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Data Availability Statement: All data are included in the Supporting Information for publication online. Supporting Information is available online at https://setac.onlinelibrary.wiley.com/doi/10.1002/etc.5620#support-information-section . Copyright © 2023 Crown copyright and The Authors. While chemicals are vital to modern society through materials, agriculture, textiles, new technology, medicines, and consumer goods, their use is not without risks. Unfortunately, our resources seem inadequate to address the breadth of chemical challenges to the environment and human health. Therefore, it is important we use our intelligence and knowledge wisely to prepare for what lies ahead. The present study used a Delphi-style approach to horizon-scan future chemical threats that need to be considered in the setting of chemicals and environmental policy, which involved a multidisciplinary, multisectoral, and multinational panel of 25 scientists and practitioners (mainly from the United Kingdom, Europe, and other industrialized nations) in a three-stage process. Fifteen issues were shortlisted (from a nominated list of 48), considered by the panel to hold global relevance. The issues span from the need for new chemical manufacturing (including transitioning to non-fossil-fuel feedstocks); challenges from novel materials, food imports, landfills, and tire wear; and opportunities from artificial intelligence, greater data transparency, and the weight-of-evidence approach. The 15 issues can be divided into three classes: new perspectives on historic but insufficiently appreciated chemicals/issues, new or relatively new products and their associated industries, and thinking through approaches we can use to meet these challenges. Chemicals are one threat among many that influence the environment and human health, and interlinkages with wider issues such as climate change and how we mitigate these were clear in this exercise. The horizon scan highlights the value of thinking broadly and consulting widely, considering systems approaches to ensure that interventions appreciate synergies and avoid harmful trade-offs in other areas. We recommend further collaboration between researchers, industry, regulators, and policymakers to perform horizon scanning to inform policymaking, to develop our ability to meet these challenges, and especially to extend the approach to consider also concerns from countries with developing economies. Environ Toxicol Chem 2023;00:1–17. © 2023 Crown copyright and The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC. This article is published with the permission of the Controller of HMSO and the King's Printer for Scotland. Department for Environment, Food and Rural Affairs

With the recent increasing interest of researchers for Brain-Computer Interface (BCI), emerges a challenge for safety and security fields. Thus, the general objective of this research is to explore, from an engineering perspective, the trends and main research needs on the risks and applications of BCIs in safety and security fields. In addition, the specific objective is to explore the BCIs as an emerging risk. The method used consists of the sequential application of two phases. The first phase is carried out a scoping literature review. And with the second phase, the BCIs are analyzed as an emerging risk. With the first phase, thematic categories are analyzed. The categories are fatigue detection, safety control, and risk identification within the safety field. And within the security field are the categories cyberattacks and authentication. As a result, a trend is identified that considers the BCI as a source of risk and as a technology for risk prevention. Also, another trend based on the definitions and concepts of safety and security applied to BCIs is identified. Thus, “BCI safety” and “BCI security” are defined. The second phase proposes a general emerging risk framing of the BCI technology based on the qualitative results of type, level, and management strategies for emerging risk. These results define a framework for studying the safety and security of BCIs. In addition, there are two challenges. Firstly, to design techniques to assess the BCI risks. Secondly, probably more critical, to define the tolerability criteria of individual and social risk.

Background: Elevated Low density Lipoprotein (LDL) levels have been traditionally associated with development of atherosclerotic coronary artery disease (CAD). As LDL-cholesterol levels are not always raised in acute coronary syndrome (ACS) patients, sd-LDL is an emerging risk factor. The purpose of the present study was tri-fold. Firstly, it aimed to investigate the association of sd-LDL as a risk factor in ACS patients. Secondly, it aimed to correlate the presence of sd-LDL with severity of coronary artery disease as determined by coronary angiography. Lastly, it aimed to correlate the presence of sd-LDL with short-term outcomes. Methods: This was a prospective, hospital-based, cross-sectional, case-control study conducted over a 1-year study duration. Patients above the age of 18 years diagnosed with ACS within 24 h of admission were studied. Blood samples were collected after all patients had undergone coronary angiography and sd-LDL levels were measured. Results: ACS patients had significantly higher sd-LDL levels than non-ACS patients (16.10 ± 1.42 mg/dL vs. 12.67 ± 0.71 mg/dL, P = 0.036). Males had significantly higher sd-LDL levels than females (16.79 ± 1.55 mg/dl vs. 10.77 ± 2.62 mg/dl, P=0.047). Patients with non-left anterior descending coronary artery (LAD) involvement had significantly higher sd-LDL levels compared to patients with LAD involvement (21.92 ± 3.55 mg/dL vs. 14.03 ± 1.35 mg/dL, P = 0.007). Conclusion: These results suggest that sd-LDL is a risk factor for the development of ACS in an Indian population. Cardiol Res. 2021;12(4):251-257 doi: https://doi.org/10.14740/cr1254

Pulmonary mucormycosis is an uncommon pulmonary fungal disease, which is commonly seen in immunocompromised individuals. It is caused by fungi of class Zygomycetes. It constitutes the third most common invasive fungal infection following aspergillosis and candidiasis. Risk factors include patients with hematological malignancies, diabetes mellitus, and immunocompromised states. It is difficult to diagnose early due to non-specific clinical presentation and delay in treatment associated with greater mortality. As we know that Tuberculosis and HIV are highly prevalent in country like India. Post pulmonary tuberculosis is emerging as a risk factor for Pulmonary mucormycosis in the developing countries like India. Patients with non-resolving pneumonia are generally misdiagnosed as Pulmonary tuberculosis. The diagnosis of Pulmonary Mucormycosis is based upon demonstration of fungal hyphae in the clinical specimen. We highlight the importance of clinical suspicion in these cases for early diagnosis and early treatment initiation can reverse morbidity and mortality associated with Pulmonary Mucormycosis. We report 2 cases of Pulmonary mucormycosis present in post-pulmonary tuberculosis patients.

Cardiac arrhythmias and the resulting sudden cardiac death are significant cardiovascular complications that continue to impose a heavy burden on patients and society. An emerging body of evidence indicates that nonalcoholic fatty liver disease (NAFLD) is closely associated with the risk of cardiac arrhythmias, independent of other conventional cardiometabolic comorbidities. Although most studies focus on the relationship between NAFLD and atrial fibrillation, associations with ventricular arrhythmias and cardiac conduction defects have also been reported. Mechanistic investigations suggest that a number of NAFLD-related pathophysiological alterations may potentially elicit structural, electrical, and autonomic remodeling in the heart, contributing to arrhythmogenic substrates in the heart. NAFLD is now the most common liver and metabolic disease in the world. However, the upsurge in the prevalence of NAFLD as an emerging risk factor for cardiac arrhythmias has received little attention. In this review, we summarize the clinical evidence and putative pathophysiological mechanisms for the emerging roles of NAFLD in cardiac arrhythmias, with the purpose of highlighting the notion that NAFLD may serve as an independent risk factor and a potential driving force in the development and progression of cardiac arrhythmias.

