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Prenatal diagnosis by chorionic villus sampling: lessons of the first 600 cases.

Chorionic villus sampling (CVS) has emerged as a first trimester alternative to amniocentesis for the prenatal detection of genetic disorders. We report our experience in 600 consecutive CVS procedures to better delineate the safety, efficacy and reliability of this new method of prenatal diagnosis. Adequate samples were obtained at the initial visit in 97 per cent of the cases, and successful cultures were established in 98.7 per cent of these patients. Chromosome abnormalities were detected in 5.9 percent of those pregnancies tested because of advanced maternal age (greater than or equal to 35 years). A discrepancy between the villus karyotype and that of the fetus was found in 2.0 per cent of cases, and most commonly consisted of mosaicism in the villus sample for a chromosomal abnormality that was not found in fetal samples. The risk of spontaneous abortion following the procedure was 6.3 per cent. We conclude that chorionic villus sampling is an acceptably safe and reliable procedure, but further investigation is needed before it can become an established technique in prenatal diagnosis.

Abortion, Spontaneous↗

Safety and efficacy of flecainide in subjects with Long QT-3 syndrome (DeltaKPQ mutation): a randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: We conducted a study of chronic therapy with flecainide versus placebo in a small group of LQT-3 patients with the DeltaKPQ deletion to evaluate the safety and efficacy of flecainide in this genetic disorder. In vitro studies have shown that flecainide provides correction of the impaired inactivation associated with the DeltaKPQ deletion. METHODS: A randomized, double-blind, placebo-controlled clinical trial was conducted with flecainide and placebo in six male LQT-3 subjects with the DeltaKPQ deletion. RESULTS: The lowest possible dose of flecainide associated with at least a 40 ms reduction in the QTc interval was determined in an initial open-label, dose-ranging investigation using one-fourth or half of the recommended maximal antiarrhythmic flecainide dose. QTc reduction was achieved with a flecainide dose of 1.5 mg/kg per day in 4 subjects and with 3.0 mg/kg per day in 2 subjects. Subjects were randomized to four 6-month alternating periods of flecainide and placebo therapy based on the open-label dose findings. Average QTc values during placebo and flecainide therapies were 534 ms and 503 ms, respectively, with an adjusted reduction in QTc of -27.1 ms (95% confidence interval: -36.8 ms to -17.4 ms; P<0.001) at a mean flecainide blood level of 0.11+/-0.05 microg/ml. Minimal prolongation in QRS occurred (mean: +2.5 ms), and there were no major adverse cardiac effects. CONCLUSIONS: Chronic low-dose flecainide significantly shortens the QTc interval in LQT-3 subjects with the DeltaKPQ mutation. No major adverse drug effects were observed with flecainide during this trial, but the sample size is not large enough to evaluate the safety of flecainide therapy in patients with this mutation.

Adolescent↗

Personal dust exposures at a food processing facility.

A field study was performed to quantify personal dust exposures at a food processing facility. A review of the literature shows very little exposure information in the food processing industry. The processing area consisted of a series of four rooms, connected by a closed-loop ventilation system, housed within a larger warehouse-type facility. Workers were exposed to various fruit and vegetable dusts during the grinding, sieving, mixing and packaging of freeze-dried or air-dried products. Eight two-hour periods were monitored over two days. Personal total suspended particulate samples were collected on 37 mm PVC filters with 5 microm pore size according to National Institute for Occupational Safety and Health (NIOSH) Method 0500. The filters were analyzed gravimetrically. The two-hour task sampling personal dust exposures ranged from 0.33-103 mg/m3. For each worker, an eight-hour time weighted average (TWA) concentration was calculated, and these ranged from 3.08-59.8 mg/m3. Although there are no directly appropriate occupational exposure limits that may be used for comparison, we selected the Threshold Limit Value (TLV) for particulates not otherwise classified (PNOC) of 10 mg/m3 for inhalable particles. Neglecting the respiratory protection used, five out of eight of the worker time-weighted averages exceeded the TLV. It should be noted that the TLV is based on the inhalable fraction and in this study total suspended particulate was measured; additionally, the TLV is applicable for dusts that are insoluble or poorly soluble, and have low toxicity, which may have limited protective ability in this case due to the irritant nature of certain dusts (e.g., jalapeno peppers, aloe vera). Sieving resulted in significantly higher exposure than grinding and blending. Measuring area concentrations alone in this environment is not a sufficient method of estimating personal exposures due to work practices for some operations.

