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1.  Occupational Exposure to Nitrous Oxide in Dental Operatories 
Anesthesia Progress  1986;33(2):91-97.
Occupational exposures to nitrous oxide (N20) were measured in numerous dental operatories. In all cases, the National Institute of Occupational Safety and Health (NIOSH) recommended time-weighted average (for one operation) of 25 ppm was exceeded by wide margins (NIOSH considers 50 ppm to be attainable in dental operatories). However, a new risk assessment is necessary to determine appropriate exposure limits. Many of the operatories were not equipped with scavenging systems and none of them used a scavenging device in combination with a local exhaust ventilation system. Scavenging devices and local exhaust ventilation should be used to control nitrous oxide exposures. Leaks in N20 delivery systems, which were found to be commonplace, should also be controlled. Research and development efforts are needed to improve upon the already existing scavenging devices, and provision for local exhaust ventilation needs to be included in the design of dental operatories.
PMCID: PMC2175458  PMID: 3459383
2.  Nitrous Oxide and Occupational Exposure: It's Time to Stop Laughing 
Anesthesia Progress  1989;36(6):252-257.
Although nitrous oxide (N2O) has been widely used since 1844, in recent years it has been implicated in a number of serious health hazards such as reproductive, nerve, liver, and kidney disorders. The National Institute of Safety and Health (NIOSH) recommends a limit of 25 ppm for chronic exposure to N2O in the dental office. Our study monitored ambient N2O levels in the dental office. N2O levels were compared for procedures performed in open clinics and private operatories as well as with and without a gas-scavenging system. Measurements were taken in the Dental Breathing Zone (DBZ) and Dental Chair Foot (DCF) at regular intervals. A four- to eightfold increase in average N2O levels was noted in the DBZ for unscavenged versus scavenged procedures. A three- to fourfold increase for unscavenged versus scavenged procedures was similarly noted in the DCF. N2O were significantly higher in private operatories than in open clinics, due to limited room volumes and in the DBZ over the DCF, due to mask leakage and increased oral exhalation. Scavenged N2O levels for both operatory types did not meet NIOSH guidelines. In contrast to previous studies using any form of gas removal, our study shows a significant decrease in N2O level achieved with an adequate scavenger system. With only four states regulating the use of N2O, and with concern over its deleterious effects growing, additional states and the federal government are expected to enact legislation regulating the use of N2O in the near future.
PMCID: PMC2163978  PMID: 2490056
3.  Air Cleaning Technologies 
Executive Summary
This health technology policy assessment will answer the following questions:
When should in-room air cleaners be used?
How effective are in-room air cleaners?
Are in-room air cleaners that use combined HEPA and UVGI air cleaning technology more effective than those that use HEPA filtration alone?
What is the Plasmacluster ion air purifier in the pandemic influenza preparation plan?
The experience of severe acute respiratory syndrome (SARS) locally, nationally, and internationally underscored the importance of administrative, environmental, and personal protective infection control measures in health care facilities. In the aftermath of the SARS crisis, there was a need for a clearer understanding of Ontario’s capacity to manage suspected or confirmed cases of airborne infectious diseases. In so doing, the Walker Commission thought that more attention should be paid to the potential use of new technologies such as in-room air cleaning units. It recommended that the Medical Advisory Secretariat of the Ontario Ministry of Health and Long-Term Care evaluate the appropriate use and effectiveness of such new technologies.
Accordingly, the Ontario Health Technology Advisory Committee asked the Medical Advisory Secretariat to review the literature on the effectiveness and utility of in-room air cleaners that use high-efficiency particle air (HEPA) filters and ultraviolet germicidal irradiation (UVGI) air cleaning technology.
Additionally, the Ontario Health Technology Advisory Committee prioritized a request from the ministry’s Emergency Management Unit to investigate the possible role of the Plasmacluster ion air purifier manufactured by Sharp Electronics Corporation, in the pandemic influenza preparation plan.
Clinical Need
Airborne transmission of infectious diseases depends in part on the concentration of breathable infectious pathogens (germs) in room air. Infection control is achieved by a combination of administrative, engineering, and personal protection methods. Engineering methods that are usually carried out by the building’s heating, ventilation, and air conditioning (HVAC) system function to prevent the spread of airborne infectious pathogens by diluting (dilution ventilation) and removing (exhaust ventilation) contaminated air from a room, controlling the direction of airflow and the air flow patterns in a building. However, general wear and tear over time may compromise the HVAC system’s effectiveness to maintain adequate indoor air quality. Likewise, economic issues may curtail the completion of necessary renovations to increase its effectiveness. Therefore, when exposure to airborne infectious pathogens is a risk, the use of an in-room air cleaner to reduce the concentration of airborne pathogens and prevent the spread of airborne infectious diseases has been proposed as an alternative to renovating a HVAC system.
Airborne transmission is the spread of infectious pathogens over large distances through the air. Infectious pathogens, which may include fungi, bacteria, and viruses, vary in size and can be dispersed into the air in drops of moisture after coughing or sneezing. Small drops of moisture carrying infectious pathogens are called droplet nuclei. Droplet nuclei are about 1 to 5μm in diameter. This small size in part allows them to remain suspended in the air for several hours and be carried by air currents over considerable distances. Large drops of moisture carrying infectious pathogens are called droplets. Droplets being larger than droplet nuclei, travel shorter distances (about 1 metre) before rapidly falling out of the air to the ground. Because droplet nuclei remain airborne for longer periods than do droplets, they are more amenable to engineering infection control methods than are droplets.
Droplet nuclei are responsible for the airborne transmission of infectious diseases such as tuberculosis, chicken pox (varicella), measles (rubeola), and dessiminated herpes zoster, whereas close contact is required for the direct transmission of infectious diseases transmitted by droplets, such as influenza (the flu) and SARS.
The Technology
In-room air cleaners are supplied as portable or fixed devices. Fixed devices can be attached to either a wall or ceiling and are preferred over portable units because they have a greater degree of reliability (if installed properly) for achieving adequate room air mixing and airflow patterns, which are important for optimal effectiveness.
Through a method of air recirculation, an in-room air cleaner can be used to increase room ventilation rates and if used to exhaust air out of the room it can create a negative-pressure room for airborne infection isolation (AII) when the building’s HVAC system cannot do so. A negative-pressure room is one where clean air flows into the room but contaminated air does not flow out of it. Contaminated room air is pulled into the in-room air cleaner and cleaned by passing through a series of filters, which remove the airborne infectious pathogens. The cleaned air is either recirculated into the room or exhausted outside the building. By filtering contaminated room air and then recirculating the cleaned air into the room, an in-room air cleaner can improve the room’s ventilation. By exhausting the filtered air to the outside the unit can create a negative-pressure room. There are many types of in-room air cleaners. They vary widely in the airflow rates through the unit, the type of air cleaning technology used, and the technical design.
Crucial to maximizing the efficiency of any in-room air cleaner is its strategic placement and set-up within a room, which should be done in consultation with ventilation engineers, infection control experts, and/or industrial hygienists. A poorly positioned air cleaner may disrupt airflow patterns within the room and through the air cleaner, thereby compromising its air cleaning efficiency.
