Reversal of Autism Symptoms among Dizygotic Twins through a Personalized Lifestyle and Environmental Modification Approach: A Case Report and Review of the Literature.

The prevalence of autism has been increasing at an alarming rate. Even accounting for the expansion of autism spectrum disorder diagnostic (ASD) criteria throughout the 1990's, there has been an over 300% increase in ASD prevalence since the year 2000. The often debilitating personal, familial, and societal sequelae of autism are generally believed to be lifelong. However, there have been several encouraging case reports demonstrating the reversal of autism diagnoses, with a therapeutic focus on addressing the environmental and modifiable lifestyle factors believed to be largely underlying the condition. This case report describes the reversal of autism symptoms among dizygotic, female twin toddlers and provides a review of related literature describing associations between modifiable lifestyle factors, environmental exposures, and various clinical approaches to treating autism. The twins were diagnosed with Level 3 severity ASD "requiring very substantial support" at approximately 20 months of age following concerns of limited verbal and non-verbal communication, repetitive behaviors, rigidity around transitions, and extensive gastrointestinal symptoms, among other common symptoms. A parent-driven, multidisciplinary, therapeutic intervention involving a variety of licensed clinicians focusing primarily on addressing environmental and modifiable lifestyle factors was personalized to each of the twin's symptoms, labs, and other outcome measures. Dramatic improvements were noted within several months in most domains of the twins' symptoms, which manifested in reductions of Autism Treatment Evaluation Checklist (ATEC) scores from 76 to 32 in one of the twins and from 43 to 4 in the other twin. The improvement in symptoms and ATEC scores has remained relatively stable for six months at last assessment. While prospective studies are required, this case offers further encouraging evidence of ASD reversal through a personalized, multidisciplinary approach focusing predominantly on addressing modifiable environmental and lifestyle risk factors.

Pneumoconiosis among artisanal miners in Chunya district, Mbeya, Tanzania.

This case series sheds light on the pulmonary diseases afflicting artisanal gold miners in Chunya district, Mbeya, Tanzania. We present 3 cases from a group of 21 miners. The patients, ranging in age and mining exposure, exhibited symptoms of severe pulmonary conditions, including pneumoconiosis, pulmonary hypertension and Cor pulmonale, attributed to prolonged exposure to dust and inadequate protective measures in mining environments. These cases underscore the urgent need for enhanced occupational health standards and preventive strategies in artisanal mining communities.

Association between the severity of hypothermia and in-hospital mortality in patients with infectious diseases: The J-Point registry.

Aim: Hypothermia is associated with poor prognosis in patients with sepsis. However, no studies have explored the correlation between the severity of hypothermia and prognosis. Methods: Using data from the Japanese accidental hypothermia network registry (J-Point registry), we examined adult patients aged ≥18 years with infectious diseases whose initial body temperature was ≤35°C from April 1, 2011 to March 31, 2016, in 12 centers. Patients were divided into three groups according to their body temperature: Tertile 1 (T1) (32.0-35.0°C), Tertile 2 (T2) (28.0-31.9°C), and Tertile 3 (T3) (<28.0°C). In-hospital mortality was employed as a metric to assess outcomes. We conducted a multivariate logistic regression analysis to investigate the relationship between the three categories and the occurrence of in-hospital mortality. Results: A total of 572 patients were registered, and 170 eligible patients were identified. Of these patients, 55 were in T1 (32.0-35.0°C), 76 in T2 (28.0-31.9°C), and 39 in T3 (<28.0°C) groups. The overall in-hospital mortality rate in accidental hypothermia (AH) patients with infectious diseases was 34.1%. The in-hospital mortality rates in the T1, T2, and T3 groups were 34.5%, 36.8%, and 28.2%, respectively. The multivariable analysis demonstrated no significant differences regarding in-hospital mortality among the three groups (T2 vs. T1, adjusted odds ratio [OR]: 1.29; 95% confidence interval [CI]: 0.58-2.89 and T3 vs. T1, adjusted OR: 0.83; 95% CI: 0.30-2.31). Conclusion: In this multicenter retrospective observational study, hypothermia severity was not associated with in-hospital mortality in AH patients with infectious diseases.

