be used to refine estimates of exposure for agricultural workers. This framework will support the improvement of indirect exposure assessment tools (e.g., surveys and questionnaires) and inform more comprehensive and appropriate direct observation approaches to derive quantitative estimations of soil exposure.

IMPACT STATEMENT

We propose a novel classification of activity pattern data that links macro and micro-activities through the quantification and characterization of meso-activities and demonstrate how the application of our qualitative framework improves soil exposure estimation for agricultural workers. These methodological advances may inform a more rigorous approach to the evaluation of pesticide and other chemical and biological exposures incurred by persons engaged in the cultivation of agricultural commodities in soil.

Urban Soil Safety Policies: The Next Frontier for Mitigating Lead Exposures and Promoting Sustainable Food Production

Urban soils bear the persistent legacy of leaded gasoline and past industrial practices. Soil safety policies (SSPs) are an important public health tool with the potential to inform, identify, and mitigate potential health risks faced by urban growers, but little is known about how these policies may protect growers from exposures to lead and other soil contaminants. We reviewed and evaluated 43 urban agriculture (UA) policies in 40 US cities pertaining to soil safety. About half of these cities had a least one SSP that offered recommendations or provided services for soil testing. Eight cities had at least one SSP containing a requirement pertaining to any topic (e.g., soil testing, a specific best practice for growing). We found notable inconsistencies across SSPs for "acceptable" levels of lead in soils and the activities and behaviors recommended at each level. We specify research needed to inform revisions to US Environmental Protection Agency guidance for lead in soils specific to UA. We conclude with a series of recommendations to guide the development or revision of SSPs.

Key considerations for assessing soil ingestion exposures among agricultural workers

BACKGROUND

Soil ingestion is a critical, yet poorly characterized route of exposure to contaminants, particularly for agricultural workers who have frequent, direct contact with soil.

OBJECTIVE

This qualitative investigation aims to identify and characterize key considerations for translating agricultural workers' soil ingestion experiences into recommendations to improve traditional exposure science tools for estimating soil ingestion.

METHODS

We conducted qualitative in-depth interviews with 16 fruit and vegetable growers in Maryland to characterize their behaviors and concerns regarding soil contact in order to characterize the nature of soil ingestion in the agricultural context.

RESULTS

We identified and discussed four emergent themes: (1) variability in growers' descriptions of soil and dust, (2) variability in growers' soil contact, (3) growers' concerns regarding soil contact, (4) growers' practices to modify soil contact. We also identified environmental and behavioral factors and six specific agricultural tasks that may impact soil ingestion rates.

SIGNIFICANCE

Our investigation fills an important gap in occupational exposure science methodology by providing four key considerations that should be integrated into indirect measurement tools for estimating soil ingestion rates in the agricultural context. Specifically, a task-based framework may provide a structure for future investigations of soil contact that may be useful in other populations.

Charting a Path Forward: Assessing the Science of Chemical Risk Evaluations under the Toxic Substances Control Act in the Context of Recent National Academies Recommendations

BACKGROUND

In 2016, Congress enacted the Frank R. Lautenberg Chemical Safety for the 21st Century Act ("the Lautenberg Act"), which made major revisions to the main U.S. chemical safety law, the 1976 Toxic Substances Control Act (TSCA). Among other reforms, the Lautenberg Act mandates that the U.S. Environmental Protection Agency (U.S. EPA) conduct comprehensive risk evaluations of chemicals in commerce. The U.S. EPA recently finalized the first set of such chemical risk evaluations.

OBJECTIVES

We examine the first 10 TSCA risk evaluations in relation to risk science recommendations from the National Academies to determine consistency with these recommendations and to identify opportunities to improve future TSCA risk evaluations by further implementing these key approaches and methods.

DISCUSSION

Our review of the first set of TSCA risk evaluations identified substantial deviations from best practices in risk assessment, including overly narrow problem formulations and scopes; insufficient characterization of uncertainty in the evidence; inadequate consideration of population variability; lack of consideration of background exposures, combined exposures, and cumulative risk; divergent approaches to dose-response assessment for carcinogens and noncarcinogens; and a flawed approach to systematic review. We believe these deviations result in underestimation of population exposures and health risks. We are hopeful that the agency can use these insights and have provided suggestions to produce chemical risk evaluations aligned with the intent and requirements of the Lautenberg Act and the best available science to better protect health and the environment-including the health of those most vulnerable to chemical exposures. https://doi.org/10.1289/EHP9649.

Health-related quality of life for pembrolizumab (pembro) plus ipilimumab (ipi) versus pembro plus placebo in patients with metastatic NSCLC with PD-L1 tumor proportion score ≥ 50%: KEYNOTE-598

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Background: In the phase 3 KEYNOTE-598 study (NCT03302234), OS (HR, 1.08; 95% CI, 0.85–1.37; P = 0.74) and PFS (1.06; 95% CI, 0.86–1.30; P = 0.72) were not improved for pembro + ipi vs pembro + placebo in patients (pts) with previously untreated metastatic NSCLC with PD-L1 tumor proportion score (TPS) ≥50% and without EGFR/ALK genomic alterations. Incidence of treatment-related grade 3–5 AEs, fatal AEs, and AEs leading to discontinuation was higher with pembro + ipi vs pembro + placebo. We present prespecified patient-reported outcome (PRO) analyses from KEYNOTE-598. Methods: Pts (n = 568) with previously untreated stage IV NSCLC with PD-L1 TPS ≥50% were randomized 1:1 to pembro 200 mg Q3W for up to 35 cycles + ipi 1 mg/kg or placebo Q6W for up to 18 cycles. The EORTC QLQ-C30, QLQ-LC13, EQ-5D-5L, and NSCLC-SAQ were administered at cycles 1‒7, then every 3 cycles through cycle 19, and every 4 cycles until PD or a maximum of 35 cycles. Change from baseline in global health status (GHS)/quality of life (QoL) score from the QLQ-C30 and the time to true deterioration (TTD) in the composite endpoint of cough (LC13), chest pain (LC13), or dyspnea (C30) were secondary objectives in KEYNOTE-598. Change from baseline in GHS/QoL was analyzed using a constrained longitudinal data analysis model with missing at random assumption. Difference in TTD was evaluated using a Cox proportional hazards model and stratified log-rank test. PROs were analyzed in all pts who completed ≥1 PRO assessment and received ≥1 dose of study treatment. P values are two-sided and nominal. Results: As of data cutoff (Sept 1, 2020), PRO analyses included 280 pts in the pembro + ipi group and 280 pts in the pembro + placebo group. QLQ-C30 completion rates were 95.7% in the pembro + ipi group vs 96.1% in the pembro + placebo group at baseline and 63.6% vs 70.0% at week 18. QLQ-LC13 completion rates were 95.4% vs 96.4% at baseline and 63.6% vs 69.6% at week 18. Mean QLQ-C30 GHS/QoL scores at baseline were 62.8 in the pembro + ipi group and 64.2 in the pembro + placebo group and were similar between the groups across the follow-up period. Least squares (LS) mean (95% CI) change from baseline to week 18 in GHS/QoL scores was improved in both groups (pembro + ipi: 3.7 [0.9‒6.5]; pembro + placebo: 4.1 [1.4‒6.9]), with no significant difference between groups (LS mean difference −0.4 [−4.0 to 3.1], P = 0.82). Median TTD in composite of cough, chest pain, or dyspnea was not reached (NR; 95% CI, 13.0 mo–NR) in the pembro + ipi group vs 20.0 (95% CI, 12.7–NR) mo in the pembro + placebo group (hazard ratio, 0.98 [95% CI, 0.74‒1.30]; P = 0.91). Conclusions: There was no difference in health-related QoL or TTD in lung cancer symptoms between pembro + ipi and pembro + placebo in pts with previously untreated metastatic NSCLC with PD-L1 TPS ≥50%. Clinical trial information: NCT03302234.