The effectiveness of an in-room air cleaner to remove airborne pathogens from room air depends on several factors, including the airflow rate through the unit’s filter and the airflow patterns in the room. Tested under a variety of conditions, in-room air cleaners, including portable or ceiling mounted units with either a HEPA or a non-HEPA filter, portable units with UVGI lights only, or ceiling mounted units with combined HEPA filtration and UVGI lights, have been estimated to be between 30% and 90%, 99% and 12% and 80% effective, respectively. However, and although their effectiveness is variable, the United States Centers for Disease Control and Prevention has acknowledged in-room air cleaners as alternative technology for increasing room ventilation when this cannot be achieved by the building’s HVAC system with preference given to fixed recirculating systems over portable ones.
Importantly, the use of an in-room air cleaner does not preclude either the need for health care workers and visitors to use personal protective equipment (N95 mask or equivalent) when entering AII rooms or health care facilities from meeting current regulatory requirements for airflow rates (ventilation rates) in buildings and airflow differentials for effective negative-pressure rooms.
The Plasmacluster ion technology, developed in 2000, is an air purification technology. Its manufacturer, Sharp Electronics Corporation, says that it can disable airborne microorganisms through the generation of both positive and negative ions. (1) The functional unit is the hydroxyl, which is a molecule comprised of one oxygen molecule and one hydrogen atom.
Plasmacluster ion air purifier uses a multilayer filter system composed of a prefilter, a carbon filter, an antibacterial filter, and a HEPA filter, combined with an ion generator to purify the air. The ion generator uses an alternating plasma discharge to split water molecules into positively and negatively charged ions. When these ions are emitted into the air, they are surrounded by water molecules and form cluster ions which are attracted to airborne particles. The cluster ion surrounds the airborne particle, and the positive and negative ions react to form hydroxyls. These hydroxyls steal the airborne particle’s hydrogen atom, which creates a hole in the particle’s outer protein membrane, thereby rendering it inactive.
Because influenza is primarily acquired by large droplets and direct and indirect contact with an infectious person, any in-room air cleaner will have little benefit in controlling and preventing its spread. Therefore, there is no role for the Plasmacluster ion air purifier or any other in-room air cleaner in the control of the spread of influenza. Accordingly, for purposes of this review, the Medical Advisory Secretariat presents no further analysis of the Plasmacluster.
Review Strategy
The objective of the systematic review was to determine the effectiveness of in-room air cleaners with built in UVGI lights and HEPA filtration compared with those using HEPA filtration only.
The Medical Advisory Secretariat searched the databases of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, INAHATA (International Network of Agencies for Health Technology Assessment), Biosis Previews, Bacteriology Abstracts, Web of Science, Dissertation Abstracts, and NIOSHTIC 2.
A meta-analysis was conducted if adequate data was available from 2 or more studies and where statistical and clinical heterogeneity among studies was not an issue. Otherwise, a qualitative review was completed. The GRADE system was used to summarize the quality of the body of evidence comprised of 1 or more studies.
Summary of Findings
There were no existing health technology assessments on air cleaning technology located during the literature review. The literature search yielded 59 citations of which none were retained. One study was retrieved from a reference list of a guidance document from the United States Centers for Disease Control and Prevention, which evaluated an in-room air cleaner with combined UVGI lights and HEPA filtration under 2 conditions: UVGI lights on and UVGI lights off. Experiments were performed using different ventilation rates and using an aerosolized pathogen comprised of Mycobaterium parafortuitum, a surrogate for the bacterium that causes tuberculosis. Effectiveness was measured as equivalent air changes per hour (eACH). This single study formed the body of evidence for our systematic review research question.
Experimental Results
The eACH rate for the HEPA-UVGI in-room air cleaner was statistically significantly greater when the UV lights were on compared with when the UV lights were off. (P < .05). However, subsequent experiments could not attribute this to the UVGI. Consequently, the results are inconclusive and an estimate of effect (benefit) is uncertain.
The study was reviewed by a scientific expert and rated moderate for quality. Further analysis determined that there was some uncertainty in the directness of the outcome measure (eACH); thus, the GRADE level for the quality of the evidence was low indicating that an estimate of effect is very uncertain.
There is uncertainty in the benefits of using in-room air cleaners with combined UVGI lights and HEPA filtration over systems that use HEPA filtration alone. However, there are no known risks to using systems with combined UVGI and HEPA technology compared with those with HEPA alone. There is an increase in the burden of cost including capital costs (cost of the device), operating costs (electricity usage), and maintenance costs (cleaning and replacement of UVGI lights) to using an in-room air cleaner with combined UVGI and HEPA technology compared with those with HEPA alone. Given the uncertainty of the estimate of benefits, an in-room air cleaner with HEPA technology only may be an equally reasonable alternative to using one with combined UVGI and HEPA technology
In-room air cleaners may be used to protect health care staff from air borne infectious pathogens such as tuberculosis, chicken pox, measles, and dessiminated herpes zoster. In addition, and although in-room air cleaners are not effective at protecting staff and preventing the spread of droplet-transmitted diseases such as influenza and SARS, they may be deployed in situations with a novel/emerging infectious agent whose epidemiology is not yet defined and where airborne transmission is suspected.
It is preferable that in-room air cleaners be used with a fixed and permanent room placement when ventilation requirements must be improved and the HVAC system cannot be used. However, for acute (temporary) situations where a novel/emerging infectious agent presents whose epidemiology is not yet defined and where airborne transmission is suspected it may be prudent to use the in room air cleaner as a portable device until mode of transmission is confirmed. To maximize effectiveness, consultation with an environmental engineer and infection control expert should be undertaken before using an in-room air cleaner and protocols for maintenance and monitoring of these devices should be in place.
If properly installed and maintained, in room air cleaners with HEPA or combined HEPA and UVGI air cleaning technology are effective in removing airborne pathogens. However, there is only weak evidence available at this time regarding the benefit of using an in-room air cleaner with combined HEPA and UVGI air cleaner technology instead of those with HEPA filter technology only.
PMCID: PMC3382390  PMID: 23074468
4.  Natural Ventilation for the Prevention of Airborne Contagion 
PLoS Medicine  2007;4(2):e68.
Institutional transmission of airborne infections such as tuberculosis (TB) is an important public health problem, especially in resource-limited settings where protective measures such as negative-pressure isolation rooms are difficult to implement. Natural ventilation may offer a low-cost alternative. Our objective was to investigate the rates, determinants, and effects of natural ventilation in health care settings.
Methods and Findings
The study was carried out in eight hospitals in Lima, Peru; five were hospitals of “old-fashioned” design built pre-1950, and three of “modern” design, built 1970–1990. In these hospitals 70 naturally ventilated clinical rooms where infectious patients are likely to be encountered were studied. These included respiratory isolation rooms, TB wards, respiratory wards, general medical wards, outpatient consulting rooms, waiting rooms, and emergency departments. These rooms were compared with 12 mechanically ventilated negative-pressure respiratory isolation rooms built post-2000. Ventilation was measured using a carbon dioxide tracer gas technique in 368 experiments. Architectural and environmental variables were measured. For each experiment, infection risk was estimated for TB exposure using the Wells-Riley model of airborne infection. We found that opening windows and doors provided median ventilation of 28 air changes/hour (ACH), more than double that of mechanically ventilated negative-pressure rooms ventilated at the 12 ACH recommended for high-risk areas, and 18 times that with windows and doors closed (p < 0.001). Facilities built more than 50 years ago, characterised by large windows and high ceilings, had greater ventilation than modern naturally ventilated rooms (40 versus 17 ACH; p < 0.001). Even within the lowest quartile of wind speeds, natural ventilation exceeded mechanical (p < 0.001). The Wells-Riley airborne infection model predicted that in mechanically ventilated rooms 39% of susceptible individuals would become infected following 24 h of exposure to untreated TB patients of infectiousness characterised in a well-documented outbreak. This infection rate compared with 33% in modern and 11% in pre-1950 naturally ventilated facilities with windows and doors open.
