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Objective: This study explores frontline educators' experience with learner burnout in the clinical learning environment (CLE) and how perceived burnout may impact assessment., Methods: A survey was sent to 105 Pediatric Hospital Medicine faculty and fellows at 7 sites across the United States representing diverse CLEs. They were invited to participate in an 11-question web-based survey that was developed, edited, and revised in step-wise fashion. It consisted of 5-point Likert scale, forced-choice, and dichotomous questions. Data from the web-based survey were compiled for descriptive purposes and analyzed for trends., Results: The response rate was 53%. Most respondents (83%) perceive learner burnout at least once per year, but median comfort in identifying burnout was 3 (scale 1-5, 3 = neutral). Factors associated with comfort were education as primary niche (P = .01) and having wellness training (P = .045). In terms of the impact of perceived learner burnout impacts on assessment, 88% report impact on feedback sessions and 60% reported impact on summative assessment; most are more lenient. Stated belief in whether perceived burnout should or should not impact assessment had 60% sensitivity and 84% specificity in predicting whether it does., Conclusions: Frontline educators routinely perceive learner burnout in the CLE and it often impacts educators' assessment of a learner. The discrepancy between the expected and actual impact may suggest amplification of known barriers to accurate assessment in the CLE. Comfort associated with wellness training suggests that interventions targeting frontline educators in the CLE may improve their ability to simultaneously support and assess learners., (Copyright © 2021 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Our specific aim was to assess the gender distribution of aspects of scholarly productivity and professional standing for pediatric hospital medicine over a 5-year period. We also evaluated for correlation between the makeup of editorial boards, conference planning committees, and chosen content., Methods: We reviewed scholarly publications, presentations, editorial boards, planning committees, awardees, and society leadership in pediatric hospital medicine from 2015 to 2019 and determined gender using published methods to assess for differences between observed proportions of women authors and presenters and the proportion of women in the field., Results: The field of pediatric hospital medicine at large is 69% women (95% confidence internal [CI] 68%-71%), and an estimated 57% of senior members are women (95% CI 54%-60%). We evaluated 570 original science manuscripts and found 67% (95% CI 63%-71%) women first authors and 49% (95% CI 44%-53%) women senior authors. We evaluated 1093 presentations at national conferences and found 69% (95% CI 65%-72%) women presenters of submitted content and 44% (95% CI 37%-51%) women presenters of invited content. Senior authorship and invited speaking engagements demonstrated disproportionately low representation of women when compared with senior members of the field (senior authorship, P = .002; invited presenters, P < .001). Strong positive correlation between gender composition of conference planning committees and selected content was also noted (r = 0.94)., Conclusion: Our study demonstrated representative gender distribution for some aspects of scholarly productivity in pediatric hospital medicine; however, a lack of gender parity exists in senior roles., Competing Interests: CONFLICT OF INTEREST DISCLOSURE: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Background and Objectives: The Accreditation Council for Graduate Medical Education requires that residents demonstrate increasing autonomy during their training. Although residents report a better educational environment with hospitalists present during family-centered rounds (FCRs), there is a concern that attending presence may reduce resident autonomy. We aim to determine the effect of FCRs without an attending during rounds on senior residents' sense of autonomy., Methods: We conducted a multicenter, retrospective, preintervention-postintervention study at 5 children's hospitals to evaluate the effect of rounding without an attending on senior residents' self-efficacy, using a questionnaire developed by using Bandura's principles of self-efficacy and Accreditation Council for Graduate Medical Education milestones. Questions addressed skills of diagnosis and/or management, communication, teaching, and team management. We compared preintervention and postintervention results using paired t tests and Wilcoxon rank tests. One-way analysis of variance tests were used to compare means among >2 groups., Results: 116 (82% response rate) of 142 eligible senior residents completed the questionnaire, which yielded a high reliability (α = 0.80) with a 1-factor score. The average composite score of self-efficacy significantly improved after intervention compared with the preintervention score (66.71 ± 6.95 vs 60.91 ± 6.82; P < .001). Additional analyses revealed meaningful improvement of each individual item postintervention. The highest gain was reported in directing bedside teaching (71.8% vs 42.5%; P < .001) and answering learner questions on rounds (70.7% vs 47.0%; P < .001)., Conclusions: Conducting FCRs without an attending increases resident reported self-efficacy regarding core elements of patient care and team leadership. In future studies, researchers should examine the impact of rounding without the attending on other stakeholders, such as students, interns, patients and/or families., Competing Interests: POTENTIAL CONFLICTS OF INTEREST: The authors indicate they have no potential conflicts of interest disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Perfluoroalkyl substances (PFAS) are a complex group of anthropogenic compounds with exceptional properties. Due to their high persistence and mobility, they have caused ubiquitous environmental contamination and in part accumulate in the food chain. In the general population, diet is the main source of PFAS exposure, with the important sources fish and meat. As a vegan diet implies the complete exclusion of any animal products, it might be expected that vegans have lower blood levels of PFAS compared to omnivores. Furthermore, lower levels of cholesterol is one of the well-documented nutritional effects in vegans, but cholesterol levels were also found to be associated with higher PFAS levels in epidemiological studies. To examine the relations of internal PFAS levels and the levels of cholesterol in vegans and omnivores, the cross-sectional "Risks and Benefits of a Vegan Diet" (RBVD) study was used involving 36 vegans and 36 omnivores from Berlin/Germany. Nine perfluoroalkyl substances were quantified in plasma using a triple-stage quadrupole mass spectrometer. Lower median plasma concentrations were found in vegans compared to omnivores for perfluorooctane sulfonic acid (PFOS) (2.31 vs. 3.57 ng/ml, respectively; p = 0.02) and for perfluorononanoic acid (PFNA) (<0.25 vs. 0.41 ng/ml, respectively; p < 0.0001). No significant differences of the median concentrations were observed for perfluorooctanoic acid (PFOA) (1.69 vs. 1.44 ng/ml, respectively, p = 0.26) and perfluorohexane sulfonic acid (PFHxS) (1.96 vs. 1.79 ng/ml, respectively; p = 0.70). The strongest correlations with food groups, derived from a food frequency questionnaire, were observed between levels of PFOA and water consumption (in case of the total study population, n = 72), and between levels of PFOS as well as PFNA and the consumption of 'meat and meat products' (in case of the omnivores, n = 36). Levels of Low Density Lipoprotein (LDL) cholesterol were confirmed to be considerably lower in vegans compared to omnivores (86.5 vs. 115.5 mg/dl, respectively; p = 0.001), but no associations between the four main PFAS and LDL cholesterol were observed (all p > 0.05) at the low exposure level of this study. According to the results of our study, a vegan diet may be related to lower PFAS levels in plasma. We highlight the importance of the adjustment of dietary factors like a vegan diet in case of epidemiological studies dealing with the impact of PFAS on the levels of blood lipids., (Copyright © 2021 The Authors. Published by Elsevier GmbH.. All rights reserved.)

