The World Federation of Neurology and the challenges in Environment Neurology.

Since its establishment the World Federation of Neurology (WFN) has manifested a keen interest in the environment and its relation to neurological diseases. Thus, in 2007 the WFN renamed the "Neurotoxicological Research Group" to "Environmental Neurology Research Group". In this short article, we review some recent events which illustrate the WFN involvement in Environmental Neurology as well its concerns about global health matters involving environmental issues.

The Significance of a Cooperative Medical System for Treating Decompression Illness on the Izu Peninsula in Japan.

INTRODUCTION: In 2011, our hospital on the Izu peninsula began to hold meetings to discuss how to manage patients with decompression illness (DCI) to establish a cooperative medical system. We retrospectively investigated the influence of these meetings and the changes subsequently effected. METHODS: A medical chart review was retrospectively performed to investigate all cases between January 2005 and December 2017 in which the transport of patients with DCI via a physician-staffed helicopter emergency medical service (HEMS) was attempted. The patients were divided into 2 groups: the preprogram group and the postprogram group. RESULTS: There were 63 patients in the preprogram group and 65 in the postprogram group. There were no cases in which a patient's symptoms deteriorated during transportation by the HEMS. The frequency of dispatch to the scene for direct evacuation in the postprogram group (86%) was greater than that in the preprogram group (74%), but the difference was not statistically significant (P=0.09). In the postprogram group, the duration of activities at the scene or the first aid hospital was significantly shorter in comparison to the preprogram group (P=0.01). CONCLUSIONS: This retrospective study revealed simultaneity between the introduction of the yearly meetings and a reduced duration of the HEMS staff's activity at either the scene or the first aid hospital.

[Exposome: from an intuition to a mandatory research field in occupational and enviromental medicine.] / Esposoma: da intuizione a linea di ricerca obbligata nelle Scienze Mediche Occupazionali e Ambientali.

OBJECTIVES: As Genomics aims at the collective characterization and quantification of genes, exposomics refers to the totality of lifetime environmental exposures, consisting in a novel approach to studying the role of the environment in human disease. The aim is to assess all human environmental and occupational exposures in order to better understand their contribution to human diseases. The "omics" revolution infact mostly regards the underlying method: scientific knowledge is expected to come from the analysis of increasingly extensive databases. METHODS: The primary focus is on air pollution and water contaminants, but all the determinants of human exposure are conceptually part of the idea of exposome, including physical and psychological factors. Using 'omic' techniques the collected exposure data can be linked to biochemical and molecular changes in our body. RESULTS: Since the first formulation of the idea itself of Exposome many efforts have been made to translate the concept into research, in particular two important studies have been started in Europe. CONCLUSIONS: We herein suggest that Occupational Medicine could be a precious contributor to the growth of exposure science also in its omic side thanks to the methods and to the knowledges part of our background.

Implementation of a novel occupational and environmental medicine specialty teleconsultation service: the VHA experience.

OBJECTIVE: Occupational and environmental medicine (OEM) physician specialty practices continue to grow in scope and intensity across the Veterans Health Administration. This study characterizes the implementation of a novel, nationwide telemedicine program that provides OEM specialty consultation to providers across the Veterans Health Administration. METHODS: We examined provider requests and specialist responses for a 6-month pilot from May to October 2013. Characteristics of consult users, determinants of case complexity, and specific applications of OEM specialty expertise were identified. RESULTS: Over a 6-month period, employee occupational health providers consulted the OEM telemedicine pilot a total of 65 times. Employee occupational health providers without formal training repeatedly identified complex cases related to work and disability. CONCLUSIONS: The program has created a new system management solution to deliver expert, in-depth consultation and real-time provider education in OEM.

Commentary on the contributions and future role of occupational exposure science in a vision and strategy for the discipline of exposure science.