Emerging evidence has spurred a considerable evolution of concepts relating to atherosclerosis, and has called into question many previous notions. Here I review this evidence, and discuss its implications for understanding of atherosclerosis. The risk of developing atherosclerosis is no longer concentrated in Western countries, and it is instead involved in the majority of deaths worldwide. Atherosclerosis now affects younger people, and more women and individuals from a diverse range of ethnic backgrounds, than was formerly the case. The risk factor profile has shifted as levels of low-density lipoprotein (LDL) cholesterol, blood pressure and smoking have decreased. Recent research has challenged the protective effects of high-density lipoprotein, and now focuses on triglyceride-rich lipoproteins in addition to low-density lipoprotein as causal in atherosclerosis. Non-traditional drivers of atherosclerosis—such as disturbed sleep, physical inactivity, the microbiome, air pollution and environmental stress—have also gained attention. Inflammatory pathways and leukocytes link traditional and emerging risk factors alike to the altered behaviour of arterial wall cells. Probing the pathogenesis of atherosclerosis has highlighted the role of the bone marrow: somatic mutations in stem cells can cause clonal haematopoiesis, which represents a previously unrecognized but common and potent age-related contributor to the risk of developing cardiovascular disease. Characterizations of the mechanisms that underpin thrombotic complications of atherosclerosis have evolved beyond the ‘vulnerable plaque’ concept. These advances in our understanding of the biology of atherosclerosis have opened avenues to therapeutic interventions that promise to improve the prevention and treatment of now-ubiquitous atherosclerotic diseases. This Review discusses recent research that has transformed our understanding of the biology of atherosclerosis, and examines its implications for the treatment of atherosclerotic cardiovascular disease.

To evaluate the association between the severity and extent of periodontitis and arterial stiffness using the cardio-ankle vascular index (CAVI). A cross-sectional study of 2888 Electricity Generation Authority of Thailand (EGAT) employees aged 44–78 years was conducted. The severity of periodontitis was evaluated based on mean clinical attachment level (CAL). The percentage of sites with CAL ≥ 5 mm was used to divide the extent of periodontitis into healthy (0%), localized (> 0–< 30%), and generalized (≥ 30%). The CAVI value, a novel blood pressure-independent arterial stiffness parameter, was analyzed as both continuous and categorical data (low: < 9 or high: ≥ 9). Regression analysis was used to estimate the level of association. The participants demonstrated a mean CAL, % sites with CAL ≥ 5 mm, and a CAVI value of 3.2 ± 1.2 mm, 16.0 ± 20.8%, and 8.24 ± 1.12, respectively. Higher mean CAVI was observed with greater mean CAL and % sites with CAL ≥ 5 mm. The mean CAVI of the healthy, localized, and generalized periodontitis groups were 8.01 ± 1.11, 8.22 ± 1.12, and 8.51 ± 1.04, respectively (p < 0.01). Linear and logistic regression analysis demonstrated a significant relationship between CAVI and all periodontal variables with β = 0.004–0.17 and OR = 1.01–1.58, respectively. There is a significant dose-dependent association between the severity and extent of periodontitis and arterial stiffness measured by CAVI in Thai adults. Preventing arterial stiffness, an early sign of cardiovascular events, by controlling the emerging risk factors, such as periodontitis, might have a high impact on health promotion.

In the wake of the withdrawal of the nonsteroidal anti-inflammatory drug rofecoxib, regulators worldwide reconsidered their approach to postmarket safety. Many have since adopted a “life cycle” approach to regulation of medicines, facilitating faster approval of new medicines while planning for potential postmarket safety issues. A crucial aspect of postmarket safety is the effective and timely communication of emerging risk information using postmarket safety advisories, commonly issued as letters to healthcare professionals, drug safety bulletins, media alerts, and website announcements. Yet regulators differ in their use of postmarket safety advisories. We examined the capacity of regulators in the United States, Europe, Canada, and Australia to warn about postmarket safety issues through safety advisories by assessing their governance, legislative authority, risk communication capabilities, and transparency.

This study investigated the potential pathogenic bacteria that are associated with domestic dog stool in Port Harcourt Metropolis. Convenience sampling techniques were used for sample collection outcome. A total of fifty dog stool samples were collected aseptically into a sterile stool container from different locations (Agip Estate, Rumuokoro Community, Government Residential Area, Sand-fill Borokiri, Port Harcourt Township, and Rivers State University lecturers’ quarters) all within Port Harcourt City. Bacteriological analysis was determined using standard microbiological analytical and identification techniques. Statistical analysis was performed using Statistical Package for Social Science version 21 for frequency, percentage, prevalence rate and correlation at 0.01 and 0.05 level of significance. Potential pathogens with associated percentages that were isolated are E coli (20.0%), Klebsiella species (16.0%), Pseudomonas species (4.0%), Proteus species (28.0%), Bacillus species (4.0%), Staphylococcus aureus (14.0%), and unidentified [other Staphylococcus species] (4.0%). However, the research further revealed that Proteus species (28.0%), was the most prevalent pathogen, while Bacillus species (4.0%), Pseudomonas species (4.0%), and Streptococcus species (4.0%), were the least prevalent among pet dogs studied. The correlation analysis showed no significant relationship between isolates with socio-demographic data of pet owner and Pet biodata respectively. From the analysis, correlation coefficient values of .269 and .124 were obtained for Age of Pet Owner and Gender of Owner respectively. It also show a direct correlation but by implication, a very weak, non-significant (p0.05). Furthermore, negative non-significant correlation (p>0.05) was observed for marital status of Pet Owner (r=-.158) and Age of Pet (r=-.023) and isolate. Also, correlation association between isolates and some risk factors using the correlation analysis matrix revealed an indication of an indirect but moderate association between isolates and Caressing (r=-.347, p=0.01). However, other risk factors like vaccination (r=.042), Feeding Pattern(r=.125), Pet Bathing (r=.220) and Eating with pet in same plate (r=.146), did not prove statistical significance at p>0.05. The results from the study strongly suggest that pet dogs carry potential pathogenic organisms in their faecal matter that can serve as a source of infection to the pet owners. It is, therefore, very critical that these pets should be treated and possibly vaccinated frequently, even as their faecal matters should be well disposed to prevent possible zoonotic infectious epidemic outbreak in our global communities.