As a consequence of the toxicological lead characteristics, a reduction of its exposure should consider all sources. Game meat might contain elevated levels of lead due to the use of lead ammunition. The aim of the present study was to investigate the effects of acidic marination on the bioavailability of ammunition-derived lead in game meat (Roe deer), using the growing pig as an animal model. Furthermore, the study should provide evidence that the large-area scattering of lead particles leads to noticeable differences in the individual lead intake per game meat portion. Pigs of group A ( n 7) received lead-shot game meat, which was cooked in water. Pigs of group B ( n 7) received lead-shot game meat, which was first marinated (wine and vinegar) and then cooked. The lead content of both game meat preparations was equal with 0⋅77-0⋅79 mg Pb/portion. Pigs of group C ( n 4) received lead-free game meat, which was also marinated and cooked. Additionally, lead acetate was administered intravenously to group D pigs ( n 4). Blood samples were taken on elevated time points before and after game meat intake/i.v.-application. The acidic marination increased the bioavailability of orally ingested lead, resulting in significantly higher blood lead concentrations. The bioavailability of lead was 2⋅7 % when game meat was just cooked and 15 % when the meat was marinated before. The considerable variation of the individual blood lead concentrations suggests that an inhomogeneous distribution of ammunition-derived lead particles (in terms of size and number) causes individually non-comparable lead intakes from the consumption of game meat., (© The Author(s) 2021.)

Purpose: Professional identity formation is the process of internalizing the ideals, values, and beliefs of a profession. In recent years, research on clinician-educator (CE) identity formation has expanded, yet gaps exist in understanding initial influences on an educator identity, sustainment throughout a career, and development of successful pathways for early CEs. This study explored the initial influences on and characteristics of the professional identity formation of CEs in an age-diverse, multispecialty population in the United States., Method: This was a cross-sectional qualitative study of a purposive sample of medical educators at 6 institutions across the United States between 2018 and 2019. Focus groups were conducted to obtain participants' perspectives on their career choice and subsequent formation of their professional identity as CEs. The authors used a thematic analysis of focus group data to identify themes and domains through an iterative process., Results: Twelve focus groups were conducted with a total of 93 participants. Responses were categorized into 5 domains: community supportive of medical education, culture of institution and training, personal characteristics, facilitators, and professionalization of medical education. Themes highlighted the importance of role models and mentors, an affinity and aptitude for teaching and education, specific facilitators for entry into a career in medical education, the evolution from a layperson, importance of formalized training programs, and a supportive academic community., Conclusions: Clinicians experienced a variety of factors that influenced their initial career choice in medical education and subsequent professional identity formation as a CE. This study confirms and expands the current understanding of this process in an age-diverse, multispecialty population of CEs. Educators and administrators designing career development programs across the continuum of medical education should consider these aspects as they mentor and support their learners and faculty., (Copyright © 2020 by the Association of American Medical Colleges.)

Pediatric medical educators have the dual challenge of remaining up-to-date in the field of pediatrics and in the field of medical education. Due to the volume of information published in these 2 fields it can be nearly impossible to remain current in both fields of practice. To facilitate interpretation of the most recent medical education research, the authors conducted an annotated bibliography of medical education literature published in 2019. The purpose of this annotated bibliography was to identify manuscripts which had the potential to significantly influence a pediatric educator's practice. Using a 2-staged review process, the authors reviewed abstracts from 13 medical education and specialty journals. All reviews were independently completed by 2 different reviewers for each journal in both stages. A total of 4700 abstracts were reviewed and 17 key manuscripts were identified. The authors grouped the key manuscripts into 6 core themes: bedside teaching, learning climate, bias, learner autonomy, learner in trouble, and resident competency. This annotated bibliography provides the authors' condensed summary of the medical education manuscripts most likely to influence educational practices for the busy pediatric medical educator., (Copyright © 2021 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Pediatric Hospital Medicine (PHM), a field early in its development and with a robust pipeline of women, is in a unique position to lead the way in gender equity. We describe the proportion of women in divisional and fellowship leadership positions at university-based PHM programs (n = 142). When compared with the PHM field at large, women appear to be underrepresented as PHM division/program leaders (70% vs 55%; P< .001) but not as fellowship directors (70% vs 66%; P > .05). Women appear proportionally represented in associate/assistant leadership roles when compared with the distribution of the PHM field at large. Tracking these trends overtime is essential to advancing the field.

Background: Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients., Methods: The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure., Results: Interrupted time series analysis of EHR orders (n pre = 493; n post = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (n pre = 263; n post = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% ( P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported., Conclusions: A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Dechloranes, like Dechlorane Plus® are commonly used flame retardants identified by the EU as substances of very high concern (SVHC) because of their persistence and bioaccumulation potential. To characterize the dechlorane exposure of Germans in the last two decades, 180 archived blood plasma samples of the German Environmental Specimen Bank (students aged 20-29 years) collected at six time points between 1995 and 2017 were analyzed for four dechloranes; namely Dechlorane Plus® (syn- and anti-DDC-CO), dechlorane 602 (DDC-DBF), and dechlorane 603 (DDC-Ant). These were quantified using a GC-MS/MS method. Overall, anti- and syn-DDC-CO were detected in 88% and 98% of the samples, whereas DDC-DBF and DDC-Ant were found in 40% and 37% of the samples, respectively. The median (95th percentile) values were 1.0 ng/g lipid weight (l.w.) (3.0 ng/g l.w.). for anti-DDC-CO, 0.6 ng/g l.w (1.9 ng/g l.w.). for syn-DDC-CO, 0.1 ng/g l.w (0.6 ng/g l.w.). for DDC-DBF, and 0.1 ng/g l.w (0.2 ng/g l.w.). for DDC-Ant. The 95th percentile concentrations of the sum of syn- and anti-DDC-CO decreased from 4.2 ng/g l.w. in 1995, to 2.9 ng/g l.w. in 1999, and subsequently increased to 3.7 ng/g l.w. in 2008, and up to 5.9 ng/g l.w. in 2017. A statistically significant decrease with time was observed for DDC-DBF and DDC-Ant, but not for DDC-CO. Our medians found in blood samples in 2017 are similar to those observed in Germany in 2013/14, but higher compared to values reported in other European countries. Overall, more toxicological and monitoring data is needed to better characterize the potential impact on health., (Copyright © 2020 Elsevier GmbH. All rights reserved.)