Opening windows and doors maximises natural ventilation so that the risk of airborne contagion is much lower than with costly, maintenance-requiring mechanical ventilation systems. Old-fashioned clinical areas with high ceilings and large windows provide greatest protection. Natural ventilation costs little and is maintenance free, and is particularly suited to limited-resource settings and tropical climates, where the burden of TB and institutional TB transmission is highest. In settings where respiratory isolation is difficult and climate permits, windows and doors should be opened to reduce the risk of airborne contagion.
In eight hospitals in Lima, opening windows and doors maximised natural ventilation and lowered the risk of airborne infection. Old-fashioned clinical areas with high ceilings and large windows provide greatest protection.
Editors' Summary
Tuberculosis (TB) is a major cause of ill health and death worldwide, with around one-third of the world's population infected with the bacterium that causes it (Mycobacterium tuberculosis). One person with active tuberculosis can go on to infect many others; the bacterium is passed in tiny liquid droplets that are produced when someone with active disease coughs, sneezes, spits, or speaks. The risk of tuberculosis being transmitted in hospital settings is particularly high, because people with tuberculosis are often in close contact with very many other people. Currently, most guidelines recommend that the risk of transmission be controlled in certain areas where TB is more likely by making sure that the air in rooms is changed with fresh air between six and 12 times an hour. Air changes can be achieved with simple measures such as opening windows and doors, or by installing mechanical equipment that forces air changes and also keeps the air pressure in an isolation room lower than that outside it. Such “negative pressure,” mechanically ventilated systems are often used on tuberculosis wards to prevent air flowing from isolation rooms to other rooms outside, and so to prevent people on the tuberculosis ward from infecting others.
Why Was This Study Done?
In many parts of the world, hospitals do not have equipment even for simple air conditioning, let alone the special equipment needed for forcing high air changes in isolation rooms and wards. Instead they rely on opening windows and doors in order to reduce the transmission of TB, and this is called natural ventilation. However, it is not clear whether these sorts of measures are adequate for controlling TB transmission. It is important to find out what sorts of systems work best at controlling TB in the real world, so that hospitals and wards can be designed appropriately, within available resources.
What Did the Researchers Do and Find?
This study was based in Lima, Peru's capital city. The researchers studied a variety of rooms, including tuberculosis wards and respiratory isolation rooms, in the city's hospitals. Rooms which had only natural measures for encouraging airflow were compared with mechanically ventilated, negative pressure rooms, which were built much more recently. A comparison was also done between rooms in old hospitals that were naturally ventilated with rooms in newer hospitals that were also naturally ventilated. The researchers used a particular method to measure the number of air changes per hour within each room, and based on this they estimated the risk of a person with TB infecting others using a method called the Wells-Riley equation. The results showed that natural ventilation provided surprisingly high rates of air exchange, with an average of 28 air changes per hour. Hospitals over 50 years old, which generally had large windows and high ceilings, had the highest ventilation, with an average of 40 air changes per hour. This rate compared with 17 air changes per hour in naturally ventilated rooms in modern hospitals, which tended to have lower ceilings and smaller windows. The rooms with modern mechanical ventilation were supposed to have 12 air changes per hour but in reality this was not achieved, as the systems were not maintained properly. The Wells-Riley equation predicted that if an untreated person with tuberculosis was exposed to other people, within 24 hours this person would infect 39% of the people in the mechanically ventilated room, 33% of people in the naturally ventilated new hospital rooms, and only 11% of the people in the naturally ventilated old hospital rooms.
What Do These Findings Mean?
These findings suggest that natural methods of encouraging airflow (e.g., opening doors and windows) work well and in theory could reduce the likelihood of TB being carried from one person to another. Some aspects of the design of wards in old hospitals (such as large windows and high ceilings) are also likely to achieve better airflow and reduce the risk of infection. In poor countries, where mechanical ventilation systems might be too expensive to install and maintain properly, rooms that are designed to naturally achieve good airflow might be the best choice. Another advantage of natural ventilation is that it is not restricted by cost to just high-risk areas, and can therefore be used in many different parts of the hospital, including emergency departments, outpatient departments, and waiting rooms, and it is here that many infectious patients are to be found.
Additional Information.
Please access these Web sites via the online version of this summary at
Information from the World Health Organization on tuberculosis, detailing global efforts to prevent the spread of TB
The World Health Organization publishes guidelines for the prevention of TB in health care facilities in resource-limited settings
Tuberculosis infection control in the era of expanding HIV care and treatment is discussed in an addendum to the above booklet
The Centers for Disease Control have published guidelines for preventing the transmission of mycobacterium tuberculosis in health care settings
Wikipedia has an entry on nosocomial infections (diseases that are spread in hospital). Wikipedia is an internet encyclopedia anyone can edit
A PLoS Medicine Perspective by Peter Wilson, “Is Natural Ventilation a Useful Tool to Prevent the Airborne Spread of TB?” discusses the implications of this study
PMCID: PMC1808096  PMID: 17326709
5.  Lung Function and Incidence of Chronic Obstructive Pulmonary Disease after Improved Cooking Fuels and Kitchen Ventilation: A 9-Year Prospective Cohort Study 
PLoS Medicine  2014;11(3):e1001621.
Pixin Ran, Nanshan Zhong, and colleagues report that cleaner cooking fuels and improved ventilation were associated with better lung function and reduced COPD among a cohort of villagers in Southern China.
Please see later in the article for the Editors' Summary
Biomass smoke is associated with the risk of chronic obstructive pulmonary disease (COPD), but few studies have elaborated approaches to reduce the risk of COPD from biomass burning. The purpose of this study was to determine whether improved cooking fuels and ventilation have effects on pulmonary function and the incidence of COPD.
Methods and Findings
A 9-y prospective cohort study was conducted among 996 eligible participants aged at least 40 y from November 1, 2002, through November 30, 2011, in 12 villages in southern China. Interventions were implemented starting in 2002 to improve kitchen ventilation (by providing support and instruction for improving biomass stoves or installing exhaust fans) and to promote the use of clean fuels (i.e., biogas) instead of biomass for cooking (by providing support and instruction for installing household biogas digesters); questionnaire interviews and spirometry tests were performed in 2005, 2008, and 2011. That the interventions improved air quality was confirmed via measurements of indoor air pollutants (i.e., SO2, CO, CO2, NO2, and particulate matter with an aerodynamic diameter of 10 µm or less) in a randomly selected subset of the participants' homes. Annual declines in lung function and COPD incidence were compared between those who took up one, both, or neither of the interventions.
Use of clean fuels and improved ventilation were associated with a reduced decline in forced expiratory volume in 1 s (FEV1): decline in FEV1 was reduced by 12 ml/y (95% CI, 4 to 20 ml/y) and 13 ml/y (95% CI, 4 to 23 ml/y) in those who used clean fuels and improved ventilation, respectively, compared to those who took up neither intervention, after adjustment for confounders. The combined improvements of use of clean fuels and improved ventilation had the greatest favorable effects on the decline in FEV1, with a slowing of 16 ml/y (95% CI, 9 to 23 ml/y). The longer the duration of improved fuel use and ventilation, the greater the benefits in slowing the decline of FEV1 (p<0.05). The reduction in the risk of COPD was unequivocal after the fuel and ventilation improvements, with an odds ratio of 0.28 (95% CI, 0.11 to 0.73) for both improvements.