At present, there is a growing trend toward the intentional adulteration of dietary supplements (DS) with synthetic pharmaceuticals, which represents an alarming emerging risk to consumers and a serious problem for regulatory agencies. An amazing array of synthetic drugs and their analogues have been reported as adulterants in DS. Mainly, the presence of analogues represents a serious health risk as their efficacy and toxic effects have not been clinically assessed yet and may result in unpredictable adverse effects. The purpose of this review is to provide an overview, over the period 2009-2019, of the most frequently reported adulterants in DS for the treatment of erectile dysfunction, obesity/overweight, diabetes mellitus, and hypertension and the analytical methods used for their detection.

This study draws on the Planned Risk Information Seeking Model (PRISM) to assess Zika virus information seeking and systematic processing, paying particular attention to the relationship between perceived knowledge and knowledge insufficiency. Novel risks, such as Zika, provide an interesting context for examining whether information-seeking models, such as PRISM, are able to predict information seeking when available information is limited or scarce. A cross-sectional, online study of men and women of childbearing age (N = 494) residing in the state of Florida was conducted. Our results provide some support for the PRISM for predicting Zika information seeking intention, as well as systematic processing of information. We also found that individuals with high levels of perceived knowledge were more likely to report high level of knowledge insufficiency, illustrating that contextual factors may impact the fit of risk information seeking models.

Prostate is surrounded by a specific fat depot called periprostatic adipose tissue (PPAT) that contributes through paracrine mechanisms to prostate cancer (PCa) progression. Like other white adipose tissues, PPAT stores lipids and is an endocrine organ. However, PPAT is still poorly characterized. Nevertheless, current evidence highlights that soluble factors secreted from PPAT might promote PCa aggressiveness and local dissemination. In addition, the ability of adipocytes to provide lipids to tumor cells participates in tumor aggressiveness. The secretory and metabolic profile of PPAT is modified by obesity, a state associated with greater occurrences of aggressive diseases. Beyond obesity, the excessive accumulation of PPAT, independently of the ponderal status of the patients, is an emerging risk factor in aggressive diseases. Characterization of the role of human PPAT on PCa progression will undoubtedly provide, in the near future, new therapeutic strategies and new risk stratification factors in PCa.

Background: Previous studies suggested an association between Chlamydia pneumoniae and Mycoplasma pneumonia with atherosclerosis, separately. Until now, according to inconsistent information, the relationship between C.pneumoniae and M.pneumoniae with atherosclerosis is controversial. Objective: The aim of this study is to investigate the association between C.pneumoniae and M.pneumoniae as two separate risk factors with atherosclerosis through systematic review and metaanalysis study. Methods: We searched databases, such as Pubmed, SID, Magiran, Google scholar and Iranmedex, using the following keywords in English and Persian language: C. pneumoniae, M. pneumoniae, and atherosclerosis. Data were analyzed with meta-analysis and a random effect model. Also, in this study, heterogeneity of articles was estimated by using the I2 index. Finally, the data were analyzed with STAT (version 11.2). Results: Among thirty-eight articles for C. pneumoniae and five articles for M. pneumoniae individually reviewed that included 2980 samples for M. pneumoniae and 23298 samples for C. pneumoniae, the result demonstrated that the association between M. pneumoniae and C. pneumoniae with atherosclerosis is significant with OR (odds ratio) = 1.58 (95% Confidence Interval (CI): 1.00 to 2.50), OR (odds ratio) = 2.25 (95% Confidence Interval (CI): 1.91 to 2.64), respectively. Conclusion: This systematic review study provides strong evidence for the role of persistent bacterial infections, such as M. pneumoniae and C. pneumoniae, in potential atherosclerosis. Thus, a novel way should be employed for the complete management of bacterial infection.

La Bioeconomía Circular (BEC) puede dar lugar a una serie de vulnerabilidades para la seguridad (entendida como inocuidad) de los alimentos, piensos, salud humana, animal y medioambiente. En el marco de la Bioeconomía Circular se extienden prácticas relacionadas con la obtención y reciclado de materiales, nuevos ingredientes de origen biológico usados junto con nuevas tecnologías para producir alimentos y piensos, nuevos bioestimulantes, bioplaguicidas y biofertilizantes, en definitiva una serie de nuevos insumos y procesos cuyo potencial riesgo para la cadena alimentaria, salud humana y medioambiente debe ser evaluados. La caracterización de residuos, migración de productos químicos y contaminantes en los diversos compartimentos ambientales constituyen nuevos problemas analíticos que deben ser abordados con nuevas metodologías, en donde la espectrometría de masas de alta resolución, la digitalización y el análisis de datos cobra una mayor relevancia. The Circular Bioeconomy (CBEC) can give rise to a number of vulnerabilities for food and feed safety human and animal health and the environment. Within the framework of the Circular Bioeconomy, practices related to the sourcing and recycling ofmaterials, new bio-based ingredients used together with new technologies to produce food and feed, new biostimulants, biopesticides and biofertilisers, in short a series of new inputs and processes whose potential risk to the food chain, human health and the environment must be assessed. The characterisation of residues, migration of chemical products and pollutants in the various environmental compartments constitute new analytical problems that must be tackled with new methodologies, where high resolution mass spectrometry, digitalisation and data analysis become more relevant.

Traditionally, early warning systems for food safety are based on monitoring targeted food safety hazards. Optimal early warning systems, however, should identify signals that precede the development of a food safety risk. Moreover, such signals could be identified in factors from domains adjacent to the food supply chain, so-called drivers of change and other indicators. In this study, we show for the first time that such drivers and indicators may indeed represent signals that precede the detection of a food safety risk. The dairy supply chain in Europe was used as an application case. Using dynamic unsupervised anomaly detection models, anomalies were detected in indicator data expected by domain experts to impact the development of food safety risks in milk. Additionally, a Bayesian network was used to identify the chemical food safety hazards in milk associated with an anomaly for the Netherlands. The results showed that the frequency of anomalies varied per country and indicator. However, all countries showed in the period investigated (2008–2019), anomalies in the indicators “raw milk price” and “barely milk price” and no anomalies in the indicator” income of dairy farms”. A cross-correlation analysis of the number of Rapid Alert for Food and Feed (RASFF) notifications and anomalies in indicators revealed significant correlations of many indicators but difference between countries was observed. Interesting, for all countries the cross corelation with indicator “milk price” was significant, albeit the lag time varied from 5 months (United Kingdom) to 22 months (Italy). This finding suggests that severe changes in domains adjacent to the food supply chain may trigger the development of food safety problems that become visible many months later. Awareness of such relationships will provide the opportunity for food producers or inspectors to take timely measures to prevent food safety problems.