Dust↗

Preliminary experience with an EUS-guided trucut biopsy needle compared with EUS-guided FNA.

BACKGROUND: EUS-guided FNA is a sensitive method for the diagnosis of malignancy. However, EUS-FNA is often laborious and usually requires the presence of a cytopathologist or cytotechnician. The development of an EUS-guided Trucut biopsy (EUS-TCB) needle may simplify the procedure and expand the application of EUS-directed procurement of biopsy specimens. The aim of this study was to determine the feasibility of using the EUS-TCB for the diagnosis of intraintestinal and extraintestinal lesions and compare the results with this needle with those of EUS-FNA. METHODS: The EUS-TCB and EUS-FNA were used to evaluate patients with known or suspected intraintestinal or extraintestinal mass lesions and/or lymphadenopathy. Patient records were retrospectively reviewed to determine the accuracy and safety of both techniques. RESULTS: Nineteen patients had tissue samples obtained with both the EUS-TCB and EUS-FNA from 20 sites (2 sites in 1 patient) between December 2001 and March 2002. Accuracy was higher with EUS-TCB than EUS-FNA, although the difference was not significant (85% vs. 60%), despite performing fewer passes with the former (mean [SD] 2.0 [0.7], range 1-4; vs. mean 3.3 [1.5], range 1-10; p < 0.05). No complications were identified. CONCLUSIONS: This preliminary study suggests EUS-TCB can safely be used to obtain biopsy specimens of intraintestinal and extraintestinal mass lesions and lymphadenopathy. Its use may reduce the number of needle passes compared with EUS-FNA. This may reduce costs by shortening the procedure, diminishing the need for an onsite cytopathologist or technician, and lowering the frequency of nondiagnostic procedures. Prospective studies are needed to verify these findings.

Aged↗

Analysis of third-party certification approaches using an occupational health and safety conformity-assessment model.

The occupational health and safety conformity-assessment model presented in this article was developed (1) to analyze 22 public and private programs to determine the extent to which these programs use third parties in conformity-assessment determinations, and (2) to establish a framework to guide future policy developments related to the use of third parties in occupational health and safety conformity-assessment activities. The units of analysis for this study included select Occupational Safety and Health Administration programs and standards, International Organization for Standardization-based standards and guidelines, and standards and guidelines developed by nongovernmental bodies. The model is based on a 15-cell matrix that categorizes first-, second-, and third-party activities in terms of assessment, accreditation, and accreditation-recognition activities. The third-party component of the model has three categories: industrial hygiene/safety testing and sampling; product, equipment, and laboratory certification; and, occupational health and safety management system registration/certification. Using the model, 16 of the 22 programs were found to have a third-party component in their conformity-assessment structure. The analysis revealed that (1) the model provides a useful means to describe and analyze various third-party approaches, (2) the model needs modification to capture aspects of traditional governmental conformity-assessment/enforcement activities, and (3) several existing third-party conformity-assessment systems offer robust models that can guide future third-party policy formulation and implementation activities.

Accreditation↗

Occupational exposure to diesel exhaust in the Canadian federal jurisdiction.

To assess the impact of the proposed American Conference of Governmental Industrial Hygienists threshold limit value-time-weighted average to diesel particulate matter (DPM), 177 full-shift samples were taken in 23 workplaces under Canadian federal jurisdiction. National Institute for Occupational Safety and Health (NIOSH) Method 5040 (Elemental Carbon: Diesel Exhaust) was used to assess exposure. Quality control tests were conducted prior to field sampling by taking air samples in the exhaust stream of two diesel engines mounted on a test bed and having them analyzed by two laboratories using the same thermal program. Field sampling results indicated that 77% of the elemental carbon (EC) levels were below the currently proposed limit of 20 microg/m(3), and 54% below 10 microg/m(3). The geometric mean concentration of EC was 24.4 microg/m(3) in high-activity and 4.0 microg/m(3) in low-activity work sites. Corresponding arithmetic mean concentrations were 41.4 and 8.4 microg/m(3), respectively. The ratio of EC to total carbon (TC) was close to 90% for all quality control samples. It was no higher than 50% for the field samples, and it varied significantly with EC concentration. Finally, results are presented from the analysis of 41 samples by a third laboratory using a thermal-optical method slightly different from NIOSH 5040. Even if one were to opt for EC as a surrogate for DPM, unless analysis details (particularly the thermal program) are specified, significant differences in the results can be expected. This could lead to problems for regulatory agencies and for epidemiologic research.

