RESUMEN

BACKGROUND: We investigated whether hypertension may be a mediator in the pathway linking environmental noise exposure to incident MI and stroke. METHODS: Separately for MI and stroke, we built two population-based cohorts from linked health administrative data. Participants were residents of Montreal (Canada) between 2000 and 2014, aged 45 years and older who were free of hypertension and MI or stroke at time of entry. MI, stroke and hypertension were ascertained from validated case definitions. Residential long-term environmental noise exposure, expressed as the annual mean level acoustic equivalent 24 h (LAeq24h), was estimated from a land use regression model. We performed mediation analysis based on the potential outcomes framework. We used a Cox proportional hazards model for the exposure-outcome model and a logistic regression for the exposure-mediator model. In sensitivity analysis we applied a marginal structural approach to estimate the natural direct and indirect effects. RESULTS: Each cohort included approximately 900 000 individuals, with 26 647 incident cases of MI and 16 656 incident cases of stroke. 36% of incident MI and 40% of incident stokes had previously developed hypertension. The estimated total effect per interquartile range increase (from 55.0 to 60.5 dB A) in the annual mean LAeq24h was 1.073 (95% confidence interval (CI): 1.070-1.077) for both MI for stroke. We found no evidence of exposure-mediator interaction for both outcomes. The relationships between environmental noise and MI and stroke was not mediated by hypertension. CONCLUSIONS: This population-based cohort study suggests that the main route by which environmental noise exposure may cause MI or stroke is not through hypertension.

Asunto(s)

RESUMEN

Background: Noise has been related to several cardiovascular diseases (CVDs) such as coronary heart disease and to their risk factors such as hypertension, but associations with stroke remain under-researched, even if CVD likely share similar pathophysiologic mechanisms. Aim: The objective of the study was to examine the association between long-term residential exposure to total environmental noise and stroke incidence in Montreal, Canada. Materials and Methods: We created an open cohort of adults aged ≥45years, free of stroke before entering the cohort for the years 2000 to 2014 with health administrative data. Residential total environmental noise levels were estimated with land use regression (LUR) models. Incident stroke was based on hospital admissions. Cox hazard models with age as the time axis and time-varying exposures were used to estimate associations, which were adjusted for material deprivation, year, nitrogen dioxide, stratified for sex, and indirectly adjusted for smoking. Results: There were 9,072,492 person-years of follow-up with 47% men; 26,741 developed stroke (21,402 ischemic; 4947 hemorrhagic; 392 had both). LUR total noise level acoustic equivalent for 24 hours (LAeq24h) ranged 44 to 79 dBA. The adjusted hazard ratio (HR) for stroke (all types), for a 10-dBA increase in LAeq24h, was 1.06 [95% confidence interval (CI): 1.03-1.09]. The LAeq24h was associated with ischemic (HR per 10 dBA: 1.08; 95% CI: 1.04-1.12) but not hemorrhagic stroke (HR per 10 dBA: 0.97; 95% CI: 0.90-1.04). Conclusion: The results suggest that total environmental noise is associated with incident stroke, which is consistent with studies on transportation noise and other CVD.

Asunto(s)

