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K Teschke

Publications and source records attributed to K Teschke.

At least 37 records · Page 2Linked to original sources

A model for predicting endotoxin concentrations in metalworking fluid sumps in small machine shops.

METHODS: In British Columbia, Canada, nineteen small machine shops which used water-based metalworking fluids (MWF) were examined. One bulk MWF sample was taken from each independent sump (N=140) and tested for endotoxin using the Limulus Amoebocyte Lysate assay. Factors that might influence the MWF sump endotoxin concentration were investigated using mixed effect multiple regression modelling to control for repeated measures within shops. RESULTS: The geometric mean (GM) endotoxin concentration was 6791 EU/ml. Contamination of MWF with tramp oil, MWF pH, MWF temperature, and MWF type were significant predictors of sump fluid endotoxin concentration (model P=0.0001, ordinary least squares R(2) =0.36). Concentrations of endotoxin in sump fluids were increased by MWF contamination with tramp oils such as hydraulic oils, preservative oils, spindle oils, slidway lubricants, gear lubricants, and greases (model predicted GM=17400 EU/ml vs. 1600 EU/ml without tramp oil). Concentrations were also elevated where pH was lower than 8.5 (predicted GM=10600, vs 3600 EU/ml for pH 8.5 to 9.5), where soluble fluids were used (predicted GM=11800 vs. 2800 EU/ml for synthetic fluids), and where sump fluid temperatures were higher (predicted GM=2600 EU/ml at 11 degrees C vs. 21500 EU/ml at 32 degrees C). The within-shop correlation of sump bulk fluid endotoxin concentrations was 38%. CONCLUSIONS: Minimizing tramp oil contamination, using synthetic fluids, and monitoring pH and temperature would be valuable tools for controlling endotoxin contamination in MWF sumps. In addition, since there was correlation within-shop, contamination of one sump in a shop may suggest changing the fluids in all.

Endotoxins↗

The measurement of volatile constituents in Foray 48B, an insecticide prepared from Bacillus thuringiensis var. kurstaki.

Foray 48B, an insecticide prepared from Bacillus thuringiensis var. kurstaki (Btk), has been used for many years to combat infestations of Gypsy moths. Foray 48B also contains a large number of 'inert ingredients' which are not disclosed by the manufacturer. Gypsy moths usually enter the country through marine- and airports in close proximity to urban areas, which consequently need to be sprayed. The population affected often demands more detailed information than what is available including the potential presence of volatile organic agents which could be released during spraying, posing a potential health hazard. Four different methods were investigated using GC/mass spectrometry regarding their ability to capture volatile agents associated with Foray 48B. It was found that solid phase micro-extraction was most efficient in capturing volatile agents from the head-space of Foray 48B. Separate trials using 95:5% ethanol/isopropanol mixture and toluene in an impinger configuration were much less efficient. Standard techniques using activated charcoal tubes in the laboratory setting as well as in a field trial did not capture any compounds. It was concluded that the volatile agents associated with Foray 48B did not appear to constitute a significant health hazard and no one agent was a likely candidate to serve as a tracer for Foray 48B exposure.

Bacillus thuringiensis↗

Evidence of recall bias in volunteered vs. prompted responses about occupational exposures.

BACKGROUND: Recall bias remains a concern in case-control studies, although few investigations have found evidence of differential recall. This study examined whether differences in occupational exposure reporting occur in volunteered vs. prompted questionnaire responses. METHODS: In a large, population-based, case-control study of a childhood cancer, neuroblastoma, we calculated odds ratios for broad occupational exposure groups on the assumption that in the absence of recall bias, risk estimates for such broad groupings should be close to the null value. RESULTS: Prompted exposures and work activities showed little evidence of differential recall by parents of cases and controls (all OR < 1.2), but case parents were more likely to volunteer information about other exposures or activities (ORs: 1.35-1.71). Case mothers were also more likely than control mothers to report activities involving indirect exposure (OR = 1.41). CONCLUSIONS: These findings suggest that prompted exposure questions are less likely to be subject to recall bias than open-ended questions.

Case-Control Studies↗

Occupational exposure to formaldehyde and wood dust and nasopharyngeal carcinoma.

