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INTRODUCTION: In this case report, we have presented a patient whose liver transplant course was greatly affected by a previously undiagnosed disease process that ultimately led to an unexpected perioperative death. CASE REPORT: A 52-year-old woman with idiopathic hepatoportal sclerosis presented for liver transplantation 2 years postmesocaval shunt placement. Lab and pathology studies at the time of liver biopsy and shunt placement were negative for iron deposition. Preoperative workup was negative for cardiac disease. At the outset of her liver transplant, the patient developed refractory hypotension secondary to cardiogenic shock. Intraoperative transesophageal echocardiography and postoperative transthoracic echocardiography demonstrated dilated cardiomyopathy with severely depressed systolic function. Upon succumbing to ventricular fibrillation cardiac arrest, an autopsy revealed hemochromatosis of the heart, pancreas, kidneys, adrenals, and explanted liver. CONCLUSION: Dilated cardiomyopathy, congestive heart failure, and other unexpected disease processes resulting from hemochromatosis can greatly influence the care of postshunt liver failure patients.

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Twenty-seven laboratory experiments were conducted in a simulated smoking room to quantify rates of environmental tobacco smoke (ETS) leakage to a nonsmoking area as a function of the physical and operational characteristics of the smoking room. Data are presented for the various types of leakage flows, the effect of these leaks on smoking room performance and nonsmoker exposure, and the relative importance of each leakage mechanism. The results indicate that the first priority for an effective smoking room is to maintain it depressurized with respect to adjoining nonsmoking areas. The amount of ETS pumped out by the smoking room door when it is opened and closed can be reduced significantly by substituting a sliding door for the standard swing-type door. An "open doorway" configuration used twice the ventilation flow of those with smoking room doors, but yielded less reduction in nonsmoker exposure. Measured results correlated well with results modeled with mass-balance equations (R(2) = 0.82-0.99). Most of these results are based on sulfur hexafluoride (SF(6)) tracer gas leakage. Because five measured ETS tracers showed good correlation with SF(6), these conclusions should apply to ETS leakage as well. Field tests of a designated smoking room in an office building qualitatively agreed with model predictions.

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This article provides an understanding of the approaches for determining exposure and dose to populations in the vicinity of hazardous waste sites. A review of the federal legislation and jurisdiction for assessments is provided, and the approaches of the U.S. Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry are compared. These methods strive to aid in the evaluation of public health impacts of contaminants that were, are, or may be released to the community, and they are concerned with various aspects of the contaminant fate, human contact, and toxic response for chemicals of concern. Such approaches have been designed for generic contamination scenarios, but they aim to be applicable to a wide range of chemicals and sites in the real world. Along with any modeling framework for exposure and dose characterization, detailed information or real data are requisite for the completion of any site-specific assessment. What kinds of data are needed and where they may be found are also discussed. A comprehensive framework for exposure characterization, recently proposed by Georgopoulos and Lioy, is outlined. The framework is one employing the following elements: chemodynamic analyses of sources and receptors; characterization of the target population; toxicokinetic/toxicodynamic analyses; uncertainty/error analyses; and evaluation of the characterization performance.

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Urinary banzo[a]pyrene (BaP) metabolite levels were compared to human environmental exposure to BaP through inhalation and dietary ingestion to assess the predictive validity of the exposure biomarker. These measurements were made for 14 adult volunteers over 14 consecutive days, once during summer/fall, again during winter periods. Based on personal air monitoring, median potential inhalation doses of 11.0 and 2.3 ng/day were estimated for the winter and summer/fall studies, respectively. A median potential ingested dose of 176 ng/day, estimated from "duplicate plate" sampling, exceeded inhalation by 6- and 122-fold for the winter and summer/fall studies, respectively. "Total" urinary BaP metabolites were measured using a published "reverse metabolism" (BaP) method of analysis. Median rates of urinary BaP metabolite elimination for the winter and summer/fall studies were 121 and 129 ng/day, respectively. The changes in inhaled and ingested potential doses were regressed on the change in urinary metabolite elimination from week 1 to week 2 to test the predictive validity of the biomarker measurement. The regression was statistically significant (r = 0.620, p = 0.015, n = 25) when body weight was included and two extreme values were removed. Consistent with the exposure measurements showing diet as the dominant route of exposure, most of the variation in urinary metabolite elimination was explained by the ingested dose. It is concluded that the measurement of urinary BaP by "reverse metabolism" is qualitative and of marginal predictive validity as an exposure biomarker due to the method's low recoveries and the large unexplained variance.