Pediatric educators desire to and should strive to incorporate current educational methods and ideas into their professional practices. The overwhelming volume of medical education literature makes this difficult. This article provides an overview of 18 key articles from the 2018 literature that the authors considered impactful for the field of pediatric medical education. The author group has extensive combined leadership experience and expertise across the continuum of pediatric medical education and used an iterative, staged process to review 2270 abstracts from 13 medical education-related journals. This process aimed to identify a subset of articles that were most relevant to educational practice and scholarship and most applicable to pediatric medical education. Author pairs independently reviewed and scored abstracts and reached consensus to identify the abstracts that best met these criteria. Selected abstracts were discussed using different author pairs to determine the final articles included in this review. The 18 articles selected are summarized. The results showed a cluster of studies related to assessment, learner education and teaching, communication, and culture and climate. This review offers a summary for educators interested in remaining knowledgeable and current regarding the most relevant and valuable information in the field of medical education., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Perfluoroalkyl substances (PFASs) are a complex group of man-made chemicals with high stability and mobility leading to ubiquitous environmental contamination and accumulation in the food chain. In human serum/plasma samples, perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) are the lead compounds. They are immunotoxic in experimental animals, and epidemiological studies provided evidence of a diminished production of vaccine antibodies in young children. However, information on children of the first year of age is missing but relevant, as they have a relatively high exposure if breastfed, and may have a higher susceptibility as their immune system is developing. In a cross-sectional study with 101 healthy 1-year-old children, internal levels of persistent organic pollutants and a broad panel of biological parameters were investigated at the end of the 1990s. Additional analysis of PFASs resulted in plasma levels (mean ± SD) of PFOA and PFOS of 3.8 ± 1.1 and 6.8 ± 3.4 µg/L, respectively, in the 21 formula-fed children, and of 16.8 ± 6.6 and 15.2 ± 6.9 µg/L in the 80 children exclusively breastfed for at least 4 months. The study revealed significant associations between levels of PFOA, but not of PFOS, and adjusted levels of vaccine antibodies against Haemophilus influenza type b (Hib, r = 0.32), tetanus (r = 0.25) and diphtheria (r = 0.23), with no observed adverse effect concentrations (NOAECs) determined by fitting a 'knee' function of 12.2, 16.9 and 16.2 µg/L, respectively. The effect size (means for PFOA quintiles Q1 vs. Q5) was quantified to be - 86, - 54 and - 53%, respectively. Furthermore, levels of PFOA were inversely associated with the interferon gamma (IFNɣ) production of ex-vivo lymphocytes after stimulation with tetanus and diphtheria toxoid, with an effect size of - 64 and - 59% (means Q1 vs. Q5), respectively. The study revealed no influence of PFOA and PFOS on infections during the first year of life and on levels of cholesterol. Our results confirmed the negative associations of PFAS levels and parameters of immune response observed in other epidemiological studies, with high consistency as well as comparable NOAECs and effects sizes for the three vaccine antibodies investigated, but for PFOA only. Due to reduction of background levels of PFASs during the last 20 years, children in Germany nowadays breastfed for a long duration are for the most part not expected to reach PFOA levels at the end of the breastfeeding period above the NOAECs determined.

Pediatric hospital medicine (PHM) is the newest recognized subspecialty in pediatrics within the United States. While fellowships in PHM have been available for several years, completion of a 2-year fellowship has become a requirement for subspecialty certification. Pediatric hospitalists provide substantial teaching to trainees, and therefore, PHM fellowships must include dedicated training around teaching and medical education. The purpose of this study was to determine how current PHM fellowships prepare graduates for their roles as medical educators. Two surveys were developed from the published PHM core competencies and Entrustable Professional Activities for pediatric subspecialties. One survey was disseminated to all active PHM program directors and the second was disseminated to all PHM fellowship graduates who completed training between 2012 and 2016. Items included those related to program structure and training/assessment in medical education. A total of 21 program directors (response rate = 58%) and 46 fellowship graduates (response rate = 46%) participated in the survey. All graduates (100%) reported teaching learners in their current setting. Many (67%) fellowship programs offered formal training in medical education, and this is greater than the 50% that was previously described. Direct observation (71%) was the most common method of assessment. Most graduates reported their fellowship provided optimal training in feedback and teaching during family centered rounds but suboptimal training in other skills such as curriculum development. The results of this study highlight areas for improvement in fellowship curriculum and assessment to better prepare fellows for their roles as educators., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© International Association of Medical Science Educators 2020.)

Epidemiological studies have indicated the thyroid-disrupting effects of persistent organic pollutants (POPs). However, the association of low-exposure POPs with thyroid hormones (THs) remains unclear. Here, we aim to assess the association of low exposure of POPs, including polybrominated diphenyl ethers (PBDEs), polychlorinated biphenyls (PCBs), polychlorinated dibenzo- p -dioxins and furans (PCDD/Fs), and polybrominated dibenzo- p -dioxins and furans, with THs [total L -thyroxine (TT 4 ), total 3,3',5-triiodo- L -thyronine (TT 3 ), and total 3,3',5'-triiodo- L -thyronine (TrT 3 )] measured in human breast milk. Ninety-nine breast milk samples were collected from the LUPE cohort (2015-2016, Bavaria, Germany). Fourteen PBDEs, 17 PCBs, and 5 PCDD/Fs had quantification rates of >80%. Nonmonotonic associations were observed. In adjusted single-pollutant models, (1) TT 4 was inversely associated with BDE-99, -154, and -196; (2) TT 3 was inversely associated with BDE-47, -99, -100, -197, -203, -207, and OCDD; and (3) TrT 3 was inversely associated with BDE-47, -99, -183, and -203. Multipollutant analysis using principal component analysis and hierarchical clustering revealed inverse associations of PBDEs (BDE-28, -47, -99, -100, -154, -183, and -197) with TT 4 and TrT 3 . These results indicate that POPs at low levels might be related to reduced THs. This study shows that human breast milk might be an appropriate specimen to evaluate the thyroid disruption of POPs.

As a newly recognized subspecialty, understanding programmatic models for pediatric hospital medicine (PHM) programs is vital to lay the groundwork for a sustainable field. Although variability has been described within university-based PHM programs, there remains no national benchmark for community-based PHM programs. In this report, we describe the workload, clinical services, employment, and perception of sustainability of 70 community-based PHM programs in 29 states through a survey of community site leaders. The median hours for a full-time hospitalist was 1,882 hours/year with those employed by community hospitals working 8% more hours/year and viewing appropriate morning pediatric census as 20% higher than those employed by university institutions. Forty-three out of 70 (63%) site leaders perceived their programs as sustainable, with no significant difference by employer structure. Future studies should further explore root causes for workload discrepancies between community and academic employed programs along with establishing potential standards for PHM program development.

