Stefanos N. Kales

Lead, Mercury, and Arsenic in US- and Indian-Manufactured Ayurvedic Medicines Sold via the Internet

CONTEXT Lead, mercury, and arsenic have been detected in a substantial proportion of Indian-manufactured traditional Ayurvedic medicines. Metals may be present due to the practice of rasa shastra (combining herbs with metals, minerals, and gems). Whether toxic metals are present in both US- and Indian-manufactured Ayurvedic medicines is unknown. OBJECTIVES To determine the prevalence of Ayurvedic medicines available via the Internet containing detectable lead, mercury, or arsenic and to compare the prevalence of toxic metals in US- vs Indian-manufactured medicines and between rasa shastra and non-rasa shastra medicines. DESIGN A search using 5 Internet search engines and the search terms Ayurveda and Ayurvedic medicine identified 25 Web sites offering traditional Ayurvedic herbs, formulas, or ingredients commonly used in Ayurveda, indicated for oral use, and available for sale. From 673 identified products, 230 Ayurvedic medicines were randomly selected for purchase in August-October 2005. Country of manufacturer/Web site supplier, rasa shastra status, and claims of Good Manufacturing Practices were recorded. Metal concentrations were measured using x-ray fluorescence spectroscopy. MAIN OUTCOME MEASURES Prevalence of medicines with detectable toxic metals in the entire sample and stratified by country of manufacture and rasa shastra status. RESULTS One hundred ninety-three of the 230 requested medicines were received and analyzed. The prevalence of metal-containing products was 20.7% (95% confidence interval [CI], 15.2%-27.1%). The prevalence of metals in US-manufactured products was 21.7% (95% CI, 14.6%-30.4%) compared with 19.5% (95% CI, 11.3%-30.1%) in Indian products (P = .86). Rasa shastra compared with non-rasa shastra medicines had a greater prevalence of metals (40.6% vs 17.1%; P = .007) and higher median concentrations of lead (11.5 microg/g vs 7.0 microg/g; P = .03) and mercury (20,800 microg/g vs 34.5 microg/g; P = .04). Among the metal-containing products, 95% were sold by US Web sites and 75% claimed Good Manufacturing Practices. All metal-containing products exceeded 1 or more standards for acceptable daily intake of toxic metals. CONCLUSION One-fifth of both US-manufactured and Indian-manufactured Ayurvedic medicines purchased via the Internet contain detectable lead, mercury, or arsenic.

Firefighters and on-duty deaths from coronary heart disease: a case control study

BackgroundCoronary heart disease (CHD) is responsible for 45% of on-duty deaths among United States firefighters. We sought to identify occupational and personal risk factors associated with on-duty CHD death.MethodsWe performed a case-control study, selecting 52 male firefighters whose CHD deaths were investigated by the National Institute for Occupational Safety and Health. We selected two control populations: 51 male firefighters who died of on-duty trauma; and 310 male firefighters examined in 1996/1997, whose vital status and continued professional activity were re-documented in 1998.ResultsThe circadian pattern of CHD deaths was associated with emergency response calls: 77% of CHD deaths and 61% of emergency dispatches occurred between noon and midnight. Compared to non-emergency duties, fire suppression (OR = 64.1, 95% CI 7.4–556); training (OR = 7.6, 95% CI 1.8–31.3) and alarm response (OR = 5.6, 95% CI 1.1–28.8) carried significantly higher relative risks of CHD death. Compared to the active firefighters, the CHD victims had a significantly higher prevalence of cardiovascular risk factors in multivariate regression models: age ≥ 45 years (OR 6.5, 95% CI 2.6–15.9), current smoking (OR 7.0, 95% CI 2.8–17.4), hypertension (OR 4.7, 95% CI 2.0–11.1), and a prior diagnosis of arterial-occlusive disease (OR 15.6, 95% CI 3.5–68.6).ConclusionsOur findings strongly support that most on-duty CHD fatalities are work-precipitated and occur in firefighters with underlying CHD. Improved fitness promotion, medical screening and medical management could prevent many of these premature deaths.

Prognostic Factors in Patients with Methanol Poisoning

OBJECTIVE To identify prognostic factors in methanol poisoning and determine the effect of medical interventions on clinical outcome. METHODS Retrospective review of all patients treated for methanol poisoning from 1982 through 1992 at The Toronto Hospital. Presenting history, physical examination, results of laboratory tests, medical interventions, and final outcomes after hemodialysis were abstracted. RESULTS Of 50 patients treated for methanol poisoning, 18 (36%) died, 32 (64%) survived. Seven of the 32 survivors sustained visual sequelae (22%), the remaining 25 (78%) recovered completely. Patients presenting with coma or seizure had 84% (16/19) mortality compared to 6% (2/31) in those without (p < 0.001). Initial arterial pH < 7 was also associated with significantly higher mortality (17/19, 89% vs 1/31, 3%, p < 0.001). There were no differences in time from presentation to dialysis between survivors and fatalities (8.4 +/- 3.6 vs 7.6 +/- 3.5 hours, p = 0.47). The deceased patients had higher mean methanol concentration than the survivors (83 +/- 53 vs 41 +/- 25 mmol/L, p = 0.004). Subgroup analysis of 19 patients presenting with visual symptoms who survived showed prolonged acidosis (5.4 +/- 2.3 vs 3.0 +/- 2.1 hours, p = 0.06) in those with persistent visual sequelae. CONCLUSIONS Coma or seizure on presentation and severe metabolic acidosis, in particular initial arterial pH < 7, are poor prognostic indicators in methanol poisoning. Survivors presented with lower methanol concentrations. Patients with residual visual sequelae had more prolonged acidosis than those with complete recovery. Future studies will be needed to confirm the effect of correction of acidosis on final clinical outcome.