Long-term real-world outcomes of first-line (1L) pembrolizumab (pembro) monotherapy in PD-L1 ≥50% metastatic NSCLC

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Background: Pembro monotherapy was approved in the US in October 2016 as 1L therapy for patients with metastatic NSCLC and PD-L1 tumor proportion score (TPS) ≥50% based on findings from KEYNOTE-024. With 5-year follow-up in KEYNOTE-024, median overall survival (OS) was 26.3 months (95% CI, 18.3–40.4) in the pembro arm. With 4-year follow-up in KEYNOTE-042, median OS was 20.0 months (15.9–24.2) in the pembro PD-L1 ≥50% subgroup. Our aim was to describe long-term, real-world outcomes with 1L pembro monotherapy for patients treated at US oncology practices with disease characteristics similar to those in the KEYNOTE trials. Methods: Patients initiating 1L pembro monotherapy from December 1, 2016, through November 30, 2017, were selected from the US nationwide Flatiron Health de-identified, electronic health record-derived database if they had stage IV or recurrent metastatic NSCLC with PD-L1 TPS ≥50%, ECOG performance status 0–1, and no known EGFR/ALK/ROS1 aberration (confirmed negative EGFR/ALK for nonsquamous tumors). Enhanced manual chart review was used to determine real-world progression (rwP), tumor response (rwTR), and reasons for pembro discontinuation. OS and real-world progression-free survival (rwPFS) were estimated using the Kaplan-Meier method. Data cutoff was August 31, 2020. Results: Median study follow-up was 38.4 months (range, 33.1–44.9). Of 228 eligible patients, median age was 71 years (range, 46–82); 123 (54%) were women; 156 (68%), 12 (5%), and 60 (26%) had nonsquamous, not otherwise specified, and squamous NSCLC, respectively; and 209 (92%) were current/former smokers. History of brain metastasis was recorded for 17 (7%). Pembro was discontinued by 151 patients (66%), most commonly because of disease progression (70; 46%) and secondarily for toxic effect of therapy (35; 23%); 87 patients (38%) received ≥1 additional lines of therapy. OS, rwPFS, and rwTR results are shown below. Conclusions: In this real-world study with 3-year follow-up, patients with PD-L1 TPS ≥50% metastatic NSCLC without known EGFR/ALK aberrations and good performance status treated with 1L pembro monotherapy experienced median OS of 23 months, similar to the OS observed in phase III pivotal clinical trials, supporting the long-term OS benefits of 1L pembro monotherapy in this patient population.[Table: see text]

PSIII-14 The effects of variant auditory stimuli on goat kids’ formant patterns from birth to weaning

The objective of this study was to determine if exposure to human voice during early development affected the frequency of vocal formants (peaks in the harmonic spectrum) in Boer goat kids (n=13). The proposed mechanism is due to mimicry and imprinting on human or goat by comparing the developmental changes based on the presence of human vocal frequencies. From birth to weaning at d 60, goat kids were exposed to various ambient sound patterns through 3 treatments and frequency changes were studied to see if there was a change due to the presence of human voice. Treatment 1 was exposed to human voice vocalization via recording (n=5), treatment 2 was exposed to doe vocalization (n=4), and treatment 3 had no human or doe vocalization (n=4). Throughout the study, all kids were located in similarly controlled pen sizes roughly 2.44 x 3.05 m, received the same diets that exceed the NRC requirements for goat kids and ad libitum access to water. Kids were isolated and individually recorded weekly for approximately 120 to 1000 s using VoceVista Software. The software allowed researchers to record the frequency and intensity of kids’ bleats over the 7 wk period. Each goat kid’s fundamental frequency and second through fifth harmonics were collected at 5 locations through each week’s recording. There was no significant difference found between the three treatment groups throughout the study. However, there was a significant difference (P< 0.05) between the fundamental frequency, second, third, fourth, and fifth harmonics over the 7 wk period. The average fundamental frequency for wk 1 was (573 ± 61 Hz) compared to wk 7 (467 ± 47 Hz). The results of this study suggest that as the kids developed their frequencies progressively lowered over the 7 wk and various auditory exposures had no effect on their formant patterns.

59 The effects of audio exposure to goat kids’ relative intensity ratios of harmonics from birth to weaning

This study evaluated the effects of exposure to sound stimuli on goat kids’ relative intensity ratios (RIR) of harmonics one through five from d 0 to d 49 of growth. RIR are the ratio between a harmonic and the first harmonic. Day zero boer kids were randomly assigned to three treatment groups: treatment 1 (n=5) was only exposed to a single human voice recording, treatment 2 (n=4) was exposed to their boer dams, and treatment 3 (n=4) was exposed to no vocalizations. Each group was housed in pens (2.44 x 3.05 m) and received the same diets, which met or exceeded NRC requirements. The kids were isolated in their respective pens 1x/wk for 7 wk for 120 to 1000 s to obtain vocalization recordings. The kid’s vocalizations were collected via a Blue Snowball iCE condenser microphone and laptop. VoceVista Video software was utilized to analyze the relative intensities (dB) of the first five harmonics. Results indicate there is no difference in average RIR between the human and treatment 1 of the second, third, and the fifth harmonics. Kids raised next to the dams had significantly lower average (P < 0.05) RIR for all of the harmonics. No significant difference was noted between the average RIR of harmonics three, four, and five of treatment 3 and the human recording. No difference in the RIR of second, third, and fifth harmonics suggest that a goat kid exposed to only human vocalization exhibits a human-like tone in relation to these harmonics within the first 7 wks. A difference in treatment two from the average RIR of the dams and no difference between treatments one and three compared to the human recording indicate that exposure to vocalizations during growth does have an effect on seven-week-old kid harmonic intensities.

58 The relationship between the first harmonic intensity levels among boer goat siblings from birth to weaning

This study was conducted to determine whether the intensity levels of the first harmonic in small ruminants, such as Boer goats, are common among siblings or are affected by the environment in which they are raised. The first harmonic of a vocalization is the lowest frequency heard from that vocalization. All sequential harmonics are based upon the first. Three pens (2.44m x 3.05m) were created to control the external sound stimuli to which the kids (n=13) were exposed to. Pen 1 (n=4; 6, 7, 8, 9) was set up adjacent to the dams to ensure adult goat vocalizations were heard. Pen 2 (n=5; 1, 2, 3, 4, 5) involved a recording of a human voice played on a CD player. Pen 3 (n=4; 10, 11, 12, 13) was set up to limit external sound stimuli. Kids were placed in each pen upon birth order with the exception of one set of twins in pen 2. A set of triplets was included in the study with one sibling in each pen. Recordings were conducted using VoceVista Video software 1x/wk for 7 wk, from birth to weaning. Intensity levels of the first harmonic from each recording of each kid were compared to intensity levels of any of its siblings included in the study. One example of same sex siblings showed a significant difference (P < 0.05) from each other’s first harmonic intensity levels. Siblings of opposite genders showed no difference in intensity level in the first harmonics. The results of this study indicate that the intensity levels of the first harmonic of goat kids in the first 7 wks could be a result of relatedness rather than the influence of external sound. Additionally, the development the first harmonic intensity level among siblings is independent of external sound and gender.

