Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial [RESEARCH]

Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial [RESEARCH]: "

Objective To evaluate the effectiveness of treatment with collar or physiotherapy compared with a wait and see policy in recent onset cervical radiculopathy.

Design Randomised controlled trial.

Setting Neurology outpatient clinics in three Dutch hospitals.

Participants 205 patients with symptoms and signs of cervical radiculopathy of less than one month’s duration

Interventions Treatment with a semi-hard collar and taking rest for three to six weeks; 12 twice weekly sessions of physiotherapy and home exercises for six weeks; or continuation of daily activities as much as possible without specific treatment (control group).

Main outcome measures Time course of changes in pain scores for arm and neck pain on a 100 mm visual analogue scale and in the neck disability index during the first six weeks.

Results In the wait and see group, arm pain diminished by 3 mm/week on the visual analogue scale (β=–3.1 mm, 95% confidence interval –4.0 to –2.2 mm) and by 19 mm in total over six weeks. Patients who were treated with cervical collar or physiotherapy achieved additional pain reduction (collar: β=–1.9 mm, –3.3 to –0.5 mm; physiotherapy: β=–1.9, –3.3 to –0.8), resulting in an extra pain reduction compared with the control group of 12 mm after six weeks. In the wait and see group, neck pain did not decrease significantly in the first six weeks (β=–0.9 mm, –2.0 to 0.3). Treatment with the collar resulted in a weekly reduction on the visual analogue scale of 2.8 mm (–4.2 to –1.3), amounting to 17 mm in six weeks, whereas physiotherapy gave a weekly reduction of 2.4 mm (–3.9 to –0.8) resulting in a decrease of 14 mm after six weeks. Compared with a wait and see policy, the neck disability index showed a significant change with the use of the collar and rest (β=–0.9 mm, –1.6 to –0.1) and a non-significant effect with physiotherapy and home exercises.

Conclusion A semi-hard cervical collar and rest for three to six weeks or physiotherapy accompanied by home exercises for six weeks reduced neck and arm pain substantially compared with a wait and see policy in the early phase of cervical radiculopathy.

Trial registration Clinical trials NCT00129714.

"

Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial

Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial: "

Objective To evaluate the effectiveness of an active strategy to implement the validated Canadian C-Spine Rule into multiple emergency departments.

Design Matched pair cluster randomised trial.

Setting University and community emergency departments in Canada.

Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals.

Interventions Six hospitals were randomly allocated to the intervention and six to the control. At the intervention sites, active strategies were used to implement the Canadian C-Spine Rule, including education, policy, and real time reminders on radiology requisitions. No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites.

Main outcome measure Diagnostic imaging rate of the cervical spine during two 12 month before and after periods.

Results Patients were balanced between control and intervention sites. From the before to the after periods, the intervention group showed a relative reduction in cervical spine imaging of 12.8% (95% confidence interval 9% to 16%; 61.7% v 53.3%; P=0.01) and the control group a relative increase of 12.5% (7% to 18%; 52.8% v 58.9%; P=0.03). These changes were significant when both groups were compared (P<0.001). No fractures were missed and no adverse outcomes occurred.

Conclusions Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity. Final imaging rates were much lower at intervention sites than at most US hospitals. Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide.

Trial registration Clinical trials NCT00290875.

"

UK Fire & Rescue Service Standards

UK Fire & Rescue Service Standards

"Medical and Occupational Evidence for Recruitment and Retention in the Fire & Rescue Service." (2004) http://www.communities.gov.uk/documents/fire/pdf/130418.pdf   

Sleep Apnea and Bus Drivers

From the Atlanat Injury Law and Civil Litigation Blog

April 25, 2005 8:32 PM Posted By Ken Shigley Comments / Questions (0)

8 die due to bus driver's sleep apnea and trucking company's poor brake maintenance

The Federal Motor Carrier Safety Administration has determined that bus driver fatigue combined with poor brake maintenance by a trucking company tired driver to kill eight on a Texas church bus in 2003. As is commonly the case, the church that owned the bus was never informed that it was required to comply with Federal Motor Carrier Safety Regulations, including driver medical qualifications. The bus driver, who had chronic insomnia and sleep apnea, had never obtained the required medical certificate. The bus struck a tractor-trailer that had been pulled off on the side of the Interstate when poorly maintained brakes began smoking. See Newsday article.

The Shigley Law Firm represents plaintiffs in wrongful death and catastrophic injury cases statewide in Georgia, and in other states subject to the multijurisdictional practice and pro hac vice rules in each state. Ken Shigley was designated as a "SuperLawyer" in Atlanta Magazine and one of the "Legal Elite" in Georgia Trend Magazine. He is a Certified Civil Trial Advocate of the National Board of Trial Advocacy, Chair of the Southeastern Motor Carrier Liability Institute and former chair of the Georgia Insurance Law Institute. He particularly focuses on cases arising from truck wrecks and accidents (tractor trailers truck wrecks, semi truck wrecks,18 wheeler truck wrecks, big rig truck wrecks, log truck wrecks, dump truck wrecks).

 

ORIGINAL ARTICLE

Sleepiness and sleep-related accidents in commercial bus drivers

Marjorie Vennelle & Heather M. Engleman & Neil J. Douglas

Received: 6 March 2009 / Accepted: 15 June 2009

# Springer-Verlag 2009

Sleep Breath

DOI 10.1007/s11325-009-0277-z

 

 

Abstract:

Introduction Professional drivers are at high risk of sleepiness due to a combination of factors including shift work and obstructive sleep apnea/hypopnea syndrome (OSAHS), and sleepiness in professional drivers is highly dangerous. This study aimed to determine the prevalence of excessive daytime sleepiness and accident rates in bus drivers.

Materials and methods:

Drivers employed at bus depots within 30 miles of Edinburgh were given a sleep questionnaire. One thousand eight hundred fifty-four drivers were approached, and 677 (37%; 25 female) completed questionnaires with a 97% response rate among the 456 given directly to drivers by the researcher.

Results 

Of the responding drivers, 133 (20% of total, 19% of researcher-delivered questionnaires) reported an Epworth sleepiness score >10. Eight percent of drivers reported falling asleep at the wheel at least once/month, and 7% having an accident, and 18% a near-miss accident due to sleepiness while working.

