Western Occupational & Environmental Medical Association
Leading Occupational & Environmental Medicine

e-Newsletter – October 2011

Welcome to WOEMA’s 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 newsletter via email every other month with contents appearing on this website. This e-newsletter includes links to pertinent information. Contributions from members of articles, photos, links may be sent to:woema@woema.org  — Peter Swann, MD, FAAFP, Newsletter Editor

– President’s Message
– ACOEM Election Opens November 1
– WOEMA Board Election Ballots Arriving Soon
– News You Can Use from the Literature
– California Fee Schedule Bill Update
– Chronic Pain Use: Comparison of Current Guidelines

President’s Message: WOHC in Las Vegas a Big Win for WOEMA!
Roger Belcourt, MD, MPH, FACOEM

If you attended this year’s WOHC, you know first-hand what a tremendous conference it was. Special thanks goes to Conference Chair Paula Lenny, MD, and her committee who devoted a year in planning to bring it together so well. Their dedication paid off in spades as demonstrated by the outstanding evaluations we received. Everything from the CME sessions, to the worksite tours, to the special events, and networking made it a big win for all of us in WOEMA. If you missed it or want to re-visit some of the presentations, you can download PDFs of the speaker presentations. [Download] We hope you’ll join us next year in San Francisco at the InterContinental Hotel, September 13-15, 2012. [Watch video]

ACOEM Election Opens November 1

Ballots for the ACOEM Board election can soon be accessed through www.acoem.org. Voting will be open from November 1 through December 15. Notice is provided in the ACOEM E-News and this year, members will also be reminded about the upcoming election in a general information mailing. Don’t forget to cast your vote. Two WOEMA members are candidates for election: Steven Pike, MD andMichael Fischman, MD.

WOEMA Board Election Ballots Arriving Soon

WOEMA Members approved the slate of candidates as presented to the membership at the Annual Business Meeting held at the Western Occupational Health Conference in Las Vegas on September 9, and a mail ballot will be sent out within the next two weeks. Candidates for uncontested postions are: Peter Vasquez, MDRamon Terrazas, MDWilliam Lewis, MD, and Sachin Kapoor, DO. Runnng for two contested director positions are four candidates: Bryce Breitenstein, MD, Anne Searcy, MD, Robert Blink, MD, and Steven Feinberg, MD.

News You Can Use From the Literature
by Constantine J. Gean, MD, MS, MBA, FACOEM


A useful review of the latest journal articles of interest to the field of occupational medicine.

Current evidence is “insufficient” to assess the balance of benefits and harms of prostate cancer screening PSA testing for healthy men younger than age 75 years of age
 per the conclusions of the U.S. Preventive Services Task Force (USPSTF) in an update of their 2002 prostate cancer recommendations based on evaluation of randomized, controlled trials of the benefits of prostate cancer screening; cohort and cross-sectional studies of the psychological harms of false-positive prostate-specific antigen test results; and evidence on the natural history of prostate specific antigen-detected prostate cancer. In men age 75 years or older, the USPSTF recommends against screening for prostate cancer. The USPSTF concludes that for men younger than age 75 years, the recommendation is,No Recommendation based on a conclusion that the quality of the current evidence is “Grade: I (Insufficient Evidence)”. Ann Intern Med. 2008 Aug 5;149(3):185-91 [Read Here] and [Read Here]

Apples and pears can reduce stroke risk by 52% per a 10-year prospective, population-based cohort study, including 20,069 men and women aged 20 to 65 years and free of cardiovascular diseases at baseline. Participants completed a validated, 178-item food frequency questionnaire. Cox proportional hazards models indicated that higher intake of white fruits and vegetables was inversely associated with incident stroke (HR =0.48). Each 25-g/d increase in white fruit and vegetable consumption was associated with a 9% lower risk of stroke (HR=0.91).  Stroke. 2011 Sep 15. [Epub ahead of print]

A living, tissue-engineered intervertebral disc (IVD) composed of a gelatinous nucleus pulposus surrounded by an aligned collagenous annulus fibrosus placed in the caudal spine of rats for up to 6 months was evaluatedWhen implanted into the rat caudal spine, tissue-engineered IVD maintained disc space height, produced de novo extracellular matrix, and integrated into the spine, yielding an intact motion segment with dynamic mechanical properties similar to that of native IVD. Authors conclude studies demonstrate the feasibility of engineering a functional spinal motion segment and represent a critical step in developing biological therapies for degenerative disc disease.  Proc Natl Acad Sci U S A. 2011 Aug 9;108(32):13106-11. Epub 2011 Aug 1. [Read Here]