Background and Objectives: Within the field of pediatric hospital medicine, physicians can choose to work at community-based or university-based centers. The factors that motivate pediatric hospitalists to work specifically at community sites have not yet been fully explored. Our objective with this study was to elucidate the motivators for pediatric hospitalists to begin and continue work at community sites., Methods: A qualitative study was performed via phone-based focus groups. Physicians were included if they were able to attend 1 of the offered group sessions and they self-identified as spending the majority of their time working as community-based pediatric hospitalists. Data were analyzed through a constant comparative analysis., Results: Five themes emerged regarding factors that motivate pediatricians to begin and continue their careers as hospitalists in the community. The themes were (1) professional impact, (2) scope of practice, (3) personal and professional satisfaction, (4) community involvement, and (5) job availability., Conclusions: This study reveals the key factors that motivate community pediatric hospitalists to begin and continue working in the community., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objective: Peer observation and feedback (POF) is the direct observation of an activity performed by a colleague followed by feedback with the goal of improved performance and professional development. Although well described in the education literature, the use of POF as a tool for development beyond teaching skills has not been explored. We aimed to characterize the practice of POF among pediatric hospitalists to explore the perceived benefits and barriers and to identify preferences regarding POF., Methods: We developed a 14-item cross-sectional survey regarding divisional expectations, personal practice, perceived benefits and barriers, and preferences related to POF. We refined the survey based on expert feedback, cognitive interviews, and pilot testing, distributing the final survey to pediatric hospitalists at 12 institutions across the United States., Results: Of 357 eligible participants, 198 (56%) responded, with 115 (58%) practicing in a freestanding children's hospital. Although 61% had participated in POF, less than one half (42%) reported divisional POF expectation. The most common perceived benefits of POF were identifying areas for improvement (94%) and learning about colleagues' teaching and clinical styles (94%). The greatest perceived barriers were time (51%) and discomfort with receiving feedback from peers (38%), although participation within a POF program reduced perceived barriers. Most (76%) desired formal POF programs focused on improving teaching skills (85%), clinical management (83%), and family-centered rounds (82%)., Conclusions: Although the majority of faculty desired POF, developing a supportive environment and feasible program is challenging. This study provides considerations for improving and designing POF programs., (Copyright © 2019 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Linear and cyclic volatile methylsiloxanes (l-VMS and c-VMS) are man-made chemicals with no natural source. They have been widely used in cosmetics, personal care products, coatings and many other products. As a consequence of their wide use, VMS can be found in different environmental media, as well as in humans. We bought 14 new silicone baking moulds and 3 metallic moulds from the market and used them in different baking experiments. Four of the silicone baking moulds were produced in Germany, two in Italy, four in China, and for the other moulds were no information available. The metal forms were all produced in Germany. VMS were measured in the indoor air throughout the baking process and at the edge and in the center of the finished cakes using a GC/MS system. Additionally, the particle number concentration (PNC) and particle size distribution were measured in the indoor air. The highest median concentrations of VMS were observed immediately following baking: 301 μg/m 3 of D7, 212 μg/m 3 of D6, and 130 μg/m 3 of D8. The silicone moulds containing the highest concentrations of c-VMS corresponded with distinctly higher concentrations of the compounds in indoor air. Using a mould for more than one baking cycle reduced the indoor air concentrations substantially. Samples collected from the edge of the cake had higher concentrations relative to samples from the center, with a mean initial concentration of 6.6 mg/kg of D15, 3.9 mg/kg of D9, 3.7 mg/kg of D12, and 4.8 mg/kg of D18. D3 to D5 were measured only at very low concentrations. Before starting the experiment, an average PNC of 7300 particles/cm 3 was observed in the room's air, while a PNC of 140,000 particles/cm 3 was observed around the electric stove while it was baking, but this PNC slowly decreased after the oven was switched off. Baking with 4 of the moulds exceeded the German indoor precaution guide value for c-VMS, but the health hazard guide value was not reached during every experiment. Compared to other exposure routes, c-VMS contamination of cake from silicone moulds seems to be low, as demonstrated by the low concentrations of D4 and D6 measured. For less volatile c-VMS > D6 the results of the study indicate that food might play a more important role for daily intake. As a general rule, silicone moulds should be used only after precleaning and while strictly following the temperature suggestions of the producers., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Indoor air quality (IAQ) and exposure to indoor chemicals are widely discussed in terms of personal discomfort and health risks. In contrast to ambient air and working environments, legally binding regulations are only partially established for indoor contaminants, and other available European guidelines are limited. To correct these deficits, the German Committee on Indoor Guide Values (AIR), formerly known as the Ad hoc Working Group (Ad hoc AG), performed health assessments of indoor air contaminants. The main tasks were to develop toxicologically based indoor air guide values, health-based guideline values, and reference values largely based on the 95th percentile of the concentrations found in a reference population. Here, we provide a comprehensive overview of the indoor air values set in Germany and discuss the basis of their derivation. This overview includes a description of legally binding standards, indoor air guide values for 38 substances or groups, and guidelines for TVOC (total volatile organic compounds), particulate matter, and carbon dioxide as well as risk-related guidelines for carcinogenic substances., (Copyright © 2019 Elsevier GmbH. All rights reserved.)

Smoking in car interiors is of particular concern because concentrations of potentially harmful substances can be expected to be high in such small spaces. To assess the potential exposure for occupants, especially children, we performed a comprehensive evaluation of the pollution in 7 passenger cars while tobacco cigarettes and new electronic smoking products (IQOS, e-cigarette) were being smoked. We collected data on the indoor climate and indoor air pollution with fine and ultrafine particles and volatile organic compounds while the cars were being driven. Smoking of an IQOS had almost no effect on the mean number concentration (NC) of fine particles (>300 nm) or on the PM 2.5 concentration in the interior. In contrast, the NC of particles with a diameter of 25-300 nm markedly increased in all vehicles (1.6-12.3 × 10 4 /cm 3 ). When an e-cigarette was vaped in the interior, 5 of the 7 tested cars showed a strong increase in the PM 2.5 concentration to 75-490 μg/m 3 . The highest PM 2.5 levels (64-1988 μg/m 3 ) were measured while tobacco cigarettes were being smoked. With the e-cigarette, the concentration of propylene glycol increased in 5 car interiors to 50-762 μg/m 3 , whereby the German indoor health precaution guide value for propylene glycol was exceeded in 3 vehicles and the health hazard guide value in one. In 4 vehicles, the nicotine concentration also increased to 4-10 μg/m 3 while the e-cigarette was being used. The nicotine concentrations associated with the IQOS and e-cigarette were comparable, whereas the highest nicotine levels (8-140 μg/m 3 ) were reached with tobacco cigarettes. Cigarette use also led to pollution of the room air with formaldehyde (18.5-56.5 μg/m 3 ), acetaldehyde (26.5-141.5 μg/m 3 ), and acetone (27.8-75.8 μg/m 3 ). Tobacco cigarettes, e-cigarettes, and the IQOS are all avoidable sources of indoor pollutants. To protect the health of other non-smoking passengers, especially that of sensitive individuals such as children and pregnant women, these products should not be used in cars., (Copyright © 2019 Elsevier GmbH. All rights reserved.)

Indoor go-kart driving and viewing is enjoyed by people of all ages. However, it may pose health hazards, especially for children, pregnant women, cardiovascular patients, and elderly individuals. Depending on the race length, for example, high concentrations of various contaminants may result in severe health problems. Therefore, this project investigated the Indoor Air Quality of eight indoor go-kart facilities. In general, karts that used regular fuel produced the highest concentrations of CO, benzene, TVOC, and BaP, with maximum levels up to 150 mg/m 3 , 170 μg/m 3 , 2690 μg/m 3 , and 8.7 ng/m 3 , respectively. As expected, the maximum CO concentrations at go-kart facilities that used liquid gas and electric karts (20 and <6 mg/m 3 , respectively) were significantly lower than those at other facilities. The highest 95th percentile values for NO (2680 μg/m 3 ) and NO 2 (280 μg/m 3 ) were measured for karts with liquid gas. The alkane, alkene, and cycloalkane groups, as well as benzene and the alkyl benzenes, were the predominant components of the measured TVOCs. Overall, owners of indoor go-kart tracks should ensure that the ventilation with regard to combustion products is optimally adapted in any case to reduce the levels of critical air pollutants., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Wide variability exists in the clinical workload of pediatric hospitalists without an accepted standard for benchmarking purposes. By using data obtained from interviews of pediatric hospital medicine (PHM) program leaders, we describe the clinical workload of university-based programs and report on the program sustainability perceived by PHM program leaders. The median clinical hours reported for a full-time pediatric hospitalist were 1800 hours per year, with a median of 15 weekends worked per year. Furthermore, program leaders reported an ideal number of clinical hours as 1700 hours per year. Half of the interviewed program leaders perceived their current models as unsustainable. Programs perceived as unsustainable were more likely than those perceived as sustainable to require a higher number of weekends worked per year or to be university employed. Further research should focus on establishing benchmarks for the workloads of pediatric hospitalists and on evaluating factors that can affect sustainability., (© 2018 Society of Hospital Medicine.)