RESUMEN

BACKGROUND: Cardiovascular effects of environmental noise are a growing concern. However, the evidence remains largely limited to the association between road traffic noise and hypertension and coronary heart diseases. OBJECTIVES: To investigate the association between long-term residential exposure to environmental/transportation noise and the incidence of myocardial infarction (MI) in the adult population living in Montreal. METHODS: An open cohort of adults aged 45 years old and over, living on the island of Montreal and free of MI before entering the cohort was created for the years 2000-2014 with the Quebec Integrated Chronic Disease Surveillance System; a systematic surveillance system from the Canadian province of Quebec starting in 1996. Residential noise exposure was calculated in three ways: 1) total ambient noise levels estimated by Land use regression (LUR) models; 2) road traffic noise estimated by a noise propagation model CadnaA and 3) distances to transportation sources (roads, airport, railways). Incident MI was based on diagnostic codes in hospital admission records. Cox models with time-varying exposures (age as the time axis) were used to estimate the associations with various adjustments (material deprivation indicator, calendar year, nitrogen dioxide, stratification for sex). Indirect adjustment based on ancillary data for smoking was performed. RESULTS: 1,065,414 individuals were followed (total of 9,000,443 person-years) and 40,718 (3.8%) developed MI. We found positive associations between total environmental noise, estimated by LUR models and the incidence of MI. Total noise LUR levels ranged from ~44 to ~79 dBA and varied slightly with the metric used. The adjusted hazard ratios (HRs) (also adjusted for smoking) were 1.12 (95% Confidence Intervals [CI]: 1.08-1.15), 1.11 (95%CI: 1.07-1.14) and 1.10 (95%CI: 1.06-1.14) per 10 dBA noise levels increase respectively in Level Accoustic equivalent 24 h (LAeq24 h), Level day-evening-night (Lden) and night level (Lnight). We found a borderline negative association between road noise levels estimated with CadnaA and MI (HR: 0.99 per 10 dBA; 95%CI: 0.98-1.00). Distances to major roads and highways were not associated with MI while the proximity to railways was positively associated with MI (HR for ≤100 vs > 1000 m: 1.07; 95%CI: 1.01-1.14). A negative association was found with the proximity to the airport noise exposure forecast (NEF25); HR (<1 vs >1000 m) = 0.88 (95%CI: 0.81-0.96). CONCLUSIONS: These associations suggest that exposure to total environmental noise at current urban levels may be related to the incidence of MI. Additional studies with more accurate road noise estimates are needed to explain the counterintuitive associations with road noise and specific transportation sources.

Asunto(s)

RESUMEN

OBJECTIVES: Since 2004, the Montreal heat response plan (MHRP) has been developed and implemented on the Island of Montreal to reduce heat-related health effects in the general population. In this paper, we aimed to assess the barriers and facilitators to implementation of the MHRP and evaluate the awareness of key elements of the plan by healthcare professionals and individuals from vulnerable populations. METHODS: Data were gathered from monitoring reports and a questionnaire administered to managers of healthcare institutions and healthcare workers in Montreal-area health and social services institutions. Individual interviews and focus groups with healthcare workers and with individuals with schizophrenia or suffering from drug or alcohol dependencies were performed. Data were categorized according to predefined subthemes. Coding matrices were then used to determine the most frequently occurring elements in the subthemes. RESULTS: Our results indicate that actions are progressively implemented each year in the healthcare network. Intensification of surveillance for signs of heat-related illness is the most frequently reported measure. Identification and prioritization of clientele and homecare patients are identified as a challenge, as is ensuring the availability of sufficient personnel during a heat wave. Analysis of practice and awareness in healthcare professionals reveals that preventive measures are known and applied by the personnel. Individuals from vulnerable population groups were not uniformly aware of preventive measures, and consequently, variability was observed in their application. CONCLUSION: The framework proposed in this study revealed valuable information that can be useful to improve plans aimed at reducing heat-related health effects in the population.

Asunto(s)

RESUMEN

Diesel exhaust (DE) emissions from a parking garage located in the basement of a school were characterized during spring and winter using direct reading devices and integrated sampling methods. Concentrations of CO and NO2 were evaluated using electrochemical sensors and passive colorimetric tubes, respectively. Elemental and total carbon concentrations were measured using the NIOSH 5040 method. Particle number concentrations (PNCs), respirable particulate matter (PMresp) mass concentrations, and size distributions were evaluated using direct reading devices. Indoor concentrations of elemental carbon, PNC, CO, and NO2 showed significant seasonal variation; concentrations were much higher during winter (p < 0.01). Concentrations of the PMresp and total carbon did not show significant seasonal variation. Pearson correlation coefficients were 0.9 (p < 0.01) and 0.94 (p < 0.01) between the parking garage and ground floor average daily PNCs, and between the parking garage and first floor average daily PNCs, respectively. Since DE is the main identified source of fine and ultrafine particles in the school, these results suggest that DE emissions migrate from the parking garage into the school. Our results highlight the relevance of direct reading instruments in identifying migration of contaminants and suggest that monitoring PNC is a more specific way of assessing exposure to DE than monitoring the common PMresp fraction.