This article shows how an emerging risk is covered by the media and how this interacts with political attention and policy implementation. Gas drilling has resulted in earthquakes in the Netherlands over the past 25 years. We show that an increase in the frequency and magnitude has not stimulated greater media attention. Media and political attention increased only after the media had interpreted the risk as a safety issue. Once this had happened, newspapers and political debates tended to focus on the emotionally loaded aspects. This is in contrast with the regulatory agenda, which followed its own course by focusing on factual information. By using a new method – supervised-machine learning – we analyse a large, longitudinal data set to explore patterns over time. Our findings shed new light on risk- and agenda-setting theory, confirming that media and politics agendas reinforce each other, but the regulatory agenda is not strongly influenced by them.

The Human T-Lymphotropic Virus type 1 (HTLV-1) affects up to 10 million people worldwide. It is directly associated to one of the most aggressive T cell malignancies: Adult T Cell Leukemia-Lymphoma (ATLL) and a progressive neurological disorder, Tropical Spastic Paraparesis/ HTLV-1 Associated Myelopathy (TSP/HAM). Also, infected patients tend to have more severe forms of infectious diseases such as Strongyloidiasis and Tuberculosis. HTLV spreads through parenteral, sexual, and vertical (mother-to-child) routes. Effective viral transmission is produced mainly by cell to cell mechanism, unlike other retroviruses such as HIV, which usually spread infecting cells in a cell-free form. HTLV also has a peculiar distribution, with clusters of high endemicity in nearby areas of very low prevalence or absence of the virus. This could be explained by factors including a possible founder effect, the predominance of mother to child transmission and the cell-to-cell transmission mechanisms. More data on viral epidemiology are needed in order to develop strategies in endemic areas aimed at reducing viral dissemination. In this review, we critically analyze HTLV-1 pathogenesis, epidemiology, diagnosis, associated diseases, preventive strategies, and treatments, with emphasis to the emerging risk for Europe and particularly Spain, focusing on prevention methods to avoid viral transmission and associated diseases.

Long-term observation of penguin abundance and distribution may warn of changes in the Antarctic marine ecosystem and provide support for penguin conservation. We conducted an unmanned aerial vehicle (UAV) survey of the Adélie penguin (Pygoscelis adeliae) colony on Inexpressible Island and obtained aerial images with a resolution of 0.07 m in 2018. We estimated penguin abundance and identified the spatial extent of the penguin colony. A total of 24,497 breeding pairs were found on Inexpressible Island within a colony area of 57,507 m2. Based on historical images, the colony area expanded by 30,613 m2 and abundance increased by 4063 pairs between 1983 and 2012. Between 2012 and 2018 penguin abundance further increased by 3314 pairs, although the colony area decreased by 1903 m2. In general, Adélie penguins bred on Inexpressible Island at an elevation 55% of penguins had territories within 150 m of the shoreline. This suggests that penguins prefer to breed in areas with a low elevation and close to the shoreline. We observed a retreat of the shoreline on Inexpressible Island between 1983 and 2018, especially along the northern coast, which may have played a key role in the expansion of the penguin colony on the northern coast. In sum, it appears that retreating shorelines reshaped penguin distribution on the island and may be an emerging risk factor for penguins. These results highlight the importance of remote sensing techniques for monitoring changes in the Antarctic marine ecosystem and providing reliable data for Antarctic penguin conservation.

Globalisation supports the clustering of critical infrastructure systems, sometimes in proximity to lower-magnitude (VEI 3–6) volcanic centres. In this emerging risk landscape, moderate volcanic eruptions might have cascading, catastrophic effects. Risk assessments ought to be considered in this light.

Background and Purpose: Several formulations of tacrolimus are available, but evidence of the benefit of changing to the most recent formulations is lacking. Tacrolimus intra-patient variability (tacrolimus IPV) is an emerging risk factor associated with poor graft outcomes after solid organ transplantations. Here, we examined the modifications of tacrolimus IPV after switching to a different formulation of tacrolimus.Experimental Approach: We identified 353 solid organ transplant recipients that were switched in our center from immediate-release (IR-tacrolimus) or prolonged-release tacrolimus (PR-tacrolimus) to extended-release, LCP-tacrolimus (LCP-tacrolimus). Among them, 54 patients underwent at least 3 available tacrolimus blood concentrations before and after the switch, allowing us to investigate tacrolimus IPV.Key Results: The switch was considered as a safe procedure since only four of the 353 patients presented a graft rejection after the switch, and no patient was hospitalized for tacrolimus overdose. The tacrolimus IPV estimated by the coefficient of variation (CV-IPV) was stable before and after the switch to LCP-tacrolimus (CV-IPV: 29.0% (IQR 25–75 (15.5; 38.5) before and 24.0% (15.8; 36.5) after the switch, p = 0.65).Conclusion and Implications: Switching from IR- or PR-tacrolimus to LCP-tacrolimus is a safe procedure. However, the CV-tacrolimus IPV was not impacted by the change of formulation.

Driven by climate change, wildfires are increasing in frequency, duration, and intensity across the Western United States. Outdoor workers are being exposed to increasing wildfire-related particulate matter and smoke. Recognizing this emerging risk, Washington adopted an emergency rule and is presently engaged in creating a permanent rule to protect outdoor workers from wildfire smoke exposure. While there are growing bodies of literature on the exposure to and health effects of wildfire smoke in the general public and wildland firefighters, there is a gap in knowledge about wildfire smoke exposure among outdoor workers generally, and construction workers specifically, a large category of outdoor workers in Washington totaling 200,000 people. In this study, several data sources were linked including state-collected employment data and national ambient air quality data to gain insight into the risk of PM2.5 exposure among construction workers and evaluate the impacts of different air quality thresholds that would have triggered a new Washington emergency wildfire smoke rule aimed at protecting workers from high PM2.5 exposure. Results indicate the number of poor air quality days has increased in August and September in recent years. Over the last decade these months with the greatest potential for particulate matter exposure coincided with an annual peak in construction employment that was typically 9.4 to 42.7% larger across Washington counties (one county was 75.8%). Lastly, the “encouraged” threshold of the Washington emergency rule (20.5 μg/m3) would have resulted in 5.5 times more days subject to the wildfire rule on average across all Washington counties compared to its “required” threshold (55.5 μg/m3), and in 2020 the rule could have created demand for 1.35 million N-95 filtering facepiece respirators among construction workers. These results have important implications for both employers and policy makers as rules are developed. The potential policy implications of wildfire smoke exposure, exposure control strategies, and data gaps that would improve understanding of construction worker exposure to wildfire smoke are also discussed.

Background Anxiety disorders are the most prevalent mental disorders and are an emerging risk factor for coronary artery disease and its complications. We determine the relationship between having a clinical diagnosis of an anxiety disorder and coronary endothelial dysfunction (CED) using invasive coronary reactivity testing across both sexes. Methods and Results Patients presenting with chest pain and nonobstructive coronary artery disease (stenosis P =0.011) that persisted in women but not in men. After adjusting for covariables, anxiety was significantly associated with any CED among all patients (odds ratio [95% CI], 1.36 [1.10–1.68]; P =0.004), and after stratifying by sex in women but not in men. Conclusions Anxiety disorders are significantly associated with CED in women presenting with chest pain and nonobstructive coronary artery disease. Thus, CED may represent a mechanism underpinning the association between anxiety disorders and coronary artery disease and its complications, highlighting the role of anxiety as a potential therapeutic target to prevent cardiovascular events.