Discussion:

This study shows a concerningly high rate of sleepiness and sleep-related accidents among bus drivers. Screening for OSAHS among commercial drivers needs to be seriously evaluated with some urgency.

 

Introduction:

Driving skill impairment from sleepiness can be greater than that from having a blood alcohol over the legal limit [1]. It is estimated that sleepiness causes 16% of all road traffic accidents (RTAs) and more than 20% of motorway crashes [2] and that between 50% and 29% of deaths and serious injuries in accidents are caused by sleep-related RTAs [1]. While most of these accidents are related to lack of sleep, many result from medical causes of sleepiness. The most common disorder causing excessive daytime sleepiness is the obstructive sleep apnea/hypopnea syndrome (OSAHS). Drivers with untreated OSAHS are at a high risk of sleep-related RTAs as the sedentary and monotonous nature of driving are conducive to sleepiness. OSAHS is much commoner in the obese [3] and those with sedentary occupations including professional drivers are at increased risk of obesity.

Thus, an excessive prevalence of OSAHS in professional bus and heavy-goods drivers has been suggested in some studies [4–6] but has not been assessed in the UK. This study aimed to determine the prevalence of sleep disorders symptoms, excessive daytime sleepiness, and accident rates in professional bus drivers in east central Scotland.

M. Vennelle : H. M. Engleman : N. J. Douglas

Department of Sleep Medicine, University of Edinburgh,

Edinburgh, UK

Department of Sleep Medicine, Royal Infirmary of Edinburgh,

51 Little France Crescent,

Edinburgh EH16 4SA, UK

e-mail: m.vennelle@ed.ac.uk

Wizard of Oz Environmental Exposures

The Tin Woodman.

From Wikipedia

In the classic 1939 movie The Wizard of Oz, the Tin Man was played by actor Jack Haley. Ray Bolger was originally cast to play the role, however he wished to switch roles with Buddy Ebsen who was playing the scarecrow. Ebsen was perfectly fit for the role,^{[neutrality disputed]} but the character's makeup originally contained tin powder; Ebsen accidentally breathed the powder into his lungs, thus bringing him to the near edge of death, and was rushed to a hospital. This forced him to give up the role (ironically, Ebsen would outlive both Haley and Bolger). Haley based his breathy speaking style in the movie on the voice he used for telling his son bedtime stories. His portrayal of the character is by far the most famous. There is no explanation in the film of how the Tin Man became the Tin Man. It is subtly implied that he was always made of tin; the only reference to the tinsmith is the Tin Man's remark "The tinsmith forgot to give me a heart".

Again from Wikipedia.........

In 1939, Hamilton played the role of the Wicked Witch of the West, opposite Judy Garland's Dorothy in The Wizard of Oz, creating not only her most famous role, but also one of the screen's most memorable villains. Hamilton was chosen when the more traditionally attractive Gale Sondergaard refused to wear makeup designed to make her appear ugly. Hamilton suffered severe burns during a second (and unused) take of her fiery exit from Munchkinland, in which the trap door's drop was delayed to eliminate the brief glimpse of it seen in the final edit. Hamilton had to recuperate in a hospital and at home for six weeks after the accident before returning to the set to complete her work on the now-classic film, and refused to have anything to do with fire for the rest of the filming. Judy Garland had visited her while Hamilton recuperated at home.^[2] Studio executives cut some of Margaret's most wicked scenes, worrying they would frighten children.

Exercise vs multimodal intervention for back pain (nurses)

The comparative effectiveness of a multimodal program versus exercise alone for the secondary prevention of chronic low back pain and disability.
Ewert T, Limm H, Wessels T, Rackwitz B, von Garnier K, Freumuth R, Stucki G.

Department of Physical Medicine and Rehabilitation, Ludwig-Maximilian University, Munich, Germany. Correspondence: Gerold Stucki MD gerold.stucki@med.uni-muenchen.de

OBJECTIVE: The objective of this study was to examine whether a multimodal, secondary prevention program (MP) is superior to a general physical exercise program (EP) in influencing the process leading to chronic low back pain (LBP) in nurses with a history of back pain. 

DESIGN: The study was conducted as a randomized controlled parallel-group trial.

SETTING: The interventions were performed in a single center at the Department of Physical and Rehabilitation Medicine at the University of Munich in Germany. 

PARTICIPANTS: A total of 235 nurses from 14 nearby hospitals and nursing homes who experienced at least one episode of back pain during the previous 2 years were invited into the study. Of these, 183 nurses were enrolled and 169 (83 in the MP and 86 in the EP) qualified for the intent-to-treat analysis. 

INTERVENTIONS: The EP consisted of 11group sessions, each lasting 1 hour. After introductory sessions,
subsequent sessions included general physical strengthening and stretching exercises as well as instructions for a home-training program. The MP consisted of 17 group sessions of 1.75 hours and one individual session of 45 minutes. In addition to the full EP, the MP included 5 psychological units, 7 segmental stabilization exercises units, and 8 ergonomic and workplace-specific units. 

MAIN OUTCOME MEASUREMENTS: The primary study end-point variable was pain interference, and the secondary study end-point variables were pain intensity and functioning as measured with the West Haven-Yale Multidimensional Pain Inventory and the Short Form-36, respectively. These study end-point variables were defined a priori.

RESULTS: There was no statistically significant difference between the 2 groups. Small-to-moderate effects were observed in both intervention programs across all study end-point variables. For pain interference, the effect size at 12 months after intervention was 0.58 in the MP and 0.47 in the EP. 

CONCLUSIONS: A multimodal program is not superior to a general exercise program in influencing the process leading to chronic LBP in a population of nurses with a history of pain. The most likely explanation is a common psychological mechanism leading to improved pain interference that is irrespective of the program used. Considering the lower resources of the general exercise program, the expense for a multimodal program is not justified for the secondary prevention of LBP and disability.

US Doctor liable despite no patient relationship

http://www.ama-assn.org/amednews/2009/08/10/prca0810.htm

Doctor liable despite no patient relationship

In the Courts. By Amy Lynn Sorrel, AMNews staff. Posted Aug. 10, 2009.
Nevertheless, an Arizona appeals court recently found that a doctor doing one such exam on behalf of a workers' compensation carrier could be held partially liable for the death of a man he evaluated. The doctor is asking the state Supreme Court to hear the case. Before Dr. Krasner's evaluation, Ritchie signed a limited liability agreement stating: "It is very important that [Ritchie] realize that no doctor-patient relationship exists between you and Dr. Krasner. Because of this, the results of this evaluation will not be given to you or to anyone that you may request to receive them. This is done to insure that all findings will be neutral, and that the evaluators are completely independent and not involved in your disability claim."

