Radio frequency radiation-related cancer: assessing causation in the occupational/military setting.

BACKGROUND AND AIM: We reexamine whether radio frequency radiation (RFR) in the occupational and military settings is a human carcinogen. METHODS: We extended an analysis of an already-reported case series of patients with cancer previously exposed to whole-body prolonged RFR, mainly from communication equipment and radar. We focused on hematolymphatic (HL) cancers. We used analysis by percentage frequency (PF) of a cancer type, which is the proportion of a specific cancer type relative to the total number of cancer cases. We also examined and analyzed the published data on three other cohort studies from similar military settings from different countries. RESULTS: The PF of HL cancers in the case series was very high, at 40% with only 23% expected for the series age and gender profile, confidence interval CI95%: 26-56%, p<0.01, 19 out of 47 patients had HL cancers. We also found high PF for multiple primaries. As for the three other cohort studies: In the Polish military sector, the PF of HL cancers was 36% in the exposed population as compared to 12% in the unexposed population, p<0.001. In a small group of employees exposed to RFR in Israeli defense industry, the PF of HL cancers was 60% versus 17% expected for the group age and gender profile, p<0.05. In Belgian radar battalions the HL PF was 8.3% versus 1.4% in the control battalions as shown in a causes of deaths study and HL cancer mortality rate ratio was 7.2 and statistically significant. Similar findings were reported on radio amateurs and Korean war technicians. Elevated risk ratios were previously reported in most of the above studies. CONCLUSIONS: The consistent association of RFR and highly elevated HL cancer risk in the four groups spread over three countries, operating different RFR equipment types and analyzed by different research protocols, suggests a cause-effect relationship between RFR and HL cancers in military/occupational settings. While complete measurements of RFR exposures were not available and rough exposure assessments from patients interviews and from partial exposure data were used instead, we have demonstrated increased HL cancers in occupational groups with relatively high RFR exposures. Our findings, combined with other studies, indicate that exposures incurred in the military settings evaluated here significantly increased the risk of HL cancers. Accordingly, the RFR military exposures in these occupations should be substantially reduced and further efforts should be undertaken to monitor and measure those exposures and to follow cohorts exposed to RFR for cancers and other health effects. Overall, the epidemiological studies on excess risk for HL and other cancers together with brain tumors in cellphone users and experimental studies on RFR and carcinogenicity make a coherent case for a cause-effect relationship and classifying RFR exposure as a human carcinogen (IARC group 1).

Trauma care and case fatality during a period of frequent, violent terror attacks and thereafter.

BACKGROUND: From September 1999 through January 2004 during the second Intifada (al-Aqsa), there were frequent terror attacks in Jerusalem. We assessed the effects on case fatality of introducing a specialized, intensified approach to trauma care at the Hebrew University-Hadassah Hospital Shock Trauma Unit (HHSTU) and other level I Israeli trauma units. This approach included close senior supervision of prehospital triage, transport, and all surgical procedures and longer hospital stays despite high patient-staff ratios and low hospital budgets. Care for lower income patients also was subsidized. METHODS: We tracked case fatality rates (CFRs) initially during a period of terror attacks (1999-2003) in 8,127 patients (190 deaths) at HHSTU in subgroups categorized by age, injury circumstances, and injury severity scores (ISSs). Our comparisons were four other Israeli level I trauma centers (n = 2,000 patients), and 51 level I U.S. trauma centers (n = 265,902 patients; 15,237 deaths). Detailed HHSTU follow-up continued to 2010. RESULTS: Five-year HHSTU CFR (2.62 %) was less than half that in 51 U.S. centers (5.73 %). CFR progressively decreased; in contrast to a rising trend in the US for all age groups, injury types, and ISS groupings, including gunshot wounds (GSW). Patients with ISS > 25 accounted for 170 (89 %) of the 190 deaths in HHSTU. Forty-one lives were saved notionally based on U.S. CFRs within this group. However, far more lives were saved from reductions in low CFRs in large numbers of patients with ISS < 25. CFRs in HHSTU and other Israeli trauma units decreased more through the decade to 1.9 % up to 2010. CONCLUSIONS: Sustained reductions in trauma unit CFRs followed introduction of a specialized, intensified approach to trauma care.

Long-term effects of repealing the national maximum speed limit in the United States.

