Cadmium (Cd) and Lead (Pb) topsoil levels and incidence of childhood leukemias

There are few well-established risk factors for childhood leukemias. While the frequency of childhood leukemias might be partially attributable to some diseases (accounting for a small fraction of cases) or ionizing radiation, the role of heavy metals has not been assessed. The objective of our study was to assess the potential association between levels of cadmium (Cd) and lead (PB) in soil and childhood leukemias incidence. We conducted a population-based case-control study of childhood leukaemia in Spain, covering 2897 incident cases gathered from the Spanish Registry of Childhood Tumours and including 14 Spanish Regions with a total population of 5,307,433 children (period 1996-2015). Cd and Pb bioavailable levels at every children's home address were estimated using data from the Geochemical Atlas of Spain. We used logistic regression to estimate odds ratios (ORs) and their 95% confidence intervals (95%CIs); we included as covariates: sex, rurality, employment rate and socioeconomic status. Metal levels were analysed according to two definitions: as continuous variable assuming linearity and as categorical variables to explore a potentially nonlinear association (quantiles). Increases in both Cd and Pb topsoil levels were associated with increased probability of childhood leukemias incidence. The results for the models with the continuous variables showed that a unit increase on the topsoil level was associated with an OR of 1.11 for Cd (95%CI 1.00-1.24) and an OR of 1.10 for Pb (95%CI 0.99-1.21). Our study may point towards a possible link between residential Cd and Pb topsoil levels and the probability of childhood leukemias incidence. Residing in a location with the highest concentrations of these heavy metals compared to those locations with the lowest could increase the risk around a 20%, for both Cd and Pb.This work was supported by Carlos III Health Institute: FIS 12/01416, AESI PI16CIII/00009, AESI PI19CIII/00025.S

Recommendations for ophthalmologic practice during the easing of COVID-19 control measures

In the context of the COVID-19 pandemic, this paper provides recommendations for medical eye care during the easing of control measures after lockdown. The guidelines presented are based on a literature review and consensus among all Spanish Ophthalmology Societies regarding protection measures recommended for the ophthalmologic care of patients with or without confirmed COVID-19 in outpatient, inpatient, emergency and surgery settings. We recommend that all measures be adapted to the circumstances and availability of personal protective equipment at each centre and also highlight the need to periodically update recommendations as we may need to readopt more restrictive measures depending on the local epidemiology of the virus. These guidelines are designed to avoid the transmission of SARS-CoV-2 among both patients and healthcare staff as we gradually return to normal medical practice, to prevent postoperative complications and try to reduce possible deficiencies in the diagnosis, treatment and follow-up of the ophthalmic diseases. With this update (5th) the Spanish Society of Ophthalmology is placed as one of the major ophthalmology societies providing periodic and systematized recommendations for ophthalmic care during the COVID-19 pandemic

