Vitamin D - Importance in Humans

From Medscape Medical News High-Dose Vitamin D Supplement May Reduce Risk of Falling Among Older People Laurie Barclay, MD October 1, 2009 — High-dose vitamin D supplementation may reduce the risk of falling among older people, according to the results of a meta-analysis reported in the October 2 Online First issue of the BMJ. "In several trials of older individuals at risk for vitamin D deficiency, vitamin D supplementation improved strength, function, and balance in a dose-related pattern," write H.A. Bischoff-Ferrari, MD, MPH, from the University of Zurich in Zurich, Switzerland, and colleagues. "Most importantly, these benefits translated into a reduction in falls. Overall, however, results have been mixed for fall prevention with vitamin D; for example, several trials of vitamin D have had non-significant results." The goal of this meta-analysis was to evaluate the efficacy of supplemental and active forms of vitamin D with or without calcium in preventing falls among older individuals. The reviewers searched for relevant articles in Medline, the Cochrane central register of controlled trials, BIOSIS, and Embase up to August 2008, and they found additional studies from bibliographies and abstracts and by consulting clinical experts. When indicated, the reviewers contacted study authors for additional data. Inclusion criteria were double-blind, randomized controlled trials enrolling groups of individuals of mean age 65 years or older, with sufficiently specified fall assessment. Participants in included trials were given a defined oral dose of supplemental vitamin D (vitamin D3 [cholecalciferol] or vitamin D2 [ergocalciferol]) or an active form of vitamin D (1α-hydroxyvitamin D3 [1α-hydroxycalciferol] or 1,25-dihydroxyvitamin D3 [1,25-dihydroxycholecalciferol]). There were 8 randomized controlled trials of supplemental vitamin D that met inclusion criteria, enrolling a total of 2426 participants. The investigators observed heterogeneity among trials for dose of vitamin D (700 - 1000 IU/day vs 200 - 600 IU/day; P = .02) and for achieved 25-hydroxyvitamin D3 concentration (25 [OH)D concentration: < 60 nmol/L vs ≥ 60 nmol/L; P = .005). In 7 trials enrolling a total of 1921 subjects, use of high-dose supplemental vitamin D was associated with a 19% reduction in fall risk (pooled relative risk (RR), 0.81; 95% confidence interval [CI], 0.71 - 0.92). Achieved serum 25 (OH)D concentrations of at least 60 nmol/L were associated with a 23% reduction in fall risk (pooled RR, 0.77; 95% CI, 0.65 - 0.90). In contrast, 2 trials enrolling a total of 505 subjects showed that use of low-dose supplemental vitamin D was not associated with a notable reduction in fall risk (pooled RR, 1.10; 95% CI, 0.89 - 1.35). Also, achieved serum 25 [OH)D concentrations of less than 60 nmol/L appeared to affect fall risk significantly (pooled RR, 1.35; 95% CI, 0.98 - 1.84). In 2 randomized controlled trials (n = 624) meeting inclusion criteria, active forms of vitamin D were associated with a 22% reduction in fall risk (pooled RR, 0.78; 95% CI, 0.64 - 0.94). "Supplemental vitamin D in a dose of 700-1000 IU a day reduced the risk of falling among older individuals by 19% and to a similar degree as active forms of vitamin D," the study authors write. "Doses of supplemental vitamin D of less than 700 IU or serum 25-hydroxyvitamin D concentrations of less than 60 nmol/l may not reduce the risk of falling among older individuals." Limitations of this study include potential publication bias and larger-than-expected variation between trials. "Doses of 700 IU to 1000 IU supplemental vitamin D a day could reduce falls by 19% or by up to 26% with vitamin D3," the study authors conclude. "This benefit may not depend on additional calcium supplementation, was significant within 2-5 months of treatment, and extended beyond 12 months of treatment....Active forms of vitamin D do not appear to be more effective than 700-1000 IU of supplemental vitamin D for fall prevention in older persons." A Swiss National Foundations Professorship grant, the Velux Foundation, the Baugarten Foundation, the Vontobel Foundation, and a fellowship from the Robert Bosch Foundation supported this study. One of the review authors was funded by the National Institute on Aging. The other review authors have disclosed no relevant financial relationships. BMJ. Published online October 2, 2009. Authors and Disclosures Journalist Laurie Barclay, MD freelance writer and reviewer, MedscapeCME Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships. Medscape Medical News © 2009 Medscape, LLC