OBJECTIVES: To investigate whether occupational exposures to formaldehyde and wood dust increase the risk of nasopharyngeal cancer (NPC). METHODS: A multicentered, population based case-control study was carried out at five cancer registries in the United States participating in the National Cancer Institute's SEER program. Cases (n=196) with a newly diagnosed NPC between 1987 and 1993, and controls (n=244) selected over the same period from the general population through random digit dialing participated in structured telephone interviews which inquired about suspected risk factors for the disease, including a lifetime history of occupational and chemical exposure. Histological type of cancer was abstracted from clinical records of the registries. Potential exposure to formaldehyde and wood dust was assessed on a job by job basis by experienced industrial hygienists who were blinded as to case or control status. RESULTS: For formaldehyde, after adjusting for cigarette use, race, and other risk factors, a trend of increasing risk of squamous and unspecified epithelial carcinomas was found for increasing duration (p=0.014) and cumulative exposure (p=0.033) but not for maximum exposure concentration. The odds ratio (OR) for people cumulatively exposed to >1.10 ppm-years was 3.0 (95% confidence interval (95% CI) 1.3 to 6.6) compared with those considered unexposed. In analyses limited to jobs considered definitely exposed, these trends became stronger. The associations were most evident among cigarette smokers. By contrast, there was no association between potential exposure to formaldehyde and undifferentiated and non-keratinising carcinomas. There was little evidence that exposure to wood dust increased risk of NPC, as modest crude associations essentially disappeared after control for potential exposure to formaldehyde. CONCLUSIONS: These results support the hypothesis that occupational exposure to formaldehyde, but not wood dust, increases risk of NPC. This association seems to be specific to squamous cell carcinomas. Established cohorts of workers exposed to formaldehyde and wood dust should continue to be monitored for NPC and other respiratory cancers. Future studies of NPC should take into account histological type in assessing risk from environmental and host factors.

Adolescent↗

Childhood cancer in the offspring of male sawmill workers occupationally exposed to chlorophenate fungicides.

The objective of this study was to determine whether paternal occupational exposure to chlorophenol fungicides and their dioxin contaminants is associated with childhood cancer in the offspring of sawmill workers. We used data from 23,829 British Columbian sawmill workers employed for at least 1 continuous year between 1950 and 1985 in 11 sawmills that used chlorophenates. Probabilistic linkage of the sawmill worker cohort to the provincial marriage and birth files produced an offspring cohort of 19,674 children born at least 1 year after the initiation of employment in the period 1952-1988. We then linked the offspring cohort to the British Columbia Cancer Registry. We included all malignancies in cases younger than 20 years of age that appeared on the cancer registry between 1969 and 1993. We calculated standardized incidence ratios (SIRs) using the British Columbia population as a reference. A nested case-control analysis assessed the effects of paternal cumulative exposure and windows of exposure on the risk of developing cancer in the offspring. We identified 40 cases of cancer during 259,919 person-years of follow-up. The all-cancer SIR was 1.0 [95% confidence interval (CI), 0.7-1.4]; the SIR for leukemia was 1.0 (CI, 0.5-1.8); and the SIR for brain cancer was 1.3 (CI, 0.6-2.5). The nested case-control analysis showed slightly increased risks in the highest categories of chlorophenol exposure, although none was statistically significant. Our analyses provide little evidence to support a relationship between the risk of childhood cancer and paternal occupational exposure to chlorophenate fungicides in British Columbian sawmills.

Adolescent↗

Downsizing and industrial restructuring in related to changes in psychosocial conditions of work in British Columbia sawmills.

OBJECTIVES: This paper investigates changes in the psychosocial and physical work conditions of the sawmill industry in British Columbia, Canada, over the past 35 years. METHODS: Shifts in work conditions were examined within the context of historical changes in sawmill labor demography and job taxonomy as the industry was both downsized and restructured, largely in response to an economic recession in the early 1980s. RESULTS AND CONCLUSIONS: Downsizing eliminated approximately 60% of the work force and 1/4 of sawmill job titles. Although all the job categories in restructured sawmills showed increased levels of control, the gradient in control across job categories was steeper in 1997 than in 1965; this change may have important health implications particularly for the unskilled workers in the restructured mills.

British Columbia↗

Exposures to wood dust in U.S. industries and occupations, 1979 to 1997.