Validity of new biomarkers of internal dose for use in the biological monitoring of occupational and environmental exposure to low concentrations of b

Validity of new biomarkers of internal dose for use in the biological monitoring of occupational and environmental exposure to low concentrations of benzene and toluene: "Conclusions Our research confirmed the validity of t,t-MA and SPMA for use in the biological monitoring of exposure to low concentrations of benzene. Urinary benzene showed comparable validity to SPMA; both parameters are affected by smoking cigarettes in the hours before urine collection, so it is best to ask subjects to refrain from smoking for 2 h before urine collection. Urinary toluene was found to be a more specific biomarker than SBMA."

Fwd: [occ-env-med-l] Flu Spread in temperate zones by aerosol, in tropics by contact: A hypothesis

PLoS Currents: Influenza. 2009 Aug 18:RRN1002.

RRNID: RRN1002.1

http://www.ncbi.nlm.nih.gov/rrn/articlerender.fcgi?acc=RRN1002

accessed 15 September 2009 

Transmission of influenza virus in temperate zones is predominantly by aerosol, in the tropics by contact: A hypothesis

Anice Lowen^* and Peter Palese^†

^*Mount Sinai School of Medicine and ^†Mount Sinai School of Medicine, NY

Terms of use: This research note is distributed under the Creative Commons Attribution 3.0 License.

See this research note at PLoS Currents: Influenza.

Using the guinea pig model, we have previously shown that the aerosol transmission of a seasonal human influenza virus is blocked by humid (80% relative humidity) or warm (30°C) ambient conditions. In contrast, we found that transmission by a contact route proceeded at high efficiency despite increased temperature or humidity. Based on these findings, and the observed seasonal behavior of influenza viruses in various regions of the world, we hypothesize herein that the predominant mode of influenza virus transmission differs in temperate and tropical climates. Specifically, we predict that aerosol transmission predominates during the winter season in temperate regions, while contact is the major mode of spread in the tropics. With this idea in mind, possible explanations for the current summer-time spread of swine-origin influenza viruses are discussed.

Modes of influenza virus transmission

Despite its fundamental importance to controlling the spread of infection, the mode with which influenza viruses transmit from host-to-host remains a point of significant controversy. Three vehicles of viral spread have been implicated: fomites, large respiratory droplets (usually said to be >10 μM in diameter), and small airborne droplet nuclei (usually said to be < 5 μM in diameter) [1]. Evidence supporting a role for each mode in the transmission of influenza viruses between humans has been reported [reviewed in [1],[2]] and under experimental conditions using the guinea pig model all three modes have been observed, albeit with differing efficiencies [3]. Based on the literature and our own findings, we propose that the possible modes of influenza virus transmission encompass the entire spectrum, from direct contact through to long-range airborne transmission. Which mode of transmission is the most important, or occurs with the highest frequency, is subject to the prevailing circumstances. These circumstances would include the types of surfaces available for fomite transmission, the rate and direction of air exchange, amount of virus shed from the infectious individual, the strain of influenza virus and – importantly – environmental conditions. The critical question then becomes, not what is the predominant mode of influenza virus transmission, but rather what conditions are favorable to each type of spread? The answer to this question would allow investigation of how variation in mode of transmission with prevailing conditions impacts the epidemiology of influenza. One aspect of this bigger picture in which we are particularly interested is the interplay between the mode of transmission and the seasonality of influenza.

Influenza seasonality

In temperate regions of the world influenza epidemics occur with a marked winter-time seasonality. Thus, in the Northern Hemisphere, peak influenza activity is seen between November and March, while in the Southern Hemisphere, cases of influenza are most frequent from May to September (Fig. 1).

Figure 1. Weekly influenza activity for five countries spanning the Americas. Adapted from reference [4], this graph illustrates the differing patterns of influenza activity seen in temperate and tropical (here exemplified by Colombia) regions. The latitude of the capital city of each country is indicated in brackets in the figure legend.

In the tropics, by contrast, influenza activity tends to be much more sporadic, with isolations occurring either throughout the year or in temporally irregular outbreaks (Fig. 1) [4]. For many years the underlying reasons for influenza seasonality were widely discussed but poorly understood [5],[6]; recently, however, we have reported compelling evidence obtained in the guinea pig model which suggests that seasonal variation in humidity and temperature may direct seasonal fluctuations in influenza activity [7],[8]. In addition, as demonstrated below, our data revealed that transmission by the aerosol route (here defined as encompassing both large and small droplet spread) is acutely sensitive to both humidity and temperature, while transmission by the contact route is not.

Sensitivity of aerosol transmission to humidity and temperature

By combining the guinea pig transmission model with the use of an environmentally controlled chamber, we have been able to systematically evaluate the effects of temperature and relative humidity on influenza virus transmission [7],[8]. To specifically test the effects on transmission by the aerosol route, we used an experimental design in which infected and exposed guinea pigs were placed in separate cages [7]. Each cage was open to air flow on the top and on one side and pairs of cages were placed at a minimum distance of approximately 2 cm such that the guinea pigs were not able to touch each other. Following this arrangement, four infected and four naïve animals were placed together into an environmental chamber and monitored for virus shedding over a period of one week. This strategy revealed a strong impact of ambient temperature and humidity conditions on the aerosol transmission of influenza viruses (Fig. 2). In general, we found that cold and dry conditions were most favorable, while aerosol transmission was completely blocked by warm (30°C) or humid (80% relative humidity) conditions.

Figure 2. Aerosol transmission of influenza A/Panama/2007/1999 virus varies with relative humidity and temperature. Nasal wash titers of intranasally inoculated animals are indicated by dashed lines, while nasal wash titers of exposed animals are shown with solid lines. In each experiment, n = 4 inoculated guinea pigs and 4 exposed guinea pigs. The environmental conditions under which each experiment was performed are indicated at the top (temperature) and at the left (relative humidity, RH). Comparison of results across each row shows the decrease in aerosol transmission with increasing temperature; comparison of results down each column indicates the decrease in aerosol transmission with the increase in relative humidity [7]. 