Hypertension in 90% of Americans

Lancet focuses on blood pressure: Hypertension "uncontrolled and conquering the world" August 22, 2007 Michael O'Riordan New York, NY - With an estimated 1.5 billion people expected to be hypertensive by 2025, an argument making the case that hypertension is "uncontrolled and conquering the world" is not hyperbole. This staggering number, as well as the fact that the risk of becoming hypertensive is greater than 90% for individuals in developed countries, highlights the growing problem of uncontrolled hypertension, both in developed as well as undeveloped countries, according to an editorial appearing in the August 18, 2007 issue of the Lancet [1]. "Many people still believe that hypertension is a disease that can be cured, and stop or reduce medication when blood-pressure levels fall," the Lancet editorialists write. "Physicians need to convey the message that hypertension is the first and easily measurable irreversible sign that many organs in the body are under attack. Perhaps this message will also make people think more carefully about the consequences of an unhealthy lifestyle and help to give preventive measures a real chance of success." Hypertension, according to the Lancet, remains a problematic disorder, despite functioning healthcare systems, a large number of available effective treatments, and overwhelming evidence in various patient populations. Screening for hypertension, they point out, is not done systematically, and diagnosis is often made at a late stage when target-organ damage has already started. In addition, the optimum time to start treatment remains "under discussion." Both the editorial and seminar authors point out that compliance remains one of the biggest barriers to treating hypertension, despite very effective and cost-effective treatments. Even a Rhodes scholar, such as former President Bill Clinton, was under the false impression that medication can be stopped once blood pressure is lowered. While lifestyle interventions—low-salt diet, weight loss, exercise, and alcohol restriction—remain the preferred means of lowering blood-pressure levels, adherence to these changes is "notoriously poor," and antihypertensive medications might need to be considered in even some normotensive individuals, argue Messerli, Williams, and Ritz. The authors note that patients respond differently to the drug classes and that the most "important question to ask when selecting initial drug treatment is which class of drug will deliver the most effective blood-pressure lowering." For patients with blood pressure 20 mm Hg or more above goal, the guidelines recommend two-drug combinations, as monotherapy is likely to be insufficient. High-risk hypertensive patients not only should receive combination therapy for optimum blood-pressure control but also should receive a statin and low-dose aspirin, add Messerli and colleagues.

New Test for Spreading Breast Cancer

FDA Approves First Molecular-Based Lab Test to Detect Metastatic Breast Cancer The U.S. Food and Drug Administration today approved the first molecular-based laboratory test for detecting whether breast cancer has spread (metastasized) to nearby lymph nodes. The GeneSearch BLN Assay detects molecules that are abundant in breast tissue but scarce in a normal lymph node. The presence or absence of breast cancer cells in underarm lymph nodes is a powerful predictor of whether the cancer has spread and is used to help decide appropriate therapy for a woman with metastatic breast cancer. Lymph nodes are part of the system that helps protect the body against infection. The first lymph node that filters fluid from the breast is called the “sentinel node,” because that is where breast cancer cells are likely to spread first. During a lumpectomy or mastectomy to remove a breast tumor, surgeons commonly remove the sentinel node for examination under a microscope. Sometimes the sentinel node is examined immediately and if tumor cells are found, additional lymph nodes are removed. A more extensive microscopic examination, requiring one to two days for results, is almost always performed. If tumor cells are only found with the later microscopic examination, the patient may require a second surgery to remove the remaining lymph nodes. “The GeneSearch BLN Assay offers a new approach to sentinel node testing,” said Daniel Schultz, M.D., director of the FDA’s Center for Devices and Radiological Health. “Results of this rapid test are available while patients are on the operating table, providing a way for some women to avoid a second operation.” In a clinical trial, the GeneSearch BLN Assay showed strong agreement with results from extensive microscopic examination of the lymph nodes of 416 patients. The test accurately predicted that breast cancer had spread nearly 88 percent of the time in women with metastasis. Patients without metastasis were identified accurately 94 percent of the time. Most of the women were also studied to compare the BLN Assay with immediate microscopic examination during surgery. The test gave fewer false negative results, but slightly more false positive results. A false negative test result, when the cancer has actually spread, may delay the needed removal of additional lymph nodes. A false positive test, indicating metastasis when there is none, may result in a more extensive surgery and puts the women at risk of unnecessary lymphedema (swelling due to fluid build-up following lymph node removal) and other side effects. The GeneSearch BLN Assay is manufactured by Veridex, a Johnson & Johnson Company, of Warren, N.J.