Medio ambiente y supervivientes de cáncer pediátrico

Introducción. La creciente conciencia social de la relación entre la salud y el medio ambiente (MA) es un motor principal de cambio en las políticas y sistemas de salud durante el siglo XXI. Aunque todas las enfermedades son el resultado final de una combinación variable de dos determinantes, el interno o constitucional y el externo o medioambiental, la constante degradación y contaminación de los ecosistemas está provocando un aumento de las enfermedades medioambientalmente relacionadas, entre ellas el cáncer. Además, por su idiosincrasia, los niños, son especialmente vulnerables a los efectos deletéreos de los contaminantes medioambientales. La salud medioambiental constituye una disciplina clínica que integra la salud pública, ecología y la promoción de la salud con la práctica clínica de los profesionales sanitarios. En las Unidades de Salud Medioambiental Pediátricas (PEHSUs) se trabaja con herramientas como la Historia Clínica Medioambiental del Superviviente de Cáncer Infanto-Juvenil (PEHis) que nos permite evaluar de una forma integrativa el juicio clínico etiológico y pronóstico, incluida la calidad de vida, de los supervivientes de cáncer infanto-juvenil (SCIJ). La PEHis es una herramienta clínica innovadora, sencilla y reproducible que consolida el trabajo de las PEHSUs y genera nuevos perfiles profesionales que proporcionan un seguimiento con un enfoque integrativo y global para mejorar la supervivencia y la calidad de vida de los SCIJ. Objetivos. Estudiar la influencia del MA en la etiología y pronóstico, incluyendo supervivencia y calidad de vida, del cáncer infanto-juvenil de la Región de Murcia. Metodología. Tesis doctoral realizada por compendio de publicaciones. A) En el primer artículo analizamos la asociación entre los focos industriales de contaminación ambiental de la Región de Murcia y la incidencia de cáncer en menores de 15 años. B) En el segundo artículo analizamos la distribución geográfica durante períodos críticos del desarrollo (embarazo, primera infancia y el momento del diagnóstico) de todos los casos incidentes de leucemia aguda (LA) infantil (<15 años) diagnosticados en la Región de Murcia durante el período 1998-2013 incorporando la PEHis para una evaluación de riesgo individual y comunitaria en el estudio de los agrupamientos de cáncer infantil. C) En el tercer trabajo analizamos las tasas de supervivencia de 146 pacientes menores de 15 años diagnosticados de leucemia aguda linfoblástica (LAL) entre 1998-2016 en la Región de Murcia. Se evaluó la exposición a humo ambiental de tabaco (HAT) y otros factores pronósticos conocidos para determinar el impacto en la supervivencia global, la supervivencia libre de eventos, la incidencia acumulada de recaída y la incidencia acumulada de mortalidad relacionada con el tratamiento. D) En el cuarto artículo comparamos la calidad de vida relacionada con la salud (CVRS) de 117 SCIJ entre 8-18 años con un grupo sano emparejados por sexo y edad. Posteriormente se identificaron las asociaciones de los factores sociodemográficos, clínicos, ambientales y de estilos de vida, obtenidos de la PEHis, con la CVRS. Conclusiones. A) La integración de la PEHis, considerando distintos periodos críticos (embarazo, infancia y momento del diagnóstico), en un SIG es útil para la identificación y estudio de clústeres de cáncer infanto-juvenil, mejorando los sistemas de información y vigilancia de la salud pública y comunitaria. B) Existe una asociación entre la proximidad a focos de actividad industrial y un mayor riesgo de cáncer infantil. C) La exposición persistente a HAT es un factor pronóstico modificable de las LAL infantiles. D) La CVRS de los SCIJ de la Región de Murcia es similar a la de controles sanos. Vivir en entornos contaminados con peor calidad del aire exterior, el déficit de contacto con la Naturaleza, el sedentarismo, el uso excesivo de dispositivos electrónicos y la pobreza empeoran la CVRS. E) La incorporación de la PEHis en los programas de largo seguimiento de SCIJ contribuye a mejorar el juicio clínico etiológico y pronóstico, situando en el eje central de las intervenciones una perspectiva ecológica para prevenir y/o disminuir el daño asociado a los efectos tardíos y mejorando la CVRS a través de la creación de ambientes y estilos de vida más saludables.Introduction. The growing social awareness of the relationship between health and the environment is a major driver of change in health policies during the 21st century. Although all diseases are the final outcome of a variable combination of two determinants, the internal or constitutional and the external or environmental, the constant deterioration and contamination of ecosystems is causing an increase in environmentally related diseases, including cancer. Furthermore, due to their idiosyncrasy, children are especially vulnerable to the deleterious effects of environmental pollutants. Environmental health is a clinical discipline that integrates public health, ecology and health promotion with the clinical practice of health professionals. In the Pediatric Environmental Health Specialty Units (PEHSUs) we work with tools such as the Environmental Clinical History of the Childhood and Adolescent Cancer Survivor (PEHis) that allows us to evaluate in an integrative way the etiological and prognostic clinical judgment, including quality of life, of childhood and adolescent cancer survivors (CACS). The PEHis is an innovative, simple and reproducible clinical tool that consolidates the work of the PEHSUs and generates new professional profiles that provide follow-up with an integrative and global approach to improve survival and quality of life of the CACS. Objectives. To study the influence of the environment on the etiology and prognosis, including survival and quality of life, of childhood and adolescent cancer in the Region of Murcia. Methods. Thesis made by compendium of publications. A) In the first article we analyze the association between the industrial sources of environmental pollution in the Region of Murcia and the incidence of cancer in children under 15 years of age. B) In the second article we analyze the spatial distribution during critical periods of development (pregnancy, early childhood and the time of diagnosis) of all incident cases of childhood acute leukemia (AL) (<15 years) diagnosed in the Region of Murcia during the period 1998-2013 incorporating the PEHis for an individual and community risk assessment in the study of childhood cancer clusters. C) In the third study, we analyzed survival rates in 146 patients under the age of 15 years diagnosed with acute lymphoblastic leukemia (ALL) between 1998 -2016 in the Region of Murcia. Evaluation of parental second-hand smoke (SHS) and other known prognostic factors were assessed for impact on overall survival, event-free survival, cumulative incidence of relapse, and treatment-related mortality. D) In the fourth article we compared the health-related quality of life (HRQoL) of 117 CACS between 8-18 years with a healthy group matched by sex and age. Subsequently, we identified the associations of sociodemographic, clinical, environmental and lifestyle factors, obtained from the PEHis, with the HRQoL. Conclusions. A) The integration of the PEHis, considering critical periods (pregnancy, early childhood and time of diagnosis), in a Geographic Information System (GIS) is useful for the identification and study of childhood and adolescent cancer clusters, improving the information systems and public and community health surveillance. B) There is an association between proximity to sources of industrial activity and an increased risk of childhood cancer. C) Persistent exposure to SHS is a modifiable prognostic factor for childhood ALL. D) The HRQoL of the CACS of the Region of Murcia is similar to healthy controls. Living in polluted environments with poorer outdoor air quality, lack of contact with Nature, sedentary lifestyle, excessive use of electronic devices and poverty worsen the HRQoL of the CACS in the Region of Murcia. D) The incorporation of PEHis in long-term follow-up programs for CACS contributes to improve the etiological and prognostic clinical judgment, placing an ecological perspective at the center of the interventions to prevent and / or reduce the damage associated with late effects and improving the HRQoL through the creation of healthier environments and lifestyles