Insensitivity of contact transmission to humidity and temperature

To evaluate whether transmission by the contact route would also be affected by humidity and temperature, we used an experimental design in which infected and exposed guinea pigs were placed in the same cage together [8]. This set up allows for transmission to occur by direct or indirect contact, as well as by short-range aerosol transmission. As with the aerosol transmission experiments, environmental conditions were controlled within a chamber and exposure occurred over a period of one week. As shown in Figure 3, these experiments indicated that the efficiency of transmission by the contact route varies very little with relative humidity or temperature.

Figure 3. Contact transmission of A/Panama/2007/1999 virus is relatively insensitive to effects of temperature and humidity. Nasal wash titers of intranasally inoculated animals are indicated by dashed lines, while nasal wash titers of exposed animals are shown with solid lines. In each experiment, n = 4 inoculated guinea pigs and 4 exposed guinea pigs. The environmental conditions under which each experiment was performed are indicated above the corresponding graph [8]. 

Hypothesis: differing modes of transmission predominate in temperate and tropical zones

Overall, our data in the guinea pig model indicate that aerosol transmission is acutely sensitive to relative humidity and temperature, while contact transmission is not. An interesting hypothesis follows from these findings, namely that the transmission of influenza viruses during the winter season in temperate regions occurs predominantly by an aerosol route, while transmission year-round in the tropics is mainly through direct or indirect contact. If correct, this hypothesis could explain the documented differences in seasonality between temperate and tropical regions of the world. Specifically, if viral spread in the tropics relies mainly on fomites or direct contact, then transmission would be expected to proceed year-round despite hot and humid climatic conditions. The persistence of influenza viruses in the human populations of the tropics is likely of great importance to the global epidemiology of seasonal influenza: spread throughout the year in tropical regions is thought to allow the seeding of new influenza virus strains into the Northern and Southern Hemispheres in their respective autumn months [9]. Thus, the ability of influenza viruses to transmit by multiple different routes, which vary in their sensitivity to environmental conditions, may be essential to the maintenance of these viruses in the global human population.

Summer-timer transmission of swine-origin H1N1 influenza viruses

In recent months, a very interesting exception to the standard seasonality of influenza has developed. Following its introduction into humans in the spring of 2009, the Northern Hemisphere has seen extensive spread of a swine-origin influenza virus (SOIV) over the spring and summer months [10]. Several possible explanations for this phenomenon exist: i) the increased number of summer cases is simply due to increased surveillance and testing of patients with influenza-like illness; ii) a unique viral trait allows SOIV strains to transmit by the aerosol route even under warm or humid conditions; iii) unlike conventional human strains, SOIV is able to transmit by aerosol under unfavorable conditions due to the lack of immunity against it in the human population; or iv) the transmission currently being seen in the Northern Hemisphere is occurring by the contact route and is occurring with unusually high efficiency due to the low level of immunity in the population. Given that the conventional H1N1 and H3N2 viruses which circulated in the winter of 2008/09 have not been detected out of season in high numbers, we feel that the first explanation is most likely incorrect. The remaining hypotheses are all feasible and time and experimentation will tell which is correct. At the present time, our favored hypothesis is the fourth, that summer-time transmission by a contact route is occurring with increased frequency due to the antigenic novelty of the strain. If correct, we would expect increased transmission in the coming winter months. In addition, if SOIV becomes established in the human population over the long term, then we would expect to see subsequent epidemics fall into the conventional pattern of winter-time seasonality.

Acknowledgements

Figure 1 is derived from the published work of C. Viboud, W.J. Alonso and L. Simonsen.

Funding information

Funding for this work was provided by the Center for Research on Influenza Pathogenesis (NIAID contract HHSN266200700010C) and the W. M. Keck Foundation (to P.P.). A.C.L. is a Parker B. Francis Fellow in Pulmonary Research.

Competing interests

The authors have declared that no competing interests exist.

References

1. Tellier R. Review of aerosol transmission of influenza A virus. Emerg Infect Dis. 2006 Nov;12(11):1657-62. Review. PubMed PMID: 17283614. [PubMed]
2. Brankston G, Gitterman L, Hirji Z, Lemieux C, Gardam M. Transmission of influenza A in human beings. Lancet Infect Dis. 2007 Apr;7(4):257-65. Review. PubMed PMID: 17376383. [PubMed]
3. Mubareka S, Lowen AC, Steel J, Coates AL, García-Sastre A, Palese P. Transmission of Influenza Virus via Aerosols and Fomites in the Guinea Pig Model. J Infect Dis. 2009 Feb 9. [Epub ahead of print] PubMed PMID: 19203260. [PubMed]
4. Viboud C, Alonso WJ, Simonsen L. Influenza in tropical regions. PLoS Med. 2006 Apr;3(4):e89. Epub 2006 Mar 7. PubMed PMID: 16509764; PubMed Central PMCID: PMC1391975. [PubMed]
5. Dowell SF. Seasonal variation in host susceptibility and cycles of certain infectious diseases. Emerg Infect Dis. 2001 May-Jun;7(3):369-74. PubMed PMID: 11384511; PubMed Central PMCID: PMC2631809. [PubMed]
6. Lofgren E, Fefferman NH, Naumov YN, Gorski J, Naumova EN. Influenza seasonality: underlying causes and modeling theories. J Virol. 2007 Jun;81(11):5429-36. Epub 2006 Dec 20. Review. PubMed PMID: 17182688; PubMed Central PMCID: PMC1900246. [PubMed]
7. Lowen AC, Mubareka S, Steel J, Palese P. Influenza virus transmission is dependent on relative humidity and temperature. PLoS Pathog. 2007 Oct 19;3(10):1470-6. PubMed PMID: 17953482; PubMed Central PMCID: PMC2034399. [PubMed]
8. Lowen AC, Steel J, Mubareka S, Palese P. High temperature (30 degrees C) blocks aerosol but not contact transmission of influenza virus. J Virol. 2008 Jun;82(11):5650-2. Epub 2008 Mar 26. PubMed PMID: 18367530; PubMed Central PMCID: PMC2395183. [PubMed]
9. Rambaut A, Pybus OG, Nelson MI, Viboud C, Taubenberger JK, Holmes EC. The genomic and epidemiological dynamics of human influenza A virus. Nature. 2008 May 29;453(7195):615-9. Epub 2008 Apr 16. PubMed PMID: 18418375; PubMed Central PMCID: PMC2441973. [PubMed]
10. WHO (2009) Influenza A(H1N1) - update 61http://wwwwhoint/csr/don/2009_08_12/en/indexhtml.

