Western Occupational & Environmental Medical Association
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Leading Occupational & Environmental Medicine

eNewslertter – December 2009

Welcome to WOEMA’s new monthly e-newsletter. After over 50 years, gone is WOEMA’s printed newsletter for this new electronic format. WOEMA is committed to providing on-going communications to members while reducing its carbon footprint by eliminating paper usage. WOEMA members receive the full version of the newsletter every other month. It includes links to pertinent information. Below are just a few of the items contained in the recent issues. — Peter Swann, MD, FAAFP, Newsletter Editor

Message from the President
eNews
Who’s Who in OEM
News You Can Use from Dr. Gean 

Membership Survey


Messsage from WOEMA President Steve Schumann, MD

Year 2009 is coming to a close and it has been a terrific twelve months for WOEMA. Your Board began the year with its January meeting at Association headquarters in San Francisco. We established a theme that would percolate through all plans and activities in 2009, i.e., “Value to Members.” Our commitment was, and is, to assure that everything we would do would translate into additional value for WOEMA members – and I know we were successful.

Right out of the gate, several committees formulated exciting and creative plans that would benefit membership. The Web Site Committee under Co-Chairs Sachin Kapoor and Hong Zhang significantly upgraded our web site with new format and content as well as added networking capability through Twitter and Face Book.

The Education Committee under sterling leadership of Leslie Israel achieved great success in developing and implementing web based educational programs.

Scott Levy was triumphant in the chronically underappreciated role of membership chair, nearly single handedly maintaining our membership level while most other organizations suffered a decline.

Legislative Affairs Committee added Co-Chair Paul Papanek who teamed with Legislative AdvocateDon Schinske to develop a policy platform that would outline WOEMA goals, later adopted in part by ACOEM. The LA Committee leadership also participated in a variety of legislative and regulatory activities through membership in the CMA Work Comp TAC as well as meeting with the Division of Workers’ Compensation regarding upcoming changes in the California Fee Schedule. We were similarly active where able in UT, AZ, NV and HI.

WOHC 2010 exceeded all expectations regarding quality of presentations, venue, and attendance as well as satisfying the Board fiduciary responsibility. Chair Peter Vasquez and Operations Manager Shannon Jamieson provided exceptional direction.

The final Board meeting at WOHC 2009 implemented two important items: 1) development of a strategic plan that will keep us focused on continuing to assure Value to Members, and 2) a new WOEMA leadership plan authored by Roman Kownacki that will support the continued pipeline of excellent leaders, including opportunities for advancement to ACOEM.

Our crowning achievement was earning accreditation through the IMQ, a subsidiary of the CMA, to issue Continuing Medical Education for our own programs as well as others where we collaborate. That accomplishment came as a result of much hard work by many, particularly Education Chair Leslie Israel and Education Committee which included: Dennis Pocekay, Rupa Das, Paula Lenny.

Finally, we continued to enjoy superb administrative leadership from Kerry Parker, Shannon Jamieson and their team at the WOEMA headquarters. Their leadership and support we felt in every project, and in fact, Kerry’s talent was recognized at AOHC 2009 in San Diego where she was awarded the President’s ACOEM Award, first ever to a non-physician. Richly deserved.

So, 2009 has been a great year. We are alive and well and 2010 looks even better. Paul Papanek as our new President is ready to go and we have an even broader and deeper leadership team in place. We invite you to join us as active participants. Let us know you are interested.


E-News

Almaraz-Guzman II: The decision by the CA Workers Compensation Appeals Board – what it means, its impact, and how to drive accurate impairment ratings.  A WOEMA member’s opinion: by Steven D. Feinberg, MD

Airborne Transmissible Disease Safety Standards: California’s new standards are the first specific regulatory response, at either the state or federal level, to worker safety in the face of diseases such as SARS, H1N1, tuberculosis, and West Nile virus.

Lead Standards: WOEMA has been invited to take the lead in petitioning state for new lead standards, a process that could take 4-5 years. Last year, WOEMA worked with the CA DPH to develop Medical Guidelines for the Lead-Exposed Worker.

The AMA Guides – Sixth Edition emphasizes the fundamental skills physicians need to evaluate and communicate patient impairements. ACOEM member price is $132.