Air Pollutants, Occupational↗

The emotional impact of injury following an international terrorist incident.

BACKGROUND: Terrorism represents a major public health threat throughout the world. Bombings of the United States Embassies in East Africa in 1998 resulted in extensive physical and emotional casualties. METHODS: This study examined posttraumatic stress reactions, worry, and feelings of safety in the workplace in the context of injury in a convenience sample of 21 individuals directly exposed to the bombing in Dar es Salaam, Tanzania. Eight months postbombing, participants completed a self-report instrument examining demographics, exposure, injury, initial reaction, posttraumatic stress, worry, and feelings of safety in the workplace. Descriptive statistics and multiple regression were used to analyze the data. The "Impact of Event Scale-Revised" measured current posttraumatic stress. RESULTS: Report of injury predicted posttraumatic stress, intrusion, and arousal but not avoidance/numbing. Injury and intrusion were significant predictors of ongoing worry. CONCLUSIONS: Even relatively minor injury may be associated with ongoing posttraumatic stress and worry. The participants in the sample were all highly exposed which, along with the small sample size, may have limited the ability to establish other expected relationships.

Adult↗

Sex differences in principal farm operators' tractor driving safety beliefs and behaviors.

OBJECTIVE: To examine the widely accepted hypothesis that farm women are more concerned with safety issues and behaviors than their male counterparts are. METHODS: A telephone survey was administered to a random sample of Kentucky principal farm operators, 90 of whom were women. Participants were questioned about their tractor safety beliefs and practices. RESULTS: No significant sex differences in tractor safety perceptions and behavior were observed. CONCLUSIONS: Socialization of women to the role of principal farm operator may override their typically greater sensitivity to safety issues, an important consideration when designing safety campaigns for this population.

Adult↗

Does disadvantage start at home? Racial and ethnic disparities in health-related early childhood home routines and safety practices.

BACKGROUND: Little is known about whether racial/ethnic differences exist in household family activities, safety practices, and educational opportunities known to impact young children's healthy development and school success. OBJECTIVE: To examine whether racial/ethnic disparities exist in early childhood home routines, safety measures, and educational practices/resources. METHODS: The 2000 National Survey of Early Childhood Health is a telephone survey of a nationwide sample of parents of 2608 children aged 4 to 35 months. Differences in family activities, safety measures, and educational practices/resources were examined for white, black, and Hispanic children. RESULTS: Minority children are less likely than white children to have consistent daily mealtimes and bedtimes, and more frequently never eat lunch or dinner with their family. Minority parents are less likely to install stair gates or cabinet safety locks and to turn down hot water settings. Minority parents less often read daily to their child, Hispanic parents more often never read to their child, and minority households average fewer children's books. Black children average more hours watching television daily. Disparities persisting in multivariate analyses included: minority children having increased odds of never eating lunch or dinner with their family, black children not having regular mealtimes (odds ratio, 1.8; 95% confidence interval, 1.2-2.7) and watching 1 more hour of television daily, black parents not installing cabinet locks, minority parents having twice the odds of not installing stair gates and not reading to their child daily, and minority homes having fewer children's books (black homes, -30; and Hispanic homes, -20). Children whose parents completed surveys in Spanish also experienced several disparities. CONCLUSIONS: Young minority children experience multiple disparities in home routines, safety measures, and educational practices/resources that have the potential to impede their healthy development and future school success. Such disparities might be reduced or eliminated through targeted education and intervention by pediatric providers.

Black People↗

Gun ownership and counseling of Alabama pediatricians.