5 to 6 blood pressure measurements averaged together was optimal to greatly reduce within-patient variability of BP measurements per a study of 111,181 systolic BP measurements (3,218 research, 7,121 clinic, and 100,842 home measurements) over 18 months in 444 veterans with hypertension followed for 18 months. Ann Intern Med. 2011 Jun 21;154(12):781-8, W-289-90 [Read Here]

Gastric-bypass surgery linked to alcoholism (HR 1.7), depression (hazard ratio [HR], 1.9), suicide (HR, 2.7), and substance abuse (HR, 2.7), per a retrospective cohort study compared 12,277 patients followed for an average of 9 years who underwent antiobesity surgery in Sweden between 1980 and 2006 with a matched control cohort of 122,770 people sampled from the general population. The primary surgical procedures were gastric bypass, vertical banded gastroplasty, and gastric banding, which were conducted in almost equal proportions. Gastric-bypass patients were more at risk for abusing alcohol than those who had restrictive procedures, such as banding. [Read Here]

LAP-BAND Adjustable Gastric Banding (LAGB) appears to result in a mean excess weight loss of 42.8% in 54.3% of patients after 12 years or longer; however, nearly 1 out of 3 patients experienced band erosion, and nearly 50% of the patients required removal of their bands (contributing to a reoperation rate of 60%. 151 patients started the study with 82 followed for the whole period. 60.3% were satisfied with neutral quality-of-life index , however, authors conclude LAGB appears to result in relatively poor long-term outcomes. Arch Surg. 2011 Jul;146(7):802-7. Epub 2011 Mar 21. [Read Here]

About half of the states are at risk of dengue fever outbreaks and the US faces increasing health threats from climate change per an analysis by the Natural resources Defense Council (NRDC) of data from the US Centers for Disease Control and Prevention and the National Climatic Data Center found that because of climate change. At least 28 states have been colonized by mosquitoes associated with Dengue and an estimated 173.5 million people live in these areas. Only 3 states (FL, MD, and VA) have plans for dealing with this potential threat. Other climate-related health risks include heat exhaustion, flooding injuries, and increased smog worsening asthma and lung disease. The NRDC has posted maps online that allow assessment local risks. [Read Here] and [Read Here]
Women with a healthy lifestyle likely to live 15 years longer than those less healthy, and men 8.4 years longer from an multivariate case-cohort analysis
 based on 9,691 deaths from a 1986 a cohort of 120,852 men and women aged 55-69 y who provided information on dietary and other lifestyle habits. Mortality was followed-up until 1996. A healthy lifestyle” score, comprising four factors (not smoking, being physically active for at least 30 minutes a day, BMI between 18.5 and 25, and adhering to a Mediterranean diet (including limiting alcohol to 0.5 to 2 glasses a day) was assessed and highest to lease quartiles were compared. Expressed as an “aging effect”, the least healthy women had the same risk of death as the healthiest women who were 15.1 years older (95% CI: 9.9, 20.2 y). In men this effect was 8.4 years (95% CI: 5.0, 11.8 y). Am J Clin Nutr. 2011 Sep;94(3):913-20. Epub 2011 Jul 27.[Read Here]

Diabetic patients with spinal stenosis (SpS) and degenerative spondylolisthesis (DS) benefited from spinal surgery, though intervertebral disc herniation (IDH) patients with diabetes did not benefit from surgical intervention per a study of Baseline characteristics and outcomes of 199 patients with diabetes were compared a nondiabetic population in a total of 2,405 patients operated on for either IDH, SpS, or DS. Older patients with diabetes had more postoperative complications. Spine 2011;36:290-307. [Read Here]

Clinical pharmacogenomics – as companies seek expanded access to genetic information, the US FDA Center for Drug Evaluation and Research (CDER) issued a guidance document for comment to the pharmaceutical industry and other investigators evaluating how variations in the human genome could affect the clinical responses of drugs. Three specific examples were cited in the document: (1) The HIV drug Abacavir produces a hypersensitivity reaction in the 5%-8% of patients with HLA-B*5701 allele (2) Clopidogrel (Plavix), has a genetic CYP2C19 allele linked to reduced production of active metabolite and poorer clinical responses, and (3)with Warfarin, variations in the cytochrome P450 enzyme CYP2C9 and in the VKORC1 gene account for a substantial part of the variability in warfarin’s effect in patients. [Read Here]
Multidetector computed tomography (MDCT) is a useful test for routine evaluation of suspected appendicitis
in adults per a study of 2,871 consecutive adult patients adults referred for MDCT for suspected appendicitis from January 2000 to December 2009. 675 of 2,871 patients (23.5%) had confirmed acute appendicitis. The sensitivity, specificity, and negative and positive predictive values of MDCT were 98.5%, 98.0%, 99.5%, and 93.9% respectively. Ann Intern Med. 2011 Jun 21;154(12):789-96, W-291. [Read Here]