Exposure science is a holistic concept without prejudice to exposure source. Traditionally, measurements aimed at mitigating environmental exposures have not included exposures in the workplace, instead considering such exposures to be an internal affair between workers and their employers. Similarly, occupational (or industrial) hygiene has not typically accounted for environmental contributions to poor health at work. Many persons spend a significant amount of their lifetime in the workplace, where they maybe exposed to more numerous chemicals at higher levels than elsewhere in their environment. In addition, workplace chemical exposures and other exogenous stressors may increase epigenetic and germline modifications that are passed on to future generations. We provide a brief history of the development of exposure science from its roots in the assessment of workplace exposures, including an appendix where we detail current resources for education and training in exposure science offered through occupational hygiene organizations. We describe existing successful collaborations between occupational and environmental practitioners in the field of exposure science, which may serve as a model for future interactions. Finally, we provide an integrated vision for the field of exposure science, emphasizing interagency collaboration, the need for complete exposure information in epidemiological studies, and the importance of integrating occupational, environmental, and residential assessments. Our goal is to encourage communication and spur additional collaboration between the fields of occupational and environmental exposure assessment. Providing a more comprehensive approach to exposure science is critical to the study of the "exposome", which conceptualizes the totality of exposures throughout a person's life, not only chemical, but also from diet, stress, drugs, infection, and so on, and the individual response.

Search and rescue response to a large-scale rockfall disaster.

OBJECTIVE: To describe the prehospital management and safety of search and rescue (SAR) teams involved in a large-scale rockfall disaster and monitor the acute and chronic health effects on personnel with severe dolomitic dust exposure. METHODS: SAR personnel underwent on-site medical screening and lung function testing 3 months and 3 years after the event. RESULTS: The emergency dispatch center was responsible for central coordination of resources. One hundred fifty SAR members from multidisciplinary air- and ground-based teams as well as geotechnical experts were dispatched to a provisionary operation center. Acute exposure to dolomite dust with detectable silicon and magnesium concentrations was not associated with (sub)acute or chronic sequelae or a clinically significant impairment in lung function in exposed personnel. CONCLUSIONS: The risk for personnel involved in mountain SAR operations is rarely reported and not easily investigated or quantified. This case exemplifies the importance of a multiskilled team and additional considerations for prehospital management during natural hazard events. Safety plans should include compulsory protective measures and medical monitoring of personnel.

Optimizing health care delivery by integrating workplaces, homes, and communities: how occupational and environmental medicine can serve as a vital connecting link between accountable care organizations and the patient-centered medical home.

In recent years, the health care reform discussion in the United States has focused increasingly on the dual goals of cost-effective delivery and better patient outcomes. A number of new conceptual models for health care have been advanced to achieve these goals, including two that are well along in terms of practical development and implementation-the patient-centered medical home (PCMH) and accountable care organizations (ACOs). At the core of these two emerging concepts is a new emphasis on encouraging physicians, hospitals, and other health care stakeholders to work more closely together to better coordinate patient care through integrated goals and data sharing and to create team-based approaches that give a greater role to patients in health care decision-making. This approach aims to achieve better health outcomes at lower cost. The PCMH model emphasizes the central role of primary care and facilitation of partnerships between patient, physician, family, and other caregivers, and integrates this care along a spectrum that includes hospitals, specialty care, and nursing homes. Accountable care organizations make physicians and hospitals more accountable in the care system, emphasizing organizational integration and efficiencies coupled with outcome-oriented, performance-based medical strategies to improve the health of populations. The ACO model is meant to improve the value of health care services, controlling costs while improving quality as defined by outcomes, safety, and patient experience. This document urges adoption of the PCMH model and ACOs, but argues that in order for these new paradigms to succeed in the long term, all sectors with a stake in health care will need to become better aligned with them-including the employer community, which remains heavily invested in the health outcomes of millions of Americans. At present, ACOs are largely being developed as a part of the Medicare and Medicaid systems, and the PCMH model is still gathering momentum and evolving among physicians. But, the potential exists for implementation of both of these concepts across a much broader community of patients. By extending the well-conceived integrative concepts of the PCMH model and ACOs into the workforce via occupational and environmental medicine (OEM) physicians, the power of these concepts would be significantly enhanced. Occupational and environmental medicine provides a well-established infrastructure and parallel strategies that could serve as a force multiplier in achieving the fundamental goals of the PCMH model and ACOs. In this paradigm, the workplace-where millions of Americans spend a major portion of their daily lives-becomes an essential element, next to communities and homes, in an integrated system of health anchored by the PCMH and ACO concepts. To be successful, OEM physicians will need to think and work innovatively about how they can provide today's employer health services-ranging from primary care and preventive care to workers' compensation and disability management-within tomorrow's PCMH and ACO models.