BACKGROUND: We analyzed 1,632 measurements of airborne wood dust reported to OSHA's Integrated Management Information System in the period 1979 to 1997. METHODS: The relationships between wood dust concentrations and various factors documented in the OSHA database were examined in a multiple regression model. RESULTS: Exposures ranged from less than 0.03 to 604 mg/m3, with an arithmetic mean of 7.93 and a geometric mean of 1.86. Reported exposure levels decreased substantially over time (e.g., unadjusted geometric mean in 1979 = 4.59 mg/m3; in 1997 = 0.14 mg/m3). High exposure jobs included sanders in the transportation equipment industry (unadjusted geometric mean = 17.5 mg/m3), press operators in the wood products industry (12.3 mg/m3), lathe operators in the furniture industry (7.46 mg/m3), and sanders in the wood cabinet industry (5.83 mg/m3). CONCLUSIONS: In the multiple regression model, year, state, job, and industry were found to be predictors of exposure. Year and state were likely surrogates for other factors which directly influence exposure, but which were not included in the IMIS database, such as the use of engineering control measures.

Air Pollutants, Occupational↗

Neuroblastoma and parental occupation.

OBJECTIVES: We evaluated parental occupation and the risk of neuroblastoma using data from a large case-control study conducted by the Children's Cancer Group and the Pediatric Oncology Group. METHODS: We compared the distribution of 73 paternal and 57 maternal occupational groups among 504 newly diagnosed cases of neuroblastoma and individually matched controls obtained by telephone random digit dialing in the United States and Canada. RESULTS: An increased risk of neuroblastoma was found for fathers employed as broadcast, telephone and dispatch operators (odds ratio [OR] = 6.1; 95% confidence interval [CI] = 0.7-50.9), electrical power installers and power plant operators (OR = 2.7; CI = 0.9-8.1), landscapers and groundskeepers (OR = 2.3; CI = 1.0-5.2), and painters (OR = 2.1; CI = 0.9-4.8). Elevated odds ratios were found for mothers employed as farmers and farm workers (OR = 2.2; CI = 0.6-8.8), florists and garden store workers (OR = 2.4; CI = 0.6-9.9), hairdressers and barbers (OR = 2.8; CI = 1.2-6.3), electric power installers and power plant operators, and sailors, fishers, and railroad workers. No increase in risk was found for other paternal occupations previously associated, including electricians, electrical equipment assemblers and repairers (OR = 1.1; CI = 0.6-2.0), or welders (OR = 0.5; CI = 0.1-1.6). CONCLUSION: The study reinforced some prior evidence of increased risks in electrical, farming and gardening, and painting occupations, but failed to confirm other previously reported associations. Further analyses of exposure to electromagnetic fields, metals, solvents, and pesticides are currently under way.

Adolescent↗

Perceptions of the causes of bladder cancer, nasal cancer, and mesothelioma among cases and population controls.

To understand the reasons for underreporting of occupational cancers, we investigated cases' perceptions of the causes of cancer. As part of a case-control study in the province of British Columbia, Canada, 105 bladder cancer cases, 48 nasal cancer cases, 51 mesothelioma cases, and 159 population-based controls (frequency matched to cases on age and sex) were interviewed using structured questions about their smoking, medical, residential, occupational, and carcinogen exposure histories. We asked cases what they thought caused their disease, and asked population controls about their understanding of the etiologies of the three cancers. Most cases and controls (69%) indicated that they had "no idea" about causes, with the exception that the majority of mesothelioma cases (70%) recognized asbestos as a cause. Smoking was perceived as a cause of bladder cancer by 21 percent of cases. Many cases knew about the asbestos and smoking etiologies from discussions with their physicians. Chemicals were commonly cited as causes of nasal and bladder cancer, but very few specific known or probable carcinogens for these sites were named. Cases (12%) more frequently than controls (2%) thought prior disease or trauma was a cause for all three types of cancer. Other etiologic factors less frequently listed by subjects included environmental pollution, hereditary factors, drugs, and radiation. Most cases recognized the major cause of mesothelioma, but few subjects knew about lifestyle or occupational causes of bladder cancer or nasal cancer, suggesting that education about the multiple cancer risks of smoking and about occupational carcinogens needs to be improved.

Aged↗

Wheat antigen content of inhalable dust in bakeries: modeling and an inter-study comparison.