Environmental context Many human activities cause the release of plastic and associated plasticisers to land, where chemicals may persist for extended periods and be taken up by organisms. However, quantitative information of the terrestrial occurrence, fate and exposure of phthalate and non-phthalate plasticisers is lacking. Research into this field is needed, especially as society moves away from phthalates to the next generation of plasticisers which may themselves represent an emerging risk. Abstract Modern society is widely dependent upon plastic. Therefore, it is unsurprising that macro- and microplastic pollution is found in every environmental compartment on earth. Plasticisers are chemicals added to plastics to increase their flexibility. Like plastics themselves, plasticisers are also widely present in the environment. Plasticisers and plastic debris may undergo long-range transport in the atmosphere and the oceans, contaminating even the most remote areas of land. In addition, although plasticisers typically degrade in a matter of weeks–months, they can persist in soil for decades and have been shown to occur in all land uses studied. Some plasticisers are genotoxic and can be taken up by soil organisms, which may pose a risk to ecosystems and human health. To date the majority of data on plasticisers exists for phthalates. However, plasticisers are a diverse range of chemicals and with the increasing transfer to non-phthalate alternatives, research into the fate and effects of emerging plasticisers is required to determine their environmental risk and management options. Data on the occurrence and ecotoxicity of emerging plasticisers, in addition to the impacts of all plasticisers on terrestrial ecosystems, therefore, remain a key research need within the wider plastics debate.

Klebsiella pneumoniae of sequence type (ST) 11 is a hyper-epidemic nosocomial clone, which is spreading worldwide among humans and emerging in pets. This is the first report, to the best of our knowledge, of multidrug-resistant (MDR) K. pneumoniae ST11 carrying blaSCO-1 and blaDHA-1, isolated from a four-month-old dog in Belgium. Antimicrobial susceptibility testing (AST) of the isolate, performed via broth microdilution following the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines, revealed resistance to eight different classes of antimicrobials, including carbapenems, in particular ertapenem, third-generation cephalosporins and fluoroquinolones. A hybrid approach, combining long- and short-read sequencing, was employed for in silico plasmid characterization, multi-locus sequence typing (MLST) and the identification and localization of antimicrobial resistance (AMR) and virulence-associated genes. Three plasmids were reconstructed from the whole-genome sequence (WGS) data: the conjugative IncFIB(K), the non-mobilizable IncR and the mobilizable but unconjugative ColRNAI. The IncFIB(K) plasmid carried the blaSCO-1 gene, whereas IncR carried blaDHA-1, both alongside several other antimicrobial resistance genes (ARGs). No virulence genes could be detected. Here, we suggest that the resistance to ertapenem associated with susceptibility to imipenem and meropenem in K. pneumoniae could be related to the presence of blaSCO-1 and blaDHA-1, combined with permeability defects caused by point mutations in an outer membrane porin (OmpK37). The presence of the blaSCO-1 gene on a conjugative IncFIB(K) plasmid is worrisome as it can increase the risk of transmission to humans, to animals and to the environment.

Introduction. Shiga toxin-producing Escherichia coli (STEC) can cause severe disease and large outbreaks. In England, the incidence and clinical significance of STEC serogroups other than O157 (non-O157) is unknown due to a testing bias for detection of STEC O157. Since 2013, the implementation of PCR to detect all STEC serogroups by an increasing number of diagnostic laboratories has led to an increase in the detection of non-O157 STEC. Hypothesis/Gap statement. Due to a bias in testing methodologies to select for STEC serogroup O157 in frontline diagnostic laboratories in most countries, very little surveillance data have been previously generated on non-O157 STEC. Aim. Five years (2014–2018) of STEC national surveillance data were extracted and descriptive analysis undertaken to assess disease severity of non-O157 STEC strains. Methods. Data from 1 January 2014 to 31 December 2018 were extracted from the National Enhanced Surveillance System for STEC and analysed. Results. The implementation of Gastrointestinal Polymerase Chain Reaction (GI-PCR) has resulted in a four-fold increase in the detection of non-O157 STEC cases between 2014 and 2018. There were 2579 cases infected with 97 different non-O157 serogroups. The gender distribution was similar amongst STEC O157 and non-O157 STEC cases with 57 and 56 % of cases being female respectively, but a significantly higher proportion of cases (P stx1a caused the highest proportion of diarrhoea (93 %) and caused the same level of bloody diarrhoea as stx2a (39 %). However, stx2a caused the highest proportion of vomiting (46 %), hospitalisation (49 %) and considerably more HUS (29 %) than other stx profiles. Conclusion. The implementation of PCR targeting stx at diagnostic laboratories has shown that non-O157 STEC, most notably STEC O26, are an emerging risk to public health.

Alzheimer’s disease (AD) is one of the most prevailing neurodegenerative diseases, characterized by memory dysfunction and the presence of hyperphosphorylated tau and amyloid β (Aβ) aggregate in multiple brain regions, including the hippocampus and cortex. The exact etiology of AD has not yet been confirmed. However, epidemiological reports suggest that populations who were exposed to environmental hazards are more likely to develop AD than those who were not. Arsenic (As) is a naturally occurring environmental risk factor abundant in the Earth’s crust and human exposure to As predominantly occurs through drinking water. Convincing evidence suggests that As causes neurotoxicity and impairs memory and cognition although the hypothesis and molecular mechanism of As-associated pathobiology in AD are not clear yet. However, exposure to As and its metabolites leads to various pathogenic events such as oxidative stress, inflammation, mitochondrial dysfunctions, ER stress, apoptosis, impaired protein homeostasis, and abnormal calcium signaling. Evidence has indicated that As exposure induces alterations that coincide with most of the biochemical, pathological, and clinical developments of AD. Here, we overview existing literature to gain insights into the plausible mechanisms that underlie As-induced neurotoxicity and the subsequent neurological deficits in AD. Prospective strategies for the prevention and management of arsenic exposure and neurotoxicity have also been discussed.