Reimagining Public Health in the Aftermath of a Pandemic

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented challenge for society, affecting those already subject to unacceptable health inequalities and resulting in vast economic impacts. The pandemic reminds everyone of the value and necessity of public health.In the context of an era that will be shaped by COVID-19, we outline the coming series of challenges and transitions in public health and the needed actions over the next 5 years to reinvent our public health systems. Multiple limitations in current US and global public health systems have been uncovered by the pandemic, including insufficient preparedness and surveillance capabilities complicated by long-standing and worsening health inequalities and the rapid spread of misinformation that needs to be countered. We foresee 3 phases for public health over the next 5 years: (1) reactive crisis management, (2) efforts to maintain initial gains, and (3) efforts to sustain and enhance progress.A reinvented public health system will depend highly on leadership and political will, rethinking how we categorize and address population-level risk, employing 21st-century data sciences, and applying new communication skills.

0364 Sex and Race Influence Objective and Self-Report Sleep and Circadian Measures in Emerging Adults at Risk for Bipolar Spectrum Disorder

Introduction

There is a critical need to understand key factors that impact sleep and circadian rhythm function for emerging adults at risk for bipolar spectrum disorder (BSD). Sex and race are common demographic factors contributing to differences in health outcomes; however, the influence of these variables on sleep and circadian rhythm patterns for emerging adults at risk for BSD has not been characterized.

Methods

Multiple objective and self-report facets of sleep and circadian function, including dim light melatonin onset (DLMO), and measures derived from actigraphy and sleep diaries, were assessed in a 20-day ecological momentary assessment (EMA) study of 150 emerging adults (mean ± SD, 21.8 ± 2.1y; 58.7% female; 57.9% White, 23.4% Black, 10.3% Asian or Pacific Islander, 8.0% Other ethnicity) at-risk for BSD. Bivariate Pearson correlations (two-tailed, p <.05) were conducted between the sleep and circadian measures. ANCOVAs, controlling for BSD status, were conducted to evaluate differences on sleep and circadian characteristics by sex and race.

Results

Males exhibited better actigraphic sleep efficiency and later DLMO phase than females, whereas females exhibited more actigraphic discrete sleep periods. White participants exhibited more actigraphy-measured total sleep time, better sleep efficiency, and fewer sleep periods, and self-reported more total sleep time and better sleep efficiency than Black participants.

Conclusion

We show for the first time that sex and race are significant predictors of objective and self-reported sleep and circadian rhythm measures in a large sample of emerging adults at risk for BSD participating in an EMA study. Our findings extend the existing literature to a novel clinical population and to a naturalistic setting and inform ongoing research on sex and racial health disparities in sleep and circadian rhythms.

Support

This work was supported by NIH R01 MH77908 and R01 MH102310; a Banting Postdoctoral Fellowship from the Social Sciences and Humanities Research Council; and a National Science Foundation Graduate Student Research Fellowship.

Deregulation and the Assault on Science and the Environment

The quality of the environment is a major determinant of the health and well-being of a population. The role of scientific evidence is central in the network of laws addressing environmental pollution in the United States and has been critical in addressing the myriad sources of environmental pollution and the burden of disease attributable to environmental factors. We address the shift away from reasoned action and science to a reliance on belief and document the efforts to separate regulation from science and to remove science-based regulations and policies intended to protect public health. We outline the general steps for moving from research to policy, show how each has been undermined, offer specific examples, and point to resources that document the enormity of the current efforts to set aside scientific evidence.

Pembrolizumab plus chemotherapy for first-line treatment of metastatic nonsquamous non-small-cell lung cancer: a network meta-analysis

Aim: A systematic review and network meta-analysis were conducted to evaluate the efficacy of pembrolizumab + pemetrexed + platinum relative to other regimens in metastatic nonsquamous non-small-cell lung cancer (NSq-NSCLC). Patients & methods: Eligible studies evaluated first-line regimens in NSq-NSCLC patients without known targetable mutations. Relative treatment effects were synthesized with random effects proportional hazards Bayesian network meta-analyses. Results: The hazard ratio (HR) for overall survival (OS) for pembrolizumab + pemetrexed + platinum was statistically significant over all platinum-doublet (HR range: 0.42–0.61), platinum-doublet + bevacizumab (HR range: 0.44–0.53) and platinum-doublet + atezolizumab regimens (HR range: 0.56–0.62). Additionally, pembrolizumab + pemetrexed + platinum numerically improved OS over atezolizumab + paclitaxel + carboplatin + bevacizumab (HR: 0.65; 95% credible interval: 0.43, 1.01). Pembrolizumab + pemetrexed + platinum had 95.6% probability of being the best treatment regimen for OS. Conclusion: Pembrolizumab + pemetrexed + platinum is likely the most efficacious first-line regimen for metastatic NSq-NSCLC.

Building Healthy Community Environments: A Public Health Approach

Environmental quality has a profound effect on health and the burden of disease. In the United States, the environment-related burden of disease is increasingly dominated by chronic diseases. At the local level, public health practitioners realize that many policy decisions affecting environmental quality and health transcend the authorities of traditional health department programs. Healthy decisions about the built environment, including housing, transportation, and energy, require broad collaborative efforts. Environmental health professionals have an opportunity to address the shift in public health burden toward chronic diseases and play an important role in the design of healthy communities by bringing data and tools to decision makers. This article provides a guide for community leaders to consider the public health effects of decisions about the built environment. We present a conceptual framework that represents a shift from compartmentalized solutions toward an inclusive systems approach that encourages partnership across disciplines and sectors. We discuss practical tools to assist with environmental decision making, such as Health Impact Assessments, environmental public health tracking, and cumulative risk assessment. We also identify priorities in research, practice, and education to advance the role of public health in decision making to improve health, such as the Health Impact Assessment, as a core competency for environmental health practitioners. We encourage cross-disciplinary communication, research, and education that bring the fields of planning, transportation, and energy in closer collaboration with public health to jointly advance the systems approach to today's environmental challenges.

Epidemiology: a foundation of environmental decision making

Many epidemiologic studies are designed so they can be drawn upon to provide scientific evidence for evaluating hazards of environmental exposures, conducting quantitative assessments of risk, and informing decisions designed to reduce or eliminate harmful exposures. However, experimental animal studies are often relied upon for environmental and public health policy making despite the expanding body of observational epidemiologic studies that could inform the relationship between actual, as opposed to controlled, exposures and health effects. This paper provides historical examples of how epidemiology has informed decisions at the U.S. Environmental Protection Agency, discusses some challenges with using epidemiology to inform decision making, and highlights advances in the field that may help address these challenges and further the use of epidemiologic studies moving forward.

Opportunities and Challenges for Dietary Arsenic Intervention

The diet is emerging as the dominant source of arsenic exposure for most of the U.S. population. Despite this, limited regulatory efforts have been aimed at mitigating exposure, and the role of diet in arsenic exposure and disease processes remains understudied. In this brief, we discuss the evidence linking dietary arsenic intake to human disease and discuss challenges associated with exposure characterization and efforts to quantify risks. In light of these challenges, and in recognition of the potential longer-term process of establishing regulation, we introduce a framework for shorter-term interventions that employs a field-to-plate food supply chain model to identify monitoring, intervention, and communication opportunities as part of a multisector, multiagency, science-informed, public health systems approach to mitigation of dietary arsenic exposure. Such an approach is dependent on coordination across commodity producers, the food industry, nongovernmental organizations, health professionals, researchers, and the regulatory community. https://doi.org/10.1289/EHP3997.