Education, like clinical medicine, should be based on the most current evidence in the field. Unfortunately, medical educators can be overwhelmed by the sheer volume and range of resources for this literature. This article provides an overview of 15 articles from 2016 that the authors consider the top articles in the field of pediatric medical education. The 7 authors, all medical educators with combined leadership and expertise across the continuum of pediatric medical education, used an iterative 3-stage process to review more than 6339 abstracts published in 2016. This process was designed to identify a small subset of articles that were most relevant to educational practices and most applicable to pediatric medical education. In the first 2 stages, pairs of authors independently reviewed and scored abstracts in 13 medical education-related journals and reached consensus to identify the articles that best met these criteria. In the final stage, all articles were discussed using a group consensus model to select the final articles included in this review. This article presents summaries of the 15 articles that were selected. The results revealed a cluster of studies related to observed standardized clinical encounters, self-assessment, professionalism, clinical teaching, competencies/milestones, and graduate medical education management strategies. We provide suggestions on how medical educators can apply the findings to their own practice and educational settings. This narrative review offers a useful tool for educators interested in keeping informed about the most relevant and valuable information in the field., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Adverse health effects of airborne particulate matter depend on parameters like particle size, particle surface and chemical composition. Major emission of indoor particles is caused by combustion processes like tobacco smoking and cooking. Nevertheless, the use of household electrical appliances, such as vacuum cleaners, flat irons or hair dryers, can produce particles as well. In this study the emissions of different hair dryers and flat irons were investigated using a test chamber. The particle number concentrations, particle volume concentrations, as well as the size distributions were measured. Particles were sampled and analyzed by electron microscopy, inductively coupled plasma mass spectrometry and gas chromatography mass spectrometry. Moreover different volatile organic compounds (VOCs) were measured. Each tested appliance, especially flat irons produced small particles with diameters far below 100nm and might be a nonnegligible source for indoor particles. Copper was the main identified element in most of the particles emitted from hair dryers, but in the emission of two hair dryers silver-containing nanoparticles were found as well. Various VOCs were observed in the emission of both flat irons and hair dryers, while cyclic siloxanes were detected only in the emission of flat irons. The use of flat irons or hair dryers may significantly contribute to the personal particle exposure., (Copyright © 2017 Elsevier B.V. All rights reserved.)

A higher body mass index (BMI) has been positively associated with the rate of excretion of di-2-ethylhexyl phthalate (DEHP) metabolites in urine in data from the National Health and Nutrition Examination Survey (NHANES), suggesting an association between DEHP exposure and BMI. The association, however, may be due to the association between body mass maintenance and higher energy intake, with higher energy intake being accompanied by a higher intake of DEHP. To examine this hypothesis, we ran a Monte Carlo simulation with a DEHP physiologically-based pharmacokinetic (PBPK) model for adult humans. A realistic exposure sub-model was used, which included the relation of body weight to energy intake and of energy intake to DEHP intake. The model simulation output, when compared with urinary metabolite data from NHANES, supported good model validity. The distribution of BMI in the simulated population closely resembled that in the NHANES population. This indicated that the simulated subjects and DEHP exposure model were closely aligned with the NHANES population of interest. In the simulated population, the ordinary least squares regression coefficient for log(BMI) as a function of log(DEHP nmol/min) was 0.048 (SE 0.001), as compared with the reported value of 0.019 (SE 0.005). In other words, given our model structure, the higher energy intake in the overweight and obese, and the concomitant higher DEHP exposure, describes the reported relationship between BMI and DEHP., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Tris(2-butoxyethyl) phosphate (TBOEP; 20 µg/kg b.w.) was orally administered to three female and three male volunteers. In urine samples collected for 39 h three metabolites of TBOEP were quantitated. bis(2-butoxyethyl) phosphate (BBOEP), tris(2-(3-hydroxy)butoxyethyl) phosphate (OH-TBOEP), bis(2-butoxyethyl)-(2-hydroxyethyl) phosphate (BBOEHEP) were observed in all urine samples within the first 7 h with highest concentration for BBOEHEP. C max of OH-TBOEP was in the range of 2-4 h and t 1/2 was between 1.5 and 6.1 h. Similar results were obtained for BBOEHEP. In contrast BBOEP showed several maxima within 25 h and, therefore, no toxicokinetic data were calculated. As proof of concept 54 urine samples of children staying at day-care centers in Germany were analysed for all 3 biomarkers. Only BBOEP and BBOEHEP were detected in about 80% of the samples with a median of 0.16 µg/l for BBOEP and 0.18 µg/l for BBOEHEP. A recalculation of daily intake (DI) based on BBOEHEP resulted in a clear undercut of the current reference dose of 50 µg/kg per day. As observed in other studies a calculation of the DI based on the dust concentrations and oral uptake of 20 mg of dust for 8 h for young children results in considerably higher DI but would also not exceed the RfD.

Problem: Residency clinician-educator tracks have been created; however, they have generally been limited to a single discipline or program and experienced some challenges. The Graduate Medical Education Scholars Track (GMEST), an embedded longitudinal, multimodal, multidisciplinary clinician-educator track for residents, was piloted at the Pritzker School of Medicine, University of Chicago, in academic year 2014-2015., Approach: The GMEST is a two-year experience completed during residency training. The goal is to prepare trainees for academic careers as clinician-educators with a focus on medical education scholarship. This track is designed for residents from diverse training programs with variable clinical schedules and blends a live interactive program, asynchronous instruction and discussion, and overarching multimodal mentorship in medical education. Participants are expected to complete a capstone medical education project and submit it to institutional, regional, and/or national venues., Outcomes: Data gathered from the 2014-2016 and 2015-2017 cohorts demonstrated that 21/22 (95%) participants were satisfied with the GMEST curriculum, felt it was important to their development as future clinician-educators, and felt it would positively influence their ability to work in medical education. Further, 18/22 (82%) participants wished to pursue a career as a clinician-educator and in medical education leadership and/or scholarship., Next Steps: The authors will longitudinally track graduates' future career positions, projects, publications, and awards, and cross-match and compare GMEST graduates with non-GMEST residents interested in medical education. Faculty mentors, program directors, and the Medical Education, Research, Innovation, Teaching, and Scholarship community will be asked for feedback on the GMEST.

9H-carbazole is generated from incomplete combustion of diverse fossil fuels and biomass, in tobacco smoke and from industrial processes, while halogenated carbazoles have natural and anthropogenic sources. We analyzed 9H-carbazole and 14 halogenated carbazoles in dust samples from 14 schools, 13 daycare centers, and 13 residences, as well as 5 indoor air samples from residences in Munich, Germany. Overall, we present first data of various carbazoles in different indoor environments without visible combustion sources. The median (95th percentile) values of the halogenated analytes mainly detected in the entire study group were 10.3ng/g (308ng/g) for 9H-carbazole, 13.3ng/g (735ng/g) for 3,6-dichloro-9H-carbazole, 6.2ng/g (159ng/g) for 1,3,6-tribromo-9H-carbazole, and 1.2ng/g (21.1ng/g) for 2,7-dibromo-9H-carbazole. For most of the target analytes, the highest concentrations were observed in dust samples from schools, and the lowest were found in residences. In the air samples, all analytes were found only at low levels, with median values of 7.7pg/m 3 for 9H-carbazole and 6.1pg/m 3 for 2,3,6,7-tetrachloro-9H-carbazole. For 9H-carbazole, "typical" and "high" non-dietary intake of children through dust ingestion using median and 95th percentile values were calculated to be 0.03ng/kg b.w. and 1.1ng/kg b.w. daily, respectively. Due to limited toxicological information and exposure data for other relevant pathways (e.g., dietary intake), the risk assessment is inconclusive. Nevertheless, there are indications that 9H-carbazole has carcinogenic properties and that halogenated carbazoles have dioxin-like toxicities. Therefore, further research is essential., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Rounds are a critical activity on any inpatient service, but there is little literature describing the purpose of rounds from the perspective of faculty and trainees in teaching hospitals., Objective: To evaluate and compare the perceptions of pediatric and internal medicine attendings and medical students regarding the purpose of inpatient attending rounds., Methods: The authors conducted 10 semistructured focus groups with attendings and medical students in the spring of 2014 at 4 teaching hospitals. The protocol was approved by the institutional review boards at all institutions. The authors employed a grounded theory approach to data collection and analysis, and data were analyzed by using the constant- comparative method. Two transcripts were read and coded independently by 2 authors to generate themes., Results: Forty-eight attendings and 31 medical students participated in the focus groups. We categorized 218 comments into 4 themes comprised of 16 codes representing what attendings and medical students believed to be the purpose of rounds. These themes included communication, medical education, patient care, and assessment., Conclusions: Our results highlight that rounds serve 4 purposes, including communication, medical education, patient care, and assessment. Importantly, both attendings and students agree on what they perceive to be the many purposes of rounds. Despite this, a disconnect appears to exist between what people believe are the purposes of rounds and what is happening during rounds., (© 2017 Society of Hospital Medicine)