OBJECTIVE: To examine the personal behavior of primary care pediatricians in Alabama with respect to a gun control policy. The American Academy of Pediatrics supports removal of handguns from homes, safe gun storage in homes with guns, and counseling patients about gun safety practices. DESIGN: Survey. SETTING: Primary care pediatricians. PATIENTS OR OTHER PARTICIPANTS: Population-based sample. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The proportion of pediatricians who were gun and handgun owners was examined. In addition, the safety behaviors and counseling practices reported by pediatricians were examined. RESULTS: The response rate for pediatricians was 67%. Fifty percent of pediatricians reported owning a gun. Thirty-four percent of pediatricians had a handgun in their household. Eleven percent of pediatricians had unsafe gun practices, where unsafe was defined as having a loaded gun in the home or car at least some of the time. The most common reason for owning a handgun or having a loaded gun in the home or car was personal protection. Only a third (33%) of pediatricians routinely counseled their patients about gun safety. Long gun owners were less likely to counsel patients about bike helmet safety and were less likely to use car seats and bike helmets for their own children. CONCLUSIONS: A large proportion of Alabama pediatricians are gun owners, but most store weapons safely. Although long gun owners were less likely to use car seats or bike helmets and less likely to counsel patients regarding bike helmet use, no effect of gun ownership on counseling about gun safety was identified.

Adult↗

Limb defects and chorionic villus sampling: results from an international registry, 1992-94.

BACKGROUND: Several reports of limb defects occurring among infants exposed to chorionic villus sampling (CVS) during pregnancy resulted in concern about the safety of this procedure for prenatal diagnosis. To avoid publication bias and evaluate the true risk of limb defects in a CVS cohort, the World Health Organization initiated international registration of post-CVS limb defects in 1992. METHODS: From May, 1992, to May, 1994, 77 infants or fetuses with limb defects from 138 996 pregnancies having CVS were reported to the WHO CVS Registry. These cases were analysed by standardised methods-ie, exclusion of syndromes, inherited disorders, and defects occurring in previable fetuses. The included limb deficiencies were studied by pattern analysis. FINDINGS: Defects of the upper limbs were reported in 64.6%, of the lower limbs in 12.5%, and of both upper and lower limbs in 20.8% of cases. These figures are in agreement with the distribution of limb defects in several large population-based studies. Transverse limb defects occurred in 40.8% and longitudinal defects in 59.2%, compared with 42.7% and 57.3% in an unexposed population. INTERPRETATION: The analysis of this cohort did not show any differences from the background population in the overall frequency or pattern distribution of limb deficiencies. There was also no correlation between gestational age at CVS and severity of defects. Therefore these results do not indicate any increased risk of limb defects after CVS.

Arm↗

Oral vinorelbine pharmacokinetics and absolute bioavailability study in patients with solid tumors.

BACKGROUND: Vinorelbine is a vinca alkaloid obtained by hemisynthesis, which makes the molecule more lipophilic than the other vincas. An injectable formulation is already marketed for the treatment of non small cell lung cancer (NSCLC) and advanced breast cancer (ABC). A new oral form has been developed and its file registration is being submitted. As part of its development, a clinical study was conducted to determine the absolute bioavailability and pharmacokinetics of oral vinorelbine administered as softgel capsules, and to evaluate its safety profile compared with intravenous administration. PATIENTS AND METHODS: Thirty-two patients with solid tumours were included in the study. Patients fasted and were randomised to receive vinorelbine on day 1, either as a 20 minute intravenous (i.v.) infusion of 25 mg/m2 or as softgel capsules at a dose of 80 mg/m2. Patients were treated with the alternate route after a one week wash-out period. Blood and urine samples for pharmacokinetic analysis were collected during each vinorelbine administration. Safety was assessed after each administration using the CALGB/expanded CTC classification. RESULTS: Twenty-four patients were eligible for pharmacokinetic evaluation. Oral vinorelbine was rapidly absorbed at 80 mg/m2 (Tmax 1.4 +/- 0.7 h) and showed a bioavailability of 43 +/- 14, and close to 40% based on AUC(last) and AUC(inf), respectively. A bioequivalence analysis was conducted on dosage-normalised blood exposures. Equivalence was demonstrated between 80 mg/m2 oral and 30 mg/m2 i.v., and between 60 mg/m2 oral and 25 mg/m2 i.v. The inter-individual variability was equivalent for both routes (CV: 38% and 39% for oral and i.v., respectively). A correlation was found in both methods between AUClast and % nadir variation in white blood cells (WBC) and polymorphonuclears (PMN). More cases of neutropenia (all grades pooled), leucopenia (grades 3-4 only) and nausea (grades 2-3) were induced by 80 mg/m2 oral vinorelbine than by 25 mg/m2 i.v. The greatest intensity of these effects, following oral administration, probably reflects the higher, observed drug exposure. CONCLUSION: At therapeutic dosage levels, pharmacokinetic behaviour and safety profiles were similar for both routes. The absolute bioavailability of the oral vinorelbine (new, soft gelatine capsule) was close to 40%. Inter-individual variability in drug exposure was equivalent in both routes. The pharmacokinetic/pharmacodynamic (PK/PD) relationship in haematological toxicity was independent of the routes of administration. Reliable, corresponding doses between oral and i.v. vinorelbine were established, which will result in bioequivalent AUC.