Childhood cancer in small geographical areas and proximity to air-polluting industries

AIM: Pediatric cancer has been associated with exposure to certain environmental carcinogens. The purpose of this work is to analyse the relationship between environmental pollution and pediatric cancer risk. METHOD: We analysed all incidences of pediatric cancer (<15) diagnosed in a Spanish region during the period 1998-2015. The place of residence of each patient and the exact geographical coordinates of main industrial facilities was codified in order to analyse the spatial distribution of cases of cancer in relation to industrial areas. Focal tests and focused Scan methodology were used for the identification of high-incidence-rate spatial clusters around the main industrial pollution foci. RESULTS: The crude rate for the period was 148.0 cases per 1,000,0000 children. The incidence of pediatric cancer increased significantly along the period of study. With respect to spatial distribution, results showed significant high incidence around some industrial pollution foci group and the Scan methodology identify spatial clustering. We observe a global major incidence of non Hodgkin lymphomas (NHL) considering all foci, and high incidence of Sympathetic Nervous System Tumour (SNST) around Energy and Electric and organic and inorganic chemical industries foci group. In the analysis foci to foci, the focused Scan test identifies several significant spatial clusters. Particularly, three significant clusters were identified: the first of SNST was around energy-generating chemical industries (2 cases versus the expected 0.26), another of NHL was around residue-valorisation plants (5 cases versus the expected 0.91) and finally one cluster of Hodgkin lymphoma around building materials (3 cases versus the expected 2.2) CONCLUSION: Results suggest a possible association between proximity to certain industries and pediatric cancer risk. More evidences are necessary before establishing the relationship between industrial pollution and pediatric cancer incidence.The authors wish to express their gratitude to all the participants of the study. This work was supported by Mount Sinai International Exchange Program for Minority Students (grant MD001452) from the National Center on Minority Health and Health Disparities of the U.S. National Institutes of Health; and Prof. Fernando A. López, grateful for the financial support offered by the projects from Programa de Ayudas a Grupos de Excelencia de la Región de Murcia, Fundación Seneca (#19884-GERM-15) and Ministry of Economy and Competiveness (ECO2015-651758-P).S