Mobile phone text-message reminders improved management by 23.7% immediately after intervention, and by 24.5% 6 months later, for a Kenyan rural health malaria control program assessed by a a cluster-randomized controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. Facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for 6 months, or the control group, in which health workers did not receive any text messages. Management success was determined by assessment of correct treatment, dispensing, and counseling tasks concordant with Kenyan national guidelines. Lancet 2011 Aug 27;378(9793):795-803. Epub 2011 Aug 3. [Read Here]

Dietary supplementation with vitamin E significantly increased the risk of prostate cancer among healthy men per a randomized study of 35,533 men between 8/22/01 and 6/24/04 with pre-study PSAs of 4.0 ng/mL or less, a negative digital rectal examination, and age 50 years or older for black men and age 55 years or older for all others. The absolute increase in risk of prostate cancer per 1,000 person-years was 1.6 for vitamin E supplemented patients. JAMA. 2011 Oct 12;306(14):1549-56. [Read Here]

Early stage diabetes reversible with two month 600 calorie per day diet per a study of 11 volunteers (patients: age 35-65 years, HbA1c 6.5-9.0%, diabetes duration [Read Here]
FDA allowed unsafe seafood onto market after bp oil spill disaster per a report charging FDA’s levels of concern significantly underestimate risk from seafood contaminants among sensitive Gulf Coast populations
 by failing to: (1) account for the increased vulnerability of the developing fetus and child; (2) utilize appropriate seafood consumption rates; (3) include all relevant health endpoints; and (4) incorporate health protective estimates of exposure duration and acceptable risk. For benzo(a)pyrene and naphthalene, revised levels of concern are between 2-4 orders of magnitude below the level set by FDA. Comparison of measured levels of PAHs in Gulf seafood with the revised levels of concern, revealed that up to 53% of Gulf shrimp samples were above levels of concern for pregnant women who are high end seafood consumer. Environ Health Perspect. 2011 Oct 12. [Epub ahead of print]

Women eating a better diet leading up to pregnancy are less likely to have babies with birth defects per a study of 3,400 women who had a baby with a neural tube defect or a cleft lip or palate and 6,100 normal control deliveries studied from Oct., 1997 through Dec., 2005. Women with a diet closely matched to the USDA Food Guide Pyramid were half as likely to have a baby with anencephaly than women whose diet was farthest from those guidelines, and were 34% percent less likely to have a baby with cleft lip and 26% less likely to have one with cleft palate. Arch Pediatr Adolesc Med. 2011 Oct 3. [Epub ahead of print]
For gastric bypass patients, mortality from any cause vs. controls decreased by 40% during a mean follow up of 7.2 years , (37.6 vs. control 57.1 deaths per 10,000 person-years
 , aka, 10k p-y); mortality in the surgery group decreased by 56% for CAD (2.6 vs. 5.9 per 10k p-y), by 92% for diabetes (0.4 vs. 3.4 per 10k p-y), and by 60% for cancer (5.5 vs. 13.3 per 10k p-y).
 This per a retrospective cohort study of 7,925 surgical patients and 7,925 severely obese matched control subjects. Rates of death not caused by disease, but by causes such as accidents and suicide, were 58% higher in the surgery group than in the control group (11.1 vs. 6.4 per 10k p-y). N Engl J Med 2007; 357:753-761August 23, 2007. [Read Here]

California Fee Schedule Bill Update

The Fee Schedule Conversion bill, SB 923 (de Leon), which was broadly supported by WOEMA’s membership, stalled in the Assembly in September. The bill, sponsored by USHealthworks, would have required the Division of Workers Compensation (DWC) to convert the physician fee schedule (OMFS) to an RBRVS-based schedule by Jan. 1, 2013. WOEMA will work with the author and the sponsor help move the bill out of the Assembly in early 2012. [Legislative Affairs Updates]

Chronic Opioid Use: Comparison of Current Guidelines

Recent controversies about opioid misuse, including misuse among patients with chronic pain treated under Workers’ Compensation have triggered calls for more stringent opioid prescribing guidelines. In particular, over the last decade in the United States, opioid overdoses, both fatal and non-fatal, have increased significantly, and most occur as a result of legal prescriptions, rather than illicit drug use. Indeed, although this epidemic of opioid overdoses has many causes, its epidemiology is still unclear, and may involve small numbers of physicians rather than the physician community as a whole, and may further be related to only a subset of opioid medications, such as sustained release oxycodone and a few others. In August 2011, WOEMA compared and summarized seven sets of current opioid guidelines, and has noted some important differences among them, reflecting ongoing uncertainties and controversies in the treatment of chronic pain with opioids. [read more and download]