H1N1 Small Business Planning Guide

Planning for 2009 H1N1 Influenza: A Preparedness Guide for Small Business

http://www.flu.gov/professional/business/smallbiz.html/?date=091409

Table of Contents

• Foreword
• Introduction
• How to Write Your Plan
• Keeping Healthy: 10 Tips for Businesses
• Keeping Healthy: 8 Tips for Individuals
• Frequently Asked Questions
• More Resources

Printable Version (PDF – 3.74 MB)

---

Foreword

As a small business leader, you are a valuable partner in our nation's defense against natural and man-made threats. Preparedness is the best method to defend against the impacts of all threats and all hazards, including public health threats.

As we face the possibility of a wider H1N1 influenza outbreak, it is difficult to predict how the virus may or may not change. However, we know the nation must be prepared to respond appropriately. The Department of Homeland Security is working to ensure you have the necessary tools and information to be prepared as well. The severity of illness that 2009 H1N1 influenza flu will cause (including hospitalizations and deaths) or the amount of illness that may occur as a result of seasonal influenza during the 2009–2010 influenza season cannot be predicted with a high degree of certainty. Therefore, small businesses should plan to be able to respond in a flexible way to varying levels of severity and be prepared to take additional steps if a potentially more serious outbreak of influenza evolves during the fall and winter.

Small businesses are often the backbone of private sector industries and their local communities. With this in mind, we must partner to ensure the wheels of the nation's economy continue to turn, even if faced with absenteeism, restricted services, and supply chain disruptions. If prepared, small businesses can keep their doors open and our nation's economic health and security resilient.

The most important thing you can do to prepare your business is to have a written plan.

This guide is intended to help you write your plan and help spread the message of preparedness. Also, encourage your employees to prepare their own homes and families, which includes having a plan to care for sick family members and storing a two-week supply of food and medical supplies. More information is available at www.flu.gov. With your help, we can help keep our economy and our communities healthy and safe.

Yours truly,

Janet Napolitano
Secretary of Homeland Security
September 2009

---

Introduction

Small businesses play a key role in protecting employees' health and safety as well as limiting the impact to the economy and society during an influenza pandemic. Advance planning for pandemic influenza, a novel infectious disease that could occur in varying levels of severity, is critical. Companies that provide critical services, such as power and telecommunications, have a special responsibility to their community to plan for continued operations in a pandemic and should plan accordingly.

A new influenza virus, now called 2009 H1N1 influenza, or 2009 H1N1 flu, first caused illness in Mexico and the United States in March and April, 2009. On June 11, 2009, the World Health Organization (WHO) signaled that a global pandemic of 2009 H1N1 flu was underway by raising the worldwide pandemic alert level to Phase 6. This action was a reflection of the spread of the new 2009 H1N1 flu virus across the globe, not the severity of illness caused by the virus. At the time, more than 70 countries had reported cases of 2009 H1N1 flu infection and there were ongoing community level outbreaks of 2009 H1N1 flu in multiple parts of the world. Since June, this new H1N1 virus has continued to spread. The Centers for Disease Control and Prevention (CDC) anticipates additional cases, hospitalizations and deaths associated with this pandemic in the United States during the U.S. 2009–2010 influenza season.

Community strategies that delay or reduce the impact of a pandemic (also called nonpharmaceutical interventions) may help reduce the spread of disease until a vaccine is available. Over the past several years, the Department of Health and Human Services (HHS), the CDC, and the Occupational Safety and Health Administration have developed guidelines, including checklists, to assist businesses, industries, and other employers in planning for a pandemic outbreak as well as for other potential disasters.

The Department of Homeland Security, the CDC, and the Small Business Administration have developed this booklet to help small businesses understand what impact a new influenza virus, like 2009 H1N1 flu, might have on their operations, and how important it is to have a written plan for guiding your business through a possible pandemic.

... More ...

WHO Issues Handbook on Radon - Recommends a Reference Level of 100 Bq/m3

Read the WHO Radon Handbook at:
http://www.who.int/ionizing_radiation/env/radon/en/index1.html

Also visit the EPA Radon website: http://www.epa.gov/radon

On Monday, September 21st the United Nation's World Health Organization (WHO)
said that radon is a worldwide health risk in homes. Dr. Maria Neira of WHO
said that "Most radon-induced lung cancers occur from low and medium dose
exposures in people's homes. Radon is the second most important cause of
lung cancer after smoking in many countries."  The WHO recommendations are
contained in the "Handbook on Indoor Radon: A Public Health Perspective".

Here are two excerpts from the Handbook that are worth noting.

"A national reference level for radon represents the maximum accepted
radon concentration in a residential dwelling and is an important
component of a national programme. For homes with radon concentrations
above these levels remedial actions may be recommended or required. When
setting a reference level, various national factors such as the distribution
of radon, the number of existing homes with high radon concentrations, the
arithmetic mean indoor radon level and the prevalence of smoking should be
taken into consideration. In view of the latest scientific data, WHO proposes
a reference level of 100 Bq/m3 [2.7 pCi/L] to minimize health hazards due
to indoor radon exposure.  However, if this level cannot be reached under
the prevailing country-specific conditions, the chosen reference level
should not exceed 300 Bq/m3 [8.1 pCi/L] which represents approximately
10 mSv per year according to recent calculations by the International
Commission on Radiation Protection (Executive Summary, page xi).

The proportion of all lung cancers linked to radon is estimated to lie
between 3% and 14%, depending on the average radon concentration in the
country and on the method of calculation. Radon is the second most important
cause of lung cancer after smoking in many countries. Radon is much more
likely to cause lung cancer in people who smoke, or who have smoked in the
past, than in lifelong non-smokers. However, it is the primary cause of lung
cancer among people who have never smoked (Chapter 1, page 3).