Administration, Oral↗

[Clinical phase III study of cimetropium bromide (DA3177) on the pain with upper urinary calculus: a double-blind study in comparison with scopolamine butylbromide. DA3177 Study Group].

A double-blind study was conducted to evaluate the efficacy, safety and usefulness of cimetropium bromide (DA3177) in the patients with pain caused by upper urinary calculus at a daily dose of 75 mg t.i.d. (Group D, 97 patients) in comparison with scopolamine butylbromide at a daily dose of 60 mg t.i.d. (Group B, 101 patients). According to patient's impression, the rate of "moderately improved" or better was significantly higher in Group D (68.7%) than in Group B (53.5%; Wilcoxon 2 sample test: p = 0.0044). For pain, the rate of "moderately improved" or better was 69.1% in Group D and 60.4% in Group B. In global improvement, the rate of "moderately improved" or better was significantly higher in Group D (70.1%) than in Group B (61.4%; Wilcoxon 2 sample test: p = 0.0469). The rate of "no problem in safety" showed no significant difference between Group D (91.5%) and Group B (93.3%). Adverse reactions occurred in 8.5% in Group D and 6.7% in Group B. The major adverse reactions were "dry mouth", "abdominal distension", "constipation" and "nausea". The rate of "useful" or better was 68.7% in Group D, and 60.4% in Group B. In conclusion, DA3177 was confirmed to be a useful drug for patient with pain caused by upper urinary calculus.

Adult↗

Employees exposed to lead in Washington state nonconstruction workplaces: a starting point for hazard surveillance.

A survey of selected Washington state employers was carried out to (1) determine the number of employees working in lead-using businesses, (2) characterize processes and tasks where exposures occur, and (3) determine the number of employers familiar with the lead standard, lead health effects, and how exposures can be controlled. A total of 1822 nonconstruction employers likely to use lead were identified using Washington State Department of Labor and Industries files, telephone directories, Washington State Department of Ecology files, air sampling results from state workplace inspections, and the state's Adult Blood Lead Registry. A total of 89.5% of employers returned the mail questionnaire. Of 789 employers responding that they engaged in lead-using tasks, 45% stated they were aware there was an Occupational Safety and Health Administration standard for lead, 21% had done air sampling for lead, 17% had done blood-lead screening, and 76% reported some type of industrial hygiene measures to control exposures. The most commonly reported lead-using activities included soldering; auto repair; scrap metal handling; sanding; cutting or welding surfaces coated with leaded materials; painting with leaded paints; and radiator repair. A total of 18,970 nonconstruction workers (and 9416 construction workers) were estimated to be lead-exposed in Washington in 1995. Identification of potentially exposed workers through hazard surveillance and characterization of workplace knowledge and practices (through survey and the registry) has allowed the Department of Labor and Industries to target resources toward industries most in need of exposure reduction efforts.

Adult↗

Quantification of toxic Microcystis spp. during the 2003 and 2004 blooms in western Lake Erie using quantitative real-time PCR.

