Beth A. Baker

A Strong Dose-Response Relation Between Serum Concentrations of Persistent Organic Pollutants and Diabetes Results from the National Health and Examination Survey 1999–2002

OBJECTIVE—Low-level exposure to some persistent organic pollutants (POPs) has recently become a focus because of their possible link with the risk of diabetes. RESEARCH DESIGN AND METHODS—Cross-sectional associations of the serum concentrations of POPs with diabetes prevalence were investigated in 2,016 adult participants in the National Health and Nutrition Examination Survey 1999–2002. Six POPs (2,2′,4,4′,5,5′-hexachlorobiphenyl, 1,2,3,4,6,7,8-heptachlorodibenzo-p-dioxin, 1,2,3,4,6,7,8,9-octachlorodibenzo-p-dioxin, oxychlordane, p,p′-dichlorodiphenyltrichloroethane, and trans-nonachlor) were selected, because they were detectable in ≥80% of participants. RESULTS—Compared with subjects with serum concentrations below the limit of detection, after adjustment for age, sex, race and ethnicity, poverty income ratio, BMI, and waist circumference, diabetes prevalence was strongly positively associated with lipid-adjusted serum concentrations of all six POPs. When the participants were classified according to the sum of category numbers of the six POPs, adjusted odds ratios were 1.0, 14.0, 14.7, 38.3, and 37.7 (P for trend < 0.001). The association was consistent in stratified analyses and stronger in younger participants, Mexican Americans, and obese individuals. CONCLUSIONS—There were striking dose-response relations between serum concentrations of six selected POPs and the prevalence of diabetes. The strong graded association could offer a compelling challenge to future epidemiologic and toxicological research.

Biomonitoring of 2,4-Dichlorophenoxyacetic Acid Exposure and Dose in Farm Families

Objective We estimated 2,4-dichlorophenoxyacetic acid (2,4-D) exposure and systemic dose in farm family members following an application of 2,4-D on their farm. Methods Farm families were recruited from licensed applicators in Minnesota and South Carolina. Eligible family members collected all urine during five 24-hr intervals, 1 day before through 3 days after an application of 2,4-D. Exposure profiles were characterized with 24-hr urine 2,4-D concentrations, which then were related to potential predictors of exposure. Systemic dose was estimated using the urine collections from the application day through the third day after application. Results Median urine 2,4-D concentrations at baseline and day after application were 2.1 and 73.1 μ g/L for applicators, below the limit of detection, and 1.2 μ g/L for spouses, and 1.5 and 2.9 μ g/L for children. The younger children (4–11 years of age) had higher median post-application concentrations than the older children (≥ 12 years of age) (6.5 vs. 1.9 μ g/L). The geometric mean systemic doses (micrograms per kilogram body weight) were 2.46 (applicators), 0.8 (spouses), 0.22 (all children), 0.32 (children 4–11 years of age), and 0.12 (children ≥ 12 years of age). Exposure to the spouses and children was primarily determined by direct contact with the application process and the number of acres treated. Multivariate models identified glove use, repairing equipment, and number of acres treated as predictors of exposure in the applicators. Conclusions We observed considerable heterogeneity of 2,4-D exposure among farm family members, primarily attributable to level of contact with the application process. Awareness of this variability and the actual magnitude of exposures are important for developing exposure and risk characterizations in 2,4-D–exposed agricultural populations.

Occupational medicine physicians in the United States: demographics and core competencies.

Objective: We assessed the demographic profile and opinions of current occupational medicine (OM) physicians on the importance of specific core competencies. Methods: A random sample of 1500 OM physicians listed in the membership directory of the American College of Occupational and Environmental Medicine (ACOEM) were asked to complete a voluntary survey. Results: Six hundred and ten OM physicians completed the survey. Fifty two percent worked in clinical settings, and 16% worked in corporate or industrial settings. Eighty percent were satisfied with their choice of careers. Conclusions: OM physicians appeared to be highly trained, with 60% certified in OM and 68% board certified in other specialties. The OM physicians valued staying current in the field, understanding the relationship between occupational exposure and health, and communicating with stakeholders most highly. Occupational physicians are an important source of knowledge regarding what competencies and core knowledge areas are important for OM practice.

Occupational medicine residency graduate survey: assessment of training programs and core competencies.