Replacing biomass with biogas for cooking and improving kitchen ventilation are associated with a reduced decline in FEV1 and risk of COPD.
Trial Registration
Chinese Clinical Trial Register ChiCTR-OCH-12002398
Please see later in the article for the Editors' Summary
Editors' Summary
Nearly 3 billion people in developing countries heat their homes and cook by burning biomass—wood, crop waste, and animal dung—in open fires and leaky stoves. Burning biomass this way releases pollutants into the home that impair lung function and that are responsible for more than a million deaths from chronic obstructive pulmonary disease (COPD) every year. COPD is a group of diseases that interfere with breathing. Normally, air is breathed in through the nose or mouth and travels down the windpipe into two bronchial tubes (airways) in the lungs. These tubes branch into smaller tubes (bronchioles) that end in bunches of tiny air sacs (alveoli). Oxygen in the air passes through the thin walls of these sacs into small blood vessels and is taken to the heart for circulation round the body. The two main types of COPD—chronic bronchitis (long-term irritation and swelling of the bronchial tubes) and emphysema (damage to the walls of the alveoli)—make it hard for people to breathe. Most people with COPD have both chronic bronchitis and emphysema, both of which are caused by long-term exposure to cigarette smoke, indoor air pollution, and other lung irritants. Symptoms of COPD include breathlessness during exercise and a persistent cough that produces large amounts of phlegm (mucus). There is no cure for COPD, but drugs and oxygen therapy can relieve its symptoms, and avoiding lung irritants can slow disease progression.
Why Was This Study Done?
Exposure to indoor air pollution has been associated with impaired lung function and COPD in several studies. However, few studies have assessed the long-term effects on lung function and on the incidence of COPD (the proportion of a population that develops COPD each year) of replacing biomass with biogas (a clean fuel produced by bacterial digestion of biodegradable materials) for cooking and heating, or of improving kitchen ventilation during cooking. Here, the researchers undertook a nine-year prospective cohort study in rural southern China to investigate whether these interventions are associated with any effects on lung function and on the incidence of COPD. A prospective cohort study enrolls a group of people, determines their characteristics at baseline, and follows them over time to see whether specific characteristic are associated with specific outcomes.
What Did the Researchers Do and Find?
The researchers offered nearly 1,000 people living in 12 villages in southern China access to biogas and to improved kitchen ventilation. All the participants, who adopted these interventions according to personal preferences, completed a questionnaire about their smoking habits and occupational exposure to pollutants and had their lung function measured using a spirometry test at the start and end of the study. Some participants also completed a questionnaire and had their lung function measured three and six years into the study. Finally, the researchers measured levels of indoor air pollution in a randomly selected subset of homes at the end of the study to confirm that the interventions had reduced indoor air pollution. Compared with non-use, the use of clean fuels and of improved ventilation were both associated with a reduction in the decline in lung function over time after adjusting for known characteristics that affect lung function, such as smoking. The use of both interventions reduced the decline in lung function more markedly than either intervention alone, and the benefits of using the interventions increased with length of use. Notably, the combined use of both interventions reduced the risk of COPD occurrence among the study participants.
What Do These Findings Mean?
These findings suggest that, among people living in rural southern China, the combined interventions of use of biogas instead of biomass and improved kitchen ventilation were associated with a reduced decline in lung function over time and with a reduced risk of COPD. Because participants were not randomly allocated to intervention groups, the people who adopted the interventions may have shared other unknown characteristics (confounders) that affected their lung function (for example, having a healthier lifestyle). Thus, it is not possible to conclude that either intervention actually caused a reduction in the decline in lung function. Nevertheless, these findings suggest that the use of biogas as a substitute for biomass for cooking and heating and improvements in kitchen ventilation might lead to a reduction in the global burden of COPD associated with biomass smoke.
Additional Information
Please access these websites via the online version of this summary at
The US National Heart, Lung, and Blood Institute provides detailed information for the public about COPD
The US Centers for Disease Control and Prevention provides information about COPD and links to other resources (in English and Spanish)
The UK National Health Service Choices website provides information for patients and carers about COPD, personal stories, and links to other resources
The British Lung Foundation, a not-for-profit organization, provides information about COPD in several languages
The Global Initiative for Chronic Obstructive Lung Disease works to improve prevention and treatment of COPD around the world
The World Health Organization provides information about all aspects of indoor air pollution and health (in English, French, and Spanish)
MedlinePlus provides links to other information about COPD (in English and Spanish)
PMCID: PMC3965383  PMID: 24667834
6.  The Effects of Nitrous Oxide Administration in the Healthy Elderly: N2O Elimination and Alveolar CO2 
Anesthesia Progress  1983;30(6):187-192.
Healthy young and elderly males were administered sedative concentrations of nitrous oxide/oxygen (N2O/O2) under a protocol designed to mimic that used in a dental operatory. Samples of end-tidal expired gas were taken at the end of 30-minutes inhalation of, and periodically for 70 minutes after withdrawal from, nitrous oxide/oxygen. Samples were analyzed to monitor the decline of alveolar nitrous oxide levels and any changes in alveolar carbon dioxide levels, to determine if there were any age-related differences. The fall in alveolar N2O following cessation of administration was rapid, and in a double-exponental manner as was expected. No age-related difference in N2O decline was observed. Alveolar carbon dioxide (CO2) levels were lower and more variable in the elderly group. Both groups exhibited elevated CO2 levels at the end of the N2O period, and an unexplained rise in CO2 at approximately 30 min post N2O.
PMCID: PMC2235781  PMID: 6424516
7.  Preliminary study: Formaldehyde exposure in laboratories of Sharjah university in UAE 
Laboratory technicians, students, and instructors are at high risk, because they deal with chemicals including formaldehyde. Thus, this preliminary study was conducted to measure the concentration of formaldehyde in the laboratories of the University of Sharjah in UAE.
Materials and Methods:
Thirty-two air samples were collected and analyzed for formaldehyde using National Institute for Occupational Safety and Health (NIOSH) method 3500. In this method, formaldehyde reacts with chromotropic acid in the presence of sulfuric acid to form a colored solution. The absorbance of the colored solution is read in spectrophotometer at wavelength 580 nm and is proportional to the quantity of the formaldehyde in the solution.
For the anatomy laboratory and in the presence of the covered cadaver, the mean concentration of formaldehyde was found to be 0.100 ppm with a range of 0.095–0.105 ppm. Whereas for the other laboratories, the highest mean concentration of formaldehyde was 0.024 ppm in the general microbiology laboratory and the lowest mean concentration of formaldehyde was 0.001 ppm in the environmental health laboratory. The 8-hour (time-weighted average) concentration of formaldehyde was found to be ranging between 0.0003 ppm in environmental health laboratory and 0.026 ppm in the anatomy laboratory.
The highest level of concentration of formaldehyde in the presence of the covered cadaver in anatomy laboratory exceeded the recommended ceiling standard established by USA-NIOSH which is 0.1 ppm, but below the ceiling standard established by American Conference of Governmental Industrial Hygienists which is 0.3 ppm. Thus, it is recommended that formaldehyde levels should be measured periodically specially during the dissection in the anatomy laboratory, and local exhaust ventilation system should be installed and personal protective equipment such as safety glass and gloves should be available and be used to prevent direct skin or eye contact.
