15 goldman yearinreview - ucsf cme · fastest increase from 2012 to 2015 - men: arts, design,...

Key Publications in Occupational & Environmental Health: the Year in Review

Samuel M. Goldman, MD, MPHAssociate Clinical ProfessorUCSF Division of Occupational & Environmental Medicine

Key Publications in OEM

Disclosures: None


From late 2016 through August 2017, US governmentpersonnel serving on diplomatic assignment in Havana,Cuba, reported neurological symptoms associated withexposure to auditory and sensory phenomena


Background Reports of variable auditory &

sensory phenomena in embassy,homes, hotel rooms since 2016

Perceived directional emanation

80 diplomatic staff referred by embassy medical unit to U. Miami

24 with similar “exposure” history and constellation of neurologicalfeatures c/w mild-TBI

Referred to U. Penn by State Dept Medical Services expert panel


Methods Retrospective Case Series of 21 US

personnel in Havana

Multidisciplinary team: PM&R, OEM, Neurology, Neuroradiology, Neurosurgery- Each specialist independently obtained

clinical histories and conducted comprehensive assessments

- Additional referrals: vestibular PT, neuro-optometry, neuropsych, OT, ENT, audiology

Results

“Exposure”

- 18/21 reported hearing localized sound at onset of symptoms in their homes/hotels

- Directional, intensely loud, pure tonality

High pitched in 16, also buzzing, grinding, piercing squeals

12 noted vibratory or sensory stimuli (“air baffling”)

Sensation emanated from a direction, modified by changing location

Unchanged by covering head

- Some reported 10-second pulses, others >30 min, woke from sleep


Population Men (n=10) Women (n=11) Total (n=21)

Age, mean (SD) 39 (7) 47 (8) 43 (8)

Mean days (SD) from exposure to eval 229 (98) 180 (85) 203 (93)

Symptoms: AcuteDomain Acute

n (%)

Cogn

itive / Behavioral Combined

Desire to change location

Confusion/Disorientation

Agitation/Irritability

Desire to cover head/ears

Fatigue

Feeling of paralysis

16 10

8

6

5

3

3

(76) (48)

(38)

(29)

(24)

(14)

(14)

Balance /

Vestibular Combined 10 (48)

Nausea 7 (33)

Dizziness 5 (24)

Visual

Combined

Visual changes

Eye pain

2 1

1

(10) (5)

(5)

Auditory Combined

Ear pain

Tinnitus

Hearing change

10 7

6

1

(48) (33)

(29)

(5)

Sleep Sleep problem 4 (19)

Head

ache Combined

Headache

Head Pressure

Unilateral jaw pain

11

8

5

1

(50)

(38)

(24)

(5)

Overall Combined acute 21 (100)

Immediate onset in 20/21

”good day-bad day” patterncommon

Cognitive & physical symptoms often worse after exercise


Persistent Symptoms (>3 months) & Signs


• 6 of 6 with neuropsych tests had “significant areas of cognitive weakness and/or impairment”

Course

MRI imaging normal in 21/21

Rehabilitation

- Neuro-optometric rehabilitation: “manipulation of disparity vergence and accommodative amplitude and latency”

- Vestibular PT: “focused on oculomotor function with the body in motion”

- Cognitive rehabilitation “with OT, speech therapy or both”

Early RTW exacerbated symptoms in 1/3

”Individualized return to work plans were designed to reintegrate individualsusing a stepwise process”


Conclusions “Clinical manifestations may represent a novel clinical entity” with “widespread

brain network dysfunction”

“Neurological exam & cognitive screens did not reveal evidence of malingering”

Oculomotor & vestibular findings could not be manipulated

Mass psychogenic illness usually transient, benign

Critique (4 letters to editor!):

Functional neurological diagnosis (not malingering!) not excluded

Mass psychogenic illnesses often chronic and debilitating

Claims that objective manifestations can’t be “consciously or unconsciously manipulated” are misleading. High rates of vestibular abnormalities in patients with anxiety disorders

Social network analysis should be done: many subjects had extensive communication prior to evaluations



September 1, 2018

Potential Causes?