 Who’s Who in OEM

Sokas

Meet Rosie Sokas, MD, MOH, Director, Office of Occupational Medicine, Occupational Safety and Health Administration. Dr. Sokas presented an update on the OSHA recordability requirements at the recent Western Occupational Health Conference in Scottsdale, AZ on September 11, 2009.Dr. Sokas re-joined the Occupational Safety and Health Administration in November, 2008, as Director of the Office of Occupational Medicine in the Directorate of Technical Support and Emergency Management, a position she previously held from 1997-1999. She has in the past served as Lead Medical Officer and as the Associate Director or Science at the National Institute for Occupational Safety and Health. She received her M.D. from Boston University School of Medicine, her M.Sc. and M.Occ.H from the Harvard School of Public Health and is board-certified in occupational medicine and in internal medicine. She currently holds a research professorship at the University of Illinois at Chicago School of Public Health. AT UIC she has held a tenured professorship, directed the Division of Environmental and Occupational Health Sciences and founded and directed the Illinois Public Health Research Fellowship Program. Prior faculty appointments include the University of Pennsylvania School of Medicine, where she directed the hypertension detection and screening clinic at the Philadelphia VA, and at the George Washington University School of Medicine and Health Sciences, where she directed the occupational medicine residency program, provided physician consultation for the hospital employee health service and directed the Institute for the Environment.


News You Can Use from Dr. Gean – October 2009
Compiled by Constantine J. Gean, MD, MS, MBA, FACOEM, Regional Medical Director, Liberty Mutual 


Within 14 days after a single dose, the monovalent influenza A (H1N1)
 2009 MF59-adjuvanted vaccine generates antibody responses likely to be associated with protection per preliminary analyses of 175 adults, 18 to 50 years of age, testing the monovalent influenza A/California/2009 (H1N1) surface-antigen vaccine, in both MF59-adjuvanted and nonadjuvanted forms. The most frequent reactions were pain at the injection site (70%) and muscle aches (42%).
N Engl J Med. 2009 Sep 10 [Epub ahead of print] Source

At 7 to 10 years after discography, increased new disc herniations, accelerated disc degeneration, loss of disc height and signal and the development of reactive endplate changes were seen compared to matched controls in a prospective, match-cohort study of seventy-five subjects without serious low back pain who underwent discography (L3/4, L4/5, and L5/S1) in 1997. At 7 to 10 years after baseline assessment, cohorts meeting criteria (50 discography and 52 controls) had another MRI examination. MRI graders, blind to group designation, scored both groups for qualitative and quantitative findings. Comparing discography patients vs. matched controls, results were: disc herniations – 55 new vs. 22 in the control group (new disc herniations were disproportionately found on the side of the anular puncture); disc degeneration-54 discs (35%) vs. 21 (14%). Spine 2009; 2009 Sep 14. [Epub ahead of print] Source

The FDA has approved for males aged 9-26 the use of the vaccine Gardasil for the prevention of genital warts due to human papillomavirus
 (HPV types 6 and 11) based on a randomized trial of 4,055 males ages 16 to 26 years old indicating Gardasil was nearly 90 percent effective in preventing genital warts caused by HPV types 6 and 11. (Gardasil currently is approved for use in girls and women ages 9 to 26 for the prevention of cervical, vulvar and vaginal cancer; precancerous lesions caused; and genital warts. Gardasil is given as 3 shots over 6 months. FDA NEWS RELEASE, Oct. 16, 2009 Source

The retrovirus, XMRV, was detected in 67% of 101 patients with chronic fatigue syndrome (CFS) and in only 4% of healthy comparison subjects assessed by studying peripheral blood mononuclear cells from CFS patients. Authors identified DNA from a human gammaretrovirus, xenotropic murine leukemia virus-related virus (XMRV), in 68 of 101 patients (67%) compared to 8 of 218 (3.7%) healthy controls. Cell culture experiments revealed that patient-derived XMRV is infectious and that both cell- associated and cell-free transmission of the virus are possible. Sciencexpress / 8 October 2009 / Page 1 / 10.1126/science.1179052  Source 

A case of maternal-fetal cancer transmission, confirmed by genetic testing, was reported in the PNAS. A month after  an uneventful pregnancy, a 28-year-old Japanese woman was diagnosed with acute lymphoblastic leukemia and died. The baby showed no signs of illness until11 months when she developed a swollen right cheek – tests revealed jaw and lung tumors. Genetic analysis showed a clonal match of mother and infant cancer cells (routine delivery blood collection showed the infant had the cancer cells at birth). PNAS Online / October 12, 2009 Source

Vertebroplasty surgery did not significantly affect the patient’ disability or pain per a study of 120 patients with back pain and vertebral fractures identified on imaging divided into 2 groups. The first group had the regular surgery done including injecting cement (experimental group) and the second group had everything the first group had except did not have cement injected in to the vertebra (placebo group). One month following surgery both groups reported statistically indistinguishable decreases in disability and pain. NEJM(361), 569-79 Source