PMCID: PMC3143515  PMID: 21808499
Anatomy; cadaver; concentration; formaldehyde; Sharjah University; UAE
8.  The removal of mercury from dental-operatory wastewater by polymer treatment. 
The mercury (Hg) content of dental-operatory wastewater has become an issue in many localities, and Hg removal is rapidly becoming a matter of concern for all dental clinics. This preliminary study tested the efficacy of polymers for the removal of Hg contaminants from the dental-unit wastewater stream. Two commercially available polymers were used to treat dental-operatory wastewater. Used separately, each polymer removed from 74.9% to 88.4% of the Hg from dental-wastewater supernatant. The polymers used in combination, within the recommended pH range, removed up to 99.9% of the total Hg from dental-wastewater supernatant. The estimated optimal concentration of the two polymers is approximately 2.33 ml of each per liter of waste, and more than 90% of the Hg may be removed with 0.13 ml/l. Results indicate that a combination of the two polymers may sufficiently reduce Hg levels to allow discharge of clarified supernatants into public sewer systems.
PMCID: PMC1566316  PMID: 9872711
9.  Inhalation of diesel engine exhaust affects spermatogenesis in growing male rats. 
Environmental Health Perspectives  1999;107(7):539-544.
We conducted experiments to determine whether diesel engine exhaust affects reproductive endocrine function in growing rats. The rats were assigned to three groups: a group exposed to total diesel engine exhaust containing 5.63 mg/m3 particulate matter, 4.10 ppm nitrogen dioxide, and 8.10 ppm nitrogen oxide; a group exposed to filtered exhaust without particulate matter; and a group exposed to clean air. Dosing experiments were performed for 3 months beginning at birth (6 hr/day for 5 days/week). Serum levels of testosterone and estradiol were significantly higher in animals exposed to total diesel exhaust and filtered exhaust (p < 0.05 for each group) as compared to the controls. Follicle-stimulating hormone was significantly decreased in the two groups exposed to diesel exhaust as compared to the control group (p < 0.05). Luteinizing hormone was significantly decreased in the total exhaust-exposed group as compared to the control and filtered groups (p < 0.05). Although testis weight did not show any significant difference among the groups, sperm production and activity of testicular hyaluronidase were significantly reduced in both exhaust-exposed groups as compared to the control group. Histological examination showed decreased numbers of step 18 and 19 spermatids in stage VI, VII, and VIII tubules in the testes of both diesel exhaust-exposed groups. This study suggests that diesel exhaust stimulates hormonal secretion of the adrenal cortex, depresses gonadotropin-releasing-hormone, and inhibits spermatogenesis in rats. Because these effects were not inhibited by filtration, the gaseous phase of the exhaust appears to be more responsible than particulate matter for disrupting the endocrine system.
PMCID: PMC1566672  PMID: 10379000
10.  Passive dosimetry of dental hygienists' exposure to nitrous oxide. 
Anesthesia Progress  1992;39(1-2):19-23.
This study is the first to measure exposure to waste nitrous oxide (N2O) in the dental work setting in a broad geographical region (25 states), with passive dosimeters, and for dental hygienists. Thirty-five dental hygienists who reported that they administered N2O and 20 dental hygienists who reported that they never administered N2O constituted the sample. The former (n = 35) received both a 40-hr dosimeter, which measured exposure during administration of N2O, and a 168-hr dosimeter, which measured exposure during all work hours. The latter (n = 20) received only the 168-hr dosimeter. Exposure was measured during 2 wk in April 1990. For all work hours, the mean ppm-hr was 3,636 and the mean time-weighted average (TWA) was 78 ppm. The corresponding means during administration were 2,754 ppm-hr and 842 ppm TWA. The data for dental hygienists with passive dosimeters were similar to previously reported findings for dentists as measured by infrared spectrophotometry and gas chromatography. Hygienists who worked in dental settings with scavenging equipment received higher average levels of exposure to N2O than did hygienists who worked in settings without scavenging.
PMCID: PMC2148715  PMID: 8507019
11.  Nitrous Oxide Levels In Operating and Recovery Rooms of Iranian Hospitals 
Nitrous oxide (N2O) is the oldest anesthetic in routine clinical use and its occupational exposure is under regulation by many countries. As studies are lacking to demonstrate the status of nitrous oxide levels in operating and recovery rooms of Iranian hospitals, we aimed to study its level in teaching hospitals of Tehran University of Medical Sciences.
During a 6-month period, we have measured the shift-long time weighted average concentration of N2O in 43 operating and 12 recovery rooms of teaching hospitals of Tehran University of Medical Sciences.
The results show that the level of nitrous oxide in all hospitals is higher than the limits set by different countries and anesthetists are at higher risk of exposure. In addition, it was shown that installation of air ventilation could reduce not only the overall exposure level, but also the level of exposure of anesthetists in comparison with other personnel.
The high nitrous oxide level in Iranian hospitals necessitates improvement of waste gas evacuation systems and regular monitoring to bring the concentration of this gas into the safe level.
PMCID: PMC3481765  PMID: 23113075
Nitrous oxide occupational health; Ventilation; Environmental monitoring; Iran
12.  Estimating Determinants of Dentist Productivity: New Evidence 
Journal of public health dentistry  2010;70(4):10.1111/j.1752-7325.2010.00180.x.
Productivity (output per unit of input) is a major driver of dental service capacity. This study uses 2006-2007 data to update available knowledge on dentist productivity.
In 2006-2007 the authors surveyed 1,604 Oregon general dentists regarding. hours worked, practice size, payment and patient mix, prices, dentist visits, and dentist characteristics. Effects of practice inputs and other independent variables on productivity were estimated by multiple regression and path analysis.
The survey response rate was 55.2 percent. Dentists responding to the productivity-related questions were similar to dentists in the overall sampling frame and nationwide. Visits per week are significantly positively related to dentist hours worked, number of assistants, hygienists, and number of operatories. Dentist ownership status, years of experience, and % Medicaid patients are significantly positively related to practice output. The contributions of dentist chairside time and assistants to additional output are smaller for owners, but the number of additional dentist visits enabled by more hygienists is larger for owners.
As in earlier studies of dental productivity, the key determinant of dentist output is the dentist’s own chairside time. The incremental contributions of dentist time, auxiliaries, and operatories to production of dentist visits have not changed substantially over the past three decades. Future studies should focus on ultimate measures of output -- oral health -- and should develop more precise measures of the practice’s actual utilization of auxiliaries, their skill and use of technology.
PMCID: PMC3808865  PMID: 20545830
13.  Efficacy of High-volume Evacuator in Aerosol Reduction: Truth or Myth? A Clinical and Microbiological Study 
Background and aims. Basic periodontal treatment aims at eliminating supra- and sub-gingival plaque and establishing conditions which will allow effective self-performed plaque control. This aim is primarily achieved with sonic and ultrasonic scalers. However, generation of bacterial aerosols during these procedures is of great concern to patients, the dentist and the dental assistant. The aim of this study was to compare the reduction in aerosol with and without high-volume evacuator through a microbiological study.
Materials and methods. For this clinical study a fumigated closed operatory was selected. Maxillary incisors and canines were selected as an area for scaling. Piezoelectric ultrasonic scaling was performed in the absence and in the presence of a high-volume evacuator at 12 and 20 inches from the patient's oral cavity. In both groups scaling was carried out for 10 minutes. Nutrient agar plates were exposed for a total of 20 minutes. After this procedure, nutrient agar plates were incubated in an incubator at 37°C for 24 hours. The next day the nutrient agar plates were examined for colony forming units by a single microbiologist.
Results. The results showed no statistically significant differences in colony forming units (CFU) with and without the use of a high-volume evacuator either at 12 or 20 inches from the patient's oral cavity.