Death Rate of Hip Fracture Higher than Breast Cancer in Elderly

May 18, 2007 — Older women are at greater risk for death after hip fracture than after breast cancer, according to a presentation at the American Geriatrics Society (AGS) annual meeting held in Seattle, Washington. The investigators suggest that increased awareness of mortality associated with hip fracture is needed to improve preventive measures. "This study should raise the general level of awareness of the impact of hip fracture on the lives of elderly women," coauthor Jane A. Cauley, DrPH, a professor of epidemiology at the University of Pittsburgh in Pennsylvania, told Medscape. "There is already a greater general level of awareness of the public health impact of breast cancer, but, in fact, our study showed that the mortality of breast cancer in this population was less than that of hip fracture. The public health impact on mortality was much greater for hip fracture than for breast cancer, even after adjustment." The authors concluded that older women are at a greater risk for death after hip fracture than after breast cancer diagnosis, and that increased awareness of mortality associated with hip fracture is needed to promote preventive measures. "The implications of this study are that we should aim more studies at the correct treatment of the patient with a hip fracture," S. K. Bulstra, MD, a professor of orthopaedic surgery at the University Medical Center Groiningen in the Netherlands, told Medscape. Dr. Bulstra was not involved with this study but was asked by Medscape to provide independent commentary. "Of course it is important to know whether these patients also had more comorbidity than the breast cancer patients," Dr. Bulstra said. "The reduced weight of the hip fracture group suggests a higher frequency of osteoporosis. It is also important to know if patients came from a home situation or a nursing home and how the mental status was assessed, because indeed there is a connection between survival and mental status." Dr. Bulstra's own research and experience suggest an increased mortality rate for 10 years or more after hip fracture, although the survival rate stabilizes after 2 years. Many patients are no longer able to live at home after hip fracture, which is related to their walking ability both before and after the fracture. Congestive heart failure, renal failure, liver disease, lymphoma, and weight loss each increased the 1-year mortality risk by approximately 2-fold. "Future studies should compare the effect of hip fracture and of breast cancer on quality of life in this population, in terms of functional disability, pain, mobility, and other outcomes," Dr. Cauley concluded.

Treatment at End of Life in Cancer Patients

Laurie Barclay, MD May 3, 2007 — For patients with advanced cancer, aggressive treatment in the last week of life is linked to a worse quality of death and less likelihood of dying in the place of the patient's choice, according to a presentation on May 3 at the American Geriatrics Society (AGS) annual meeting in Seattle, Washington. "We found that the greater the number of aggressive treatments these advanced cancer patients received in their last week of life, the more psychological and physical distress they experienced, as reported by family members or nurses who were with them at that time," presenter and lead author Gabriel K. Silverman, MS, an MD/PhD student at the Department of Social and Decision Sciences, Carnegie Mellon University, and the University of Pittsburgh School of Medicine in Pennsylvania, told Medscape. "Of patients who received no aggressive treatments in the days preceding their death, nearly 90% died in their preferred location, while this was true of only about a third of patients receiving two or more of these treatments. We found the reverse pattern of outcomes associated with duration of hospice use." "This study shows an association between aggressive treatment and psychological and physical distress, but that might be because people who are more distressed ask for more treatment, rather than because the treatment itself is causing distress," Dr. Arnold said. "More research is clearly needed, as is greater use of palliative care doctors at the end of life." Mr. Silverman pointed out that discussions about prognosis, goals of care, and treatment preferences, including the option of hospice care, should occur with more patients and earlier in the course of the disease. His group is now prospectively evaluating whether doctor-patient communication predicts aggressiveness of care at the end of life, and whether these treatments, in turn, affect the bereavement adjustment of close family members. "As a doctor, if I had a patient or family who wanted aggressive, life-sustaining care toward the end of their life, I would view it as a red flag warning of patient or caregiver distress," Dr. Arnold concluded. "Often patients and their families are suffering, sad, or distressed at the end of life, and when dying occurs in medical settings they may hope that aggressive treatment will help the suffering, but often it doesn't." The National Institute of Mental Health, National Cancer Institute, a predoctoral National Institutes of Health training grant in aging research, and the Center for Psycho-Oncology and Palliative Care Research, Dana-Farber Cancer Institute, supported this study. Mr. Silverman and Dr. Arnold report no relevant financial relationships. AGS 2007 Annual Scientific Meeting: Abstract P4. Presented May 3, 2007.