Media Messages and Perception of Risk for Ebola Virus Infection, United States

News media have been blamed for sensationalizing Ebola in the United States, causing unnecessary alarm. To investigate this issue, we analyzed US-focused news stories about Ebola virus disease during July 1–November 30, 2014. We found frequent use of risk-elevating messages, which may have contributed to increased public concern.

Chemical Risk Assessment: Traditional vs Public Health Perspectives

Preventing adverse health effects of environmental chemical exposure is fundamental to protecting individual and public health. When done efficiently and properly, chemical risk assessment enables risk management actions that minimize the incidence and effects of environmentally induced diseases related to chemical exposure. However, traditional chemical risk assessment is faced with multiple challenges with respect to predicting and preventing disease in human populations, and epidemiological studies increasingly report observations of adverse health effects at exposure levels predicted from animal studies to be safe for humans. This discordance reinforces concerns about the adequacy of contemporary risk assessment practices for protecting public health. It is becoming clear that to protect public health more effectively, future risk assessments will need to use the full range of available data, draw on innovative methods to integrate diverse data streams, and consider health endpoints that also reflect the range of subtle effects and morbidities observed in human populations. Considering these factors, there is a need to reframe chemical risk assessment to be more clearly aligned with the public health goal of minimizing environmental exposures associated with disease.

The bacterial virulence factors VopL and VopF nucleate actin from the pointed end

How the bacterial virulence factors VopL/F from Vibrio catalyze actin nucleation is unclear. Using multicolor TIRF microscopy imaging, Burke et al. find that VopL and VopF stimulate actin assembly via identical pointed-end nucleation mechanisms.

VopL and VopF (VopL/F) are tandem WH2-domain actin assembly factors used by infectious Vibrio species to induce actin assembly in host cells. There is disagreement about the filament assembly mechanism of VopL/F, including whether they associate with the filament barbed or pointed end. Here, we used multicolor total internal reflection fluorescence microscopy to directly observe actin assembly with fluorescently labeled VopL/F. In actin monomer assembly reactions, VopL/F exclusively nucleate actin filament assemblies, remaining only briefly associated with the pointed end. VopL/F do not associate with the ends of preassembled filaments. In assembly reactions with saturating profilin, ∼85% of VopL/F molecules also promote nucleation from the pointed end, whereas a smaller fraction (<15%) associate for ∼25 s with the barbed end of preassembled filaments, inhibiting their elongation. We conclude that VopL/F function primarily as actin nucleation factors that remain briefly (∼100 s) associated with the pointed end.

Rethinking Environmental Protection: Meeting the Challenges of a Changing World

From climate change to hydraulic fracturing, and from drinking water safety to wildfires, environmental challenges are changing. The United States has made substantial environmental protection progress based on media-specific and single pollutant risk-based frameworks. However, today’s environmental problems are increasingly complex and new scientific approaches and tools are needed to achieve sustainable solutions to protect the environment and public health. In this article, we present examples of today’s environmental challenges and offer an integrated systems approach to address them. We provide a strategic framework and recommendations for advancing the application of science for protecting the environment and public health. We posit that addressing 21st century challenges requires transdisciplinary and systems approaches, new data sources, and stakeholder partnerships. To address these challenges, we outline a process driven by problem formulation with the following steps: a) formulate the problem holistically, b) gather and synthesize diverse information, c) develop and assess options, and d) implement sustainable solutions. This process will require new skills and education in systems science, with an emphasis on science translation. A systems-based approach can transcend media- and receptor-specific bounds, integrate diverse information, and recognize the inextricable link between ecology and human health.

Legal Preparedness for Hurricane Sandy: Authority to Order Hospital Evacuation or Shelter-in-Place in the Mid-Atlantic Region

Hospitals were once thought to be places of refuge during catastrophic hurricanes, but recent disasters such as Hurricanes Katrina and Sandy have demonstrated that some hospitals are unable to ensure the safety of patients and staff and the continuity of medical care at key times. The government has a duty to safeguard public health and a responsibility to ensure that appropriate protective action is taken when disasters threaten or impair the ability of hospitals to sustain essential services. The law can enable the government to fulfill this duty by providing necessary authority to order preventive or reactive responses--such as ordering evacuation of or sheltering-in-place in hospitals--when safety is imperiled. We systematically identified and analyzed state emergency preparedness laws that could have affected evacuation of and sheltering-in-place in hospitals in order to characterize the public health legal preparedness of 4 states (Delaware, Maryland, New Jersey, and New York) in the mid-Atlantic region during Hurricane Sandy in 2012. At that time, none of these 4 states had enacted statutes or regulations explicitly granting the government the authority to order hospitals to shelter-in-place. Whereas all 4 states had enacted laws explicitly enabling the government to order evacuation, the nature of this authority and the individuals empowered to execute it varied. We present empirical analyses intended to enhance public health legal preparedness and ensure these states and others are better able to respond to future natural disasters, which are predicted to be more severe and frequent as a result of climate change, as well as other hazards. States can further improve their readiness for catastrophic disasters by ensuring explicit statutory authority to order evacuation and to order sheltering-in-place, particularly of hospitals, where it does not currently exist.

News media coverage of U.S. Ebola policies: Implications for communication during future infectious disease threats

The Ebola outbreak of 2014-2015 raised concerns about the disease's potential spread in the U.S. and received significant news media coverage. Prior research has shown that news media coverage of policy options can influence public opinion regarding those policies, as well as public attitudes toward the broader social issues and target populations addressed by such policies. To assess news media coverage of Ebola policies, the content of U.S.-focused news stories (n=1262) published between July 1 and November 30, 2014 from 12 news sources was analyzed for 13 policy-related messages. Eight-two percent of news stories mentioned one or more policy-related messages. The most frequently appearing policy-related messages overall were those about isolation (47%) and quarantine (40%). The least frequently mentioned policy-related message described dividing potentially exposed persons into distinct groups based on their level of Ebola risk in order to set different levels of restrictions (5%). Message frequency differed depending on whether news sources were located in an area that experienced an Ebola case or controversy, by news sources' political ideological perspective, and by type of news source (print and television). All policy-related messages showed significant increases in frequency after the first case of Ebola was diagnosed in the U.S. on September 30, 2014, with the exception of messages related to isolation, which showed a significant decrease. Results offer insight into how the news media covers policies to manage emerging disease threats.

The Epidemiology of Stroke in the East Asian Region: A Literature-Based Review

Stroke is a leading cause of morbidity and mortality in the developed world. Our objective was to review comparable studies of stroke incidence, prevalence, and subtypes in the East Asian region. English language epidemiologic studies of stroke published from 1984 through 2004 were identified for the East Asian region (China, Hong Kong, Taiwan, Japan, North and South Korea and the ASEAN countries). The Sudlow–Warlow criteria were modified to identify comparable studies. Stroke epidemiology is relatively well characterized in China, Taiwan, and Japan; however, little information is available for other countries. Four studies of stroke incidence, from China, Taiwan, and Japan, were identified, which reported a total of 4995 first-ever stroke events. There was an over twofold difference in the age-adjusted incidence of stroke between the Chinese Seven Cities and Okinawa study (483 vs 201 per 100 000). The 1-month case fatality rate ranged from 12·7% to 17·3%. Only one population-based study on stroke prevalence, from Taiwan, was identified: Studies show the relatively high proportion of hemorrhagic stroke (30%). Stroke epidemiology is relatively well characterized in China, Japan, and Taiwan but not in other countries in the region. More recent data are needed to monitor stroke prevention efforts and guide planning of health care resources in the region.

