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Extravasation of some agents can cause severe soft-tissue injury, consisting of necrosis and sloughing of exposed areas (Duvall and Baumann, 1980; Perry, 2008; Rudolph, 1979). Other HDs, such as zidovudine (formerly AZT), are known to have significant side effects (i. e., hematologic abnormalities) and some monoclonal antibodies (biologics) may cause malignancy and reproductive effects in treated patients (Anderson, 1982; Henderson and Gerberding, 1989; Hansel, 2010).

Initial air sampling results often showed very low concentrations of measurable HDs. However, they were questioned because of evidence suggesting that sampling methods were not sufficiently robust to capture drug that existed not only as a particulate, but also in gaseous form emanating from high efficiency particulate arrestor (HEPA) filters (Larson, 2003; Kiffmeyer, 2002) through sublimation.

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With the development of sensitive assays for certain marker HDs, the past several decades have seen a large effort to assess HD work environments using wipe samples of work surfaces, such as BSCs and countertops, and of the wider work environment, such as floors and door handles. These studies frequently found widespread contamination (Minoia, 1998; Connor, 1999; Hedmer, 2004; Nygren and Aspman, 2004). click to book plumber in .

For example, one multi-site study in the U.S. and Canada found that 75 percent of samples in pharmacies and 65 percent in nursing treatment areas showed measurable results of HDs (Connor, 1999). More than 80 studies of the ambient work environment have been published during the past few decades, with the majority having yielded detectable results for at least one of several drugs for which sampling was performed.

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cdc.gov/niosh/topics/antineoplastic/sampling. html. Several studies also linked environmental sampling results to bio-monitoring results of drug levels in workers' urine, documenting an uptake of drug levels in contaminated work environments (Minoia, 1998; Wick, 2003; Mason, 2005; Connor, 2010; Hon, 2015). These studies raise the question of whether the skin contact pathway may be not only a common but also biologically important exposure route of absorption for under-protected workers for at least some agents (Kromhout, 2000).

The special case of administration of drugs via aerosol nebulizer treatment can lead to measurable air concentrations in the breathing zone of workers who provide the treatment (Harrison, 1988) and, depending on the medication, air concentrations may result in symptoms in exposed workers (Balmes, 1995). Aerosolized medication safety recommendations are available from the Society of Infectious Disease Pharmacists (Le, 2010).

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were the first to note evidence of mutagenicity in the urine of nurses who handled cytotoxic drugs (Falck, 1979). This effect increased over the course of the work week, implying a dose-response. With improved handling practices, a decrease in mutagenic activity was seen (Falck, 1981). Researchers have also studied pharmacy personnel who reconstitute antineoplastic drugs.

They also found that mutagenicity in workers using horizontal laminar flow hoods (which blow into the face of the preparer) decreased to control levels with the use of vertical flow containment hoods, which protect the breathing zone of the preparer and now represent standard equipment (Nguyen, 1982). While the earlier literature focused on various methods for indirectly documenting worker exposure, such as the urine mutagenicity studies described above, more recent studies have used actual bio-monitoring of exposed workers to measure specific agents or their metabolites in body fluids.

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However, bio-monitoring studies present their own challenges. These include the selection of the agent(s) to be measured when oncology clinical workers handle multiple different drugs each day and choosing timing of sample collection in light of the drugs' half-life and elimination kinetics in the body. Nevertheless, positive results are undeniable evidence of drug uptake by workers.

Thus, bio-monitoring is generally not included in post-spill assessment. In the past thirty years, bio-monitoring studies have become quite commonplace, with more than 100 reports in the literature, about two-thirds of which documented drug uptake by measuring these drugs or their metabolites in the urine of at least some exposed HCWs - click to book plumber in .

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Since the 1995 OSHA guidance was issued, scores of studies have been published assessing cytogenetic effects on workers, including chromosomal aberrations, with the majority documenting an excess of cytogenicity markers of (Baker and Connor, 1996; Sessink and Bos, 1999; Connor and McDiarmid, 2006; Suspiro, 2011). Differing results between the studies are to be expected given the challenge of quantitating exposure and the variability in personal protective equipment (PPE) use and work practices.

A variety of markers for genetic damage have been examined since 1995 (see https://www. cdc.gov/niosh/topics/antineoplastic/), including sister chromatid exchange (SCEs), a measure of point mutations. More recent evidence suggests that structural chromosomal damage (e. g., gaps, breaks, translocations and copy number differences (aneuploidy)) may be prognostic of an increased cancer risk at least when considered on a population basis (i.