Blood Pressure Meds Reduce Memory Loss in Elderly

May 5, 2007 — Compared with other antihypertensive agents, centrally active angiotensin-converting enzyme inhibitors (ACEIs) are associated with slower rates of cognitive decline over 6 years in elderly people free of dementia at baseline, according to findings from the Cardiovascular Health Study (CHS) presented on May 5 at the annual meeting of the American Geriatrics Society in Seattle, Washington. "ACE inhibitors that cross the blood-brain barrier reduce cognitive decline by 50% compared [with] the decline seen in people on other blood pressure medications," presenter and lead author Kaycee M. Sink, MD, MAS, an assistant professor of internal medicine in gerontology at Wake Forest University School of Medicine in Winston-Salem, North Carolina, told Medscape.

Blood Clots During Travel

The chances of developing deep vein thrombosis double after traveling for four hours or more, the World Health Organization (WHO) said on Friday. Its study estimates that 1 in 6,000 long-haul passengers is at risk. Tall people whose legs are jammed in economy class and the very short whose feet do not touch the ground are particularly vulnerable to potentially dangerous blood clots linked to immobility during travel, the United Nations agency said. The obese, women on birth control pills and those with blood clotting disorders are also more susceptible, as are frequent travelers and those who take very long journeys. "There is an increased risk of venous thromboembolism during travel where the passenger is seated and immobile over four hours, whether in a plane, train, bus or car," said Catherine Le Gales-Camus, WHO assistant director-general for non-communicable disease and mental health. "What causes the risk is immobility," she told a news conference. "The risk is not only true for people flying." About 2 billion people travel by air each year and many more take overland trips where they sit still for prolonged periods. Health experts said the overall prevalence of deep vein thrombosis is relatively low, noting that the 1 in 6,000 ratio includes those with small or asymptomatic clots. Still, it means an average of one person is affected for every 20 long-haul flights carrying 300 passengers. To reduce the chance of developing blood clots, WHO special advisor Shanthi Mendis said travelers should exercise their calf muscles with up-and-down movements of the feet and ankle joints, and leave their seats for a few minutes when possible. Mendis cautioned air passengers against taking sleeping pills or drinking too much alcohol. People should also avoid wearing tight clothing that can constrict circulation, she said.

Patients with Diabetes - Best Way to Follow?

Heartwire 2007. © 2007 Medscape July 3, 2007(Chicago, IL) - A small but clinically relevant change appears to be coming to the management of patients with diabetes mellitus. Hemoglobin A1c (HbA1c) levels, used to assess long-term glycemic control, might soon be replaced with average blood glucose, a change experts say will add clarity for diabetic patients looking to manage their disease. Discussing the expected change here at the American Diabetes Association (ADA) 2007 Scientific Sessions last week, Dr David Nathan (Harvard University Medical School, Boston, MA) said that "patients have a glucose problem, not a hemoglobin problem" and that fasting glucose would be a better measure, as this new value "would help them understand their disease better." Reporting glycohemoglobin results as an A1c-derived average glucose, said Nathan, would have the advantage of reporting chronic glycemia in the same units as the patients' self-monitoring of daily glycemia. Nathan is the lead investigator of the international ADAGE trial, a study performed to confirm the relationship between average glucose and HbA1c levels. To date, only a few studies with relatively infrequent glucose monitoring support a strong mathematical relationship between average glucose and HbA1c, but if a switch is to be made from HbA1c to average glucose levels, an international study is needed to establish the relationship across diabetes type, races, and ethnicities, said Nathan.

Safe Fish and Concerns

EWG’s Fish List What Women Should Know About Mercury In Fish Avoid If Pregnant Shark Swordfish King mackerel Tilefish Tuna steaks Canned tuna Sea bass Gulf Coast Oysters Marlin Halibut Pike Walleye White croaker Largemouth bass Eat No More Than One Serving From This List Per Month Mahi mahi Blue mussel Eastern oyster Cod Pollock Great Lakes salmon Gulf Coast blue crab Channel catfish (wild) Lake whitefish Lowest In Mercury Blue crab (mid-Atlantic) Croaker Fish Sticks Flounder (summer) Haddock Trout (farmed) Salmon (wild Pacific) Shrimp * * Shrimp fishing and farming practices have raised serious environmental concerns. ** Farmed catfish have low mercury levels but may contain PCBs in amounts of concern for pregnant women. Data From The 1970s Show High Concentrations (No Recent Data Available) Porgy Orange Roughy Snapper Lake Trout Bluefish Bonito Rockfish