Anticipatory Nausea, Risk Factors, and Its Impact on Chemotherapy-Induced Nausea and Vomiting: Results From the Pan European Emesis Registry Study

CONTEXT

Anticipatory (prechemotherapy) nausea (AN) is a classic conditioned symptom not responding well to current antiemetics. Minimal work has been done to assess its risk factors and impact on chemotherapy-induced nausea and vomiting (CINV).

OBJECTIVES

To evaluate risk factors for AN and assess its impact on CINV development.

METHODS

We analyzed data (n = 991) from a prospective observational multisite study in eight European countries over three cycles of chemotherapy. Patient/treatment characteristics were collected before chemotherapy. History of nausea/vomiting (yes/no), patient expectation of CINV (0-100 mm visual analog scale, [VAS]), and prechemotherapy anxiety (0-100 mm VAS) also were collected before chemotherapy. A patient-completed diary during each chemotherapy cycle obtained information on AN in the 24 hours before chemotherapy administration and nausea and vomiting (episodes of vomiting and severity of nausea) daily for five days after administration of chemotherapy (0-100 mm VAS).

RESULTS

AN was reported by 8.3%-13.8% of patients, increasing in frequency and intensity over each cycle. Every 1 mm increase in AN on the VAS was significantly associated with 2%-13% of increase in the likelihood of CINV (all P-values <0.05). Key predictors of AN in Cycle 1 included metastatic disease and prechemotherapy anxiety. However, predictors of AN in subsequent cycles included prechemotherapy anxiety and AN and CINV experience in the previous cycle, the latter being the strongest predictor (odds ratio = 3.30-4.09 for CINV outcomes over the cycles).

CONCLUSION

AN is a challenging symptom, and its prevention needs to consider better CINV prevention in the previous cycles as well as managing prechemotherapy anxiety.

Informing 21st-Century Risk Assessments with 21st-Century Science

Understanding and preventing adverse impacts from chemicals in the environment is fundamental to protecting public health, and chemical risk assessments are used to inform public health decisions in the United States and around the world. Traditional chemical risk assessments focus on health effects of environmental contaminants on a chemical-by-chemical basis, largely based on data from animal models using exposures that are typically higher than those experienced by humans. Results from environmental epidemiology studies sometimes show effects that are not observed in animal studies at human exposure levels that are lower than those used in animal studies. In addition, new approaches such as Toxicology in the 21st Century (Tox21) and exposure forecasting (ExpoCast) are generating mechanistic data that provide broad coverage of chemical space, chemical mixtures, and potential associated health outcomes, along with improved exposure estimates. It is becoming clear that risk assessments in the future will need to use the full range of available mechanistic, animal, and human data to integrate multiple types of data and to consider nontraditional health outcomes and end points. This perspective was developed at the "Strengthening the Scientific Basis of Chemical Safety Assessments" workshop, which was cosponsored by the U.S. Environmental Protection Agency and the National Institute of Environmental Health Sciences, where gaps between the emerging science and traditional chemical risk assessments were explored, and approaches for bridging the gaps were considered.

First-line treatment of metastatic NSCLC (mNSCLC) patients without actionable mutations in U.S. community oncology clinical practice

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Background: Benchmarking high quality care requires defining optimally effective practice patterns. As first step, contemporary real-world practice must be detailed. The purpose of this study is to describe patient flow from diagnosis of mNSCLC to initiation of anti-cancer drug therapy in patients without known EGFR/ALK genomic tumor aberrations; the characteristics and first-line (1L) anti-cancer treatment of these patients, including induction and maintenance therapy. Methods: Retrospective database cohort study using data from an oncology EHR system, representing 17% of incident cancer cases from US community setting. Study population includes patients diagnosed with stage IV mNSCLC treated between 11/ 1/12 and 1/31/15 with follow-up to 7/31/15. Treatment patterns include regimen, number of doses, and time to regimen discontinuation. Data are analyzed descriptively, for overall cohort and by histology, with time to treatment discontinuation analyses using the Kaplan Meier method. Results: Of 4441 patients with mNSCLC, 88% had EGFR/ALK negative or unknown status. Of 79% who initiated 1L therapy, 69.5% (n = 2014) of patients (78.4% non-squamous, 21.7% squamous) were included. 55.1% were men; 89.8% were age 65+. 83.4% received induction therapy only; 16.6% received induction and maintenance therapy. 85% received a platinum combination as induction therapy; the majority either received a carboplatin doublet (53.5%) or carboplatin doublet in combination with targeted therapy (23.3%). 14.4% received a non-platinum based regimen. During induction therapy only, mean duration for the most common regimen category (platinum based combination) was 96.9 (IQR 43-129) for squamous and 79.45 (IQR 36-108) days for non-squamous patients. Of non-squamous patients who received induction followed by maintenance, mean duration of therapy was 103.9 (IQR 66-134) and 140.7 (IQR 45-208) days for induction and maintenance, respectively. Conclusions: Results describe treatment patterns in the US community 1L setting, prior to introduction of anti-PD1/PD-L1 inhibitors and new angiogenesis inhibitors. These form a starting point for benchmarking high quality care in mNSCLC.

Profilin regulates F-actin network homeostasis by favoring formin over Arp2/3 complex

Fission yeast cells use Arp2/3 complex and formin to assemble diverse filamentous actin (F-actin) networks within a common cytoplasm for endocytosis, division, and polarization. Although these homeostatic F-actin networks are usually investigated separately, competition for a limited pool of actin monomers (G-actin) helps to regulate their size and density. However, the mechanism by which G-actin is correctly distributed between rival F-actin networks is not clear. Using a combination of cell biological approaches and in vitro reconstitution of competition between actin assembly factors, we found that the small G-actin binding protein profilin directly inhibits Arp2/3 complex-mediated actin assembly. Profilin is therefore required for formin to compete effectively with excess Arp2/3 complex for limited G-actin and to assemble F-actin for contractile ring formation in dividing cells.

International cross-cultural validation study of the Canadian haemophilia outcomes: kids' life assessment tool

Health-related quality of life (HRQoL) assessment is recognized as an important outcome in the evaluation of different therapeutic regimens for persons with haemophilia. The Canadian Haemophilia Outcomes-Kids' Life Assessment Tool (CHO-KLAT) is a disease-specific measure of HRQoL for 4 to 18-year-old boys with haemophilia. The purpose of this study was to extend this disease-specific, child-centric, outcome measure for use in international clinical trials. We adapted the North American English CHO-KLAT version for use in five countries: France, Germany, the Netherlands, Spain and the United Kingdom (UK). The process included four stages: (i) translation; (ii) cognitive debriefing; (iii) validity assessment relative to the PedsQL (generic) and the Haemo-QoL (disease-specific) and (iv) assessment of inter and intra-rater reliability. Cognitive debriefing was performed in 57 boys (mean age 11.4 years), validation was performed in 144 boys (mean age 11.0 years) and reliability was assessed for a subgroup of 64 boys (mean age 12.0 years). Parents also participated. The mean scores reported by the boys were high: CHO-KLAT 77.0 (SD = 11.2); PedsQL 83.8 (SD = 11.9) and Haemo-QoL 79.6 (SD = 11.5). Correlations between the CHO-KLAT and PedsQL ranged from 0.63 in Germany to 0.39 in the Netherlands and Spain. Test-retest reliability (concordance) for child self-report was 0.67. Child-parent concordance was slightly lower at 0.57. The CHO-KLAT has been fully culturally adapted and validated for use in five different languages and cultures (in England, the Netherlands, France, Germany and Spain) where treatment is readily available either on demand or as prophylaxis.