Asunto(s)

RESUMEN

The objective of our study was to measure the impact of transportation-related noise and total environmental noise on sleep disturbance for the residents of Montreal, Canada. A telephone-based survey on noise-related sleep disturbance among 4336 persons aged 18 years and over was conducted. LNight for each study participant was estimated using a land use regression (LUR) model. Distance of the respondent's residence to the nearest transportation noise source was also used as an indicator of noise exposure. The proportion of the population whose sleep was disturbed by outdoor environmental noise in the past 4 weeks was 12.4%. The proportion of those affected by road traffic, airplane and railway noise was 4.2%, 1.5% and 1.1%, respectively. We observed an increased prevalence in sleep disturbance for those exposed to both rail and road noise when compared for those exposed to road only. We did not observe an increased prevalence in sleep disturbance for those that were both exposed to road and planes when compared to those exposed to road or planes only. We developed regression models to assess the marginal proportion of sleep disturbance as a function of estimated LNight and distance to transportation noise sources. In our models, sleep disturbance increased with proximity to transportation noise sources (railway, airplane and road traffic) and with increasing LNight values. Our study provides a quantitative estimate of the association between total environmental noise levels estimated using an LUR model and sleep disturbance from transportation noise.

Asunto(s)

RESUMEN

The availability of noise maps to assess exposure to noise is often limited, especially in North American cities. We developed land use regression (LUR) models for LAeq24h, Lnight, and Lden to assess the long-term spatial variability of environmental noise levels in Montreal, Canada, considering various transportation noise sources (road, rail, and air). To explore the effects of sampling duration, we compared our LAeq24h levels that were computed over at least five complete contiguous days of measurements to shorter sampling periods (20 min and 24 h). LUR models were built with General Additive Models using continuous 2-min noise measurements from 204 sites. Model performance (adjusted R2) was 0.68, 0.59, and 0.69 for LAeq24h, Lnight, and Lden, respectively. Main predictors of measured noise levels were road-traffic and vegetation variables. Twenty-minute non-rush hour measurements corresponded well with LAeq24h levels computed over 5 days at road-traffic sites (bias: -0.7 dB(A)), but not at rail (-2.1 dB(A)) nor at air (-2.2 dB(A)) sites. Our study provides important insights into the spatial variation of environmental noise levels in a Canadian city. To assess long-term noise levels, sampling strategies should be stratified by noise sources and preferably should include 1 week of measurements at locations exposed to rail and aircraft noise.

Asunto(s)

RESUMEN

BACKGROUND: This study's objective was to determine whether socioeconomically deprived populations are exposed to greater levels of environmental noise. METHODS: Indicators of socioeconomic status were correlated with LAeq24h noise levels estimated with a land-use regression model at a small geographic scale. RESULTS: We found that noise exposure was associated with all socioeconomic indicators, with the strongest correlations found for median household income, proportion of people who spend over 30% of their income on housing, proportion of people below the low income boundary and with a social deprivation index combining several socio-economic variables. CONCLUSION: Our results were inconsistent with a number of studies performed elsewhere, indicating that locally conducted studies are imperative to assessing whether this double burden of noise exposure and low socioeconomic status exists in other contexts. The primary implication of our study is that noise exposure represents an environmental injustice in Montreal, which is an issue that merits both investigation and concern.

Asunto(s)

RESUMEN

There is a lack of studies assessing the exposure-response relationship between transportation noise and annoyance in North America. Our aims were to investigate the prevalence of noise annoyance induced by road traffic, trains and airplanes in relation to distance to transportation noise sources, and to total environmental noise levels in Montreal, Canada; annoyance was assessed as noise-induced disturbance. A telephone-based survey among 4336 persons aged >18 years was conducted. Exposure to total environmental noise (A-weighted outdoor noise levels-LAeq24h and day-evening-night equivalent noise levels-Lden) for each study participant was determined using a statistical noise model (land use regression-LUR) that is based on actual outdoor noise measurements. The proportion of the population annoyed by road traffic, airplane and train noise was 20.1%, 13.0% and 6.1%, respectively. As the distance to major roads, railways and the Montreal International Airport increased, the percentage of people disturbed and highly disturbed due to the corresponding traffic noise significantly decreased. When applying the statistical noise model we found a relationship between noise levels and disturbance from road traffic and total environmental noise, with Prevalence Proportion Ratios (PPR) for highly disturbed people of 1.10 (95% CI: 1.07-1.13) and 1.04 (1.02-1.06) per 1 dB(A) Lden, respectively. Our study provides the first comprehensive information on the relationship between transportation noise levels and disturbance in a Canadian city. LUR models are still in development and further studies on transportation noise induced annoyance are consequently needed, especially for sources other than road traffic.