Agribusiness/Power Subsidies

POWER DRAIN OAKLAND - Some of America's richest and largest farms are paying pennies for the vast amounts of electricity needed to deliver irrigation water to California's arid Central Valley. In 2002 and 2003, agribusinesses in the Central Valley Project (CVP) paid only about one cent per kilowatt-hour for electricity to transport irrigation water, according to a 15-month investigation by Environmental Working Group (EWG). Compared to Pacific Gas & Electric's agricultural rate, that's an annual subsidy of more than $100 million from U.S. taxpayers. EWG's report is available at www.ewg.org. It shows both the price paid by each CVP irrigation district in the years studied and the amount of energy the district used. Every year the CVP, the nation's largest federally subsidized irrigation system., moves more than 2 trillion gallons of water through 1,500 miles of canals. The electricity needed to move water around the CVP would power every home in Chico for 18 months. But just as CVP contractors pay heavily subsidized rates for their water, they pay next to nothing for the power that delivers it. Through the federal Freedom of Information Act, EWG obtained U.S. Bureau of Reclamation documents that enabled us to calculate, for the first time, the rate paid by CVP agribusinesses and the value of their power subsidy. We found: CVP power rates were 10 to 15 times lower than PG&E's industrial, agricultural or residential rates. In Westlands Water District, the largest and most politically powerful irrigation district in the CVP, power subsidies in 2002 were worth about $165,000 per farm. The CVP power sold to farms by the U.S. Bureau of Reclamation is essentially unregulated. No government agency, other than the Bureau itself, oversees its rates. "In an era when other Californians have been rocked by volatile electricity prices and the constant threat of rolling blackouts, a few thousand agribusinesses are guranteed dirt-cheap power, courtesy of U.S. taxpayers," said EWG Senior Analyst Renee Sharp, lead investigator for the report. "These subsidies are not helping small farms survive, but padding the profits of the biggest and richest farms." Cheap power is just the tip of the iceberg of federal subsidies to the CVP: Department of Agriculture data show that from 1995 to 2004, CVP agribusinesses received more than $890 million in direct commodity payments, mostly for cotton and rice. An earlier EWG investigation conservatively estimated the value of CVP water subsidies at $416 million in 2002. In total, federal subsidies to the CVP easily top more than half a billion dollars a year and could well reach $1 billion Ð all at taxpayers' expense. The report recommends that CVP agribusinesses should be required to pay prices approximating market rate for the power used to store and move irrigation water. A federal agency should regulate power rates to ensure system fairness, and should make these rates publicly available. CVP contractors, and contractors in other federal water projects, should not be allowed to "double-dip" and "triple-dip" on federal subsidies. # # # EWG is a nonprofit research organization based in Washington, DC that uses the power of information to protect human health and the environment. The group's research on Power Subsidies is available online at http://www.ewg.org/reports/powersubsidies/.