Read/download the WHO Radon Handbook at:
http://www.who.int/ionizing_radiation/env/radon/en/index1.html

Also visit the EPA Radon website: http://www.epa.gov/radon

Edgar Allan Poe and CO poisoning [Gas Lighting]

Edgar Allan Poe and CO poisoning: http://www.mcsrr.org/poe/

EPA Voluntary Methamphetamine Laboratory Cleanup Guidelines

US Environmental Protection Agency News Release - October 6, 2009

Contact Information:   Latisha Petteway, petteway.latisha@epa.gov, (202) 564-3191, (202) 564-4355

EPA Publishes Voluntary Guidelines for Methamphetamine Laboratory Cleanup

WASHINGTON - EPA has issued a document providing state and local governments technical guidance for methamphetamine lab cleanups. The document, titled Voluntary Guidelines for Methamphetamine Laboratory Cleanup, is based on an extensive review of the best available science and practices for cleanup. Other issues included are best practices for specific items or materials, sampling procedures, and technical resources. 

The production and use of meth across the U.S. continues to pose considerable challenges. Although there is a decline in the domestic production of meth in recent years, vigilance is warranted because of the destructive nature of meth and the environmental hazards caused by meth labs.

The Methamphetamine Remediation Research Act of 2007 required EPA to develop these guidelines, based on the best currently available knowledge in the field of meth lab remediation.  EPA reviewed state guidance and regulations to develop these voluntary guidelines.  In addition, this document has received extensive review and refinement from a broad array of stakeholders as well as feedback from nationally recognized experts in meth lab remediation. 

More information:  http://www.epa.gov/oem/methlab.htm

IDSA policy re mandatory HCW immunization

Dear Colleagues,

As many of you are dealing with health care worker (HCW) influenza vaccination issues at your own institutions, I'm writing to announce that IDSA has strengthened its position supporting mandatory vaccination of HCWs against influenza. We believe immunization is the most effective thing we as HCWs can do to protect our patients—and ourselves—from influenza, including the 2009 novel H1N1 virus. All of us and all of our colleagues who work in direct patient care should be immunized. We owe it to our patients.

In 2007, IDSA adopted a policy supporting mandatory influenza vaccination among HCWs as part of our report,
Pandemic and Seasonal Influenza Principles for U.S. Action . In light of the current pandemic, the IDSA Board of Directors recently voted to expand that policy to address H1N1 and to support requiring unimmunized HCWs to wear masks or accept reassignment away from direct patient care to protect patients from influenza. The new policy can be found on the IDSA home page at     www.idsociety.org .

Although we support educational programs that inform HCWs about the value of getting immunized, in recent years, educational programs alone and easy access to influenza immunization have only slightly improved HCW vaccination rates in many health care systems. Most successful educational programs still average only 40 to 70 percent coverage, well short of acceptable levels.

Universal immunization of HCWs against seasonal and H1N1 influenza should be the goal of all health care institutions, whether inpatient or outpatient, when vaccine is not in short supply. Several studies demonstrate that immunizing HCWs against influenza reduces both morbidity and mortality among patients. Links to several of these studies are available on our website . In one randomized controlled trial of 20 long-term care hospitals in the United Kingdom , for example, vaccination of HCWs was associated with a substantial decrease in patient mortality, from 22.4 percent to 13.6 percent. These and other findings make it clear: Immunizing HCWs is a critical patient safety issue.

We believe employees who cannot be vaccinated due to medical contraindications, because the vaccine is in short supply, or who sign a written declination choosing not to be vaccinated for religious reasons should be required to wear masks or be reassigned from direct patient care. We understand health care institutions will not be able to establish and fully implement mandatory programs immediately. They will need to balance multiple priorities in implementing such policies, taking into account vaccine supply and distribution, mask supplies, the use and content of declination forms, staffing needs, and other local situations, particularly in this challenging influenza season.

A growing number of health care systems and institutions, including BJC HealthCare in St. Louis and Children's Hospital of Philadelphia , have adopted mandatory influenza immunization policies. For a list of additional institutions that have adopted such policies, see this website . We welcome your feedback on IDSA's stronger policy and this important patient safety issue. Please share your comments by e-mail .

In addition, we offer many immunization resources on our
H1N1 and seasonal influenza webpage , including links to vaccination information statements, question-and-answer documents explaining vaccine safety and other related issues, and vaccination guidance for state and local health officials. This page is updated regularly with the latest information related to H1N1 and seasonal influenza.

Sincerely,

Anne A. Gershon, MD, FIDSA
President, IDSA

This message brought to you by the Infectious Diseases Society of America ( http://www.idsociety.org/ ).  1300 Wilson Blvd, Suite 300, Arlington , VA 22209 Ph. (703) 299-0200

[occ-env-med-l] "Cold Truth": CA to regulate diacetyl flavoring

http://www.coldtruth.com/2009/10/08/california-finally-moves-to-control-butter-flavoring-and-end-popcorn-lung-what-about-the-rest-of-the-u-s/

California finally moves to control butter flavoring and end popcorn lung. What about the rest of the U.S.?

Posted on October 8, 2009, 12:52, by schneider.

Why is it taking years to protect workers and consumers from illness and death from butter flavoring used in thousands of foods?

It's not like it's a secret that factory workers exposed to vapors from chemical butter substitute have contracted the sometimes deadly and rare disorder called popcorn lung.

More than nine years ago, the illness was traced to workers in microwave popcorn plants throughout the Midwest where, eventually, hundreds were diagnosed with the irreversible disease.

But it wasn't just popcorn workers.

In 2006, while working at the Baltimore Sun, I wrote about several employees of California flavoring plants that worked with the diacetyl-based concoction and were sickened by the disease. One, Francisco Herrera, a young father, lost 70 percent of his lung capacity and could no longer lift his children.

In other stories that year, I reported on flavoring workers from coast-to-coast diagnosed with the disease, which is called bronchiolitis obliterans, and causes the destruction of the small airways in the lung.

Occupational medicine experts at the National Institute of Occupational Safety and Health and California's health and worker safety agencies responded almost immediately to determine how widespread the diacetyl problem was.  However, in California, their efforts were blocked by the flavoring industry and their powerful lobbyists who claimed all was fine.

It wasn't.

Finally, this week, California regulators have unveiled a first-in-the-nation proposal to control exposures to the potentially deadly flavorings chemical diacetyl.

The standard, which will be discussed at one last public meeting next month, would apply to all flavor and food manufacturing facilities that use diacetyl and flavorings that contain 1 percent or greater concentration of the chemical.

Companies using diacetly will be required to do at least the following:

• Assess the concentration of airborne diacetyl each employee is exposed to while working.
• Use engineering and work practice controls to reduce diacetyl and ensure that employees wear protective face masks when needed.
• Perform medical surveillance of workers, including health questionnaires and pulmonary function tests.
• Report any "flavor-related" diagnosis of fixed obstructive lung disease within 24 hours of becoming aware of it.