OBJECTIVES: We examined the long-term effects of the 1995 repeal of federal speed limit controls on road fatalities and injuries in fatal crashes. METHODS: We used a Poisson mixed-regression model to assess changes in the number of fatalities and injuries in fatal crashes between 1995 and 2005 on rural interstates, where all US states have raised speed limits since the repeal, as well as on urban interstates and noninterstate roads, where many states have raised speed limits. RESULTS: We found a 3.2% increase in road fatalities attributable to the raised speed limits on all road types in the United States. The highest increases were on rural interstates (9.1%) and urban interstates (4.0%). We estimated that 12 545 deaths (95% confidence interval [CI] = 8739, 16 352) and 36 583 injuries in fatal crashes (95% CI = 29 322, 43 844) were attributable to increases in speed limits across the United States. CONCLUSIONS: Reduced speed limits and improved enforcement with speed camera networks could immediately reduce speeds and save lives, in addition to reducing gas consumption, cutting emissions of air pollutants, saving valuable years of productivity, and reducing the cost of motor vehicle crashes.

Incitement, genocide, genocidal terror, and the upstream role of indoctrination: can epidemiologic models predict and prevent?

We apply the models and tools of epidemiology and public health to propose a unified field theory showing the role of ideologies, indoctrination, and incitement, in genocide, genocidal terror, and terror by groups or individuals. We examine the effects of indoctrination and incitement as exposures and risks in relation to genocide and genocidal terror. Incitement has been recognized as a trigger to these outcomes but indoctrination is upstream to incitement. Population-wide exposure to indoctrination increases susceptibility to the effects of incitement. These relationships have been seen in all major genocides and genocidal terror in the late twentieth and twenty-first centuries. There is some insight into the relationship between ideology, incitement, and genocidal acts of violence from the so-called localized genocides in Bosnia, Rwanda, Darfur, Syria, and most recently, among the Rohingya in Myanmar. There is a need to recognize the upstream role of ideologies of hate in order to determine the degree to which indoctrination posed, and continues to pose, a contributing factor. Epidemiologic models, such as the iceberg model of exposure and disease and the concept of "sick individuals" and "sick populations," guide our understanding of the content and spread of indoctrination and incitement and can provide essential insights for prevention. The hateful indoctrination and ideologies behind genocidal violence must be countered and replaced by positive ideologies and role models that emphasize respect for life and human dignity for all.

Malthusian pressures, genocide, and ecocide.

Historical models postulate that genocide cannot occur without the ideology and decisions of its authoritarian perpetrators and the indifference of bystanders. These models do not address genocidal risks from ecocide. Study objectives were to assess 1) the role of Malthusian pressures in recent genocides, 2) the role of ecocide and ecologic abuse in creating these pressures, and 3) strategies for prevention and deterrence. Analysis of reports, demographic studies, and time trends in recent genocides and recent ecocidal events from ecologic abuse suggests that Malthusian pressures and zero-sum rivalries over water, arable land, or natural resources by themselves do not lead to genocide. Such pressures may have exacerbated the political and socioeconomic predictors in Rwanda and Darfur, but not in former Yugoslavia. However, collapse of socioeconomic and governmental infrastructures following genocide can leave behind massive sustained damage to carrying capacity and sustainability. Surviving victims, if they return to their environments, will remain at risk for persecution. Ecocide--the large-scale destruction, depletion, or contamination of natural ecosystems--can result in widespread damage to health, survival, fertility, reproduction, and sustenance, and forced flight. International early warning and effective response systems are needed to deter or prevent political decisions to carry out genocide. Such systems must include long-term measures to resolve zero-sum conflicts over environmental resources and to prevent toxic risks to vulnerable populations and destruction of habitat by deliberate or wanton ecologic abuse, which itself should be redefined as a crime against humanity.

Childhood lead exposure in the palestinian authority, Israel, and Jordan: results from the Middle Eastern regional cooperation project, 1996-2000.

In the Middle East, the major sources of lead exposure have been leaded gasoline, lead-contaminated flour from traditional stone mills, focal exposures from small battery plants and smelters, and kohl (blue color) in cosmetics. In 1998-2000, we measured blood lead (PbB) levels in children 2-6 years of age in Israel, Jordan, and the Palestinian Authority (n = 1478), using a fingerstick method. Mean (peak; percentage > 10 microg/dL) PbB levels in Israel (n = 317) , the West Bank (n = 344), Jordan (n = 382) , and Gaza (n = 435) were 3.2 microg/dL (18.2 ; 2.2%) , 4.2 microg/dL (25.7; 5.2%), 3.2 microg/dL (39.3; < 1%) , and 8.6 microg/dL (> 80.0; 17.2%), respectively. High levels in Gaza were all among children living near a battery factory. The findings, taken together with data on time trends in lead emissions and in PbB in children in previous years, indicate the benefits from phasing out of leaded gasoline but state the case for further reductions and investigation of hot spots. The project demonstrated the benefits of regional cooperation in planning and carrying out a jointly designed project.