Asbestos and the Lungs

Disenfranchising Those with Lung Cancer More than 10,000 people a year die from asbestos disease, 5,000 of them from asbestos-caused lung cancer. It is precisely people like these, those most seriously harmed and dying from asbestos disease, that the Senate leadership has claimed to be helping with its series of asbestos trust fund bills. Few proposals have lived up to that claim, but the current proposal is perhaps the cruelest of all to date. The Specter/Leahy asbestos bill delivers unusually harsh treatment to victims of asbestos-caused lung cancer. First, the bill establishes criteria that are not recognized by the American Lung Association or the American Thoracic Society requiring that all lung cancer victims also have advanced-stage non-cancer asbestos disease in order to qualify for any level of assistance. But the more insidious disenfranchisement of lung cancer victims becomes apparent only when the exposure criteria in the bill are applied to a sample applicant. W.R. Grace Company Indicted on Federal Criminal Charges Read More This analysis reveals that the Specter/Leahy bill denies any and all compensation to people with confirmed asbestos-caused lung cancer if they entered the workforce after 1978, just four years after the peak of asbestos use in the U.S. of 1.4 billion pounds annually. Like all asbestos victims seeking justice, they will have their cases thrown out of court. But lung cancer victims whose asbestos exposure started after 1978 will never receive a penny from the fund because it will have expired before they can accumulate enough asbestos exposure under the newly minted exposure criteria in the bill. This disenfranchisement would affect even those people with asbestos-caused lung cancer who worked every year from 1978 through the termination of the fund in 2035 in what is characterized euphemistically as a "moderate" exposure environment, defined as working: "in areas immediate to where asbestos-containing products were being installed, repaired, or removed under circumstances that involved regular airborne emissions of asbestos fibers." (Section 121 (a) 16 (B)) For some lung cancer victims, compensation is even less likely. All individuals with a level VII claim, confirmed asbestos-caused lung cancer with bilateral pleural plaques, will have compensation denied if workplace exposure began after 1974. Lung cancer has a five-year mortality rate of 95 percent. The reason that all of these lung cancer victims receive nothing is the convoluted exposure criteria in the bill. These criteria declare, without any medical substantiation to support them, that every year of continuous daily exposure to asbestos that occurred after 1976 counts as just one half year, and if that exposure occurred after 1986, it counts only as one tenth of a year, or 36.5 days (Section 121 (a) 16 (E)). There is no medical or scientific rationale for devaluing a year of work exposure to "regular airborne emissions of asbestos" by 50 percent if that exposure was between 1976 and 1985 and by 90 percent if exposure took place after 1986. Asbestos use peaked in the U.S. in 1974, at 1.4 billion pounds; use in 1976 was clearly over 1 billion pounds, and workplace safety standards recommended by the National Institute of Occupational Safety and Health (NIOSH) were not adopted by the Occupational Safety and Health Administration (OSHA) until 1994 (NIOSH 2002), a full 18 years after the bill begins to devalue a year's worth of work around asbestos. Nor would full compliance with the OSHA standard mean that workers would not die at an excessively high rate from asbestos-caused lung cancer. The preamble to the OSHA standard itself estimates that one in every 300 workers will develop lung cancer from exposure at the legal limit (OSHA 1986). A more recent assessment concludes that one in every 200 workers will develop lung cancer if they are exposed to a career's worth of asbestos at the OSHA "safe" level. Compliance with OSHA's permissive standard is spotty. In 1999, asbestos air levels exceeded the far weaker pre-1980 "permissible exposure limit" at 13 percent of construction and 5.6 percent of manufacturing sites monitored (NIOSH 2002). This pre-1980 limit, which was established by the Mine Safety and Health Administration (MSHA) and still applies to mining, is 20 times less protective than the 1994 OSHA standard (0.1f/cc vs. 2 f/cc). Between 19 and 91 percent of all mining sites sampled between 1982 and 1991 exceeded the 1994 OSHA standard. In 1991, 32.4 percent of mining sites sampled exceeded this level. An example of the Specter/Leahy criteria The unfairness of the Specter/Leahy criteria are best understood by applying them to a hypothetical applicant to the fund who has lung cancer. For lung cancer level VII (with bilateral pleural disease) a person filing a claim with the trust would need 12 years of weighted exposure (pg 82). If exposure started in 1971, it would take 34 years of continuous exposure to meet the 12-year exposure requirement in the bill. This person, and everyone beginning continuous exposure in 1971 or earlier, would qualify for compensation, assuming all other criteria are met. For every year past 1971 that the person started working with asbestos under the "moderate exposure" criteria described above, it will take an extra 10 years of occupational exposure to meet the criteria for compensation in the bill. Thus, a person with asbestos-caused lung cancer and pleural plaques who began occupational exposure in 1974 would need 52 years of work exposure (through 2035, or "until" 2036) to meet the 12 year weighted exposure criteria in the bill. After that, the fund will have been terminated. 1974 - 1975 each year counts as a full year - total 2 years 1976 - 1985 each year counts as one half year - total 5 years 1986 - 2035 each year counts as one tenth year - total 5 years Example 1 Patient has lung cancer with bilateral pleural disease Example 2 Patient has lung cancer with 1/0 asbestosis Example 3 Patient has lung cancer with 1/1 asbestosis References National Institute for Occupational Safety and Health (NIOSH) (2002). "Work-related lung disease surveillance report." Division of Respiratory Disease Studies. Occupational Safety and Health Administration (OSHA). (1986). "Final Rule: Asbestos." 51 FR 22612. Department of Labor, Occupational Safety and Health Administration. June 20, Federal Register.