Background: For some time, a new form of waterpipe smoking has been advertised, where steam stones moistened with aroma fluids (Shiazo) are heated electronically. Since there is no combustion of tobacco, it is often assumed that the produced vapor is not harmful to health. To clarify this issue, we performed a comprehensive inner and outer exposure assessment during the use of an electronic Shiazo waterpipe., Methods: Three volunteers smoked an electronic waterpipe operated with nicotine-free Shiazo stones in a thoroughly ventilated room for 2 h. In three smoking sessions, three fluids with different flavorings were vaporized. In parallel, emissions of particles, volatile organic compounds, polycyclic aromatic hydrocarbons (PAH), and metals were measured in indoor air. Within a biomonitoring study, urinary metabolite profiles of air pollutants were checked. For comparison, the components of the Shiazo fluids were also analyzed., Results: During the smoking sessions, concentrations of formaldehyde, acetaldehyde, glycerine, and propylene glycol rose significantly in the indoor environment. The content of putative carcinogenic PAH in indoor air increased by 42% to 174 ng/m 3 . Particle number concentrations ranged from 39,968 to 65,610 particles/cm 3 (median), with peaks at diameters from 25 to 31 nm. 3‑HPMA, the mercapturic acid metabolite of the pyrolysis product acrolein, was strongly elevated in urine samples of the smokers. All fluids contained high amounts of contact allergens., Conclusions: Electronic Shiazo waterpipes release various harmful substances that considerably impact indoor air quality. Compared to conventional waterpipes, the release of pollutants is lower. Nevertheless, smoking with Shiazo waterpipes is a source of health risks for both users and bystanders.

Perfluorinated compounds are fully fluorinated anthropogenic substances that have been used in various products, applications, and industrial processes. Due to their persistence and toxic effects, some of them are restricted, and therefore replacement products have been developed. The aim of the study was to quantify the body burden of different perfluorinated substances in two adult populations living close to or about 80km apart from a former perfluorooctanoate (PFOA) production plant who are exposed via drinking water, and in a control population. In this plant, the replacement emulsifier 3H-perfluoro-3-[(3-methoxy-propoxy)propanoic acid] (ADONA) has been used in the production of fluoropolymers since 2008. We quantified 7 perfluorinated compounds and ADONA in a total of 396 plasma samples collected at different time points. With regard to samples collected in 2015 or 2016, the highest 95th percentile levels were 13.5μg/l for perfluorooctane sulfonate (PFOS), 3.0μg/l for perfluorononanoate (PFNA), and 1.5μg/l for perfluorohexane sulfonate (PFHxS). For PFOA, the highest 95th percentile was found at the site close to the facility (85.5μg/l), while in the control region the value was 2.4μg/l. Overall, the concentration of PFOA and PFOS declined over time in all study regions. ADONA was detected only in few samples slightly above the limit of quantification (0.2μg/l). While health risks related to ADONA are unlikely under the present exposure situation, the exposure to PFOA via tap water should be reduced markedly, especially for the population living close to the plant., (Copyright © 2016 Elsevier GmbH. All rights reserved.)

For decades, plasticizers have been produced in high quantities to improve the flexibility and durability of products. One possible replacement product is alkylsulfonic acid phenylesters (ASEs), marketed as Mesamoll ® . This study aimed to quantify the ASE dust contamination of residences and daycare centers to obtain insight into the recent exposure situation. ASEs were quantified in dust samples collected from 25 residences and 25 daycare centers using GC/MS measurements. Median (95th percentile) values of the sum of tetra- to heptadecylphenylesters are higher in daycare centers, with a value of 19.6mg/kg (216mg/kg), compared to residences, with a value of 7.6mg/kg (171mg/kg). A daily non-dietary intake of 0.08 and 0.86μg/kg b.w., respectively, was observed using the median and 95th percentile values obtained from dust samples. These levels are 1250 and 115 times below a previously set temporary tolerable daily intake value. Nevertheless, the fact that basic data on toxicity and exposure via other pathways are limited or unavailable at present has to be considered., (Copyright © 2016 Elsevier GmbH. All rights reserved.)

Objective: To describe personal music player (PMP) usage among adolescents, sociodemographic determinants and association with audiometric notches., Design: Audiometric evaluation to assess hearing status, and standardized questionnaires to evaluate PMP listening behaviors, leisure noise exposures and self-reported hearing loss symptoms. Sociodemographic information was collected using a parent questionnaire. Noise exposure by PMP usage equivalent for a 40 h week was estimated based on self-reported volume and duration of use., Study Sample: A total of 2143 students (54% females) attending 9th grade in Regensburg, Germany, during 2009 to 2011., Results: Overall, 85% of the students reported using PMPs. Exposure level exceeded 80 dB(A) in approximately one third, and 85 dB(A) in one quarter, of those who used PMP. An audiometric notch was found in 2.3% of participants, but was not significantly associated with higher PMP exposure., Conclusions: PMP exposure above the occupational limits of 80 and 85 dB(A) set by the Directive 2003/10/EC may be a risk factor for developing noise-induced hearing loss. Educational measures to ameliorate high risk behaviors in PMP usage are needed, particularly for socially disadvantaged groups.

Waterpipe (WP) smoking, also known as shisha or hookah smoking, is growing in western countries as an alternative to cigarette smoking, especially in younger age groups. A majority of smokers mistakenly believe that shisha smoking is a social entertainment practice that leads to more social behavior and relaxation and that this type of smoking is safe or less harmful and less addictive than cigarette smoking.In reality, WP smokers are exposed to hundreds of toxic substances that include well-known carcinogens. High exposures to carbon monoxide and nicotine are major health threats. There is growing evidence that WP smoke causes adverse effects on the pulmonary and cardiovascular systems and there are indications that WP smoke is associated with cancer. Persons exposed to secondhand WP smoke are also at risk.More research on the health effects of WP is urgently needed and more preventive measures for public health protection. Moreover, public WP facilities should be implemented under specific nonsmoker protection laws and consequently controlled.This review summarizes recent data on exposure to WP smoking in indoor environments, the results of biomonitoring data, and the known health effects based on currently available toxicological or epidemiological studies.