The purposes of this study were (a) to compare wheat antigen content of inhalable bakery dust in Canada and the Netherlands and, (b) to evaluate the validity of dust exposure measurement as a surrogate of specific antigen exposure. Wheat antigen exposure data from the studies of Canadian and Dutch bakeries were used to explore the correlation between dust and antigen levels, and identify factors explaining variability of the antigen content of bakery dust. Direct comparison and pooling of the data were possible because the same antigen assay was used in both studies. Wheat antigen exposure samples totaling 544 were available, all originating from personal full-shift monitoring of bakery workers. The wheat antigen content of bakery dust varied greatly between the two studies and with different products within each study. Bakery dust from the Canadian study had a much higher wheat antigen content. Therefore, the interstudy difference in the wheat antigen content of bakery dust was by far the most significant in undermining the validity of the use of dust levels as a surrogate measures of wheat antigen exposure. The production of croissants, wheat bread and buns, puff pastry, bagels, and cinnamon buns was associated with increased wheat antigen content of bakery dust, while in rye bread production, bakery dust with less wheat antigen content was emitted. Although we can, in part, account for the pattern of variability in the wheat antigen content of bakery dust (explaining 49% of it), we concluded that the effort involved in modeling it accurately would probably exceed that expended in direct measurement of the antigen level. Therefore, for the exposure assessments carried out for the purpose of managing occupational risks of aeroallergen exposure in bakeries, we recommend the use of analytical techniques that can directly measure antigen exposure.

Antigens↗

Change in airway responsiveness among apprentices exposed to metalworking fluids.

To investigate early pulmonary responses to metalworking fluid exposure, we enrolled first-year machinist apprentices and apprentices in three other trades into a 2-yr longitudinal study. We obtained complete data for 82 machinists and 159 control subjects. Tests included respiratory questionnaires, spirometry, methacholine challenge, and allergy skin tests. Details on duration of exposure were collected by interview and 68 representative full shift personal samples for "total aerosol" were obtained from 13 shops (mean: 0.46 mg/m3, range: < 0.7 to 3.65 mg/m3). Machinists and control subjects did not differ at baseline. At follow-up, average change in bronchial responsiveness was double in machinists compared with control subjects (p = 0.05), and machinists were more likely to have developed new bronchial hyperresponsiveness (BHR) with asthmalike symptoms. In linear regression analysis, for predictors of methacholine slope, increased BHR was associated with duration of exposure to both synthetic and soluble metalworking fluids (p < 0.05); in logistic regression analysis, for predictors of BHR, only duration of exposure to synthetic fluids was a significant predictor. Results were not changed when workers with PC20 < 8 mg/ml at baseline were excluded. We conclude that exposure to water-based metalworking fluids (especially synthetic fluids) is associated with increasing BHR during the first 2 yr of exposure.

Adult↗

Determinants of exposure to inhalable particulate, wood dust, resin acids, and monoterpenes in a lumber mill environment.

In a lumber mill in the northern inland region of British Columbia, Canada, we measured inhalable particulate, resin acid, and monoterpene exposures, and estimated wood dust exposures. Potential determinants of exposure were documented concurrently, including weather conditions, tree species, wood conditions, jobs, tasks, equipment used, and certain control measures. Over 220 personal samples were taken for each contaminant. Geometric mean concentrations were 0.98 mg/m3 for inhalable particulate, 0.49 mg/m3 for estimated wood dust, 8.04 micrograms/m3 for total resin acids, and 1.11 mg/m3 for total monoterpenes. Multiple regression models for all contaminants indicated that spruce and pine produced higher exposures than alpine fir or mixed tree species, cleaning up sawdust increased exposures, and personnel enclosure was an effective means of reducing exposures. Sawing wood in the primary breakdown areas of the mill was the main contributor to monoterpene exposures, so exposures were highest for the barker operator, the head rig operator, the canter operator, the board edgers, and a roving utility worker in the sawmill, and lowest in the planer mills (after kiln drying of the lumber) and yard. Cleaning up sawdust, planing kiln-dried lumber, and driving mobile equipment in the yard substantially increased exposures to both inhalable particulate and estimated wood dust. Jobs at the front end of the sawmill where primary breakdown of the logs takes place had lower exposures. Resin acid exposures followed a similar pattern, except that yard driving jobs did not increase exposures.

Air Pollutants, Occupational↗

A field comparison of inhalable and thoracic size selective sampling techniques.