While California authorities are concerned primarily with 30 diacetly using companies their state, NIOSH is responsible about workers in the thousands of other companies nationwide that are presumed to use diacetyl or its substitutes. I say presumed because the manufacturers and wholesalers of the chemical have repeatedly refused to identify their customers to the public health investigators

Many in the flavoring industry still argue that diacetyl has not been proven the cause of the rare and life-threatening disease. However, Dr. Kay Kreiss and her colleagues at NIOSH – who have been tracking worker exposure to diacetyl for almost a decade – have shown repeatedly that workers exposed to the highest cumulative diacetyl doses had the greatest risk of having breathing abnormalities.

The NIOSH team continues to pursuit the risk from exposure to diacetyl and the untested chemical butter substitutes that the food industry insists are safe.  But several major industrial users are being far from helpful.

Those concerned about diacetyl exposure are waiting to see what happens at the federal worker safety level.

The newly named head of OSHA – David Michaels ­– and the acting agency head – Jordon Barab – both have years of stridently demanding federal action to protect workers and consumers from this butter flavoring.

I guess we'll wait to see what they do now that they have the power to make a difference.

Here is a link to the proposed diacetyl standard.


--
Gary Greenberg, MD MPH    Sysop / Moderator Occ-Env-Med-L MailList
Univ. N. Carolina School Public Health
Medical Director  http://www.UrbanMin.org
Urban Ministries of Wake County Open Door Clinic http://www.OpenDoorDocs.org
GNGreenberg@gmail.com                       http://occhealthnews.net

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ChemSec Newsletter October 2009 on EU RoHS Directive

 News from the International Chemical Secretariat

 Dear All,

  We are now focusing much of our work on the revision of the EU RoHS
 Directive that regulates hazardous substances within the electronics sector.
 Also - the SIN List has been updated and from today the SIN List consists of
 356 substances.

 The SIN List updated with substances newly classified within the EU – now
 containing 356 substances

 The SIN List 1.0 has been updated with 89 new substances. All of these are
 classified CMRs, substances that are Carcinogenic, Mutagenic, and toxic to
 Reproduction. This update of the SIN List is due to an extension of the list
 of substances classified as CMRs within the European Union. The SIN List
 consists of Substances of Very High Concern (SVHC) according to the official
 REACH criteria and therefore the SIN List is updated when new substances are
 defined as SVHC. One of the REACH criteria of SVHC are CMRs classified in
 accordance to the CLP Regulation (Regulation on Classification, Labelling
 and Packaging). The first update of the CLP Regulation was made in
 September, resulting in 89 new substances classified as CMRs. All of these
 89 are now included on the SIN List, which gives us a SIN List of 356
 substances.


 Review of the RoHS Directive

 The EU RoHS Directive (Restriction of Hazardous Substances in electronic
 products) is under review and ChemSec is bringing NGOs and business together
 for a stronger RoHS Directive. ChemSec has, together with the European
 Environmental Bureau and Clean Production Action, developed a position
 regarding the review of the RoHS Directive. Our aim is to make sure that the
 RoHS Directive continues to be a de facto global standard for the phase out
 of hazardous chemicals in Electrical and Electronic Equipment (EEE). This
 approach takes into account both the direct impact of substances as well as
 the impact of substances that are the result of transformations at products'
 end of life. ChemSec invites leading manufacturers of electronic products to
 support a strengthening of the RoHS proposal.


 New ChemSec report: Apple, Sony Ericsson and suppliers are removing chlorine
 and bromine from electronics

 ChemSec, together with Clean Production Action, has published a report on
 companies within the electronics sector moving away from chemicals that can
 lead to health and environmental problems. The report: "Greening Consumer
 Electronics: Moving Away from Bromine and Chlorine" features seven
 companies, among them Sony Ericsson and Apple, who have engineered
 environmental solutions that negate the need for most - or in some cases all
 - uses of brominated and chlorinated chemicals. Despite initial concerns
 that substance restrictions in RoHS would disrupt the development of new and
 improved consumer electronic products, leading companies are now moving
 beyond RoHS compliance by restricting additional bromine and chlorine based
 compounds in consumer electronic products.

 Go to the new Greening Consumer Electronics report


 ChemSec arranges RoHS Conference in the European Parliament

 On 18 November, ChemSec will arrange a conference in the European Parliament
 in Brussels, focusing on the revision of the RoHS Directive. The "Conference
 on Greening Consumer Electronics – From Hazardous Material to Sustainable
 Solutions " will be hosted by Jill Evans, Member of the European Parliament
 and EP Rapporteur on the Revision of RoHS. At the conference Apple, Sony
 Ericsson and DSM will talk about their work in phasing out bromine and
 chlorine and delivering products without brominated flame retardants and
 PVC.



 More information is available at the ChemSec website
 http://www.chemsec.org/rohs

FDA: Drug Disposal Guide for Patients

FDA NEWS RELEASE

For Immediate Release: Oct. 14, 2009

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm186598.htm

Media Inquiries: Christopher Kelly, 301-796-4676, christopher.kelly@fda.hhs.gov
Consumer Inquiries: 888-INFO-FDA

New FDA Web Page Lists Disposal Instructions for Select Medicines

The U.S. Food and Drug Administration today launched a Web page for consumers with information on how to dispose of certain drugs, including several high-potency opioids and other selected controlled substances. These medicines have the potential to be harmful, even deadly, in a single dose if taken by someone other than the intended person.

http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm

The FDA recommends that these medicines be disposed of by flushing down the sink or toilet. The goal is to keep them away from children and others who could be harmed by taking them accidentally.

Medicines not listed should be thrown away in the household trash after mixing them with some unpalatable substance, such as coffee grounds, and sealing them in a bag or other container. Another option is to dispose of them through drug take back programs, if federal and state law permit.

"The safe disposal of medicines from the home after they are no longer needed is an important concern for the FDA," said Douglas Throckmorton, M.D., deputy center director of FDA's Center for Drug Evaluation and Research.

All medicines listed have disposal instructions in their professional prescribing information; however, this information is targeted to health care professionals. The Web page provides clear instructions for consumers on whether a medicine should be flushed or disposed of in the trash.