Conclusion. It was concluded that high-volume evacuator, when used as a separate unit without any modification, is not effective in reducing aerosol counts and environmental contamination.
PMCID: PMC4206761  PMID: 25346838
Aerosols; high-volume evacuator; environmental pollution
14.  Exposure to cobalt chromium dust and lung disorders in dental technicians. 
Thorax  1995;50(7):769-772.
BACKGROUND--Dental technician's pneumoconiosis is a dust-induced fibrotic lung disease of fairly recent origin. This study was carried out to estimate its occurrence in Sweden. METHODS--Thirty seven dental technicians in central and south eastern Sweden with at least five years of exposure to dust from cobalt chromium molybdenum (CoCrMo) alloys, identified by postal survey, agreed to undergo chest radiography and assessment of lung function and exposure to inorganic dust. RESULTS--Six subjects (16%; 95% confidence interval 6% to 23%) showed radiological evidence of dental technician's pneumoconiosis. The lung function of the study group was reduced compared with historical reference material. With local exhaust ventilation dust levels were generally low, whereas in dental laboratories without such equipment high levels of dust, particularly cobalt, were found. CONCLUSIONS--Pneumoconiosis may result from exposure to inorganic dust in the manufacturing of CoCrMo-based dental constructions. It is possible to reduce this hazard substantially by local exhaust ventilation.
PMCID: PMC474651  PMID: 7570413
15.  Growth suppression of four cancer cells by hyperbaric nitrous oxide and methotrexate 
Nitrous oxide concentration is easily controlled by respiratory ventilation. It suppresses bone marrow via the inhibition of thymidylate synthesis. The aim of this work was to determine the optimal pressure and exposure duration of nitrous oxide, as well as methotrexate concentration that maximizes the suppression of 4 cancer cells: CCRF-CEM, K562, A549 and MDA-MB-231.
Each cancer cell was cultured in a hyperbaric chamber at 1, 2 and 3 atmosphere of 74% nitrous oxide for 24, 48, and 72 hours at 0, 0.3, 0.7, 1, 2, 5 and 10 µM methotrexate (MTX), respectively. The results were expressed in the ratio of the number of cancer cells cultured under specific conditions (S cells) to that under normal conditions (N cells).
The S/N ratio of CCRF-CEM cells was 87.4% in 24-hour culture, 95.0% in 48-hour culture and 115.9% in 72-hour culture (P < 0.05). The S/N ratio of K562 cells was 103.6% at 1 atm, 102.4% at 2 atm and 115.6% at 3 atm (P < 0.05). The S/N ratio of A549 cells was 94.3% at 1 atm, 94.1% at 2 atm, 99.3% at 3 atm, 96.2% in 24-hour culture, 99.2% in 48-hour culture and 99.3% in 72-hour culture (P > 0.05). However, the S/N ratio of MDA-MB 231 cells was 66.9% in 24-hour culture, 83.1% in 48 hour culture and 87.8% in 72-hour culture (P < 0.05).
Only the growth of the MDA-MB-231 cells was significantly reduced after a longer exposure time to nitrous oxide, but those of the other cells were not.
PMCID: PMC2872900  PMID: 20498814
Methotrexate; Nitrous oxide; Tumor growth suppression
16.  Quantitative analysis of bacterial aerosols in two different dental clinic environments. 
Microbial aerosols are generated during dental treatments and may represent an important source of infection. This study was designed to quantify bacterial air contamination during dental treatments in both a closed dental operatory and a multichair dental clinic. Air was sampled by using a slit type of biological air sampler. Following air sampling, blood-supplemented Trypticase soy agar plates were incubated at 37 degrees C under anaerobic conditions for 7 days. The maximum levels of air contamination in the closed dental operatory were observed while dental treatments were being performed (four trials; 216 +/- 75 CFU/m3 for ultrasonic scaling treatments and 75 +/- 22 CFU/m3 for operative treatments). At 2 h after completion of the treatments, the bacterial counts were about the same as the pretreatment levels (12 to 14 CFU/m3). In the second part of the study, a multichair dental clinic was divided into four areas, and air contamination was monitored at each site. Three sites were located in active dental treatment areas, whereas no dental treatments were performed within an 11-m radius of the fourth site. At 3 h after the beginning of dental treatments, the highest bacterial counts were obtained in the three active dental treatment areas (76 to 114 CFU/m3). However, there was noticeable contamination in the inactive dental treatment area (42 CFU/m3). Thus, bacterial aerosols were able to spread into areas where there was no dental activity. My data show that dental treatments significantly increased the levels of bacterial air contamination in both a closed dental operatory and a multichair dental clinic.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC167591  PMID: 7487047
17.  School Playground Surfacing and Arm Fractures in Children: A Cluster Randomized Trial Comparing Sand to Wood Chip Surfaces 
PLoS Medicine  2009;6(12):e1000195.
In a randomized trial of elementary schools in Toronto, Andrew Howard and colleagues show that granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with wood fiber surfaces.
The risk of playground injuries, especially fractures, is prevalent in children, and can result in emergency room treatment and hospital admissions. Fall height and surface area are major determinants of playground fall injury risk. The primary objective was to determine if there was a difference in playground upper extremity fracture rates in school playgrounds with wood fibre surfacing versus granite sand surfacing. Secondary objectives were to determine if there were differences in overall playground injury rates or in head injury rates in school playgrounds with wood fibre surfacing compared to school playgrounds with granite sand surfacing.
Methods and Findings
The cluster randomized trial comprised 37 elementary schools in the Toronto District School Board in Toronto, Canada with a total of 15,074 students. Each school received qualified funding for installation of new playground equipment and surfacing. The risk of arm fracture from playground falls onto granitic sand versus onto engineered wood fibre surfaces was compared, with an outcome measure of estimated arm fracture rate per 100,000 student-months. Schools were randomly assigned by computer generated list to receive either a granitic sand or an engineered wood fibre playground surface (Fibar), and were not blinded. Schools were visited to ascertain details of the playground and surface actually installed and to observe the exposure to play and to periodically monitor the depth of the surfacing material. Injury data, including details of circumstance and diagnosis, were collected at each school by a prospective surveillance system with confirmation of injury details through a validated telephone interview with parents and also through collection (with consent) of medical reports regarding treated injuries. All schools were recruited together at the beginning of the trial, which is now closed after 2.5 years of injury data collection. Compliant schools included 12 schools randomized to Fibar that installed Fibar and seven schools randomized to sand that installed sand. Noncompliant schools were added to the analysis to complete a cohort type analysis by treatment received (two schools that were randomized to Fibar but installed sand and seven schools that were randomized to sand but installed Fibar). Among compliant schools, an arm fracture rate of 1.9 (95% confidence interval [CI] 0.04–6.9) per 100,000 student-months was observed for falls into sand, compared with an arm fracture rate of 9.4 (95% CI 3.7–21.4) for falls onto Fibar surfaces (p≤0.04905). Among all schools, the arm fracture rate was 4.5 (95% CI 0.26–15.9) per 100,000 student-months for falls into sand compared with 12.9 (95% CI 5.1–30.1) for falls onto Fibar surfaces. No serious head injuries and no fatalities were observed in either group.
Granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Upgrading playground surfacing standards to reflect this information will prevent arm fractures.