BackgroundIt has been seemed that the gut microbiome alterations might be proposed as the metabolic disorder. However, the relationship between the microbiome and AMI has not been well validated. Methods The feces of the 44 subjects (AMI: 19; control: 25) were collected for fecal genomic DNAs extraction. The variable region V3–V4 of the 16S rRNA gene was sequencing by the platform of Illumina Miseq. The abundances of metabolites were analyzed by the Kyoto Encyclopedia of Genes and Genomes (KEGG) metabolic pathways. ResultsThe abundance of bacteria was more enriched in the AMI group both in the observed operational taxonomic units (OTUs) and faith phylogenetic diversity (PD) (p-value=0.01 and Selenomonadales was less enriched in the AMI group at the Family, Genus, and Species levels [all linear discriminant analysis (LDA) scores >2]. The seleno-compound was more abundant in the AMI group at the Family, Genus, and Species levels (all LDA scores >2).Conclusions This is the first study to demonstrate Selenomonadales and seleno-compound to be associated with the occurrence of AMI. Our findings provide an opportunity for a novel prevention and treatment of AMI.

This chapter looks at the role of corporate boards in risk oversight, risk management, and compliance through a comparative lens, drawing on examples from international guidance and diverse legal systems, primarily, the United States, the United Kingdom, leading European jurisdictions, and China. It argues that given the complexity of modern corporations and of the risk environments in which they are situated, fiduciary duties and corporate boards themselves must be understood in relation to the transnational networks of inter-related actors, regulatory regimes, and other institutions that impact how boards carry out their monitoring role. This chapter outlines the basic mechanisms of risk oversight, risk management, and compliance in various jurisdictions; discusses diverse conceptions of fiduciary duty and their limits; and considers the challenges and complexity of risk oversight and risk management, particularly with respect to emerging risk. It concludes by identifying key sources of corporate risk oversight that inform and complement corporate boards' role.

Background: Obstructive sleep apnea (OSA) is an eminently modifiable and emerging risk factor for acute stroke. This prospective study was conducted in a tertiary care center to estimate the proportion of OSA in patients presenting with acute stroke.Materials and Methods: Consecutive stable patients with acute stroke were included. Stroke severity, subtype, and anatomical location were classified using standardized scales. Included subjects were screened for OSA with a detailed history (intrusive snoring, witnessed apneas, and excessive daytime sleepiness), quantification of sleepiness (Epworth Sleepiness Scale), clinical examination, and level-3 polysomnography. OSA severity was quantified based on the Apnea–Hypopnea Index.Results: 104 clinically stable stroke patients (67 males and 37 females) were included in the study; mean age was 60.9±13.2 years. Most patients (92 [88.5%]) had ischemic stroke, 9 (8.7%) had hemorrhagic stroke, and 3 (2.9%) had a transient ischemic attack. Intrusive snoring was reported by 37 (35.6%) patients, excessive daytime sleepiness by 32 (30.8%) and witnessed apneas by 19 (18.3%) patients. On level-3 polysomnography, 74 (71.2%) patients were diagnosed to have OSA. Mild OSA was diagnosed in 34 patients, while moderate and severe OSA were diagnosed in 20 patients each.Conclusions: Our study has demonstrated a strong causal relationship between OSA and stroke, thus reinforcing the need to screen all patients with stroke for OSA. Timely institution of nocturnal noninvasive ventilation in stroke patients with OSA would help to reduce the effects of OSA on stroke morbidity and recurrence.

Body hacking through self-implantation of electronic devices (e.g., insideables and prostheses) is an emerging risky behavior with potential negative health and safety consequences, despite the claimed potential benefits. Risks become higher in unconventional settings where self-implantations are performed without experts' risk assessment and preventive measures. To understand such behavior, it is important to identify what are the motivational factors that underlie intentions to practice body-hacking. Given the scarce literature on the subject to date, this paper presents a theoretical framework of potential motivational drivers underlying the intention towards practicing body hacking in order to help setting up priorities for future research. The potential theoretical associations between intention to practice body hacking and existential, identity, ideological, cognitive, epistemic, social affiliation, and affective drivers are discussed.

PURPOSE OF REVIEW Lipoprotein (a) [Lp(a)] is highly suggested as an emerging risk factor in cardiovascular disease (CVD) prevention. However, there remains controversy regarding the shape of Lp(a) risk curve and the extent to which Lp(a) confers risk for CVD, independently of conventional lipid markers. This systematic review outlines the current state of knowledge regarding the role of Lp(a) in primary and secondary CVD prevention. RECENT FINDINGS Searches resulted in the selection of n = 19 studies. In the context of primary CVD prevention, n = 9 cohorts, n = 2 case-cohorts, and n = 2 retrospective studies were identified, the majority of which suggested a significant positive association between Lp(a) and CVD onset. In terms of secondary CVD prevention, n = 5 cohorts and n = 1 case-cohort were considered as eligible highlighting from a positive to a neutral association between Lp(a) and CVD progression. SUMMARY A positive association between Lp(a) and CVD seems to be supported by a large body of evidence yet it is comparatively moderate in magnitude and differentiates according to study population and the examined endpoints. This fact along with the lack of a definitive functional mechanism limits the potential connotation of Lp(a) in daily clinical practice.

Introduction Air pollution is an emerging risk factor for human health like cancer and other health outcomes in developing countries, especially in Iran where air pollutants concentrations are high. However, the data on health effects of air pollution are limited. Objective In this study, we have estimated the mortality for all causes (TM) and for cardiovascular diseases (CM), as well as the number of hospital admissions due to cardiovascular (HA-CVD) and respiratory diseases (HA-RD), chronic obstructive pulmonary diseases (HA-COPD), and acute myocardial infarction (AMI) due to exposure to common air pollutants. Materials and Methods In our study, the World Health Organization (WHO) method was applied to assess the mortality and morbidity rates from published relative risk (RR) and baseline incidence (BI) values. Results The results showed that 4.60% (95% CI: 3.50–5.31%) TM, 4.96% (95% CI: 3.16–10.50%) CM, 4.97% (95% CI: 3.04–6.81%) HA-RD, 5.55% (95% CI: 3.77–7.82%) HA-CVD, 2.50% (95% CI: 0–4.61%) HA-COPD and 4.73% (95% CI: 1.14–4.65%) AMI, respectively can be attributed to daily PM10 and SO2 concentrations exceeding 10μg/m3. Conclusion To reduce the adverse health impact of air pollution, health advices and recommendations by local health authorities should be given to general population especially for vulnerable people i.e. children, elderly or people with chronic lung and cardiac pathologies during the dusty days.

The use of engineered nanomaterials (ENMs) in the construction sector is a newly emerging risk as there is limited knowledge about this topic. This paper studies the potential risk of nano-enabled construction products and how these are being addressed by Coordinators for safety and health matters. Firstly, a compendium of safety data sheets (SDSs) for these products and publications about the potential for nano-exposure were analysed. Secondly, a questionnaire was sent by email to a representative sample of Coordinators in Andalusia (Spain). The key findings were that practically none of the SDSs mentioned nano-specific data and the activities that involve nanomaterials in powder form or for spraying are the riskiest. From the survey, it seems that nano-enabled construction products are widely known about, but the use of nanomaterials is very limited. The nanorisks are unknown and rarely mentioned in work safety documents. It can be concluded that, a potential relationship between hazardous profile of the product and presence of ENMs is excluded. Although the use of nanotechnology in the construction site is at an early stage, workers have already been exposed to ENMs in critical activities and risk management is not being addressed.