Fuel Economy Laws and Failure to Enforce

Real MPG: Putting the Truth in Your Tank The U.S. would have imported about 20 percent less foreign oil in 2005 if automakers met federal fuel efficiency or miles per gallon (MPG) standards based on real world driving conditions. That reduction is equivalent to more than 1.3 times the amount of oil imported from Saudi Arabia in 2005, or about two million barrels of oil per day. For consumers this translates into 33 billion gallons of gasoline saved that year. Instead, over the past 20 years, car company lobbyists and their friends in Congress have dramatically increased US dependence on foreign oil by prohibiting the EPA from requiring MPG tests that reflect how people actually drive. In the car company test for compliance with corporate MPG requirements, cars never exceed 60 miles per hour, never have the air conditioning on, never go up hills, never accelerate rapidly and always drive in perfect weather. According to several EPA analyses, these test results exaggerate real world MPG by about 25 percent for city driving and 30 percent on the highway. Bogus mileage tests are the cornerstone of car company compliance with government MPG standards. Since 1985, car companies have generally been required to meet fleet MPG averages of 27.5 for cars, and between 19.5-22.2 for trucks [†1]. Real world MPG is far lower, at about 21.7 for cars and 16.3 for trucks. Congress publicly identified this problem in 1980. If car company lobbyists, at that time, had not blocked congressional action to base federal fuel efficiency standards on real world driving conditions the U.S. would currently be saving 710 million barrels of oil per year, or about 20 percent of all the United States' imports in 2005. That is the equivalent of more than 1.3 times the 525 million barrels that the United States imported from Saudi Arabia last year. Significant oil savings do not require an increase in MPG standards. Congress could achieve vast savings simply by requiring automakers to stop deceiving the public and instead subject their vehicles to real fuel efficiency tests rather than the inaccurate, outdated tests currently prescribed by law. Many drivers know that the mileage number on their car's window sticker is inaccurate, and that cars rarely get the mileage that is advertised. But few people know that the number on the window is not the one that car companies use to meet corporate gas mileage standards. Instead, car company lobbyists and Congress have created what the Center for Auto Safety calls two sets of books when it comes to gas mileage (CAS 2004). This legally sanctioned deception dates back more than 25 years. In 1980, the U.S. House of Representatives Committee on Government Operations assessed the effectiveness of fuel efficiency standards that Congress had passed in 1975. The Committee found that: ...most new cars sold in this country do not achieve on road the fuel economy standards set by Congress. However, it should be noted that car manufacturers are deemed in compliance with the fuel economy standards mandated by Congress in 1975. American car owners and the entire U.S. economy will both be the losers if that situation is not remedied. Both will pay millions of dollars more, and both will remain more reliant on foreign oil sources, as a direct result of the needless waste of automobile fuel (HCOGO 1980). The Committee found that model year 1978 cars with government rated fuel efficiency of 27.5 miles per gallon achieved only 19 miles per gallon on the road, a shortfall of 30 percent that is essentially the same shortfall that occurs today. In addition, the Committee found that the shortfall between the government mileage ratings and real world driving could cause the U.S. to burn an extra one million barrels of gasoline per day by 1985. How the Automakers Drive/How You Drive The problem, the Committee found, was the grossly inaccurate testing procedures for measuring fuel efficiency; procedures that remain in place today. The city portion of the test is based on a simulated drive to work in Los Angeles in 1965 when congestion was much lower than it is today. The highway portion of the test was developed by the Environmental Protection Agency (EPA) in 1974 and was designed to represent a mix of interstate and freeway driving at a time when the national speed limit was 55 miles per hour. Congress eliminated the national speed limit in 1995 and states have instituted speed limits of 65 or 70 miles per hour (EPA FR 2006). Not surprisingly, neither the highway nor city test reflects real world driving behavior or gas mileage. One major difference is speed. On the highway test, cars average just 49 miles per hour and never exceed 60 miles per hour. Yet according to the EPA, recent reports show that 28 percent of all driving occurs at speeds greater than 60 miles per hour. Higher speed can dramatically reduce fuel efficiency (EPA FR 2006). In addition, the acceleration rates in both the city and highway tests are 3.3 miles-per-hour per second despite recent studies of real world driving which show that acceleration rates can be as high as 12 miles-per-hour per second. Rapid acceleration can seriously cut gas mileage. Even when the tests were developed, acceleration rates were higher in the real world. Yet, at the time, the dynamometers (treadmills for cars) on which the tests were completed did not allow for faster acceleration. Today's dynamometers allow for rapid acceleration even though rapid acceleration is not incorporated in mileage testing (EPA FR 2006). Other significant