Fission yeast profilin is tailored to facilitate actin assembly by the cytokinesis formin Cdc12

The evolutionarily conserved small actin-monomer binding protein profilin is believed to be a housekeeping factor that maintains a general pool of unassembled actin. However, despite similar primary sequences, structural folds, and affinities for G-actin and poly-L-proline, budding yeast profilin ScPFY fails to complement fission yeast profilin SpPRF temperature-sensitive mutant cdc3-124 cells. To identify profilin's essential properties, we built a combinatorial library of ScPFY variants containing either WT or SpPRF residues at multiple positions and carried out a genetic selection to isolate variants that support life in fission yeast. We subsequently engineered ScPFY(9-Mut), a variant containing nine substitutions in the actin-binding region, which complements cdc3-124 cells. ScPFY(9-Mut), but not WT ScPFY, suppresses severe cytokinesis defects in cdc3-124 cells. Furthermore, the major activity rescued by ScPFY(9-Mut) is the ability to enhance cytokinesis formin Cdc12-mediated actin assembly in vitro, which allows cells to assemble functional contractile rings. Therefore an essential role of profilin is to specifically facilitate formin-mediated actin assembly for cytokinesis in fission yeast.

Impact of CINV in earlier cycles on CINV and chemotherapy regimen modification in subsequent cycles in Asia Pacific clinical practice

PURPOSE

We sought to describe the impact of chemotherapy-induced nausea and vomiting (CINV) in prior cycles on CINV and chemotherapy regimen modification in subsequent cycles.

METHODS

Eligible patients in this multinational prospective observational study were adults (≥18 years old) receiving their first single-day highly or moderately emetogenic chemotherapy (HEC or MEC). Multivariate logistic regression was used to assess the impact of CINV in prior cycles on CINV in subsequent cycles. Other independent variables included in the model were the cycle number, age, sex, and emetogenicity of regimen.

RESULTS

There were 598 evaluable patients in cycle 2 and 533 in cycle 3, half receiving HEC and half MEC. Patients who experienced complete response (no emesis or rescue antiemetics) in earlier cycles, relative to those with no complete response, had an adjusted odds ratio (OR) of 5.9 (95% confidence interval (CI), 4.14-8.50) for experiencing complete response in subsequent cycles. Prior CINV was a significant and consistent predictor of subsequent CINV for all CINV endpoints: for emesis, OR 12.7 (95% CI, 8.47-18.9), for clinically significant nausea, OR 7.9 (95% CI, 5.66-10.9), and for clinically significant nausea and/or vomiting, OR 7.2 (5.17-10.1). Modifications to chemotherapy were recorded for 26-29% of patients in cycles 2 and 3, with CINV as the major reason for the modification for 5-9% of these patients.

CONCLUSIONS

CINV in prior cycles was a strong and consistent predictor of CINV in subsequent cycles, while the incidence of chemotherapy regimen modification due to CINV was low in individual cycles.

Baseline patient characteristics, incidence of CINV, and physician perception of CINV incidence following moderately and highly emetogenic chemotherapy in Asia Pacific countries

PURPOSE

This paper describes the incidence of chemotherapy-induced nausea and vomiting (CINV) after highly or moderately emetogenic chemotherapy (HEC or MEC) for cancer in six Asia Pacific countries.

METHODS

Sequential adult patients naïve to chemotherapy and scheduled to receive at least two cycles of single-day HEC or MEC were enrolled in this prospective observational study. Patients completed the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool on post-chemotherapy days 2 and 6 to record acute-phase (first 24 h) and delayed-phase (days 2-5) CINV.

RESULTS

There were 648 evaluable patients (318 HEC, 330 MEC) from Australia (n = 74), China (153), India (88), Singapore (57), South Korea (151), and Taiwan (125). Mean (SD) patient age was 56 (12) and 58% of patients were women; the most common primary cancers were breast (27%), lung (22%), and colon (20%). Overall in cycle 1, complete response (no emesis or rescue antiemetics) was recorded by 69% (95% confidence interval (CI), 66-73) of all evaluable patients, with country percentages ranging from 55 to 78% (p < 0.001). After HEC, no emesis was recorded by 75% and no nausea by 38% of patients. After MEC, 80% had no emesis and 50% no nausea. Acute-phase CINV was better controlled than delayed-phase CINV, and the control of nausea was the lowest of any CINV measure in all phases. In a CINV perception survey, physicians tended to overestimate emesis rate and underestimate nausea rate.

CONCLUSIONS

CINV remains a substantial problem, and country-specific information about CINV can be useful in developing strategies to improve outcomes for patients undergoing chemotherapy.

Antiemetic therapy in Asia Pacific countries for patients receiving moderately and highly emetogenic chemotherapy--a descriptive analysis of practice patterns, antiemetic quality of care, and use of antiemetic guidelines

PURPOSE

This paper reports prescribing patterns for prophylaxis of chemotherapy-induced nausea and vomiting (CINV) after highly or moderately emetogenic chemotherapy (HEC or MEC) for cancer in six Asia Pacific countries.

METHODS

In a prospective noninterventional study, 31 sites in Australia, China, India, Singapore, South Korea, and Taiwan recorded details of CINV prophylaxis for the acute phase (first 24 h) and delayed phase (days 2-5) after single-day HEC or MEC for adult patients. Additional information on CINV prophylactic medications was collected from 6-day patient diaries. Primary antiemetic therapies were defined as corticosteroids, the 5-hydroxytryptamine-3 receptor antagonists (5HT3-RAs), and neurokinin-1 receptor antagonists (NK1-RAs).

RESULTS

Evaluable patients in cycle 1 numbered 648 (318 [49%] HEC and 330 [51%] MEC) of mean (SD) age of 56 (12) years, including 58% women. For the acute phase after HEC, overall (and country range), 96% (91-100%) of patients received a 5HT3-RA, 87% (70-100%) a corticosteroid, and 43% (0-91%) an NK1-RA. CINV prophylaxis for the HEC delayed phase was more variable: including 22% (7-65%) 5HT3-RA, 52% (12-93%) corticosteroid, and 46% (0-88%) NK1-RA. For the MEC acute phase, 97% (87-100%) of patients received 5HT3-RA and 86% (73-97%) a corticosteroid. For the MEC delayed phase, 201 patients (61%) received a primary antiemetic, including 5HT3-RA (41%), corticosteroid (37%), and/or NK1-RA (4%).

CONCLUSIONS

The 5HT3-RAs were prescribed consistently in all countries, while prescribing of other antiemetic therapies was variable, and corticosteroids were under-prescribed for CINV prophylaxis, particularly in the delayed phase.