Actitudes, creencias y conocimientos de los pediatras sobre salud medioambiental en Murcia / Pediatrician attitudes, beliefs and knowledge about environmental health in Murcia, Spain

Objetivo: Estudiar las actitudes, las creencias y los conocimientos sobre salud medioambiental pediátrica (SMAP) de los pediatras de la Región de Murcia (RM). Método: Encuesta autocumplimentada, basada en los conocimientos teórico-prácticos sobre SMAP, enviada por correo postal en 2007 a los 293 pediatras que trabajan en la RM. Resultados: Respondieron 164 (56%). El 70% trabaja en atención primaria. El 5% pertenece a alguna organización no gubernamental medioambiental. Según los pediatras, los factores que más afectan a la salud infantil (sobre una puntuación máxima de 10) son: contaminantes del aire interior-tabaco (7,78), lesiones/accidentes (6,64) y contaminación del aire exterior (5,13). El 45% no registra información ambiental en las historias clínicas. Las consultas más frecuentes de los padres (de 1 a 4) son sobre lesiones y accidentes (2,16), radiación ultravioleta (2,06) y contaminación del agua de bebida (2,05). Las enfermedades respiratorias son las más relacionadas con la salud medioambiental. Conclusiones: Se debería asegurar que el contenido de la SMAP sea obligatorio en la enseñanza y la preparación de los futuros pediatras (pregrado, posgrado, formación continuada). Este trabajo podría ayudar a evaluar las necesidades y planificarlas acciones formativas en SMAP(AU)

Objective: To study pediatrician attitudes, beliefs and knowledge about pediatric environmental health (PEH) in the region of Murcia, Spain. Method: Were mailed a self administered survey based on theoretical and practical knowledge about issues related to PEH of 293 paediatricians working in the Region of Murcia. Results: The overall response rate was 56%. About 70% of respondents worked in Primary Care and 5% belonged to anon-governmental organization (NGO). Pediatricians stated that the factors most affecting the health of children (maximum score 10) were: indoor air pollutants (7.78) injuries and accidents (6.64), and outdoor air pollution (5.13). 45% did not systematically record information about the environments in the clinical registry. The most frequently asked questions by parents were (maximum score 4) related to: injuries and accidents (2.16), ultraviolet radiation (2.06) and contamination of drinking water (2.05). Pediatricians considered respiratory diseases to be most strongly related to the environment. Conclusions: Pediatric associations and institutions should include an EH syllabus in the curriculum of pregraduate and graduate students as well as in the continuing education of paediatricians. This work would help needs assessment and planning the training in PEH(AU)

United States Army Research Institute of Environmental Medicine: Warfighter research focusing on the past 25 years.

The United States Army Research Institute of Environmental Medicine (USARIEM) celebrated its 50th anniversary on July 1, 2011. This article reviews its history, evolution, and transition of its research programs as well as its scientific and military accomplishments, emphasizing the past 25 yr. During the 1990s, USARIEM published a series of pocket guides providing guidance for sustaining Warfighter health and performance in Southwest Asia, Somalia, the former Republic of Yugoslavia, Rwanda, and Haiti. Issues identified during Operation Desert Storm elicited research that improved nutritional guidelines for protracted desert operations; safer use of nuclear, chemical, and biological protective clothing; equipment, development, and fielding of efficient microclimate cooling systems; and effective evaluation of pharmaceuticals to protect soldiers from chemical and biological threats. During the first decade of the 21st century, USARIEM and the Department of the Army published official medical/performance doctrines for operations in the heat and cold and at high altitude. The current Global War on Terrorism focused research to improve doctrines for hot, cold, and high-altitude operations, reduce musculoskeletal training injuries, provide improved field nutrition, more efficient planning for operational water requirements, and improve both military clothing and materiel. This article also describes the critically important interactions and communications between USARIEM and deployed units and the benefits to Warfighters from this association. This report presents USARIEM's unique and world-class facilities, organizational changes, scientific and support personnel, and major research accomplishments, including the publication of 2,200 scientific papers over the past 25 yr.

The CDC fourth national report on human exposure to environmental chemicals: what it tells us about our toxic burden and how it assist environmental medicine physicians.