The prevalence of overweight, obesity, and substandard fitness in a population-based firefighter cohort.

Objective: To examine the prevalence of overweight and obesity in firefighters. Methods: Body mass index (BMI), waist circumference, and body fat percentage (BF%) were assessed in 478 career and 199 volunteer male firefighters from randomly selected departments. Results: High prevalence rates of overweight + obesity (BMI ≥ 25 kg/m2) and obesity (BMI ≥ 30 kg/m2) were found in career (79.5%; 33.5%) and volunteer firefighters (78.4%; 43.2%). False-positive obesity misclassification based on BMI, compared to waist circumference and BF%, was low (9.8% and 2.9%, respectively). False negatives were much higher: 32.9% and 13.0%. Obese firefighters demonstrated unfavorable cardiovascular disease (CVD) profiles. Conclusions: The prevalence of overweight and obesity exceeded that of the US general population. Contrary to common wisdom, obesity was even more prevalent when assessed by BF% than by BMI, and misclassifying muscular firefighters as obese by using BMI occurred infrequently.

Nut consumption on all-cause, cardiovascular, and cancer mortality risk: a systematic review and meta-analysis of epidemiologic studies

BACKGROUND Recent pooled analyses supported a beneficial impact of nut consumption on health, but to our knowledge, whether nuts are associated with overall decreased mortality has not been previously reviewed. OBJECTIVES We aimed to systematically review prospective studies that explored the effects of nut consumption on all-cause, cardiovascular disease (CVD), and cancer mortality and quantify the size effect through a meta-analysis. We also reviewed confounding factors associated with nut consumption to assess potential clustering with other covariates. DESIGN We searched PubMed and EMBASE for studies published up to June 2014. Study characteristics, HRs, and 95% CIs were generated on the basis of quantitative analyses. A dose-response analysis was performed when data were available. RESULTS Seven studies for all-cause mortality, 6 studies for CVD mortality, and 2 studies for cancer mortality were included in the meta-analysis with a total of 354,933 participants, 44,636 cumulative incident deaths, and 3,746,534 cumulative person-years. Nut consumption was associated with some baseline characteristics such as lower body mass index and smoking status as well as increased intakes of fruit, vegetables, and alcohol. One-serving of nuts per week and per day resulted in 4% (RR: 0.96; 95% CI: 0.93, 0.98) and 27% (RR: 0.73; 95% CI: 0.60, 0.88) decreased risk of all-cause mortality, respectively, and decreased risk of CVD mortality [RR: 0.93 (95% CI: 0.88, 0.99) and 0.61 (95% CI: 0.42, 0.91), respectively]. Effects were primarily driven by decreased coronary artery disease deaths rather than stroke deaths. Nut consumption was also associated with decreased risk of cancer deaths when highest compared with lowest categories of intake were compared (RR: 0.86; 95% CI: 0.75, 0.98), but no dose-effect was shown. CONCLUSION Nut consumption is associated with lower risk of all-cause, CVD, and cancer mortality, but the presence of confounding factors should be taken into account when considering such findings.

Blood Pressure in Firefighters, Police Officers, and Other Emergency Responders

Elevated blood pressure is a major risk factor for cardiovascular morbidity and mortality. Increased risk begins in the prehypertensive range and increases further with higher pressures. The strenuous duties of emergency responders (firefighters, police officers, and emergency medical services (EMS) personnel) can interact with their personal risk profiles, including elevated blood pressure, to precipitate acute cardiovascular events. Approximately three-quarters of emergency responders have prehypertension or hypertension, a proportion which is expected to increase, based on the obesity epidemic. Elevated blood pressure is also inadequately controlled in these professionals and strongly linked to cardiovascular disease morbidity and mortality. Notably, the majority of incident cardiovascular disease events occur in responders who are initially prehypertensive or only mildly hypertensive and whose average premorbid blood pressures are in the range in which many physicians would hesitate to prescribe medications (140-146/88-92). Laws mandating public benefits for emergency responders with cardiovascular disease provide an additional rationale for aggressively controlling their blood pressure. This review provides a background on emergency responders, summarizes occupational risk factors for hypertension and the metabolic syndrome, their prevalence of elevated blood pressure, and evidence linking hypertension with adverse outcomes in these professions. Next, discrepancies between relatively outdated medical standards for emergency responders and current, evidence-based guidelines for blood pressure management in the general public are highlighted. Finally, a workplace-oriented approach for blood pressure control among emergency responders is proposed, based on the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