Trial Registration
Current Controlled Trials ISRCTN02647424
Please see later in the article for the Editors' Summary
Editors' Summary
Playgrounds and outdoor play equipment provide children with a place to let steam off, play creatively, socialize, and learn new skills. And, in a world where childhood obesity is a burgeoning problem, playgrounds provide a place where children can be encouraged to exercise. But playgrounds are not without hazards. Even in well-maintained and well-run facilities, children can hurt themselves by falling off climbing frames, monkey bars, and other equipment or by falling from standing height during playground games such as tag. In the US alone, more than 200,000 children are treated in emergency departments for injuries sustained in playgrounds every year and about 6,400 children are admitted to hospitals because of playground injuries, most of which are bone fractures (broken bones). In fact, playground injuries in the US are more severe and have a higher hospital admission rate than any other sort of child injury except those involving vehicles.
Why Was This Study Done?
Children who fall off playground equipment are nearly four times as likely to break a bone (often in an arm) as children who fall from standing height. To reduce the number of fractures that occur in playgrounds, some governments have limited the height of playground equipment. Some have also set standards for the type of surfaces installed in playgrounds and for the depth of sand or engineered wood fiber in loose fill surfaces. These standards are based on laboratory tests in which headforms (artificial heads) are dropped onto surfaces. However, these tests provide no information about the ability of different surfaces to prevent broken arms and other specific injuries in the real world. In this cluster randomized trial (a study in which groups of people are randomly assigned to receive different interventions), the researchers compare the rates of arm fractures in elementary (primary) school playgrounds in Toronto (Canada) that have wood fiber surfacing with the rates in playgrounds that have granite sand surfacing.
What Did the Researchers Do and Find?
The researchers randomly assigned 37 elementary schools that had qualified for school board funding for replacement playground equipment to receive either wood fiber (19 schools) or granite sand surfacing (18 schools) in their playgrounds. 19 of the schools complied with their randomization (12 installed fiber and seven installed sand); two schools installed sand although they were randomized to install fiber and seven schools installed fiber instead of sand. The researchers evaluated the playgrounds and their surfaces several times during the 2.5-year study and collected data on how playground injuries happened and types of injuries from the schools, parents, and medical reports. Among the schools that complied with randomization, falls from height into sand resulted in 1.9 arm fractures per 100,000 student-months whereas falls into fiber resulted in 9.4 arm fractures per 100,000 student-months. Arm fracture rates and other injury rates were also higher for falls from height into fiber than into sand when all the schools that had installed new surfaces were considered. However, the rates of arm fracture and other injuries that did not involve a fall from height did not vary between surfaces.
What Do These Findings Mean?
The accuracy of these findings is limited by the small number of arm fractures that occurred during the trial—only 20 children who fell into fiber and two who fell into sand broke an arm. The accuracy of the findings may also be limited by the failure of many schools to comply with randomization although the researchers found no obvious differences between the schools that did and did not comply with randomization that might have affected the trial's outcome. However, even with these limitations, the findings of this real-world study indicate that granitic sand surfaces substantially reduce the risk of arm fractures and other injuries caused by falls from playground equipment when compared with wood fiber surfaces. Thus, because falls from playground equipment are more likely to cause a fracture than falls from standing height, if playground surfacing standards are adjusted to reflect the findings of this study (that is, if sand surfaces are recommended in preference to wood fiber surfaces), many arm fractures in children should be prevented.
Additional Information
Please access these Web sites via the online version of this summary at ttp://
Safe Kids Canada provides information about playground safety and other aspects of childhood safety (in English and French)
Safe Kids Worldwide is a global network of organizations whose mission is to prevent accidental childhood injury (in English and Spanish)
The Nemours Foundation, a nonprofit organization for child health, provides information for parents on playground safety
The Royal Society for the Prevention of Accidents provides information on the safety of indoor and outdoor play areas
The US Centers for Disease Control and Prevention provides fact sheets on playground injuries
The US Consumer Product Safety Commission also has information on playground safety, including resources designed for children such as The Further Adventures of Kidd Safety and Little Big Kids, a booklet on play safety written by children for children
PMCID: PMC2784292  PMID: 20016688
18.  Health hazards and nitrous oxide: a time for reappraisal. 
Anesthesia Progress  1991;38(1):1-11.
Recent adoption by the American Conference of Governmental Industrial Hygienists of a Threshold Limit Value of 50 ppm for an 8-hour average exposure to nitrous oxide (N2O) increases the likelihood for its regulation by state and federal occupational health agencies. This review outlines current information on the health risks of N2O inhalation to provide a basis from which safe and reasonably attainable exposure limits can be proposed. Although N2O was for many years believed to have no toxicity other than that associated with its anesthetic action, bone marrow depression in patients administered N2O for extended periods of time and neurological abnormalities in health care workers who inhaled N2O recreationally have disproved this notion. Retrospective surveys of dental and medical personnel have also linked occupational exposure to N2O with a number of health problems and reproductive derangements. Nitrous oxide reacts with the reduced form of vitamin B12, thereby inhibiting the action of methionine synthase, an enzyme that indirectly supports methylation reactions and nucleic acid synthesis. Many, if not all, of the nonanesthetic-related adverse effects of N2O may be ascribed to this action. Animal and human studies indicate that the toxic effects of N2O are concentration- and time-dependent. It is suggested that a time-weighted average of 100 ppm for an 8-hour workday and/or a time-weighted average of 400 ppm per anesthetic administration would provide adequate protection of dental personnel and be achievable with existing pollution control methods.
PMCID: PMC2162364  PMID: 1809046
19.  Survey of responsible handling of local anesthetic in Indian dental operatory 
Dental operatory requires handling of numerous toxic fluids such as denture acrylic monomer, alcohol and formalin for effective oral care delivery. The efficacy and responsible handling of such fluids has not been analyzed among Indian dentists and this study aims to address this lacunae.
Materials and Methods:
Closed ended questionnaire was distributed through email to Indian dentists in July 2012. After inclusion/exclusion criteria, 1484 practitioners constituted the study group with a response rate of 52%.
SPSS® Version 17.0 (SPSS-IBM Inc., IL, USA) was used to carry out statistical analysis. Descriptive statistics were presented. Chi square test was used to identify the association between the parameters; P ≤ 0.05 was considered as statistically significant.
Males (80.8%), undergraduates (78%), exclusive practitioners (81.2%), urban practitioners (68.5%) were the predominant respondents. Predominant of the respondents (97%) used local anesthetic (LA) from bottles. Eight percent have encountered instances of injecting formalin instead of LA in their settings. Safe disposal rules and regulations (P ≤ 0.05), opinion on injecting the other fluids instead of LA as a severe negligent act (P ≤ 0.05) were statistically significant between age groups. Educational status did not appear to influence the outcome. Only a third of the respondents were aware of the rules and regulations for safe disposal of empty LA bottles while 49.1% were not aware of them and willing to learn.
The lacunae in responsible handling of toxic fluids need to be addressed to prevent inadvertent and negligence suits against dentists, highlighting the need through continuing dental education programmes.
PMCID: PMC3826043  PMID: 24255564
Formalin; injection; local anesthetics; responsible handling; safe disposal
20.  Occupational exposure of midwives to nitrous oxide on delivery suites 
Aims: To compare environmental and biological monitoring of midwives for nitrous oxide in a delivery suite environment.
Methods: Environmental samples were taken over a period of four hours using passive diffusion tubes. Urine measurements were taken at the start of the shift and after four hours.
Results: Environmental levels exceeded the legal occupational exposure standards for nitrous oxide (100 ppm over an 8 hour time weighted average) in 35 of 46 midwife shifts monitored. There was a high correlation between personal environmental concentrations and biological uptake of nitrous oxide for those midwives with no body burden of nitrous oxide at the start of a shift, but not for others.