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The Total Human Environmental Exposure Study (THEES) was an investigation of multimedia exposure to the ubiquitous environmental carcinogen, benzo(a)pyrene (BaP). The three-phase study was conducted in Phillipsburg, New Jersey and involved the participation of 14-15 individuals (8-10 homes) during each 14-day monitoring period. Microenvironmental sampling of air, food, water and soil indicated that environmental exposure to BaP was primarily through air and food. Exposure and risk estimates were, therefore, based on the results of personal monitoring of breathing zone air and prepared food samples. Based on a comparison of the range and magnitude of inhalation and dietary BaP exposures, food ingestion was clearly the predominant exposure to pathway. The relative contributions of other potential sources of community exposure to BaP (e.g., soil and drinking water ingestion) were also assessed. The excess cancer risk estimates for food ingestion were consistently greater than those for personal air, reflecting both the predominantly higher BaP exposures through the diet and the higher carcinogenic potency value for oral exposure. Overall, the total lifetime risk from personal exposure to BaP for nonsmokers in the community was estimated at 10(-5). In identifying risk reduction options, it is important to account for the observation that personal activities, lifestyle, and diet strongly influenced individual exposures to BaP.

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Self-completed recall diaries have become a common tool in epidemiology and exposure assessment to determine the location and/or activities of subjects during study periods. Unfortunately, little effort has been made to determine the accuracy of such an approach for providing information without significant bias. It is usually assumed that subjects are truthful and complete in their recall. An electronic datalogger has been designed to allow subjects to record location changes as they occur in real time. Subjects carried the datalogger for 3-5 days and completed recall diaries at the end of each day. The concordance between the two records was found to be relatively good for the most commonly visited locations, e.g., bed/bath, workplace, etc. Poorer agreement was found for locations of short or infrequent visits, e.g., cellar or vehicle. The merits and shortcomings of the datalogger approach are discussed. While having external validation for recall diary records is clearly necessary, reliance on subject input to the datalogger presents its own problems related to subject compliance. Electronic approaches which do not require active subject input are recommended to aid in the evaluation of recall diaries.

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It is thought that gaseous ammonia in breath neutralizes acidic air pollution and thereby potentially mitigates the pulmonary effects of pollution. The efficacy of breath ammonia depletion methods reported in recent acid aerosol exposure-health response studies was investigated. Fourteen subjects (21 to 54 y of age) performed one or more of the following hygiene maneuvers: (a) acidic oral rinse (pH 2.5); (b) tooth brushing, followed by acidic oral rinse; (c) tooth brushing, followed by distilled water rinse; and (d) distilled water rinse. Initial ammonia levels ranged from 120 to 1,280 ppb (147-1,570 micrograms/m3). Acidic rinsing resulted in an immediate 90% reduction in exhaled ammonia in all subjects, and a return to 50% of baseline levels occurred within 1 h. Depletion that resulted from tooth brushing or distilled water alone was not significant. It was concluded that acidic oral rinsing is an effective method of reducing airway ammonia, but repeated oral rinsing may be required to maintain consistent, low-breath-ammonia conditions during acid aerosol exposure studies.

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A personal radon monitor (PRM) has been developed and validated for use in studies of residential 222Rn exposure. A pilot study was performed in six New Jersey homes with elevated Rn concentrations. Occupants wore PRMs, and identical monitors were placed in many rooms of the home. Extensive assessment of PRM performance has been done. A simple model for personal Rn exposure has been tested and measured occupant exposures have been compared with stationary Rn measurements. The PRM works well, with precision limited by the counting error in the exposure range examined (2-100 kBq m-3 h). The PRM sensitivity is 2.2 kBq m-3 h, and its efficiency is 2.6 tracks (kBq m-3 h)-1 per 81 mm2 film.

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As part of the Total Human Environmental Exposure Study (THEES), a self-administered questionnaire was developed to identify sources of exposure to BaP and PM-10. Thirteen participants in ten households completed a daily personal activity log for fourteen consecutive days during January 1988. Validation of the instrument was obtained in three ways: internal questionnaire checks, comparison with pre-sampling estimates of time/activity patterns, and comparison with earlier studies. The log was found to be easy for participants to use and reliable in most of its questions. Effectiveness of the log in identifying sources of exposure was enhanced by having most responses in the form of continuous variables. While most of personal exposure to both BaP and PM-10 could be attributed to outdoor sources, a variety of household sources and personal activities were also identified. Higher levels of PM-10 were associated with use of unvented kerosene space heaters and coalstoves, stove-top cooking, ETS, and house cleaning. Personal exposure to BaP was primarily associated with ambient levels, and secondarily with ETS, coalstove use, and cooking activities.