In August of 2003 and August of 2004, blooms of potentially toxic cyanobacteria Microcystis spp. persisted in western Lake Erie. Samples collected from the bloom were analyzed for the cyanobacterial toxin microcystin and the presence of Microcystis spp. cells. Estimates of microcystin toxicity exceeding 1 microg L(-1) (microcystin-LR activity equivalents), the safety limit set by the World Health Organization, were found from the samples in both 2003 and 2004. The presence of Microcystis spp. in water samples was confirmed through standard polymerase chain reaction (PCR) using a combination of four primer sets. Quantification of Microcystis was accomplished by a real-time PCR assay utilizing specific primer-Taq-man probe sets targeted on a conserved, Microcystis-specific 16S rDNA fragment and a microcystin toxin synthetase gene mcyD. This approach allowed us to specifically study the distribution and abundance of toxic Microcystis in the lake in contrast to previous studies that have assessed Microcystis populations with less refined methods. On the basis of quantification by quantitative real-time PCR analysis, the total abundance of Microcystis cells in the bloom area varied from 4 x 10(8) to 2 x 10(3) cells L(-1). The results of this study provide novel insight regarding the distribution and abundance of Microcystis spp. in the western basin of Lake Erie, a region plagued in recent years by large-scale (>20 km2) blooms. Our results suggest that the Maumee River and Bay may serve as a source for Microcystis to western and central Lake Erie.

Bacterial Toxins↗

An exploration of the perceptions of the average driver's speed compared to perceived driver safety and driving skill.

This study investigates the self-enhancement bias in driver attitudes, the finding that drivers rate themselves better than the average driver on safety and skill perceptions (Svenson, 1978, 1981; McCormick et al., 1986). A sample of 86 New Zealand drivers were asked their perceptions of their own and others' speeds in two conditions, 50 km/h and 100 km/h. The results established the self-enhancement bias for speed and safety, but not skill. Between 85% and 90% of drivers claimed to drive slower than the 'average driver.' A new methodological technique derived from Harré and Gillett (1994) was used to investigate the direction of the self-enhancement bias. The results support the Downward Comparison Theory (Wills, 1981) because drivers consider other drivers negatively, rather than exaggerating their self-perceptions.

Acceleration↗

The use of selective serotonin reuptake inhibitors in pregnancy.

OBJECTIVE: To provide an update of literature on the safety of using selective serotonin reuptake inhibitors (SSRIs) during pregnancy. METHODS: MEDLINE was searched for English-language papers published from 1985 to 2003 on human studies of SSRIs, using the key words "serotonin reuptake inhibitors," "citalopram," "fluoxetine," "fluvoxamine," "paroxetine," and "sertraline." RESULTS: The literature search yielded 12 338 publications. Previous studies on the safety of SSRIs in pregnancy were often based on small samples from medical centres, with heterogeneous design and outcome ascertainment methods, and had yielded inconsistent results. Consequently, the management of pregnant women with depression poses challenges to clinicians who are hesitant to prescribe anti-depression drugs, including SSRIs, because of concern about potential risks to the fetuses. Failure to adequately treat maternal depression can lead to progressively worsening depression that greatly compromises maternal-fetal health and can impair bonding and childcare in the postpartum period. CONCLUSIONS: Because of the uncertainty regarding the safety of SSRI use during pregnancy, consultation with specialists experienced in treating depression may be helpful when treating pregnant women with SSRIs. Large-scale, population-based studies to comprehensively assess the safety of SSRIs in pregnancy are needed.

Depression↗

Assessment of respiratory exposures during gilsonite mining and milling operations.

An industrial hygiene study of the entire United States gilsonite industry was done by the National Institute for Occupational Safety and Health (NIOSH) to evaluate the potential for occupational health problems resulting from exposures to gilsonite and its constituents. Gilsonite is a solidified hydrocarbon substance mined only in northeastern Utah to Colorado. Industrial hygiene samples were collected at four gilsonite mining companies including nine mines and three mills. Gilsonite workers had no measurable exposures to polynuclear aromatic hydrocarbon (PNA) compounds, asbestos fibers, or hydrogen sulfide gas. Several organic gases/vapors and metals were detected in the airborne samples; but, none exceeded the current exposure standards/health criteria of the Mine Safety and Health Administration (MSHA), the American Conference of Governmental Industrial Hygienists (ACGIH), or NIOSH. Gilsonite workers in some job categories were exposed to high levels of dust, exceeding ACGIH nuisance dust recommendations. These dusts, comprised largely of aliphatic hydrocarbons, had a large aerodynamic size distribution with average mass median aerodynamic diameters (MMAD) above 30 microns.

Air Pollutants, Occupational↗