PURPOSE OF REVIEW: Recent literature is examined to identify established and emerging risk factors for valvular calcification, specifically aortic valve disease and mitral annular calcification. RECENT FINDINGS: Strong evidence implicates older age, male sex, cigarette smoking, elevated blood pressure, dyslipidemia, adiposity, and mineral metabolism as risk factors for calcific aortic valve disease. Emerging evidence suggests family history and lipoprotein(a) are additional risk factors. Recently, large-scale genome-wide analyses have identified robust associations for LPA, PALMD, and TEX41 with aortic stenosis. Factors predisposing to mitral annular calcification are less well characterized. Older age, cigarette smoking, increased body mass index, kidney dysfunction, and elevated triglycerides are associated with greater risk of mitral annular calcification, but conflicting evidence exists for sex and C-reactive protein. SUMMARY: Established and emerging risk factors for calcific aortic valve disease, including some that overlap with atherosclerosis, may represent targets for pharmacological intervention. Mitral annular calcification is comparatively less well understood though some atherosclerosis risk factors do appear to increase risk.

Cyber-attack is recognized as an emerging risk in smart grids. In this paper, we reveal a potential link between data attack and physical consequences and analyzed how the attacker can launch a malicious data attack to trigger sequential outages and thus impose large damages to the grid. In this attack mechanism, the attacker constructs an optimal false data injection attack to intentionally trigger a targeted branch outage sequence that trips multiple branches and then leads to subsequent failures. The studied attack mechanism integrates constructing an optimal data attack and identifying critical lines, and imposes a substantial security impact with a high chance of occurring. Simulations on the IEEE 118-bus system verify that the introduced attack mechanism and highlight the risk of such attacks in today's smart grids.

We use computational linguistics to develop a dynamic, interpretable methodology that can detect emerging risks in the financial sector. Our model can predict heightened risk exposures as early as mid-2005, well in advance of the 2008 financial crisis. Risks related to real estate, prepayment, and commercial paper are elevated. Individual bank exposure strongly predicts returns, bank failures, and return volatility. We also document a rise in market instability since 2014 related to sources of funding and mergers and acquisitions. Overall, our model predicts the buildup of emerging risk in the financial system and bank-specific exposures in a timely fashion. Received March 1, 2018; editorial decision November 18, 2018 by Editor Itay Goldstein.

Analysis of surveillance data for 2010–2016 in eastern Ontario, Canada, demonstrates the rapid northward spread of Ixodes scapularis ticks and Borrelia burgdorferi, followed by increasing human Lyme disease incidence. Most spread occurred during 2011–2013. Continued monitoring is essential to identify emerging risk areas in this region.

International audience; The rapid progress of innovative biorefinery technologies raises the issue of emerging risk and major accident hazard in biorefineries, as process safety aspects of such technologies are not developing at the same pace with respect to their dissemination and scale-up.To address such problem, in the present work a consequence-based approach was integrated in the framework of a consolidated QRA methodology (ARAMIS), formerly developed in the context of Seveso Directive in the process industries (mainly oil&gas). Among all the possible scenarios identified using ARAMIS, Relevant Accident Scenarios (RAS) were selected by calculating hazard distances using threshold values for the evaluation of damages on human target derived from existing regulations on the control of major accident hazards.The method has been described and used to quantify the risk associated to a biorefinery process: the conversion of lignocellulosic biomass materials to levulinic acid and gamma-valerolactone, where the use of hazardous substances and severe process conditions are required.Using the proposed approach allowed to reduce the number of scenarios to be retained for further analysis. The RAS resulted 1/3 of the scenarios initially identified, simplifying the rest of the risk assessment procedure.The integrated methodology enabled to depict a risk figure for the plant analysed which is not over-conservative, being beneficial during the risk management phase, when risk reduction measures have to be selected and implemented in order to achieve risk tolerance.

Uncertainty as an attribute of fire and emerging risks has both objective and subjective origin. Like measure uncertainty in modern metrology, the uncertainty in the risk theory has qualitative and quantitative aspects. Several methods for uncertainty quantifying are known. Taking into account the specifics of dangerous industrial objects, the probabilistic approach to quantitative estimation of their risk parameter uncertainty is inapplicable. A good alternative is to assess the fire and emerging risks in the interval setting. In addition to directly assessing the uncertainty of the results obtained — the risk indicators — it also makes it possible to estimate the parametric sensitivity of the model and to assess the conservatism of the assumptions made.

Cyber threats are an emerging risk posing a range of challenges to organizations of all sizes. Corporate risk managers need to understand that cyber risk management must not be a silo in the IT department. Cyber threats are the result of intelligent adaptive agents that cannot be managed by traditional risk management techniques only. The article describes the honeypot concept, which is a proactive measure for identifying and gathering information about attackers in order to develop suitable and effective countermeasures. In addition, this article proposes the integration of the honeypot concept into a cyber risk management approach based on the five preparedness mission areas of the Federal Emergency Management Agency (FEMA).

International audience; According to the European Union regulation, some countries have established a pre-market notification system for food supplements while others have not. As this regulation is unfulfilled, a notified and marketed food supplement ingredient in one country may be forbidden in another. Even though food supplements shall not be placed on the market if unsafe, some products may still expose the consumers to risks. The risk is increased by easier access due to worldwide dissemination fostered by the internet and free movement of goods in the European Union. The Rapid Alert System for Food and Feed and the Emerging Risks Exchange Network are described. To date, the European Union legislation does not include a provision to establish a dedicated vigilance system for food supplements (Nutrivigilance). Six European Union countries have nevertheless set up national systems, which are presented. The present lack of European Union data collection harmonization, does not allow easy cooperation between countries. This article advocates for creating a coordinated European Nutrivigilance System to detect and scrutinize adverse effects of food supplements. This, to help in directing science-based risk assessments and reinforce the science-based decision of policy makers to improve public health safety.