Microwave Weapons

Sound frequency waves NOT known to cause neurological damage

Microwaves?

US, Soviet, Chinese research into weaponizing the Frey Effect

Microwave-induced auditory perceptions through temporal lobe stimulation

“Mind Control” through auditory hallucinations



Suicide rate among US working age population increased 34%from 2000-2016, from 12.9/100,000 to 17.3/100,000

This report examines occupation-specific suicide rates in 2012& 2015 for persons aged 16-64 using data from the NationalViolent Death Reporting System (NVDRS)


Methods NVDRS: “Death from intentional use of physical force or power, against oneself,

another person, or a group or community”

- Death certificates, coroner reports, law enforcement reports

- 17 states participated in 2012 & 2015: Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin

Occupational coding

- 2010 US Census codes converted to Standard Occupational Classification (SOC) major groups

Total n = 22,053


Methods Suicide rates calculated using annual civilian noninstitutionalized working

population counts by occupational group from the US Census Current Population Survey Annual Social and Economic Supplement as denominators

Exclusions:

- unemployed at time of suicide (10%)

- incarcerated, homemaker, student, military, unpaid, or unclassifiable occupations (23%)

Total numerator in analyses for 2012 + 2015 = 14,728


Male Suicide Rates by Occupation

Occupation2012 2015 Rate change

Rate Rank Rate Rank % Rank

Construction & Extraction 43.6 1 53.2 1 22% 5

Arts, Design, Sports, Media 26.9 7 39.7 2 47% 1

Installation, Repair 31.6 2 39.1 3 24% 3

Transportation 28.4 4 30.9 4 9% 8

Production 28.4 3 30.5 5 7% 10

Protective Services 27.1 6 28.2 6 4% 11

Bldg cleaning, maintenance 27.3 5 26.8 7 -2% 14

Health care practitioners 20.8 14 25.6 8 23% 4


Female Suicide Rates by Occupation

Occupation2012 2015 Rate change

Rate Rank Rate Rank % Rank

Arts, Design, Sports, Media 11.7 1 15.6 1 34% 2

Protective Services 11.6 2 12.2 2 5% 9

Health care support 8.4 5 11.0 3 31% 3

Food Preparation & Serving 6.1 11 9.4 4 54% 1

Legal 11.1 3 9.2 5 -17% 15

Health care practitioners 10.3 4 9.0 6 -13% 13

Production 7.6 7 9.0 7 18% 6

Personal care services 6.8 9 7.7 8 14% 7


Summary Largest proportion of suicides in both 2012 & 2015

- Men: Construction & Extraction = 20%

- Women: Unpaid occupations = 29%

Highest rates of suicides in both 2012 & 2015

- Men: Construction & Extraction (43.6, 53.2)

- Women: Arts, Design, Entertainment, Sports, Media (11.7, 15.6)

Fastest increase from 2012 to 2015

- Men: Arts, Design, Entertainment, Sports, Media; 47%

- Women: Food preparation & Serving; 54%


Conclusions Suicide rates vary widely across occupations

Rates in men 3x women, but gap narrowing

Both work (low job control, job insecurity) & nonwork (e.g., relationship conflict)factors associated with psychological distress and suicide

Other factors

- Access to lethal means (e.g., protective services, health care practitioners)

- Socioeconomic (lower income, low education)

Limitations:

- SOC groups contain broad range of education/income

- Single “usual” job captured

Authors suggest opportunities for workplace suicide prevention programs


Entomofauna: the insects of an environment or region

Systematic review of 73 long-term studies around the world


Background Insects comprise 2/3 of all terrestrial species on Earth

Germany: 27-year study found 76% decline in flying insect biomass (2.8%/year) in protected areas (Hallmann et al, 2017)

Puerto Rico rainforest: 78-98% decline in ground-foraging and canopy-dwelling arthropods over 36 years (2.2-2.7%/year) (Lister & Garcia, 2018)

Previous reviews are partial in scope, restricted to individual groups of insects (e.g. butterflies, carabids) in specific regions

No study has put together a comprehensive review of all insect taxa nor compared local findings among different parts of the world