We measured inhalable, thoracic, and so-called "total" wood dust exposure in British Columbia lumber mill workers. Particle-size selective sampling was conducted using the GSP and Seven hole inhalable samplers, the PEM thoracic sampler and the 37-mm closed-face cassette "total" sampler. All measurements were full-shift personal samples, obtained from randomly selected workers. We obtained intersampler comparison data for the following pairs of instruments: GSP and 37-mm sampler; GSP and seven-hole sampler (SHS); and PEM and 37-mm sampler. The intersampler measurement ratios were estimated as: GSP/37-mm sampler = 4.2; GSP/SHS = 1.7; and PEM/37-mm sampler = 1.6. The GSP/37-mm sampler ratio is consistent with previously reported findings, while PEM/37-mm sampler and GSP/SHS ratios were both larger than expected. We found that in all comparisons, the measurement ratio had significant variability that was greatest at low ambient dust concentrations. Although it was not possible to attribute the source of the variability to specific sampler types, we concluded that the GSP sampler might be susceptible to "projectile" particles not normally aspirated, and may be vulnerable to direct aspiration of dust from accidentally contacted surfaces. The PEM was designed for environmental monitoring, and it is possible that it is unsuited to the higher particulate concentrations found in some occupational settings. Disparities among inhalable sampling techniques such as that between GSP and SHS should be investigated further in light of the proposed adoption of the inhalable method as an industrial standard.

Air Pollutants, Occupational↗

Endotoxin exposure among softwood lumber mill workers in the Canadian province of British Columbia.

An increased prevalence of respiratory problems among softwood lumber mill workers has been observed in a number of studies. These workers are potentially exposed to a variety of respiratory hazards including wood dust, abietic or other resin acids, monoterpenes, and fungi, as well as endotoxins. The objectives of this study were to determine if lumber mill workers were exposed to hazardous levels of airborne endotoxin and to identify the factors contributing to high exposures. Personal endotoxin samples (n = 216) were collected in four lumber mills in the Canadian province of British Columbia. The mean personal exposure concentration was 2.09 ng/m.(3) and 9% of the samples were above 5 ng/m.(3). Factors related to the personal endotoxin exposure were type of job, use of compressed air, the percentage of time spent in a booth or cab during a shift, and dust concentration. Log storage practices were also suspected of playing a role. The levels of exposure observed in this study were low compared to the levels reported for populations with respiratory problems attributed to endotoxins.

Air Microbiology↗

Cytogenetic analysis of South Asian berry pickers in British Columbia using the micronucleus assay in peripheral lymphocytes.

Micronuclei in peripheral blood lymphocytes from British Columbia seasonal farmworkers and controls were evaluated using the cytokinesis-block technique. The farmworkers harvested berry crops and were likely occupationally exposed to pesticides. Subjects were 39 female subjects of South Asian descent; 18 farmworkers employed during 1993 and 21 age-matched controls. The mean age was 55.9 years. Micronuceli were also scored for the presence of kinetochores. No significant difference was found between the frequency of micronucleated binucleates in the farmworkers group (19.20/1000 binucleates), and the control group (21.76/1000 binucleates). However, among the farmworkers employed in 1993, there was a positive, but not statistically significant, association between micronucleated cell frequency and weeks worked: 16.44/1000 binucleates in those working less than 20 weeks; 23.78/1000 binucleates in those working 20 to 23 weeks; and 25.43/1000 binucleates in those working more than 23 weeks. In those who had ever been employed as farmworkers, there was an elevated frequency of micronucleated cells in the group with the longest history of employment as a farmworker (25.28/1000 binucleates) compared to those with the shortest employment history (16.48/1000 binucleates). This trend remained evident after adjusting for age, red blood cell folate, meat consumption, coffee consumption and recent vaccination. A positive association between the consumption of meat and micronucleus frequency was also observed. Non-meat eaters were likely life-long vegetarians. Micronuclei in farmworkers had a lower frequency of kinetochore positive micronuclei than controls. This study indicates that South Asian berry pickers in British Columbia may be at risk for genetic damage. More studies in other ethnic groups and in males are needed to generalize the findings of this study. More direct measures of exposure are needed to elucidate the sources of genotoxicity.

Adult↗

Determinants of wheat antigen and fungal alpha-amylase exposure in bakeries.