The Centers for Disease Control (CDC) conducts ongoing assessments of the levels of environmental chemicals in the U.S. population. This ongoing study utilizes lab samples from the individuals who are part of the National Health and Nutrition Examination Survey (NHANES). The NHANES samples from the years 1999-2000, 2001-2002, and 2003-2004 (each representing about 2,400 individuals) were used for the CDC's national reports. In the CDC Fourth National Report on Human Exposure to Environmental Chemicals ("the fourth report") complete data from the above sample years were included. Each year additional chemicals are measured; the fourth report contains information on 75 previously untested compounds, for a total of 212 compounds measured. In the fourth report, blood and urinary levels of eight different forms of arsenic are reported. The fourth report, for the first time, also includes levels of solvents (30 different compounds) and provides adult rather than juvenile values for mercury. In the majority of individuals tested, acrylamides, cotinine, trihalomethanes, bisphenol A, phthalates, chlorinated pesticides, triclosan, organophosphate pesticides, pyrethroids, heavy metals, aromatic hydrocarbons, polybrominated diphenyl ethers, benzophenone from sunblock, perfluorocarbons from non-stick coatings, and a host of polychlorinated biphenyls and solvents were found. This review provides many of the ranges for xenobiotic toxins so a clinician can identify a patient's current exposure and toxic load compared to the national averages and monitor the effectiveness of prescribed treatments.

American College of Occupational and Environmental Medicine (ACOEM): a professional association in service to industry.

The American College of Occupational and Environmental Medicine (ACOEM) is a professional association that represents the interests of its company-employed physician members. Fifty years ago the ACOEM began to assert itself in the legislative arena as an advocate of limited regulation and enforcement of occupational health and safety standards and laws, and environmental protection. Today the ACOEM provides a legitimizing professional association for company doctors, and continues to provide a vehicle to advance the agendas of their corporate sponsors. Company doctors in ACOEM recently blocked attempts to have the organization take a stand on global warming. Company doctors employed by the petrochemical industry even blocked the ACOEM from taking a position on particulate air pollution. Industry money and influence pervade every aspect of occupational and environmental medicine. The controlling influence of industry over the ACOEM physicians should cease. The conflict of interests inherent in the practice of occupational and environmental medicine is not resolved by the ineffectual efforts of the ACOEM to establish a pretentious code of conduct. The conflicted interests within the ACOEM have become too deeply embedded to be resolved by merely a self-governing code of conduct. The specialty practice of occupational and environmental medicine has the opportunity and obligation to join the public health movement. If it does, the ACOEM will have no further purpose as it exists, and specialists in occupational and environmental medicine will meet with and be represented by public health associations. This paper chronicles the history of occupational medicine and industry physicians as influenced and even controlled by corporate leaders.

Paediatric environmental health speciality units in Europe: integrating a missing element into medical care.

Paediatricians are in an excellent position to identify children with environmental risk, to advise their parents about the best way of reducing or preventing such risks, and to recommend actions to the responsible politicians involved. Paediatric environmental health speciality units (PEHSU) can help to qualify and support paediatricians in this task. PEHSU is defined as a unit within a paediatric hospital or clinic that is able to recognize, assess, and prevent environment-related health risks, to help other paediatric specialists in the management of such diseases in children, as well as to provide education, training, and research, putting emphasis on thorough and adequate establishment of paediatric environmental histories (PEHis) and to the application of the precautionary principle. Although activities and services provided by each PEHSU would differ depending on the centre or community where it is located, all should include training, research, medical care and community and school health.

Assessment of feminization of male fish in English rivers by the Environment Agency of England and Wales.

In recent years there has been considerable concern over the ability of substances discharged into the environment to disrupt the normal endocrine function of wildlife. In particular, the apparent widespread feminization of male fish in rivers has received significant attention from regulators in the United Kingdom, the United States, Europe, and Japan. The U.K. and European epidemiological data sets have demonstrated that the occurrence of feminized fish is associated with effluent discharges and that the incidence and severity is positively correlated with the proportion of treated sewage effluent in receiving waters. Although weakly estrogenic substances may contribute to the overall effect, studies have concluded that steroid estrogens are the principal and most potent estrogenic components of domestic sewage. Extensive laboratory data sets confirm that steroid estrogens are capable of eliciting the effects observed in wild fish at concentrations that have been measured in effluents and in the environment. Based on evaluation of the available information, the Environment Agency (England and Wales) has concluded that the weight of evidence for endocrine disruption in fish is sufficient to develop a risk management strategy for estrogenically active effluents that discharge to the aquatic environment.