Methods

Compiled all long-term insect surveys from the past 40 years

Searched Web of Science database using keywords [insect*] AND [declin*] AND [survey]: resulted in a total of 653 publications

Excluded reports that focused on individual species, pest outbreaks or invasive species

Required periods longer than 10 years

Additional papers obtained from the literature references


Geographic location of the 73 reportsColumns represent relative proportion of taxa studied


Insect Orders Lepidoptera: butterflies & moths

Hymenoptera: bees, wasps, ants

Diptera: flies

Coleoptera: beetles (the largest Order)

Hemiptera: cicadas, aphids, “bugs”

Orthoptera: grasshoppers, crickets

Odonata: dragonflies

Plecoptera: stoneflies

Ephemeroptera: mayflies


Annual Rates of Decline of 3 Major Taxa


Proportions of Terrestrial Species In Decline


Proportion of Declining Species by Region


Main Factors Associated with Insect Declines


Summary 41% of insect species are in decline, twice the rate of vertebrates

33% of insect species threatened with extinction, increasing 1% annually

2.5% annual insect biomass decline

Declines similar in tropical & temperate regions

Habitat change is biggest driver: urbanization, agriculture, industrialization

Pollution next biggest driver: pesticides > fertilizers >> urban/industrial pollutants


What now?

Change ways of food production- Abolish use of synthetic pesticides: integrated pest management

- Drastically reduce use of agro-fertilizers

Habitat restoration- Agricultural “redesign”

Flower & grassland strips around fields

Increased crop rotations

Engineering controls to reduce runoff

- Marshland rehabilitation


Lead exposure is a risk factor for cardiovascular disease

Population risk poorly understood

Quantifies association of lead and all-cause mortality, cardiovascular mortality, ischemic heart disease mortality

Lancet Public Health, 3(4), 2018


Methods Third National Health and Nutrition Exam (NHANES-III)

- Nationally representative sample aged > 20

- Baseline exams in 1988

Medical exam & home interviews: demographics, numerous covariates

Blood: lead (graphite furnace atomic absorption spectrophotometry), HbA1c

Urine: cadmium, creatinine

Serum: cholesterol, cotinine

Cause death by linkage to National Death Index

- Followed through 2011 (n=14,289)

- All cause mortality (n=4422)

- Underlying cause: CVD (n=1801), IHD (n=988)


Analyses Cox proportional hazards models adjusted for:

- age, sex, income, ethnicity, BMI, smoking (never, current, former), serum cotinine, EtOH, physical activity, urine cadmium, hypertension, Healthy Eating Index, and HbA1c

Explored effect modification by: BP, DM, sex, age, urban residence, ethnicity, secular trends

Pb modeled as: continuous, tertiles, 5-knot restricted cubic splines


Attributable deaths due to modifiable risk factors

HR Attributable fraction

Avoidable deaths

All cause 1.37 18% 412k

CVD 1.70 28.7% 256k

IHD 2.08 37.4% 185k

Risk for increase from 10th to 90th %ile(1.0-6.7 ug/dL)


Summary Of 2.3 million annual deaths, 400,000 attributable to lead, 250,000 of which

are due to cardiovascular disease

10-fold higher than prior estimates that assumed no risk < 5ug/dL

Proposed mechanism: endothelial inflammation & oxidative damagepromoting atherosclerosis

Despite striking reductions in blood lead over the past 50 years, levels are still 10-100x higher than pre-industrial era

Limitations: single blood lead measurement 1988; residual confounding

Question 1:

Among men, what occupational group has the highest rate of suicide?

a) Health care practitioners

b) Construction & extraction

c) Food preparation

d) Architecture & engineering


Question 2:

Which of the following is NOT a proposed cause of the cluster of neurological illnesses seen in US diplomatic personnel in Cuba?

a) Sound waves

b) Microwave radiation

c) Mass psychogenic illness

d) Frey effect


Question 3:

Which factor is thought to be most responsible for insect declines?

a) Climate change

b) Invasive species

c) Intensive agriculture

d) Air pollution


15 goldman yearinreview - ucsf cme · fastest increase from 2012 to 2015 - men: arts, design,...

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