Objective: This study provides insight into Occupational Medicine (OM) residency graduates and how residency programs are meeting their education goals. Methods: A survey of graduates from nine OM residency program was performed to evaluate the effectiveness of OM residency training in the United States and Canada. Results: Eighty percent of the OM residency graduates were currently practicing OM. Three-quarters worked in clinical practice for a mean of 20 hr/wk. Other activities varied and included management, teaching and consulting. Ninety-five percent were satisfied with their OM residency training. The competencies acquired were mostly ranked highly as practice requisites, although preparation in clinical OM might be better emphasized in training. Recent OM residency graduates were more likely to be board-certified in OM than other American College of Occupational and Environmental Medicine physician members (73% vs 41%). Conclusions: OM residency graduates over the past 10 years were highly satisfied with OM residency training, with the training generally meeting practice needs.

The 2012 Core Content of Medical Toxicology

In December 2011, the Medical Toxicology Subboard, composed of representatives from emergency medicine, pediatrics, and preventive medicine, approved a revised Core Content of Medical Toxicology. The Core Content encompasses the specialty of medical toxicology and outlines the areas of knowledge considered essential for the practice of medical toxicology. Functionally, the Core Content provides the organizational framework for the development of the medical toxicology certification and cognitive expertise examinations, and details the knowledge to be tested on those examinations, beginning with the 2014 examinations. In addition, the Core Content may serve as a template for the development of medical toxicology fellowship curricula. The previous version, initiated in 2000, approved in 2002, and published in 2004, will be retired and replaced by this new version. The first Medical Toxicology Core Content was developed to assist in the construction of the first examination in 1994. This document consisted of 22 major content areas and was organized, in part, by toxicant classification. Listed under most of these major content areas were exhaustive lists of drugs and toxicants of which a medical toxicologist was expected to have knowledge. In 2000, the Medical Toxicology Subboard embarked on a major revision of the original Core Content. This undertaking was initiated to update the 1994 Core Content, as well as to improve the framework that conceptualizes the expanding breadth of medical toxicology. In addition, the Subboard wanted to devise a conceptual document that would accommodate future discoveries and changes. A task force of Medical Toxicology Subboard members was convened to develop and draft the revised Core Content, and comments were solicited from stakeholders.

2007 Survey of Medical Toxicology Practice

To date, there appear to be no studies investigating the practice settings of all Medical Toxicology (MT) diplomates. The MT Assessment of Practice Performance Taskforce queried all MT diplomates about their current practice settings relative to the number of patients seen, the most common diagnoses, and the percent of time spent in their roles as medical toxicologists (MTs) and in their primary specialty. One hundred twenty-seven surveys were completed (44% response rate). Seventy-nine percent of respondents were affiliated with poison centers. Eighty-eight percent of participants were clinically active and reported seeing or consulting on behalf of at least ten patients over a 2-year period. Acetaminophen toxicity was the most common diagnosis encountered by respondents. Other common diagnoses included antidepressant toxicity, antipsychotic toxicity, mental status alteration, metal/environmental toxicity, envenomation, and pesticide toxicity. While respondents were likely to spend more time in direct patient care in their primary specialty, compared to consulting on behalf of patients, they were more likely to consult on behalf of patients in their role as MTs. Respondents spent more time in research, education, and population health in their role as an MT than in their primary specialty. Administrative activities were more commonly reported in association with the respondents’ primary specialty than in their role as MTs. Most MTs encounter certain diagnoses with significant frequency and see a substantial number of patients within these categories. The majority spends more time on direct patient care in their primary specialty but is actively engaged in MT education, research, population health, and administration. A longitudinal assessment of MT practice patterns could inform MT curricular development and practice performance evaluation.

2007 Survey of Medical Toxicology Practice Improvement Activities

To date, there appear to be no studies that assess Medical Toxicologists’ (MTs) practice improvement (PI) activities in their Medical Toxicology practice settings. The MT Assessment of Practice Performance (APP) Taskforce queried all MT diplomates about (1) activities currently available in their practice settings that potentially would meet the requirements of APP, (2) potential APP activities that best fit with current MT practice, and (3) the relationship between MT practice patterns and APP requirements. One hundred twenty-seven surveys were completed. Participation in MT practice improvement activities is not universal, with approximately a third of the survey participants reporting that they are not involved in any practice improvement activity. Few respondents reported that they collected performance improvement-related data. Most who did so participated in CME, case, or chart reviews. Peer reviews, self-improvement plans based on chart reviews, and population research were considered the most valid measures of MT practice improvement. Communication skills were considered important topics for patient surveys. Suggested outcomes for peer assessment included accuracy of information provided, understanding medical staff concerns, timeliness of feedback, and helpfulness. Most respondents rated all of the APP options as being somewhat very intrusive. Access to those with sufficient knowledge of the diplomate’s practice improvement program to verify APP could pose a challenge to a successful completion of APP requirements. Optimal settings for the APP program administration are hospitals and poison centers. While barriers to MT APP activities exist, studying current MT diplomates’ opinions and practices could inform the future development and administration of such programs.