The Obesity Epidemic and Future Emergency Responders

Emergency responders should be fit to safely perform strenuous duties. In particular, young recruits are expected to be at or near peak career fitness. We studied the prevalence and health associations of excess weight among 370 consecutive emergency responder candidates for fire and ambulance services in Massachusetts. The mean age and BMI of the recruits were 26.3 (3.8) years and 28.5 (4.9) kg/m2, respectively. Seventy‐seven percent had BMI ≥25 kg/m2, and 33% were obese (BMI ≥30 kg/m2). After multivariate adjustment, both higher BMI categories and unit increases in BMI were significantly associated with higher blood pressures, worse metabolic profiles, and lower exercise tolerance. Excess weight is highly prevalent and associated with elevated cardiovascular risk among future emergency responders. These findings in a population expected to perform demanding duties supporting public safety merit prompt public health intervention.

Hypnopolygraphic alterations in attention deficit disorder (ADD) children

The sleep pattern of 13 prepubertal children, nonmedicated, rigourously diagnosed as Attention Deficit Disorder (ADD) was recorded for two consecutive nights. Analyses of sleep pattern variables revealed a marked reduction of sleep onset latency (p less than .01), a great number of nocturnal awakenings (p less than .01), and a high increase of Delta sleep percentage (p less than .01) for the ADD children compared to normals. In addition, the two subtypes of the disorder--ADD with hyperactivity (ADD/H) and ADD without hyperactivity (ADD/WO) or ADD undifferentiated--showed distinct hypnopolygraphic correlates. Those ADD/H children had a greater sleep fragmentation and a lesser degree of sleep efficiency. These findings would support the hypothesis that ADD is related to a deficient control of arousal level and, on the other hand, suggest that ADD/H and ADD/WO are different clinical entities.

Type 2 diabetes mellitus and medications for type 2 diabetes mellitus are associated with risk for and mortality from cancer in a German primary care cohort.

There is growing evidence that patients with type 2 diabetes mellitus have increased cancer risk. We examined the association between diabetes, cancer, and cancer-related mortality and hypothesized that insulin sensitizers lower cancer-related mortality. Participants in the Diabetes Cardiovascular Risk and Evaluation: Targets and Essential Data for Commitment of Treatment study, a nationwide cross-sectional and prospective epidemiological study, were recruited from German primary care practices. In the cross-sectional study, subjects with type 2 diabetes mellitus had a higher prevalence of malignancies (66/1308, 5.1%) compared to nondiabetic subjects (185/6211, 3.0%) (odds ratio, 1.64; 95% confidence interval, 1.12-2.41) before and after adjustment for age, sex, hemoglobin A(1c), smoking status, and body mass index. Patients on metformin had a lower prevalence of malignancies, comparable with that among nondiabetic patients, whereas those on any other oral combination treatment had a 2-fold higher risk for malignancies even after adjusting for possible confounders; inclusion of metformin in these regimens decreased the prevalence of malignancies. In the prospective analyses, diabetic patients in general and diabetic patients treated with insulin (either as monotherapy or in combination with other treatments) had a 2- and 4-fold, respectively, higher mortality rate than nondiabetic patients, even after adjustment for potential confounders (incidence of cancer deaths in patients with type 2 diabetes mellitus [2.6%] vs the incidence of cancer deaths in patients without type 2 diabetes mellitus [1.2%]). Our results suggest that diabetes and medications for diabetes, with the exception of the insulin sensitizer metformin, increase cancer risk and mortality.

Obesity and risk of job disability in male firefighters

BACKGROUND Obesity is a major public health problem and a workplace epidemic in Western societies. However, little is known about the association between obesity and job disability in specific occupational groups. AIM To examine the association between obesity and risk of job disability among firefighters. METHODS A prospective cohort study design was employed in following 358 Massachusetts firefighters enrolled in a statewide medical surveillance program. We prospectively evaluated time to development of adverse employment outcomes >6 years of follow-up. RESULTS In multivariable-adjusted Cox proportional hazard models, we found that every one-unit increase in body mass index (BMI) was associated with a 5% increased risk of job disability. Compared to firefighters in the lowest tertile of BMI (BMI < 27.2), those in the highest tertile (BMI >or= 30.2) had a significantly increased risk of an adverse employment event with a multivariable-adjusted hazard ratio (HR) of 1.98 (95% CI 1.06-3.72). There was also a significant dose-response relationship of increasing risk across tertiles, as well as a significant trend: HR 1.39 (95% CI 1.04-1.86). The highest categories of BMI had a 60-90% increased risk of job disability compared to the lowest or normal-weight categories, respectively. CONCLUSIONS Obesity is associated with higher risk of job disability in firefighters. Additional research is needed to further explore our findings. Our study may have economic and public health implications in other occupational settings.