differences between the driving tests and real world driving are the use of accessories and ambient temperature. Neither the city test nor the highway test uses accessories such as air conditioning, heating or defrosting. Air conditioning in particular can reduce fuel efficiency. In addition, the tests are conducted at 75 degrees F even though only 20 percent of all driving occurs within five degrees of this temperature. Fuel efficiency is lower at temperatures that are above and below 75 degrees. Finally, because the tests are conducted on a dynamometer rather than on the road, the automakers do not have to account for a variety of conditions that can reduce fuel efficiency including roadway roughness, hills, wind, tire pressure, heavier loads (trailers, cargo, multiple passengers), the effects of ethanol in gasoline and others (EPA Preamble 2006). A Band-Aid Approach Despite these discrepancies, Congress and the automakers have resisted real change. In 1980, confronted by inaccuracies in the testing program, automakers General Motors and Ford suggested that the car labels be adjusted so that consumers would have more accurate information. However, the automakers opposed changing the driving test so that they would comply with federal fuel efficiency standards. "That approach is anathema to the auto makers," the Committee on Government Operations reported. Ford argued to the Committee that the testing procedures were fixed by law despite evidence that EPA could have modified the test. The Committee recommended changing the test to accurately reflect mileage for the 1986 and later model years. In 1984, the EPA adopted the approach favored by the automakers. Since that year, the Agency has adjusted the mileage figures produced by the driving test downward before placing the numbers on cars' window stickers (CAS 2004). The agency lowers the city test figure by 10 percent and the highway figure by 22 percent (EPA 2006). This adjustment provides consumers with somewhat more accurate information. But the test for determining compliance with fuel efficiency standards remains grossly inaccurate. Congress Ensures that Automakers are Falling Short The result of the inaccurate driving test is that automakers are failing to meet federal fuel economy standards established by Congress in 1975. Automakers' current fleet of cars must average 27.5 miles per gallon while SUVs and light trucks must average 22.2 miles per gallon. According to EWG's estimate, the true figures are closer to 21.7 miles per gallon for cars and 16.3 miles per gallon for SUVs and light trucks. A recent on-road study by Consumers Union of more than 300 cars and trucks found that 274 delivered lower fuel economy than promised by EPA (CU 2005). Consumers Union found that its estimated mileage for 2003 model year cars was 30 percent lower than that reported to the government for purposes of complying with federal fuel efficiency standards. This discrepancy is the same as that reported by the House Committee on Government Operations for 1978 model year cars. Moving toward Real MPG For more than a quarter century, federal law has required automakers to save oil by meeting mileage standards for their cars. This law grew out of concern over the United States' economic vulnerability to unstable foreign sources of oil. Congress acknowledged that one of the best ways to reduce this vulnerability is simply to use less oil. But as long as the mileage standards have been on the books, the automakers have evaded the spirit of the law by using a bogus driving test. The test allows automakers to claim that they are meeting federal mileage standards when in fact they are not. The losers in this scheme are citizens who must now pay $3.00 a gallon for gasoline to operate vehicles that deliver significantly less gas mileage than advertised. In addition, the U.S. is more dependent on foreign oil than ever before — in no small part because of the automakers' deliberate gas mileage deception. It does not have to be this way. EPA has designed emissions tests that incorporate many of the real-world driving standards and uses them to measure automakers' compliance with pollution emissions standards. For example, EPA tests auto emissions using a cold weather city driving test known as Cold FTP in which fuel efficiency is about 12 percent lower than in the normal city test. EPA also measures car pollution using a test with the air conditioning on known as SC03 that produces fuel efficiency numbers that are about 21 percent lower than in the normal city test. And EPA runs a third test known as the US06 that incorporates rapid acceleration and high speed. Results from this test are about 30 percent lower than mileage results from a composite of the normal city and highway tests. Acting on a petition by Bluewater Network, EPA recently announced that it plans to use these three tests to produce more accurate mileage stickers for consumers. But EPA has said that it will not use the tests to improve automakers' compliance with vehicles' fuel efficiency. Recommendations It's time for Congress to mandate one test for pollution, MPG compliance, and the sticker on the window in the showroom. Test methods similar to those found in Senate Bill 3543 would be a good start. It is outrageous that car companies have been allowed to deceive the American public for decades about the real MPG of their cars. Requiring a real driving test is not a substitute for enacting higher mileage standards for cars, but it is an essential step to making cars more efficient and to reducing dependence on foreign oil.