Introduction: Variability in sleep patterns is an emerging risk factor for metabolic and cardiovascular diseases (CVD). Poor diet likely contributes to these relations, given the intricate link between sleep and diet, both of which are important determinants of cardiometabolic health. However, associations of irregular sleep with energy intake and consumption of a Mediterranean diet pattern, key markers of diet quantity and quality predictive of CVD risk, have not been evaluated. Hypothesis: Greater night-to-night variability in sleep duration will be associated with higher energy intake and poorer diet quality, defined as lower alternate Mediterranean (aMed) diet scores (range: 0-9). Methods: This was a cross-sectional analysis of 2,007 men and women (age: 68.6±9.2 y, 61% racial/ethnic minority) from the Multi-Ethnic Study of Atherosclerosis Sleep Ancillary Study. The standard deviation (SD) of sleep duration, derived from 1-wk of wrist actigraphy, was used as a measure of sleep duration variability. Diet, including daily energy intake, aMed score, and consumption of aMed components, was ascertained from a food frequency questionnaire. Multivariable linear regression models adjusted for age, race/ethnicity, sex, study site, marital status, and education, evaluated associations of sleep duration variability with diet. Sensitivity analyses, also adjusted for sociodemographic factors, were conducted to evaluate relations of weekday sleep duration SD, a potentially more representative measure of habitual sleep, with diet. Results: Mean sleep duration variability was 84±48 min. Greater sleep duration variability was associated with higher energy intake and lower aMed score; each 30-min increase in sleep duration SD related to 23±11 more kcal/d (P=0.04) and 0.06±0.02 lower aMed score (P=0.02). Higher sleep duration SD (per 30 min increase) was also associated with lower intakes of whole grains (β=-0.01±0.01, P Conclusions: We provide novel initial evidence that irregular sleep duration, particularly during weekdays, may contribute to overconsumption and poor diet quality. Further investigation into a possible mechanistic role of diet in the association of sleep variability with cardiometabolic disease risk is warranted. Longitudinal or experimental data are needed to elucidate a potential complex interplay between sleep duration variability, diet, and other health and lifestyle factors, including physical activity, obesity, and depression.

(1): Rift Valley Fever (RVF) is a zoonotic disease of significant international health concern and considered as an emerging risk to Europe, where no RVF outbreaks in humans or animals have been reported so far. (2): Using a stochastic approach, we estimated the risk of RVF virus (RVFV) introduction during the period of May to October (the period when mosquito populations, including RVFV potential vectors, are present in European countries), into previously unaffected areas (e.g., United Kingdom, UK) via virus-carrying vectors traveling in commercial aircraft from RVF-affected countries (e.g., East Africa), (3): On average N = 68 (95% CI: 0–337), RVF-virus-infected mosquitoes are estimated to be mechanically transported by planes (with N = 0 as most likely), in direct flights from RVF-affected East African countries to the UK, between May and October. This estimate is considered as low but not negligible. The model developed should be easily scaled up to other European countries by amending appropriately country-specific variables (e.g., number of flights between countries) in order to map the areas/airports of higher risk and inform risk management per country accordingly and to adopt risk-mitigation measures.

Gnathostomiasis is a foodborne parasitic zoonosis known to be endemic in Southeast Asia, India, Central and South America, with recent cases reported in Zambia, Botswana and South Africa. We report a case of gnathostomiasis acquired in Madagascar and alert clinicians of the emerging risk in southern Africa.

This study uses the Planned Risk Information Seeking Model (PRISM) to estimate the public's information seeking and avoidance intentions during the COVID-19 outbreak based on an online sample of 1031 Chinese adults and provides support for the applicability of PRISM framework in the situation of a novel high-level risk. The results indicate that information seeking is primarily directed by informational subjective norms (ISN) and perceived seeking control (PSC), while the main predictors of information avoidance include ISN and attitude toward seeking. Because ISN are the strongest predictor of both information seeking and avoidance, the way the public copes with COVID-19 information may be strongly affected by individuals' social environment. Furthermore, a significant relationship between risk perception and affective risk response is identified. Our results also indicate that people who perceive greater knowledge of COVID-19 are more likely to report greater knowledge insufficiency, which results in less information avoidance.

Background Simple and valid measures are important for studying distracted walking, an important and emerging risk factor for pedestrian injury. Based on common epidemiological indicators for distracted walking, we developed and validated an indicator to measuring distracted walking, called the ‘distraction index’. Methods A large, video-based, observational study was conducted at 20 intersections in Changsha, China. To develop a ‘distraction index’ that would quantify safety risks based on distracted walking, we calculated relationships between 7 observed distraction indicators and 3 safety outcomes. This allowed us to assess the discriminant validity of the 7 indicators and create a ‘distraction index’ that best predicts street-crossing safety based on distracted behavior. Results In total, 8,729 distracted pedestrian crossings were identified. Discriminant validity varied greatly across the distraction indicators. Compared to each individual indicators, the distraction index demonstrated the strongest capacity to discriminate all three safety measures of street-crossing. Using the three levels in the ‘distraction index’, distracted pedestrians had much higher risks of experiencing near-crash events compared to undistracted pedestrians, with odds ratios of 1.3 (95% CI: 1.1, 1.4) for low index scores, 1.6 (95% CI: 1.4, 1.9) for medium, and 1.9 (95% CI: 1.6, 2.3) for high. Conclusion The distraction index predicted pedestrian crossing safety more accurately than any of the seven individual measures of distracted walking. We recommend use of this index in future research. Learning Outcomes No widely recognized epidemiological measure exists to observe distracted walking. The newly-created ‘distraction index’ shows excellent discriminant validity compared to individual indicators of distraction.

Cardiorespiratory optimal point (COP) during exercise may be a potentially clinically useful cardiopulmonary exercise testing (CPET) variable, but its prognostic relevance for adverse cardiovascular disease (CVD) outcomes is unknown. We aimed to assess the association of COP during exercise with fatal mortality outcomes and the extent to which COP could improve the prediction of CVD mortality. Cardiorespiratory optimal point, the minimum value of the ventilatory equivalent for oxygen (VE/VO2) in a given minute of a CPET, was defined in 2,205 men who underwent CPET. Hazard ratios (HRs) (95% confidence intervals [CIs]) for outcomes and measures of risk discrimination for CVD mortality were calculated. During a median follow-up of 28.8 years, 402 fatal CHDs, 607 fatal CVDs, and 1,348 all-cause mortality events occurred. COP was continually associated with each outcome in a dose-response manner. On adjustment for established and emerging risk factors, the HRs (95% CIs) for fatal CHD, fatal CVD, and all-cause mortality were 3.05 (1.94–4.81), 2.82 (1.91–4.18) and 2.46 (1.85–3.27), respectively, per standard deviation increase in COP. After further adjustment for high sensitivity C-reactive protein, the HRs were 2.82 (1.78–4.46), 2.57 (1.73–3.81), and 2.27 (1.70–3.02), respectively. Addition of COP to a CVD mortality risk prediction model containing established risk factors was associated with a C-index change of 0.0139 (0.0040 to 0.0238; p = 0.006) at 25 years. COP during exercise is directly associated with fatal cardiovascular and all-cause mortality events in dose-response fashions. COP during exercise may improve the prediction of the long-term risk for CVD mortality.