Vaccination with ALVAC and AIDSVAX to Prevent HIV-1 Infection demonstrated a vaccine efficacy of 31.2% (P=0.04) in the modified intention-to-treat analysis involving 16,395 subjects where vaccine and placebo injections were administered to healthy men and women between ages 18 and 30 years in Thailand. End points of HIV-1 infection and early HIV-1 viremia, were assessed every 6 months for 3 years. The authors concluded that this combination of two vaccines (each not found to be effective  by itself) may reduce the risk of HIV infection in a community-based population with largely heterosexual risk. www.nejm.org October 20, 2009 (10.1056/NEJMoa0908492) Source

For non-radicular back pain with DJD, fusion is no better than intensive rehabilitation and, following fusion, less than half of patients have good outcomes with respect to  improvement in pain or function (i.e., only sporadic pain, slight loss of function, and occasional analgesics). Per a systematic review of all relevant studies on Ovid, MEDLINE and the Cochrane databases conducted through July 2008. The review found fair evidence that fusion is slightly to moderately superior to standard (nonintensive) nonsurgical therapy. For radicular back pain with HNP–the review  found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. And for spinal stenosis with back pain–the review  found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. Chou R – Spine (Phila Pa 1976) – 1-MAY-2009; 34(10): 1094-109 Source

For chronic pain patients, collaborative intervention with pain treatment resulted in modest but statistically significant improvement in a variety of outcome measures per a study of 401 patients at a VA Medical Center with musculoskeletal pain diagnoses and disability lasting 12 weeks or longer. 42 primary care CLINICIANS were randomized to the ‘assistance with pain treatment’ group or the ‘treatment as usual’ group. In the ‘assistance’ group clinicians received a 2-session clinician education program, patient assessment assistance, education and activation, symptom monitoring, feedback and were provided recommendations by specialists. The the ‘treatment as usual’ group followed standard practice without additional assistance. All patients were treated for one year by one of the groups. The ‘assistance’ group patients showed greater improvements in pain-related disability and CPG Pain Intensity (subscale beta) and greater improvement in depression severity. JAMA – 25-MAR-2009; 301(12): 1242-52 Source

Automated telephone reminders increase repeat mammography rate over printed and letter reminders, though all increase adherence rate by an average 17.8% per a study of 3547 women aged 40-75 yrs with a baseline screening mammogram assigned randomly to one of three reminder groups: (1) printed enhanced usual care reminders; (2) automated telephone reminders; or (3) enhanced letter reminders – each was delivered 2-3 mo. prior to women’s mammography due dates. Each intervention produced adherence proportions that ranged from 72% to 76% (an increase of 17.8% from baseline). Am J Prev Med. 2009 Jun;36(6):459-67. Epub 2009 Apr 11 Source

An investigation of 6 cases determined that the children were exposed to lead dust in family vehicles and in child safety seats. The 6 cases (in 5 families) were a subset of the 2008 the Maine MCLPPP which identified 55 new cases of elevated (≥15 µg/dL) venous blood lead levels among children < 6 years old. Among the 5 families, contacts included 4 persons who worked in painting and paint removal and one who was a self-employed metals recycler. Proper washing of work clothing, thorough vacuuming and wet cleaning of te vehicle interiors, and replacement of any child safety seat that tested positive for lead dust were recommended. MMWR, August 21, 2009, Source

An increase in diagnosed stage III melanomas is anticipated when the new American Joint Committee on Cancer (AJCC) classification system takes effect. The new system endorses immunohistochemical detection of nodal metastases (including micrometastases, not previously included), and there will no longer be a lower limit for the definition of nodal disease. Other changes in the 2010 AJCC melanoma classification system include (1) Mitotic rate will be an independent prognostic factor, (2) Clark’s level of invasion is being eliminated, and (3) isolated metastases arising from an unknown primary site will be classified as stage III, not stage IV. Semin Oncol. 2002 Aug;29(4):361-9 Source


WOEMA Membership Survey


Who Is WOEMA?

WOEMA conducted an on-line survey in July 2009 to assess member interests and needs. The results showed that a majority of members are in a private practice group, and half of these are in multi-specialty groups….88% are primarily practicing occupational medicine. Most members are providing primary and specialty care. 14% are doing Utilization Review. Just over 40% of the members surveyed have been in practice for over 20 years and most are located in California. The vast majority of members are board-certified. 51% of members responding are MROs and 14% are QMEs.

What are the top five concerns of WOEMA members?

#1 – Fee Schedule
#2 – Improvement in insurance regulations and procedures
#3 – Improving Medical Educational Funding
#4 – The “Marketing” of Occupational Medicine
#5 – Workplace Safety Regulations

What worries you?

#1 – Healthcare Reform
#2 – Government Regulation
#3 – Economic downturn and job insecurity