Asunto(s)

RESUMEN

PATIENT: Male, 62. FINAL DIAGNOSIS: Bipolar disorder. SYMPTOMS: Bordeline personality disorder. MEDICATION: - CLINICAL PROCEDURE: Bed bug infestation. SPECIALTY: Psychiatry. OBJECTIVE: Unusual clinical course. BACKGROUND: In the past decade, bed bug infestations have been increasingly common in high income countries. Psychological consequences of these infestations are rarely examined in the scientific literature. CASE REPORT: We present a case, based on a coroner's investigation report, of a woman with previous psychiatric morbidity who jumped to her death following repeated bed bug infestations in her apartment. Our case report shows that the bed bug infestations were the likely trigger for the onset a negative psychological state that ultimately led to suicide. CONCLUSIONS: Given the recent surge in infestations, rapid action needs to be taken not only in an attempt to control and eradicate the bed bugs but also to adequately care for those infested by bed bugs.

RESUMEN

OBJECTIVES: This review assessed the confounding effect of one traffic-related exposure (noise or air pollutants) on the association between the other exposure and cardiovascular outcomes. METHODS: A systematic review was conducted with the databases Medline and Embase. The confounding effects in studies were assessed by using change in the estimate with a 10 % cutoff point. The influence on the change in the estimate of the quality of the studies, the exposure assessment methods and the correlation between road noise and air pollutions were also assessed. RESULTS: Nine publications were identified. For most studies, the specified confounders produced changes in estimates <10 %. The correlation between noise and pollutants, the quality of the study and of the exposure assessment do not seem to influence the confounding effects. CONCLUSIONS: Results from this review suggest that confounding of cardiovascular effects by noise or air pollutants is low, though with further improvements in exposure assessment, the situation may change. More studies using pollution indicators specific to road traffic are needed to properly assess if noise and air pollution are subjected to confounding.

Asunto(s)

Asunto(s)

RESUMEN

OBJECTIVES: We investigated whether the installation of a suicide prevention barrier on Jacques-Cartier Bridge led to displacement of suicides to other jumping sites on Montréal Island and Montérégie, Québec, the 2 regions it connects. METHODS: Suicides on Montréal Island and Montérégie were extracted from chief coroners' records. We used Poisson regression to assess changes in annual suicide rates by jumping from Jacques-Cartier Bridge and from other bridges and other sites and by other methods before (1990-June 2004) and after (2005-2009) installation of the barrier. RESULTS: Suicide rates by jumping from Jacques-Cartier Bridge decreased after installation of the barrier (incidence rate ratio [IRR] = 0.24; 95% confidence interval [CI] = 0.13, 0.43), which persisted when all bridges (IRR = 0.39; 95% CI = 0.27, 0.55) and all jumping sites (IRR = 0.66; 95% CI = 0.54, 0.80) in the regions were considered. CONCLUSIONS: Little or no displacement to other jumping sites may occur after installation of a barrier at an iconic site such as Jacques-Cartier Bridge. A barrier's design is important to its effectiveness and should be considered for new bridges with the potential to become symbolic suicide sites.

Asunto(s)

RESUMEN

OBJECTIVES: The objective of this paper is to describe Montreal's heat response plan and its application during the July 2010 heat wave. PARTICIPANTS AND SETTING: The Montreal heat response plan is designed to ensure the surveillance of weather and health indicators during the summer season and to coordinate actions to be undertaken during this period to reduce morbidity and mortality due to heat, particularly when weather thresholds are reached or an increase in health indicators is observed. It was developed to coordinate and apply intervention measures on the Island of Montreal and has been in effect since 2004. INTERVENTION: In the beginning of July 2010, Montreal experienced a heat wave that lasted 5 days. During this period, health indicators such as total mortality, prehospital emergency transports, calls to the health information line and hospital admissions were monitored by the Montreal public health surveillance system. The decision to implement emergency interventions and actions performed by regional and local public health and municipal partners (intervention level) was made following attainment of a predetermined weather threshold and increases in health indicators. The significant increase in daily observed mortality from all causes and in particular people dying at home or in the community prompted the Director of public health to conduct a chart review of all people deceased from July 5 to July 11, 2010 to determine cause of death and underlying health conditions. OUTCOME: During the heat wave, there were 304 reported deaths from all causes in Montreal residents, of which 106 were probably or possibly heat-related. Major underlying health conditions in heat-related deaths included cardiovascular problems and mental health illness. Furthermore, in the case of people with mental illness who died during the heat wave, the chart review revealed that many were contacted 24 hours prior to their death by health care professionals, family members, neighbours or friends. CONCLUSION: Following the 2010 heat wave, the Montreal heat response plan and heat surveillance system were updated to include initiatives to better communicate preventive measures to the vulnerable populations and to intervene earlier during a heat wave.