Background: Structural factors of neighbourhood environments in which children live have attracted increasing attention in epidemiological research. This study investigated whether neighbourhood socioeconomic position (SEP), public playground and park space, and perceived environmental exposures were independently associated with overweight in preschool aged children while simultaneously considering individual child and family factors., Methods: Body-Mass-Index (BMI) data from 3499 children (53% boys and 47% girls) from three surveys between 2004 and 2007 from 18 school enrolment zones in the city of Munich, Germany, were analysed with hierarchical logistic regression models. An index of neighbourhood SEP was calculated with principal component analysis. Individual socioeconomic data, parental BMI, birth weight, housing characteristics, and perceived annoyance due to exposures to noise, air pollution, lack of greenspace, and traffic were collected with parental questionnaires. Measures of age-specific playground space and availability of park space derived from Geographic Information System were additionally weighted with age-specific population data., Results: In bivariate analysis perceived annoyance due to exposures to noise or lack of greenspace, high frequency of lorries, traffic jam, living in a multiple dwelling or next to a main road, low neighbourhood SEP, and low playground space were significantly associated with overweight. However, in multivariate analysis only living in a multiple dwelling was independently associated with overweight. From the considered individual child and family factors low parental education, parental overweight or obesity, and a high birthweight showed an independent relation to overweight., Conclusions: Our study identified individual child and parental factors, and living in a multiple dwelling as the strongest predictors for overweight in preschool aged children. However, perceived annoyance to built environmental exposures additionally explained overweight variance between neighbourhoods. Based on our findings interventions and policies addressing overweight prevention in young children should focus on parental behaviours and the immediate home environment., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Persistent organic pollutants are widespread in the environment, and are associated with a particular health and ecological concern. The human body burden of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDDs/Fs), polybrominated dibenzo-p-dioxins and dibenzofurans (PBDDs/Fs), polychlorinated biphenyls (PCBs), polybrominated diphenylether (PBDEs), and hexabromocyclododecanes (HBCDs) was determined. Blood samples were collected in Germany, originating from 42 randomly selected subjects between 20 and 68 years old. The median (95th percentile) concentrations, expressed as WHO2005-TEQ for PCDD/PCDFs and dioxin-like PCBs, were 6.2 (19.1) pg/g l.w. and 4.1 (8.8) pg/g l.w., respectively. PBDDs/Fs were found with a median of 2.8 pgTEQ/g l.w. and a 95th percentile of 8.7 pgTEQ/g l.w. (using similar interim TEF values as for PCDDs/Fs) On a median basis, the contribution of PCDD/Fs, dioxin-like PCBs, and PBDDs/Fs to total TEQ were 47%, 31%, and 21%, respectively. The sum of the 6 non-dioxin-like PCBs exhibited a median of 267ng/g l.w. and a 95th percentile of 834ng/g l.w. The median value for the sum of six tetra- to hepta-PBDE congeners was 1.7ng/g l.w. (95th percentile: 4.9ng/g l.w.). BDE 209 was the most abundant congener with a median of 1.8ng/g l.w. HBCDs were only found in some samples, and concentrations ranged between the limit of detection (5ng/g l.w.) and the limit of quantification (16ng/g l.w.). Results for PBDEs and HBCDs are comparable to other European studies. Our study demonstrated that the body burden of PCDD/Fs and PCBs declined continously since the last three decades, but exposure may exceed precautionary guideline levels., (Copyright © 2016 Elsevier GmbH. All rights reserved.)

Humans have been exposed to dialkyl ortho-phthalates for decades. Due to degradation the phthalate monoesters, responsible for the toxic effects, are additionally found in environmental media as well as food samples. Nevertheless, the toxicokinetic properties of the monoesters are not known. Therefore, metabolism of the phthalate monoesters mono-2-ethylhexyl phthalate (MEHP) and mono-n-butyl phthalate (MnBP) was studied in four male volunteers (23-58 years of age) after ingestion of a single dose of 50μg/kg bw D4-MEHP or 10μg/kg bw D4-MnBP. The main metabolites in urine were determined up to 46h after administration. In the MEHP-study, more than 90% of each metabolite appeared in the urine within the first 22h, and the average excreted amount of D4-MEHP and its four secondary metabolites was 62% of the administered dose. The highest value of 15% was observed for mono-2-ethyl-5-carboxy-pentyl phthalate (D4-5cx-MEPP). The mean elimination half-life of D4-MEHP was estimated to be 3.5±1.4h. In the MnBP-study, the total recovered values of D4-MnBP and its secondary metabolites ranged from 52% to 130%. The monoester itself, with a half-life of 1.9±0.5h, accounted for the majority of the ingested dose (92%), while the secondary metabolites D4-mono-3-hydroxy-n-butyl phthalate (D4-3OH-MnBP) and D4-3-carboxy-mono-propyl phthalate (D4-3cx-MPP) represented only 7.1% and 1.0% of the ingested dose, respectively. Overall, this study determined that the kinetics of the phthalate monoesters MEHP and MnBP after oral dosage are comparable to the properties of their diesters., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: The context of the close neighbourhood environment in which children live has gained increasing attention in epidemiological research. This study aimed to investigate if contextual neighbourhood socioeconomic position (SEP) was independently associated with overweight in young children aged 5-7 years while simultaneously considering a wide range of individual socioeconomic determinants and known risk factors for overweight., Methods: Objectively measured body mass index (BMI) data from 3499 children (53 % boys and 47 % girls) from three surveys between 2004 and 2007 clustered in 18 school enrolment zones in the city of Munich, Germany, were analysed with hierarchical logistic regression models. An index of neighbourhood SEP was calculated with principal component analysis using aggregated data. Individual socioeconomic data, maternal BMI, and birth weight were collected with parental questionnaires. We analysed how much of the between neighbourhood variance of overweight was attributable to individual factors and how much was explained by neighbourhood SEP., Results: The prevalence of overweight, including obesity, was 14.1 %. In the final adjusted model low neighbourhood SEP was independently associated with overweight (odds ratio (OR) = 1.42, 95 % confidence interval (CI) = 1.00-2.00) compared to high neighbourhood SEP. On the individual level low parental education (OR = 1.99, 95 % CI = 1.49-2.65) or middle parental education (OR = 1.50, 95 % CI = 1.16-1.95) compared to high parental education and nationality of the child other than German (OR = 1.53, 95 % CI = 1.17-1.99) compared to German nationality were independently associated with overweight., Conclusions: Whereas individual determinants were the main drivers in explaining between neighbourhood variance, neighbourhood SEP additionally explained differences in overweight between neighbourhoods. Thus, considering neighbourhood context in intervention planning could result in more effective strategies compared to measures only focusing on individual determinants of overweight.

Phthalates such as di-2-ethylhexyl phthalate (DEHP) were restricted due to their toxic mainly reprotoxic effects. Therefore compounds such as di-(isononyl)-cyclohexane-1,2-dicarboxylate (DINCH(®)) substitute these phthalates and the exposure of humanes to substitutes may occur. Here, kinetic data are presented to assess the exposure of humans. Male and female volunteers excreted nearly the complete orally administered dose (1mg/kg b.w. corresponding to the tolerable daily intake of EFSA) of di-(isononyl)-cyclohexane-1,2-dicarboxylate within 70 h. More than 75% were excreted within 24h. Besides the main metabolite cyclohexane-1,2-dicarboxylic acid (CHDA) quantitated after hydrolysis four further metabolites of DINCH(®) are determined. Cyclohexane-1,2-dicarboxylic acid-mono-(7-hydroxy-4-methyl)octyl ester (OH-MINCH) is the main secondary metabolite with about 14% of the administered dose. Differences in excretion of all metabolites between male and females are small. Based on the generated toxicokinetic data exposure of 20 humans is recalculated from their spot urine sample collected in 2014 and the exposure are clearly below the current tolerable daily intake of 1mg/kg b.w., (Copyright © 2016. Published by Elsevier Ireland Ltd.)