Rationale and design of the Pan Australasian chemotherapy-induced emesis burden of illness study

BACKGROUND

Preventing and managing chemotherapy-induced nausea and vomiting (CINV) remain important goals. The objective of the Pan Australasian chemotherapy-induced emesis burden of illness (PrACTICE) study was to describe the incidence of CINV after highly or moderately emetogenic chemotherapy (HEC or MEC) for cancer in current clinical practice in Australia and five Asian countries (China, India, Singapore, South Korea, and Taiwan).

STUDY DESIGN

This prospective, observational study of CINV was conducted at 31 sites in these six countries from August 2011 through September 2012 and enrolled male and female adult patients (≥18 years of age) naïve to HEC and MEC who were scheduled to receive at least two cycles of single-day chemotherapy. The primary effectiveness endpoint was complete response, defined as no vomiting or use of rescue therapy, during chemotherapy cycle 1 in the overall phase (0-120 h), acute phase (0-24 h), and delayed phase (>24-120 h). Study outcomes were analyzed descriptively. Primary outcomes, CINV incidence, and treatment patterns (chemotherapy, CINV prophylaxis, rescue medication prescription, and rescue medication use) were assessed by phase (overall, acute, delayed), by cycle (as appropriate), within and across countries, and by level of chemotherapy emetogenicity (HEC vs. MEC). The impact of CINV in cycle 1 on CINV in cycle 2 was analyzed for all patients with evaluable data for cycle 2. No site-specific analyses were performed. The remainder of this special series of papers reports on the results of this study.

Evaluation of risk factors predicting chemotherapy-related nausea and vomiting: results from a European prospective observational study

CONTEXT

Demographic, personal, clinical, and behavioral factors predicting chemotherapy-induced nausea and vomiting (CINV) have been assessed in the past, but inconsistencies exist in the literature, studies have methodological shortcomings, and many risk factors have been examined in cross-sectional studies and univariate analyses.

OBJECTIVES

To evaluate the predictive power of personal and treatment-related characteristics in the development of CINV, using a large and prospectively evaluated sample of a heterogeneous group of cancer patients receiving routine chemotherapy.

METHODS

This was a multicountry, multisite prospective study over three cycles of chemotherapy. Adult patients from eight European countries about to receive highly and moderately emetogenic chemotherapy were recruited. Clinicians completed a case report form at or before the initial chemotherapy treatment, recording patient demographic and baseline clinical characteristics. Participants completed a daily patient diary for six days per chemotherapy cycle describing their CINV experience. Baseline patient data also included a history of nausea/vomiting (yes/no), patient expectation of nausea (0-100 mm visual analogue scale [VAS]), prechemotherapy anxiety (0-100 mm VAS), and prechemotherapy nausea (0-100 mm VAS) measured during the 24-hour period before chemotherapy initiation.

RESULTS

There were 991 evaluable patients with complete Cycle 1 data, 888 for Cycle 2 data, and 769 for Cycle 3 data. A complex picture of predictor variables was shown, with different contribution of variables to the acute, delayed, and overall phases of CINV. Key predictor variables included the use of antiemetics inconsistent with international guidelines, younger age, prechemotherapy nausea, and no CINV complete response in an earlier cycle (all at P < 0.05). Anxiety, history of nausea/vomiting, and expectations of nausea were important predictors for some phases and cycles but not consistently across the CINV pathway.

CONCLUSION

The results of this study provide clarity for the relative contribution of a set of characteristics in the development of CINV. Following evidence-based clinical antiemetic guidelines is of paramount importance, alongside treating patients with increased risk for CINV more aggressively, which both could lead to more optimal CINV management. These data can assist clinicians in making decisions about the antiemetic management of their patients.

Global methylmercury exposure from seafood consumption and risk of developmental neurotoxicity: a systematic review

OBJECTIVE

To examine biomarkers of methylmercury (MeHg) intake in women and infants from seafood-consuming populations globally and characterize the comparative risk of fetal developmental neurotoxicity.

METHODS

A search was conducted of the published literature reporting total mercury (Hg) in hair and blood in women and infants. These biomarkers are validated proxy measures of MeHg, a neurotoxin found primarily in seafood. Average and high-end biomarkers were extracted, stratified by seafood consumption context, and pooled by category. Medians for average and high-end pooled distributions were compared with the reference level established by a joint expert committee of the Food and Agriculture Organization (FAO) and the World Health Organization (WHO).

FINDINGS

Selection criteria were met by 164 studies of women and infants from 43 countries. Pooled average biomarkers suggest an intake of MeHg several times over the FAO/WHO reference in fish-consuming riparians living near small-scale gold mining and well over the reference in consumers of marine mammals in Arctic regions. In coastal regions of south-eastern Asia, the western Pacific and the Mediterranean, average biomarkers approach the reference. Although the two former groups have a higher risk of neurotoxicity than the latter, coastal regions are home to the largest number at risk. High-end biomarkers across all categories indicate MeHg intake is in excess of the reference value.

CONCLUSION

There is a need for policies to reduce Hg exposure among women and infants and for surveillance in high-risk populations, the majority of which live in low-and middle-income countries.

Antiemetic guideline consistency and incidence of chemotherapy-induced nausea and vomiting in US community oncology practice: INSPIRE Study

PURPOSE

Consensus guidelines for preventing chemotherapy-induced nausea and vomiting (CINV) are variably implemented in practice. The purpose of this study was to evaluate the impact of guideline-consistent/guideline-inconsistent CINV prophylaxis (GCCP/GICP) on the incidence of no CINV after cycle 1 of highly or moderately emetogenic chemotherapy (HEC or MEC).

PATIENTS AND METHODS

This prospective observational study enrolled chemotherapy-naive adult outpatients who received single-day HEC or MEC at four oncology practice networks, all using electronic health record (EHR) systems, in Georgia, Tennessee, and Florida. Results from the Multinational Association of Supportive Care in Cancer Antiemesis Tool, a validated tool to measure CINV, administered 5 to 8 days postchemotherapy, were merged with EHR data. The primary end point, no CINV, defined as no emesis and no clinically significant nausea (score < 3 on 0-10 scale), was compared between cohorts using logistic regression.

RESULTS

A total of 1,295 patients were enrolled (mean age, 59.3 years; 70.0% female; 35.5% HEC). The overall prevalence of GCCP was 57.3%. When corticosteroids were prescribed on days 2 to 4 after all HEC, GCCP for HEC increased from 28.7% to 89.8%; when NK1-receptor antagonists were prescribed after all MEC, GCCP for MEC increased from 73.1% to 97.8%. Over 5 days postchemotherapy, the incidence of no CINV was significantly higher in the GCCP cohort than the GICP cohort (53.4% v 43.8%; P < .001). The adjusted odds of no CINV with GCCP was 1.31 (95% CI, 1.07 to 1.69; P = .037).

CONCLUSION

Increased adherence to antiemetic guidelines could significantly reduce the incidence of CINV after HEC and MEC.