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The Total Human Environmental Exposure Study (THEES) focuses on benzo(a)pyrene (BaP) as an example of a combustion-generated polycyclic aromatic hydrocarbon (PAH) compound. Primary pathways for environmental exposures to BaP are inhalation and ingestion. This program of field studies was conducted in Phillipsburg, New Jersey, a small, industrial city in the Delaware River valley. The study protocols included direct monitoring of BaP exposures via inhalation and ingestion pathways during three separate periods, each lasting 14 days. BaP concentrations in air were sampled at outdoor and in-home locations, with personal air sampling added during the latter two phases. Cooked food samples from each household were acquired, using a constant portion "second plate" of each meal prepared at home. Ambient levels were 4-10 times higher during the cold months compared with the late summer study period. Space heating and regional aerosol were major contributors to community levels of BaP in the air during the wintertime. Penetration of outdoor air, cooking activities, combustion appliances, and cigarette smoke were important sources of indoor air exposures. Cooking activities, besides releasing BaP-enriched particles indoors, produced food imbued with BaP and added substantially to exposure via the ingestion route. Among the study subjects, the range and magnitude of dietary exposures (2 to 500 ng/d) were much greater than for inhalation (10 to 50 ng/d). Nevertheless, there were ample individual cases where inhalation of BaP was the predominant exposure route. Indoor air BaP levels were closely correlated with ambient levels in most of the homes. For some individuals, measured personal air BaP exposures were adequately predicted by time-weighting of microenvironmental (i.e., outdoor and in-home) concentrations. However, enormously high exposures for ingestion or inhalation were detected only by direct observation, not from microenvironmental data.

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Exposures to acidic aerosol in the atmosphere are calculated from data reported in the scientific literature. The majority of date was not derived from studies necessarily designed to examine human exposures. Most of the studies were designed to investigate the characteristics of the atmosphere. However, the measurements were useful in defining two potential exposure situations: regional stagnation and transport conditions and local plume impacts. Levels of acidic aerosol in excess of 20 to 40 micrograms/m3 (as H2SO4) have been observed for time durations ranging from 1 to 12 hr. These were associated with high, but not necessarily the highest, atmospheric SO4(2)- levels. Exposures of 100 to 900 micrograms/m3/hr were calculated for the acid events that were monitored. In contrast, earlier London studies indicated that apparent acidity in excess of 100 micrograms/m3 (as H2SO4) was present in the atmosphere, and exposures less than 2000 micrograms/m3/hr were possible. Our present knowledge about the frequency, magnitude, and duration of acidic sulfate aerosol events and episodes is insufficient. Efforts must be made to gather more data, but these should be done in such a way that evaluation of human exposure is the focus of the research. In addition, further data are required on the mechanisms of formation of H2SO4 and on what factors can be used to predict acidic sulfate episodes.

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The assessment of human exposure to an environmental contaminant requires the measurement of levels present in each pathway of possible contact. In this paper, the design considerations and Phase I results of a human exposure study focused on Benzo(a)pyrene (BaP) are discussed. This study site, located in Phillipsburg, New Jersey, is a city that contains a metal pipe foundry, which is a suspected major source of BaP. Three outdoor PM-10 samplers (used to collect BaP-containing particles with an aerodynamic size of less than or equal to 10 micron) were located in residential areas surrounding the foundry. Ten homes were sampled indoors for PM-10. Some homes have indoor combustion sources, e.g., cigarette smoke or a coal burning stove. The indoor and outdoor samples were 24 hr in duration. The mean outdoor concentration of BaP was 0.9 ng/m3, and the indoor concentrations ranged from 0.1-8.1 ng/m3. Food samples were acquired from family meals each day. They represented a one-third portion of each meal eaten at home. The range of BaP per gram of wet weight of food was between 0.004 and 1.2 ng/g. Of the 20 wk of exposure (10 x 2 wk), 10 had higher food exposures and the other 10 had higher inhalation exposures. Of the two groups, the higher food exposures usually had a greater number of ng of BaP/wk. The dominance of one or the other pathway appeared to depend upon personal eating habits and indoor combustion source use. In some instances, outdoor air pollution led to a major portion of indoor air BaP exposures. Water appears to be a minor source of BaP exposures in the study area.

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Fog water collected at three sites in Los Angeles and Bakersfield, California, was found to have higher acidity and higher concentrations of sulfate, nitrate, and ammonium than previously observed in atmospheric water droplets. The pH of the fog water was in the range of 2.2 to 4.0. The dominant processes controlling the fog water chemistry appear to be the condensation and evaporation of water vapor on preexisting aerosol and the scavenging of gas-phase nitric acid.

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