Asunto(s)

RESUMEN

OBJECTIVE: To assess whether bed bug infestation was linked to sleep disturbances and symptoms of anxiety and depression. DESIGN: Exploratory cross-sectional study. SETTING: Convenience sample of tenants recruited in apartment complexes from Montreal, Canada. PARTICIPANTS: 39 bed bug-exposed tenants were compared with 52 unexposed tenants. MAIN OUTCOME MEASURES: The effect of bed bug-exposed tenants on sleep disturbances, anxiety and depression symptoms measured using the Pittsburgh Sleep Quality Index, 5th subscale, Generalised Anxiety Disorder 7-item scale and Patient Health Questionnaire, 9-item, respectively. RESULTS: In adjusted models, bed bug infestation was strongly associated with measured anxiety symptoms (OR (95% CI)=4.8 (1.5 to 14.7)) and sleep disturbance (OR (95% CI)=5.0 (1.3-18.8)). There was a trend to report more symptoms of depression in the bed bug-infested group, although this finding was not statistically significant ((OR (95% CI)=2.5(0.8 to 7.3)). CONCLUSIONS: These results suggest that individuals exposed to bed bug infestations are at risk of experiencing sleep disturbance and of developing symptoms of anxiety and possibly depression. Greater clinical awareness of this problem is needed in order for patients to receive appropriate mental healthcare. These findings highlight the need for undertaking of deeper inquiry, as well as greater collaboration between medical professionals, public health and community stakeholders.

RESUMEN

OBJECTIVES: Exposure to traffic-related air pollutants plays a role in several health outcomes. A large body of evidence tends to link asthma in children with traffic exposure. Increasing asthma prevalence and incidence in children in Canadian cities has been of concern for public health authorities. The following study focuses on estimating the risk of asthma prevalence attributable to residing in proximity to major roads on the Island of Montreal, Canada. METHODS: Risk functions pertaining to asthma in children and residential proximity to major roads were selected from the literature and applied to Montreal. Asthma prevalence was taken from population-based studies. Population data were retrieved from Canadian census. Exposure was estimated using the proximity to major road and highway category of the Desktop Mapping Technologies Inc. database (DMTI Spatial Inc.). RESULTS: Based on different studies, the percentage of prevalent asthma cases attributable to residing within 50 metres of a major road or highway for children aged 2, 4 and 6 years varied between 2.4% (0-4.3), 5.6% (0.1-8.6) and 5.9% (0.1-9.0). For the 5-7 year age group residing within 75 m of a major road or highway, the percent of cases was 6.4% (2.6-9.3). For children aged 8 to 10 residing within 75 m of a highway only, the percent of cases was 0.7% (0.2-0.9). CONCLUSION: These numbers represent the best crude estimates and are an indication of a possible range of cases linked to residential proximity to major roads. As there are uncertainties linked to the application of exposure-response functions, these estimates will be reassessed as new evidence is gathered through further research.

Asunto(s)

RESUMEN

BACKGROUND: Little attention has been devoted to the effects on children's respiratory health of exposure to sulphur dioxide (SO2) in ambient air from local industrial emissions. Most studies on the effects of SO(2) have assessed its impact as part of the regional ambient air pollutant mix. OBJECTIVE: To examine the association between exposure to stack emissions of SO(2) from petroleum refineries located in Montreal's (Quebec) east-end industrial complex and the prevalence of active asthma and poor asthma control among children living nearby. METHODS: The present cross-sectional study used data from a respiratory health survey of Montreal children six months to 12 years of age conducted in 2006. Of 7964 eligible households that completed the survey, 842 children between six months and 12 years of age lived in an area impacted by refinery emissions. Ambient SO(2) exposure levels were estimated using dispersion modelling. Log-binomial regression models were used to estimate crude and adjusted prevalence ratios (PRs) and 95% CIs for the association between yearly school and residential SO(2) exposure estimates and asthma outcomes. Adjustments were made for child's age, sex, parental history of atopy and tobacco smoke exposure at home. RESULTS: The adjusted PR for the association between active asthma and SO(2) levels was 1.14 (95% CI 0.94 to 1.39) per interquartile range increase in modelled annual SO(2). The effect on poor asthma control was greater (PR=1.39 per interquartile range increase in modelled SO(2) [95% CI 1.00 to 1.94]). CONCLUSIONS: Results of the present study suggest a relationship between exposure to refinery stack emissions of SO(2) and the prevalence of active and poor asthma control in children who live and attend school in proximity to refineries.