The burden of chemotherapy-induced nausea and vomiting in the Asia Pacific (AP) region: The Pan Australasian chemotherapy-induced emesis study

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Background: There are limited data on CINV in AP, a region diverse in healthcare systems and standards of care. The primary objective was to estimate the country-specific percentage of patients with complete response (CR: no emesis and no use of rescue medication) in the overall phase (0-120 hours) during cycle 1 by regimen emetogenicity. Methods: This was a prospective, observational study of highly and moderately emetogenic chemotherapy (HEC/MEC)-naive adults from 6 AP countries. Patients completed a diary over a 120 hour period following chemotherapy. The study was designed to enroll a minimum of 45 patients by HEC/MEC and country to describe CR with a 95% CI +/-15%. Results: There were 648 evaluable patients enrolled at 31 sites from Aug. 2011 - Jul. 2012. The mean age was 55.8. 57.7% were female. The most common regimens were cisplatin-based (168/318; 52.8%) for HEC, and oxaliplatin-based (156/330; 47.3%) for MEC. Site of chemotherapy administration was outpatient/day case (51.4%; 333/648) and inpatient (48.6%; 315/648). Outpatient/day case chemotherapy administration was used for all patients in Australia and Singapore. Inpatient administration was common in China (85%, 130/153) and S. Korea (64.2%, 97/151). ASCO QOPI-recommended antiemetic prophylaxis was used in 38.7% (123/318) of HEC (5HT3-RA/steroid/NK1-RA) and 83.9% (277/330) of MEC (5HT3-RA/steroid). Prophylaxis differed between countries (p<0.001). CR is shown below. Conclusions: CINV outcomes, use of guideline-recommended prophylaxis, and site of chemotherapy administration significantly varied across AP countries. There is considerable room to improve CINV outcomes and use of recommended antiemetic prophylaxis in the region. [Table: see text]

Antiemetic guideline consistency and incidence of chemotherapy-induced nausea and vomiting (CINV) in U.S. community oncology practice: INSPIRE study

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Background: Electronic Health Records (EHRs) are a valuable source to evaluate the quality of oncology care, particularly when combined with patient outcomes data. Our objective was to evaluate the impact of guideline consistent/inconsistent chemotherapy prophylaxis (GCCP, GICP) on the incidence of no CINV after cycle 1 of highly or moderately emetogenic chemotherapy (HEC or MEC). Methods: INSPIRE (Impact of NCCN Antiemesis Guideline Usage on Patient Reported Emesis) was a prospective observational, multicenter study that enrolled chemotherapy-naive adults initiating single-day HEC or MEC. Results from the MASCC Antiemesis Tool, administered 5 to 8 days after HEC/MEC, were merged with EHR data. The primary endpoint, no CINV (no emesis and no clinically significant nausea), was compared between groups using logistic regression. Results: 1,295 patients (mean age=59.3, 30.0% male, 35.5% HEC) were enrolled from Georgia Cancer Specialists (53.0%), Tennessee Oncology (38.1%), Florida Cancer Specialists (5.7%), and Cancer Specialists of N. Florida (3.2%). The prevalence of GCCP was 57.3% (28.7% HEC; 73.1% MEC). If corticosteroids were prescribed to all HEC patients on days 2-4, GCCP for HEC would increase from 28.7% to 89.8%. If NK1-receptor antagonists (NK1-RA) were prescribed to all MEC patients, GCCP for MEC would increase from 73.1% to 97.8%. GCCP and GICP-treated patients differed by age, (p=0.010), HEC/MEC (p<0.0001), primary cancer site (p<0.0001), practice site (p<0.0001). The percent with no CINV, no emesis, and no clinically significant nausea was significantly higher for GCCP patients. Conclusions: Increased GCCP could significantly reduce CINV after HEC or MEC. The main reasons for guideline inconsisteny were lack of corticosteroids in the delayed phase for HEC and lack of NK1-RA for MEC. There remains room for improvement in nausea control. [Table: see text]

Association of markers of chronic viral hepatitis and blood mercury levels in US reproductive-age women from NHANES 2001-2008: a cross-sectional study

BACKGROUND

Methylmercury (MeHg) is a neurotoxin primarily found in seafood; exposures in reproductive-age women are of concern due to vulnerability of the developing fetus. MeHg is mainly eliminated via an enterohepatic cycle involving the liver and gallbladder. Dysfunction in these organs has been associated with slower MeHg elimination in laboratory animals. We hypothesized that women testing positive for chronic hepatitis B (HBV) or C (HCV), both associated with risk of longer-term liver and gallbladder impairment, would have higher total blood mercury (TBHg) concentrations than those negative for the viruses, reflecting slower MeHg elimination.

METHODS

Geometric mean (GM) TBHg levels from a representative sample of over 5,000 seafood-consuming, reproductive-age women from eight years (2001-2008) of the US NHANES survey were compared by viral hepatitis status (as determined by serological assay) using multiple linear regression. Adjustment was made for estimated MeHg intake from seafood consumption, social and demographic variables and other predictors.

RESULTS

Women with chronic HBV had 1.52 (95% CI 1.13, 2.05, p < 0.01) times the GM TBHg of women who had not come into contact with the virus. The positive association was strongest in those with most severe disease. A modest negative association was found with HCV markers.

CONCLUSIONS

While study design prevents inferences on causality, the finding that MeHg biomarkers differ by hepatitis status in this population suggests viral hepatitis may alter the pace of MeHg elimination. Offspring of HBV-infected seafood-consuming women may be at higher risk of MeHg-induced developmental delays than offspring of those uninfected. Possible reasons for the unanticipated negative association with HCV are explored.

Host cell deformability is linked to transmission in the human malaria parasite Plasmodium falciparum

Gametocyte maturation in Plasmodium falciparum is a critical step in the transmission of malaria. While the majority of parasites proliferate asexually in red blood cells, a small fraction of parasites undergo sexual conversion and mature over 2 weeks to become competent for transmission to a mosquito vector. Immature gametocytes sequester in deep tissues while mature stages must be able to circulate, pass the spleen and present themselves to the mosquito vector in order to complete transmission. Sequestration of asexual red blood cell stage parasites has been investigated in great detail. These studies have demonstrated that induction of cytoadherence properties through specific receptor-ligand interactions coincides with a significant increase in host cell stiffness. In contrast, the adherence and biophysical properties of gametocyte-infected red blood cells have not been studied systematically. Utilizing a transgenic line for 3D live imaging, in vitro capillary assays and 3D finite element whole cell modelling, we studied the role of cellular deformability in determining the circulatory characteristics of gametocytes. Our analysis shows that the red blood cell deformability of immature gametocytes displays an overall decrease followed by rapid restoration in mature gametocytes. Intriguingly, simulations suggest that along with deformability variations, the morphological changes of the parasite may play an important role in tissue distribution in vivo. Taken together, we present a model, which suggests that mature but not immature gametocytes circulate in the peripheral blood for uptake in the mosquito blood meal and transmission to another human host thus ensuring long-term survival of the parasite.

The impact of local environmental health capacity on foodborne illness morbidity in Maryland

OBJECTIVES

We evaluated the relationship between local food protection capacity and service provision in Maryland's 24 local food protection programs (FPPs) and incidence of foodborne illness at the county level.

METHODS

We conducted regression analyses to determine the relationship between foodborne illness and local FPP characteristics. We used the Centers for Disease Control and Prevention's FoodNet and Maryland Department of Health and Mental Hygiene outbreak data set, along with data on Maryland's local FPP capacity (workforce size and experience levels, budget) and service provision (food service facility inspections, public notification programs).

RESULTS

Counties with higher capacity, such as larger workforce, higher budget, and greater employee experience, had fewer foodborne illnesses. Counties with better performance and county-level regulations, such as high food service facility inspection rates and requiring certified food manager programs, respectively, had lower rates of illness.

CONCLUSIONS

Counties with strong local food protection capacity and services can protect the public from foodborne illness. Research on public health services can enhance our understanding of the food protection infrastructure, and the effectiveness of food protection programs in preventing foodborne illness.