Mycotoxins are toxic secondary metabolites of various fungal species that can contaminate food and feed, as well as indoor environments. Numerous studies have summarized the adverse health effects of mycotoxins and described severe intoxications of humans and animals. The major health concerns are caused via the alimentary route which unambiguously is the main source for human internal exposure; however, the relevance of other pathways under environmental and occupational conditions should also be considered. Thus firstly, this review aims in summarizing literature data on potentially inhalable mycotoxins occurring in dusts or air in residences and in working environments. Secondly, it gives an overview of the overall internal body burden of mycotoxins in humans in an attempt to characterize total human exposure. These data are also discussed in relation to the current toxicologically based values used for risk assessment., (Copyright © 2015 Elsevier GmbH. All rights reserved.)

Most children are exposed to perfluoroalkyl substances (PFASs) through placental transfer, breastfeeding, and other environmental sources. To date, there are no validated tools to estimate exposure and body burden during infancy and childhood. In this study, we aimed to (i) develop a two-generation pharmacokinetic model of prenatal and postnatal exposure to perfluorooctanoic acid (PFOA), perfluorooctanesulfonate (PFOS), and perfluorohexanesulfonate (PFHxS); and to (ii) evaluate it against measured children's levels in two studies. We developed a pharmacokinetic model consisting of a maternal and a child compartment to simulate lifetime exposure in women and transfer to the child across the placenta and through breastfeeding. To evaluate the model, we performed simulations for each mother-child dyad from two studies in which maternal PFAS levels at delivery and children's PFAS levels were available. Model predictions based on maternal PFAS levels, sex of child, body weight, and duration of breastfeeding explained between 52% and 60% of the variability in measured children's levels at 6 months of age and between 52% and 62% at 36 months. Monte Carlo simulations showed that the daily intake through breastfeeding and resulting internal PFAS levels can be much higher in nursing infants than in mothers. This pharmacokinetic model shows potential for postnatal exposure assessment in the context of epidemiological studies and risk assessment.

Plasticizers have been widely used for decades as additives in diverse applications, including consumer and building products, toys, cables, and floorings. Due to toxicological concerns and restrictions of different dialkyl ortho-phthalates, other plasticizers have been increasingly used in recent years. Therefore, di-isononyl cyclohexane-1,2-dicarboxylate (DINCH), di(2-ethylhexyl) terephthalate (DEHT), di(2-ethylhexyl) adipate (DEHA), acetyl tri-n-butyl citrate (ATBC), and trioctyl trimellitate (TOTM) plasticizer levels in indoor air and dust samples from 63 daycare centers in Germany were measured. Moreover, the urine samples of 208 children who attend 27 of these facilities were analyzed for the presence of four DINCH metabolites. DINCH, DEHT, and DEHA were present in indoor air with median values of 108 ng/m(3), 20 ng/m(3), and 34 ng/m(3), respectively. Median values of 302 mg/kg for DINCH, 49 mg/kg for DEHA, 40 mg/kg for DEHT, and 24 mg/kg ATBC were found in dust. In the urine samples, the three secondary metabolites of DINCH were observed with median values (95th percentiles) of 1.7 μg/l (10.0 μg/l) for OH-MINCH, 1.5 μg/l (8.0 μg/l) for oxo-MINCH, and 1.1 μg/l (6.1 μg/l) for cx-MINCH. Overall, these metabolite levels are orders of magnitude lower than the current HBM I values set by the German Human Biomonitoring Commission. Using general exposure assumptions, the intake resulting from dust ingestion and inhalation is low for children. The total daily DINCH intake calculated from biomonitoring data was 0.5 μg/kg b.w. using median values and 9.8 μg/kg b.w. as the maximum value. At present, non-phthalate plasticizers, especially DINCH, can be found in considerable amounts in dust samples from daycare centers and as DINCH metabolites in the urine of children. In relation to previous studies, the concentrations of DINCH in dust and urine have an increasing time trend. Compared with tolerable daily intake values, the total daily intake of DINCH reached only 1% of its maximum value to date; however, due to its increased use, higher exposure of DINCH is expected in the future., (Copyright © 2015 Elsevier GmbH. All rights reserved.)

Brominated flame retardants (BFRs) are a large group of different substances used in numerous products to prevent fire hazards. Some of them are persistent in the environment, accumulate in the food chain and are of toxicological concern, while for others current data are limited. Meanwhile, BFRs have been found in many environmental media, foods, and biota including humans. This review presents recent findings obtained from monitoring data in environmental media relevant for human exposure, as well as dietary exposure. In this context, concentrations in indoor and ambient air and in house dust are outlined. Furthermore, we summarize human biomonitoring data on BFR levels in blood and breast milk. Current estimates of the overall exposure of the general population using different relevant subsets are also addressed. All of these data are discussed in relation to currently available toxicological reference values used for risk assessment purposes. Obviously, the exposure of the general population varies considerably in different parts of the world and even within countries. Polybrominated diphenyl ethers (PBDEs) and hexabromocyclododecane (HBCD) show the highest intake during infancy. While the highest intake for BDE 47 for all groups was observed in the US, the total BDE 209 and HBCD intake was highest in the UK. For HBCD and all PBDEs except BDE 209, diet accounts for a large proportion of the total intake during infancy in all countries. With regard to toddlers and adults, the contribution of diet to total intake is high in Germany and the UK, while in the US, the high concentrations of PBDE in dust resulted in a notably smaller proportion of the intake being attributed to diet., (Copyright © 2015 Elsevier GmbH. All rights reserved.)

Human biomonitoring is a valid method to determine exposure, identify time trends, and monitor the effects of restrictions and measures. To characterize the recent exposure of Germans to persistent or emerging substances, we analyzed 4 dechloranes, 33 polychlorinated naphthalenes (PCNs), and 3 cyclic volatile methyl siloxanes (cVMS) in 42 plasma samples. The samples were collected from blood donors on a random selection. The median values of both Dechlorane Plus (DDC-CO) isomers were 1.23ng/gl.w. for anti- and 0.77ng/gl.w. for syn-DDC-CO. The two other dechloranes were found at lower levels. The median level of ∑-PCNs was 575pg/gl.w. (range: 101-1406pg/gl.w.). On average, the levels of PCNs in plasma were dominated by the congeners CN73, CN66/67, and CN51, which were responsible for approximately 71% of the total amount of PCNs. The cVMS octa-, deca-, and dodecamethylcyclotetrasiloxane could be determined in only some samples, with maximum values of 0.73, 0.48, and 0.79μg/l, respectively. Regarding dechloranes, our results are similar to those from other western countries but slightly lower than results from China. The levels of PCNs in German blood are similar to those observed in the U.S.A., but considerably lower than those reported for Korea. Using a preliminary TEF (toxic equivalency factor), the mean TEQ of the 9 quantifiable PCNs in Germany was low (0.36pg TEQ/gl.w.). The PCN levels in our study group are lower compared to previous studies., (Copyright © 2015 Elsevier Ltd. All rights reserved.)