Excessive and disproportionate advertising in peer-reviewed journals.

The International Committee of Medical Journal Editors (ICMJE) has outlined ethical guidelines concerning the advertising practices of peer-reviewed journals that briefly discuss issues of excessive and disproportionate advertising. The authors evaluated these guidelines using quantitative data, assessing the types and frequencies of advertising in 2001 print issues of NEJM and JAMA, two principal members of ICMJE. Advertising ratios (ratio of advertisements to editorial content) were near unity in NEJM and 0.30 in JAMA, compared with reported ratios of 0.15 among low-circulation specialty science journals and 0.80 among high-circulation consumer magazines. In both journals, five corporations placed more than 50% of all display advertisements. The findings suggest a dissonance between the ethical guidelines and the de facto advertising practices of arguably the two most important member journals of the ICMJE. There is a need to define and apply standards for excessive and disproportionate advertising.

Death and injury from motor vehicle crashes: a tale of two countries.

OBJECTIVE: To determine why road deaths dropped by 33.9% in the United Kingdom, compared to 6.5% in the United States, between 1990 and 1999. METHODS: Deaths per billion vehicle kilometers traveled (D/BVKM), and case fatality rates (CFR) in the United States and the United Kingdom were tracked. Time trends in CFR can be used to track the direct effects of speed of impact. CFR is a crash-phase outcome that is independent of exposure, and varies approximately to the fourth power of the speed of crash impact. Joinpoint regression analysis was used to analyze changes in time trends of CFR. RESULTS: In the 1990s, the decrease in deaths in the United Kingdom was attributable mostly to the 29.6% drop in the CFR. In the United States, the CFR dropped by only 6.6%. The United Kingdom introduced speed cameras and an array of speed-calming measures. By contrast, in the United States, use of speed cameras was extremely rare, and speed limits and speeds increased in 32 of the 50 states, mostly in 1995 and 1996, after which CFR actually rose (p<.0001). Intercountry differences in time trends in seat belt use, trauma care, vehicle kilometers traveled, congestion, and driving under the influence of alcohol (DUI), along with massive increase in use of higher-risk sports utility vehicles in the United States, did not account for the contrasting trends in deaths through the 1990s. But increases in DUI in the United States after 1997 may have contributed to increases in speed-related crashes. CONCLUSIONS: The reductions in CFR, probably from small drops in speed of impact account for the disproportionately greater drop in death tolls in the United Kingdom compared to the United States. The temporal fit between drops in CFR and deaths following the introduction of speed cameras in the United Kingdom and increases in speed (speed creep), CFR, and deaths in the United States following raised speed limits suggests that diverging changes in speeds of impact accounted mainly for these changes. Use of D/BVKM to correct for exposure concealed the lack of progress after 1990 in the United States, since falling time trends in D/BVKM reflect increases in congestion. If the United States had implemented United Kingdom-type speed control policies and not raised speed limits, there would have been an estimated 6500 to 10,000 (approximately 16% to 25%) fewer road deaths per year during the period following speed-limit increases (1996 to 1999), including many DUI-related deaths. Reductions of up to 50% are now achievable based on newer population-wide strategies for speed control.

Conflicts of interest and scientific integrity.

The encroachment of conflicts of interest on the peer-review process of scientific journals is discussed, with particular reference to a current example. The authors stress the need for transparency of the connections among authors, reviewers, publishers, editors, and sources of funding to prevent erosion of trust in the scientific integrity of such publications.

Cancer risks in naval divers with multiple exposures to carcinogens.

We investigated risks for cancer and the case for a cause-effect relationship in five successive cohorts of naval commando divers (n = 682) with prolonged underwater exposures (skin, gastrointestinal tract, and airways) to many toxic compounds in the Kishon River, Israel's most polluted waterway, from 1948 to 1995. Releases of industrial, ship, and agricultural effluents in the river increased substantially, fish yields decreased, and toxic damage to marine organisms increased. Among the divers (16,343 person-years follow-up from 18 years of age to year 2000), the observed/expected ratio for all tumors was 2.29 (p<0.01). Risks increased in cohorts first diving after 1960 compared to risks in earlier cohorts, notably for hematolymphopoietic, central nervous system, gastrointestinal, and skin cancer; induction periods were often brief. The findings suggest that the increases in risk for cancer and short induction periods resulted from direct contact with and absorption of multiple toxic compounds. Early toxic effects in marine life predicted later risks for cancer in divers.