Asunto(s)

RESUMEN

Noise exposure generated by air traffic has been linked with sleep disturbances. The purpose of this systematic review is to clarify whether there is a causal link between aircraft noise exposure and sleep disturbances. Only complete, peer-reviewed articles published in scientific journals were examined. Papers published until December 2010 were considered. To be included, articles had to focus on subjects aged 18 or over and include an objective evaluation of noise levels. Studies were classified according to quality. Given the paucity of studies with comparable outcome measures, we performed a narrative synthesis using a best-evidence synthesis approach. The primary study findings were tabulated. Similarities and differences between studies were investigated. Of the 12 studies surveyed that dealt with sleep disturbances, four were considered to be of high quality, five were considered to be of moderate quality and three were considered to be of low quality. All moderate- to high-quality studies showed a link between aircraft noise events and sleep disturbances such as awakenings, decreased slow wave sleep time or the use of sleep medication. This review suggests that there is a causal relation between exposure to aircraft noise and sleep disturbances. However, the evidence comes mostly from experimental studies focusing on healthy adults. Further studies are necessary to determine the impact of aircraft noise on sleep disturbance for individuals more than 65 years old and for those with chronic diseases.

Asunto(s)

RESUMEN

OBJECTIVE: To share four Canadian cities' experiences with bed bug infestations and to explore public health roles in managing them. METHODS: We summarize presentations from a workshop at the 2010 Canadian Public Health Association Conference which examined the re-emergence of bed bugs in Canada and compared management approaches of municipal and public health authorities in four large Canadian cities. We include updates on their activities since the workshop. RESULTS: Cities across Canada have observed an increase in complaints of bed bug infestations over recent years. Toronto Public Health considers bed bugs to be a threat to health and has been heavily involved in the front-line response to bed bug complaints. In Winnipeg, Montreal and Vancouver, city inspectors are responsible for investigating complaints, and public health plays a supporting or secondary role. We identified factors that may contribute to successful management of bed bugs: sufficient funding, partnerships among many stakeholders, training and education, and surveillance and evaluation. CONCLUSION: Various public health agencies in Canadian cities have played key roles in the fight against bed bugs through new initiatives, education, and encouragement and support for others. By working with the public, owners, tenants, the health sector and other stakeholders, public health practitioners can begin to curb the resurgence of bed bugs and the social strains associated with them.

Asunto(s)

RESUMEN

OBJECTIVE: Estimate the number of awakenings additional to spontaneous awakenings, induced by the nighttime aircraft movements at an international airport in Montreal, in the population residing nearby in 2009. METHODS: Maximum sound levels (LAS,max) were derived from aircraft movements using the Integrated Noise Model 7.0b, on a 28 x 28 km grid centred on the airport and with a 0.1 x 0.1 km resolution. Outdoor LAS,max were converted to indoor LAS,max by reducing noise levels by 15 dB(A) or 21 dB(A). For all grid points, LAS,max were transformed into probabilities of additional awakening using a function developed by Basner et al. (2006). The probabilities of additional awakening were linked to estimated numbers of exposed residents for each grid location to assess the number of aircraft-noise-induced awakenings in Montreal. RESULTS: Using a 15 dB(A) sound attenuation, 590 persons would, on average, have one or more additional awakenings per night for the year 2009. In the scenario using a 21 dB(A) sound attenuation, on average, no one would be subjected to one or more additional awakenings per night due to aircraft noise. CONCLUSION: Using the 2009 flight patterns, our data suggest that a small number of Montreal residents are exposed to noise levels that could induce one or more awakenings additional to spontaneous awakenings per night.

Asunto(s)