The study's objectives were to measure flour antigen exposure in bakeries and define the determinants of exposure. Ninety-six bakery workers, employed in seven different bakeries, participated in the study. Two side-by-side full-shift inhalable dust samples were obtained from each study participant on a single occasion. The flour antigen exposure was measured as wheat antigen and fungal alpha-amylase content of the water-soluble fraction of inhalable dust, assayed via enzyme-linked immunosorbent assays. During the entire sampling period bakers were observed and information on 14 different tasks was recorded at 15-minute intervals. Other production characteristics were also recorded for each sampling day and used in statistical modeling to identify significant predictors of exposure. The mean alpha-amylase antigen exposure was 22.0 ng/m3 (ranging from below the limit of detection of 0.1 ng/m3 to 307.1 ng/m3) and the mean wheat antigen exposure was 109 micrograms/m3 (ranging from below the limit of detection of 1 microgram/m3 to 1018 micrograms/m3). Regression models that explained 74% of variability in wheat antigen and alpha-amylase antigen exposures were constructed. The models indicated that tasks such as weighing, pouring, and operating dough-brakers increased flour antigen exposure, while packing and decorating resulted in lower exposures. Croissant, puff-pastry, and bread/bun production lines were associated with increased exposure, while cake production and substitution of dusting with the use of divider oil were associated with decreased exposure. Exposure levels can be reduced by the automation of forming tasks, alteration of tasks requiring pouring of flour, and changes to the types of products manufactured.

Air Pollutants, Occupational↗

Kiln emissions and potters' exposures.

Some ten thousand British Columbia potters work in small private studios, cooperative facilities, educational institutions, or recreation centers. There has been considerable concern that this diffuse, largely unregulated activity may involve exposures to unacceptable levels of kiln emissions. Pottery kiln emissions were measured at 50 sites--10 from each of 5 categories: professional studios, recreation centers, elementary schools, secondary schools, and colleges. Area monitoring was done 76 cm from firing kilns and 1.6 m above the floor to assess breathing zone concentrations of nitrogen dioxide, carbon monoxide, sulfur dioxide, fluorides, aldehydes, aluminum, antimony, arsenic, barium, beryllium, boron, cadmium, chromium, cobalt, copper, gold, iron, lead, lithium, magnesium, manganese, mercury, nickel, selenium, silver, vanadium, and zinc. Personal exposures to the same metals were measured at 24 sites. Almost all measured values were well below permissible concentrations for British Columbia work sites and American Conference of Governmental Industrial Hygienists (ACGIH) threshold limit values (TLVs) with the following two exceptions. A single firing duration (495 minute) acrolein measurement adjacent to an electric kiln (0.109 ppm) exceeded these guidelines. One 15-minute sulfur dioxide measurement collected adjacent to a gas kiln (5.7 ppm) exceeded the ACGIH short-term exposure limit. The fact that concentrations in small, ventilated kiln rooms ranked among the highest measured gives rise to concern that unacceptable levels of contamination may exist where small kiln rooms remain unventilated. Custom designed exhaust hoods and industrial heating, ventilating, and air-conditioning systems were the most effective ventilation strategies. Passive diffusion and wall/window fans were least effective.

Aerosols↗

Fertility among a cohort of male sawmill workers exposed to chlorophenate fungicides.

The purpose of this study was to determine whether exposure to chlorophenate fungicides and their dioxin contaminants is associated with male infertility among sawmill workers. The study was conducted using fertility data compiled from 26,487 sawmill workers in 14 British Columbian sawmills. Our analysis was restricted to workers who had been employed for at least 1 continuous year between 1950 and 1985 and to live-births born at least 1 year after the initiation of employment in the period 1955-1988. We assessed fertility trends by internal comparison using Mantel-Haenszel rate ratios and by calculating standardized fertility ratios using an external and an internal reference population. We identified 19,684 births in the study period. Initially, both external and internal analyses showed that sawmill workers from mills using chlorophenates had lower fertility than workers employed in mills not using chlorophenates. After controlling for time since first hire, however, we found no inverse relation between cumulative exposure to chlorophenate fungicides and fertility. Based on the results of our study, there is little evidence for a reduction in fertility among chlorophenate-exposed sawmill workers in British Columbia. The analyses indicate the importance of time since hire as a potentially strong confounder in this type of investigation.

Adult↗