Environmental tobacco smoke exposure in childhood cancer survivors

Introduction Survival rates of childhood cancer have increased in recent decades to reach 80% in high-income countries. At the same time, the appearance of late effects derived from the treatments has been increasing, estimating that up to 70% of childhood cancer survivors (CCS) will experience some late effect throughout their life. Exposure to environmental tobacco smoke (ETS) will increase the likelihood of these late effects. Therefore, it is an important mission in long-term follow-up programs to address smoking status in all household members. Aim: To present the prevalence of exposure to ETS in a group of CCS who attend a long-term follow-up program and observe the differences at one year after a brief tobacco intervention. Material and Methods Descriptive cross-sectional study. Smoking status was analyzed in the cohabitants of 135 CCS (7 - 34 years) who attend the Long-Term Follow-Up Program in the Clinical University Hospital Virgen de la Arrixaca (Murcia, Spain) between January 2016 and December 2017 after a brief tobacco intervention. Results In the first visit, 52.6% of CCS lived with a smoker in the home. 37.7% of mothers and 33.6% of fathers were smokers. In 8.9% of households there were other smokers. One year after the first visit, exposure to ETS in the houses decreased to 43.7% (30% mothers, 27.8% parents, 8.9% others). Conclusions The parents of CCS smoke more than the national average, exposing their children to the harmful effects of tobacco. However, it is observed that it is a population group with a strong motivation to abandon consumption. More intensive interventions are needed to increase the dropout rate. Funding Statement The authors received no specific funding for this work

Urban air pollution and hospital admissions for asthma and acute respiratory disease in Murcia city (Spain).

También en inglésUrban air pollution is a major threat to child and adolescent health. Children are more vulnerable to its effects, being associated with higher morbidity and mortality due to acute and chronic diseases, especially respiratory ones. A study is performed on the relationship between urban air pollution and the rate of hospital admissions due to acute respiratory diseases. An ecological study was conducted on young people under 17 years-old in the city of Murcia, who had visited hospital emergency departments due to respiratory diseases (ICD-9) during 2015. A logistic regression was performed on the risk of hospital admission that included consultations in relation to the average daily levels of environmental pollutants (NO2, O3, PM10, SO2) obtained from the Air Quality Surveillance and Control network of the Region of Murcia. Other control variables, such as gender, age, average daily ambient temperature, and season of the year. A total of 12,354 (56% boys and 44% girls) children consulted in the emergency department for respiratory disease. Of those, 3.5% were admitted, with a mean age of 2.54 (95% CI; 2.16-2.91) years. The odds ratio (OR) of hospital admission for respiratory diseases: NO2 1.02 (95% CI; 1.01-1.04; P<.01), O3 1.01 (95% CI; 1.00-1.03; P<.01) male 1.4 (95% CI 1.11-1.79; P<.01) and winter 2.10 (95% CI 1.40-3.21; P<.01). Admissions for asthma: PM10 1.02 (95% CI; 1.01-1.04; P<.05), O3 1.04 (95% CI; 1.01-1.06; P<.01). Admissions for bronchiolitis: Age 0.69 (95% CI; 0.48-0.99; P<.05); NO2 1.03 (95% CI; 1.01-1.05; P<.01). Urban air pollution increases hospital admissions in children due to acute respiratory diseases, especially asthma and bronchiolitis. Implementing preventive measures, expanding time series and collaborative studies with open data, would help improve public health and air quality in the cities.S

Smoking in adolescents and young adults childhood cancer survivors

Introduction It is estimated that 70% of childhood cancer survivors (CCS) will present a late effect derived from the treatments used during the acute phase of cancer throughout their life, some of them potentially serious as cardiac dysfunctions or subsequent neoplasms. Smoking may increase the frequency and severity of these late effects. AIM: To present the prevalence of smokers in adolescents and young adults attending a long-term follow-up consultation in a Mediterranean Region. Methods Descriptive cross-sectional study. Smoking status was analyzed in adolescents and young adults CCS attending the Long-Term Follow-Up Program in the Clinical University Hospital Virgen de la Arrixaca (Murcia, Spain) during 2017. Results 113 adolescents and young adults were analyzed (54.9% males) with ages between 15 and 34 years (median = 20 years). 14.2% of the CCS were smokers (11.5% daily smokers and 2.7% occasional smokers) with a median consumption of 32.5 cigarette / week; 2.7% were ex-smokers. The average age of onset in smoking was 16.4 years. In their residence, 52.2% were exposed to environmental tobacco smoke, with 36.6% of mothers and 34.6% of parents smoking. Conclusions The percentage of smokers in our group is similar to that of other studies in CCS (8 - 29%) and is below the Spanish average. However, in a group so sensitive to the harmful effects of tobacco, it is essential to carry out intensive interventions in order to eliminate consumption. The prevention work in children and non-smokers is basic to prevent them from starting the consumption. Funding The authors received no specific funding for this work