Conclusions: Greater engineering control measures are needed to reduce daily exposure to midwives to below the occupational exposure standard. Further investigation of the toxicokinetics of nitrous oxide is needed.
PMCID: PMC1740444  PMID: 14634189
21.  The role of exhaust ventilation systems in reducing occupational exposure to organic solvents in a paint manufacturing factory 
This paper presents the successful design and implementation of several exhaust ventilation systems in a paint manufacturing factory. The ventilation systems were designed based on American Conference of Governmental Industrial Hygienists recommendations. The duct works, fans, and other parts were made and mounted by local manufacturers. The concentrations of toluene and xylene as the common solvents used in paint mixing factories were measured to evaluate the role of ventilation systems in controlling the organic solvents. Occupational exposure to toluene and xylene as the major pollutants was assessed with and without applying ventilation systems. For this purpose, samples were taken from breathing zone of exposed workers using personal samples. The samples were analyzed using Occupational Safety and Health Administration analytical method No.12. The samples were quantified using gas chromatography. The results showed that the ventilation systems successfully controlled toluene and xylene vapors in workplace, air well below the recommended threshold limit value of Iran (44.49 and 97.73 ppm, respectively). It was also discovered that benzene concentration in workplace air was higher than its allowable concentrations. This could be from solvents impurities that require more investigations.
PMCID: PMC2796753  PMID: 20040984
Exhaust ventilation systems; occupational exposure; paint manufacturing; ventilation standard
22.  Occupational exposure of workers to 1,3-butadiene. 
Researchers from the National Institute for Occupational Safety and Health (NIOSH) conducted an extent-of-exposure study of the 1,3-butadiene monomer, polymer, and end-user industries to determine the size of the exposed workforce, evaluate control technologies and personal protective equipment programs, and assess occupational exposure to 1,3-butadiene. A new analytical method was developed for 1,3-butadiene that increased the sensitivity and selectivity of the previous NIOSH method. The new method is sensitive to 0.2 microgram per 1,3-butadiene sample. Walk-through surveys were conducted in 11 monomer, 17 polymer, and 2 end-user plants. In-depth industrial hygiene surveys were conducted at 4 monomer, 5 polymer, and 2 end-user plants. Airborne exposure concentrations of 1,3-butadiene were determined using personal sampling for each job category. A total of 692 full shift and short-term personnel and 259 area air samples were examined for the presence of 1,3-butadiene. Sample results indicated that all worker exposures were well below the current OSHA PEL of 1000 ppm. Exposures ranged from less than 0.006 ppm to 374 ppm. The average exposure for all samples was less than 2 ppm. The present American Conference of Governmental Industrial Hygienists (ACGIH) threshold limit value for 1,3-butadiene is 10 ppm. To reduce the potential for occupational exposure, it is recommended that quality control sampling be conducted using a closed loop system. Also all process pumps should be retrofitted with dual mechanical seals, magnetic gauges should be used in loading and unloading rail cars, and engineering controls should be designed for safely voiding quality control cylinders.
PMCID: PMC1567762  PMID: 2401251
23.  The masculinization of the fetus during pregnancy due to inhalation of diesel exhaust. 
Environmental Health Perspectives  2001;109(2):111-119.
This study was conducted to determine the impact of diesel exhaust inhalation on the fetus. Seventy-two pregnant rats and 18 nonpregnant rats were divided into three groups: a group exposed to total diesel engine exhaust containing 5.63 mg/m(3) particulate matter, 4.10 ppm nitrogen dioxide, and 8.10 ppm nitrogen oxide; a group exposed to filtered exhaust without particulate matter; and a group exposed to clean air. The exposure period was from day 7 until day 20 of pregnancy. In addition, 15 pregnant rats were treated with aromatase inhibitors or testosterone to clarify the process by which diesel exhaust exerts its toxicity. The anogenital distance was significantly longer in male and female fetuses from both exhaust-exposed groups than in those of the control. Differentiation of the testis, ovary, and thymus was delayed and disturbed. Maternal testosterone and progesterone levels, which increased due to pregnancy whether or not the rats were exposed, were significantly higher and lower, respectively, in the pregnant rats exposed to total exhaust and filtered exhaust. The serum adrenocorticotropic hormone (ACTH) level and urinary excretion of 17-hydroxycorticosteroids (OHCS) did not differ among the pregnant groups. These results indicate that elevated testosterone did not result from elevated maternal adrenal function. The feto-placental-ovarian unit and inhibition of aromatase activity and synthesis caused by diesel exhaust inhalation might have played an essential role in the accumulation of testosterone. Since both exhaust-exposed groups showed almost the same reactions toward the inhalation, the gaseous phase must have included the relevant toxicants.
PMCID: PMC1240629  PMID: 11266319
24.  Exposure of midwives to nitrous oxide in four hospitals. 
The exposure of midwives to nitrous oxide in four hospitals was measured with personal samplers. In three of the four hospitals the average exposure was not significantly less than 100 parts per million (ppm). In one hospital the average exposure was 360 ppm; this was reduced by a factor of about 2.5 when a trial scavenging system was used. Differences in working practices and in the layout, size, and ventilation of the labour suites contributed to the observed differences in average exposure. Midwives and other staff working in the labour room are potentially at risk from excessive occupational exposure to nitrous oxide.
PMCID: PMC1341915  PMID: 3768665
25.  Occupational Exposure of a Medical School Staff to Formaldehyde in Tehran 
Tanaffos  2012;11(3):36-41.
Cadavers are preserved in a fixing solution containing formalin. Formaldehyde (FA) released from formalin is inhaled by the personnel in the anatomy laboratory. Exposed personnel have reported respiratory problems and various symptoms. Due to the toxicity of FA as a strong irritant and carcinogen and also lack of a national study assessing occupational exposure to FA in gross anatomy labs in Iran, the present study aimed at occupational monitoring of personnel exposed to FA and evaluating relevant symptoms in them.
Materials and Methods
A total of 20 subjects (all the staff) working in a gross anatomy lab and 20 library personnel were considered for occupational monitoring of exposure to FA during three months with various climatic conditions. They were also monitored for respiratory symptoms. Air sampling and analysis of its FA content were conducted according to the NIOSH method No.2016. Symptoms of cases and controls (library personnel) with active and passive exposure to formaldehyde were also studied by a self-report questionnaire.
In the first stage of monitoring with ventilation (supply-exhaust) system on, the exposure of personnel (Mean± SE) was 306 ± 21ppb. In the second stage of monitoring the personnel's exposure was 317 ± 26ppb with only the ventilation supply system on and in the final monitoring stage this rate was 698 ± 34ppb with the ventilation system (supply and exhaust) off. In this study, personal's exposure level to FA was higher than the indoor concentration, and the individual exposure levels of instructors were higher than those of the students. Exposure of library personnel in the adjacent department (central library) was about 50ppb. Most important complaints reported by actively exposed staff members and library personnel were the unpleasant odor (68%), cough (64%), throat irritation and runny nose (56%), burning and itching of nose (52%) and irritating eyes (48%).
Considering the level of exposure of all subjects in this study and existence of clinical symptoms, better control of the exhaust system in the gross anatomy lab and use of a more efficient ventilation system are recommended to protect the staff and instructors of the Anatomy Department.
PMCID: PMC4153202  PMID: 25191427
Formaldehyde; Personal monitoring; Respiratory symptoms

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