Ames, pesticides, and cancer revisited.

The case for continuing use of existing levels of pesticides in agriculture, espoused by Bruce Ames, is refuted. Ames' contentions that naturally occurring carcinogens are far more widespread than man-made ones, that pesticides prevent cancer by providing fruits and vegetables at lower costs to the poor, and that animal data on high risks with high doses cannot predict low risks from low doses in humans do not address key issues: 1) fruits and vegetables contain mixtures of carcinogens and anti-carcinogens, and selection effects from human exposures to these mixtures go back more than a million years; 2) exposures from bioconcentrations of biopersistent organochlorines in the food chain create particular risks for meat-eaters, who have higher cancer risks than vegetarians; 3) even low doses from ingestion of produce containing pesticide residues can cause tissue injury, which could itself promote cancer; 4) epidemiologic data show rises in cancer incidences in older people in many countries, major differences in cancer risks between countries, and converging trends in risks for populations migrating to certain countries; 5) studies of pesticide-exposed workers consistently show increased rates of cancers and birth defects and cancers in their offspring; 6) epidemiologic studies based on large databases tend to underestimate risks from environmental causes because of exposure misclassification; 7) exposures to many organochlorines may have pervasive effects on endocrine function; 8) crop yields can be increased with less use of pesticides. Studies demonstrating the latter need replication, and should be supported as part of a coherent government agenda to develop alternative farming methods.

Systemic vasculitis and prior recent exposure to organic solvents: report of two cases.

The authors describe two patients with systemic vasculitis and prior occupational exposure to organic solvents. Systemic vasculitis should be considered a sentinel event for such exposures.

Chronic ammonia inhalation and interstitial pulmonary fibrosis: a case report and review of the literature.

Ammonia is an irritant gas with a characteristic pungent odor, which is widely used in industry. Inasmuch as ammonia is highly soluble in water and, upon inhalation, is deposited in the upper airways, occupational exposures to ammonia have commonly been associated with sinusitis, upper airway irritation, and eye irritation. Acute exposures to high levels of ammonia have also been associated with diseases of the lower airways and interstitial lung. In this study, the authors report on a patient with long-term, repetitive occupational exposure to ammonia at levels at or above odor recognition who developed interstitial lung disease. The scientific literature on inhaled ammonia exposure is reviewed and discussed. The authors conclude that the taking of a careful occupational exposure history for patients presenting with shortness of breath associated with ammonia exposure may assist with an early diagnosis, thus allowing for treatment early in the disease process and prevention of further exposure.

Brain cancer with induction periods of less than 10 years in young military radar workers.

The authors have reported on 5 young patients who had brain tumors that appeared within 10 yr of initial occupational exposures to radar. Four of the patients were less than 30 yr of age when the diagnoses were initially made. Brief induction periods that follow high exposures in individual sentinel patients are a recognized indicator of impending group risk, and these periods call attention to the need for precautionary measures. Similarly, reports of short induction periods for brain cancer on the side of the head in which there has been prior use of cell phones may also indicate increased risk.

Creatine phosphate kinase elevations signaling muscle damage following exposures to anticholinesterases: 2 sentinel patients.

In this study, the authors describe 2 patients who experienced confirmed exposures to anticholinesterases that commenced in the 1970s. Subsequently, elevations in creatine phosphate kinase (CPK) were initially detected more than a decade following the first acute exposure. Beginning in the early 1980s, the patients suffered from progressive generalized muscle weakness, chronic fatigue, myopathy, neuropathy, and severe neurobehavioral impairments. Previous occupational exposures included pyridostigmine, as well as isopropyl methylphosphonofluoridate (percutaneous lethal dose [LD50] < 28 mg/kg body weight), and 1 patient had exposure to agricultural organophosphates. The authors hypothesize that the workers' CPK elevations, first detected more than a decade following acute exposures to anticholinesterases, were sentinel events for impending muscle damage and necrosis. Many Gulf War veterans with Gulf War disease who reported exposures to anticholinesterases 1 decade earlier currently suffer from vague neuromuscular and cognitive impairments. Therefore, medical programs for Gulf War veterans with Gulf War Syndrome should include surveillance for elevated CPK, abnormalities of neuromuscular conduction, and genetic susceptibility, and they should promote therapeutic trials for palliation.