Group consultation for smoking cessation in pediatrics

Introduction Health beings long before birth. Exposure to tobacco smoke (active or passive) is one of the leading causes of pregnancy complications and a risk factor for developing multiple pediatric diseases. The objective of this work is to explain how the consultation for smoking cessation of the Pediatric Environmental Health Unit works. This consultation focuses on pregnant couples although smoking cessation is also offered to parents with children diagnosed with respiratory diseases as well as parents of survivors of pediatric cancer. Methods The consult has a group structure (although in exceptional cases is done individually) and is divided into 5 in-person and 5 telephone sessions. The main actions developed in the consult are the control of nicotine dependence, and above all, behavioral and emotional dependence to tobacco. Smoking cessation consultation in pediatrics is aimed at pregnant couples or both parents (if both are smokers). Results During 2016/2017, we have developed 7 therapy groups with a mean of 5 patients per group. The individuals who have not attended all sessions and also do not respond to the telephone calls are excluded from the results. Cessation rate until the end of pregnancy is 60%. Emotional and behavioral control is very important during pregnancy and in relatives of sick children. The inclusion of the partner in the process is very important so that the cessation is long-lasting, while also promoting a smoke free childhood environments. Conclusions The strengths of group therapy are that individuals with the same characteristics (feelings, fears, motivations ...), also avoid feeling lonely during the process. The group can solve doubts and questions (fears, shyness ...) that otherwise would not be resolved. It helps us to establish pertinent emotional linkages among patients within the group. The results indicate a strong adherence to treatment

Prevalence of tobacco at the beginning of pregnancy in 1500 pregnant couples of high risk

Introduction Environmental consulting Nursing (Reproductive) is a clinical consultation detection, intervention and prevention of exposures to environmental hazards at critical periods of pregnancy (gametogenesis and pregnancy) with special attention to tobacco. The working tool is the “hoja verde” Objective: The objective of this work is to identify the prevalence of tobacco at the beginning of pregnancy and in the 12th week of gestation in pregnant couples at risk in the HCU Virgen de la Arrixaca. Methods Descriptive study using the Green Page among 1500 pregnant couples of high risk between November, 2009 to January, 2013 conducted during the first trimester of pregnancy screenings. Results Average age (years) 34.1 (females) and 36.1 (males). 87% of the woman are native of Spanish origin. At the beginning of pregnancy 34.9% of women and 45% of their partners are smokers. Intrauterine exposure to tobacco is as high as 56%. In the 12th week of gestation the percentage decreased to 17.3%. In the couples there was little change (41.5%). Conclusions Exposure to tobacco and other environmental health risk factors are elevated at the beginning of pregnancy. The approach of using ¨pregnant couple¨ in the Green Page is important for improving the overall quality of pregnancy by integrating the couple as an important part of the process. Nurses and midwives, have a privileged and strategic role in the development of tasks related to environmental health during pregnancy,. It is necessary to improve the environmental health training and preparation of nurses and midwives from the undergraduate to postgraduate levels

Threats, challenges and opportunities for paediatric environmental health in Europe, Latin America and the Caribbean.

Also version in englishIn a world that is increasingly technological and interconnected, but also more violent, overexploited and polluted, Paediatric Environmental Health (PEH) is one of the best contributions to improve global health. Few areas of the planet have a high affinity with common values and interests, such as the European Union (EU), Latin America and the Caribbean (LAC). The investments and actions of the PEH in pre- and postnatal periods during the first two decades of life will generate countless benefits in the health and well-being during the human life span. Detecting, reducing, or eliminating physical, chemical, biological and social pollutants is one of the main missions and actions of the PEH. In this special article, an update review is presented on the threats, challenges and cooperation opportunities in PEH among bio-health professionals and other social sectors involved, from the EU and LAC. New professional profiles, knowledge structures and architectures for engagement emerge. Courageous leaderships, new substantial resources, broad social changes, and the necessary collaboration between the two regions will be required to improve the health of present and future generations.International Network Environment, Survival and Childhood Cancer (ENSUCHICA) in Europe and Latin America (FFIS EU17-01-01); National Center on Minority Health and Health Disparities NIH (T37 MD001452); Fund. Séneca (MUR#19884-GERM-15); ICARUS (Horizon 2020: 690105); SaludAire-España (PI18CIII/00022); FIS 12/01416 y PI16CIII/00009.S