Throckmorton also said, "The FDA is working with other groups to improve the use of several drug disposal methods, including drug take back programs. However, for some potent medicines that can cause harm or death if inadvertently taken by family members, the FDA currently recommends flushing them down the sink or toilet to immediately and permanently remove them from the home. Simple precautions like these can reduce the likelihood of accidental and potentially dangerous exposure to unused medicines."

The FDA worked with the White House Office of National Drug Control Policy (ONDCP) to develop the first consumer guidance for proper disposal of prescription drugs. The ONDCP federal guidelines were first issued in February 2007.

For more information:

Disposal by Flushing of Certain Unused Medicines: What You Should Know

Medicines Recommended for Disposal by Flushing

Chronic Fatigue Syndrome & Retrovirus

http://www.sciencenews.org/view/generic/id/48157/title/Retrovirus_might_be_culprit_in_chronic_fatigue_syndrome

The long, fruitless search for the cause of chronic fatigue syndrome has taken a curious turn. Scientists report online October 8 in Science that an obscure retrovirus shows up in two-thirds of people diagnosed with the condition. The researchers also show the retrovirus can infect human immune cells.

These findings don't establish that the pathogen, called gammaretrovirus XMRV, causes chronic fatigue, cautions study coauthor Robert Silverman, a molecular biologist at the Lerner Research Institute of the Cleveland Clinic. "Nevertheless, it's exciting because it is a viable candidate for a cause."

Roughly 1 to 4 million people in the United States have chronic fatigue syndrome, according to the Centers for Disease Control and Prevention. The condition shows up as mental and physical exhaustion, memory lapses, muscle pain, insomnia, digestive distress and other health problems. Doctors often diagnose chronic fatigue only after ruling out everything else. Its cause is unknown.

In the new study, the researchers tested blood from 101 people with chronic fatigue syndrome and found that 68 were infected with XMRV. When the scientists analyzed blood from 218 healthy people as a control group, only eight had the virus — 4 percent. The study participants lived in various parts of the United States.

"This is a very striking association — two-thirds of the patients," says John Coffin, a virologist at Tufts University in Boston who wasn't involved in the study. A 4 percent infection rate in the healthy controls is also substantial, he notes, because it suggests that 10 million people in the United States are harboring this hidden infection.

If the retrovirus indeed is found to cause chronic fatigue, the infected 4 percent in the control group might represent people who have been infected for a short time and haven't developed symptoms, or who have kept the virus in check, says study coauthor Judy Mikovits, a cell biologist at Whittemore Peterson Institute in Reno and at the University of Nevada, Reno.

Based on its genetic makeup, XMRV arose from a mouse retrovirus that somehow jumped to humans.

Mikovits asserts that the retroviral infection might result in an immune deficiency that leads to chronic fatigue symptoms. Retroviruses are known to attack the immune system, with HIV being the best-known example. In this study, researchers showed that XMRV infected immune cells in the blood.

"This may end the controversy as to whether there is an underlying infection in some cases of chronic fatigue syndrome, but is unlikely to explain all cases," says internist Dedra Buchwald of the University of Washington in Seattle. Retroviruses can awaken latent viruses already in cells. It is possible that chronic fatigue symptoms are caused not by XMRV but by other viruses that it activates, she says.

Meanwhile, retroviruses harbor pro-growth genes, and some cause the blood cancer leukemia in animals and people. XMRV — or xenotropic murine-leukemia-virus–related virus — itself shows up in some men with prostate cancer, particularly those with aggressive malignancies, another research team reported last month in the Proceedings of the National Academy of Sciences.

Gammaretroviruses, a subset of retroviruses, also cause disease in gibbons, cats and koalas, Silverman says. "XMRV is the first member of this genus of retrovirus to be found in humans," he notes.

In the new study, the researchers also found hints that the retrovirus is transmitted by blood, as are some other viruses, including HIV. But it's probably not spreading very fast, because people with chronic fatigue "are too sick to do anything," Mikovits says.

Further research is under way to fine-tune testing for the retrovirus, and more blood analyses are planned that will clarify its occurrence rate in the general population. Mikovits and her colleagues are investigating already-approved antiretroviral drugs to see if these will benefit people who have chronic fatigue.

= -- = -- = -- = -- = -- = --

Science 9 October 2009:
Vol. 326. no. 5950, p. 215
DOI: 10.1126/science.326_215a

Virology:

Chronic Fatigue and Prostate Cancer: A Retroviral Connection?

Sam Kean

A new study published online by Science links chronic fatigue syndrome to a possibly contagious rodent retrovirus, XMRV, which has also been implicated in an aggressive form of prostate cancer. Related work by the authors also suggests CFS might best be treated with AIDS drugs. Even the lead author, Judy Mikovits, says she understands why linking CFS to both a retrovirus and prostate cancer has already drawn skepticism.

NTSB Safety Recommendations H-09-15 and -16 OSA and commercial drivers

************************************************************

                   NTSB SAFETY RECOMMENDATION

************************************************************

National Transportation Safety Board

Washington, DC 20594

October 20, 2009

************************************************************

NTSB Safety Recommendations H-09-15 and -16

************************************************************

The National Transportation Safety Board makes the following

recommendations to the Federal Motor Carrier Safety

Administration:

Implement a program to identify commercial drivers at high

risk for obstructive sleep apnea and require that those

drivers provide evidence through the medical certification

process of having been appropriately evaluated and, if

treatment is needed, effectively treated for that disorder

before being granted unrestricted medical certification. (H-

09-15)

Develop and disseminate guidance for commercial drivers,

employers, and physicians regarding the identification and

treatment of individuals at high risk of obstructive sleep

apnea (OSA), emphasizing that drivers who have OSA that is

effectively treated are routinely approved for continued

medical certification. (H-09-16)

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http://www.ntsb.gov/recs/letters/2009/H09_15_16.pdf

************************************************************

The complete recommendation letter is available on the Web

at the URL indicated above.

The letter is in the Portable Document Format (PDF) and can

be read using the Acrobat Reader 5.0 or later from Adobe

(http://www.adobe.com/prodindex/acrobat/readstep.html).

       

An archive of recommendation letters is available at

http://www.ntsb.gov/recs/letters/letters.htm.

Electronic versions of letters may or may not include

enclosures; however, related publications, accident

briefs, and aviation accident synopses may be found

on the NTSB website.

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