Primary amebic meningoencephalitis: a review of Naegleria fowleri and analysis of successfully treated cases.

Primary amebic meningoencephalitis (PAM) is a necrotizing and hemorrhagic inflammation of the brain and meninges caused by Naegleria fowleri, a free-living thermophilic ameba of freshwater systems. PAM remains a neglected disease that disproportionately affects children in tropical and subtropical climates, with an estimated mortality rate of 95-98%. Due to anthropogenic climate change, the average temperature in the USA has increased by 0.72 to 1.06 °C in the last century, promoting the poleward spread of N. fowleri. PAM is often misdiagnosed as bacterial meningitis or viral encephalitis, which shortens the window for potentially life-saving treatment. Diagnosis relies on the patient's history of freshwater exposure and the physician's high index of suspicion, supported by cerebrospinal fluid studies. While no experimental trials have been conducted to assess the relative efficacy of treatment regimens, anti-amebic therapy with adjunctive neuroprotection is standard treatment in the USA. We performed a literature review and identified five patients from North America between 1962 and 2022 who survived PAM with various degrees of sequelae.

Mottled Raynaud's phenomenon and hand-arm vibration syndrome: followed up for 10 years.

Vibration white finger is a form of secondary Raynaud's phenomenon (RP) caused by the use of handheld vibrating tools. RP usually appears on the extremities of the fingers, and its borders are well recognised. No reports have been published on 'mottled' RP in continuous observation from the onset to the disappearance of RP. A man in his 60s who had been using vibrating tools such as jackhammers and tampers for 30 years presented with sensations of coldness, burning and numbness. Whole-body cold exposure was performed outdoors in winter, and RP was photographed continuously. 'Mottled' RP can be defined as triphasic colour changes: white, blue and red. The patient was taken off work, kept warm and medicated. His symptoms improved slightly after 10 years of follow-up, but the RP did not disappear. 'Mottled' RP is rare and refractory and should be recognised as a form of RP.

When Climate Change Shows Up in the Exam Room.

Climate change is considered one of the greatest threats to humanity and the most significant global public health emergency of our lifetime. Millions of people from throughout the globe suffer and die each year from degraded air quality, extreme heat, water and vector-borne diseases as well as the mental health effects of climate change. Because clinicians are considered one of the most trusted sources of climate information, they have a unique opportunity to communicate the many health-related effects of climate change to their patients. It is important for clinicians to understand the most beneficial techniques to use when communicating with patients who may need more information regarding climate change and extreme weather events. These include 1) meeting patients where they are, 2) providing patient education, and 3) telling authentic stories. Developing and delivering effective communication strategies to our patients to prevent and prepare for climate-related health issues are paramount- if we are to make meaningful progress.

Endocrine-disrupting chemicals: Mainstream recognition of health effects and implications for the practicing internist.

Rapidly advancing evidence documents that a broad array of synthetic chemicals found ubiquitously in the environment contribute to disease and disability across the lifespan. Although the early literature focused on early life exposures, endocrine-disrupting chemicals (EDCs) are now understood to contribute substantially to chronic disease in adulthood, especially metabolic, cardiovascular, and reproductive consequences as well as endocrine cancers. The contribution to mortality is substantial, with over 90,000 deaths annually and at least $39 billion/year in lost economic productivity in the United States (US) due to exposure to certain phthalates that are used as plasticizers in food packaging. Importantly, exposures are disproportionately high in low-income and minoritized populations, driving disparities in these conditions. Though non-Hispanic Blacks and Mexican Americans comprise 12.6% and 13.5% of the US population, they bear 16.5% and 14.6% of the disease burden due to EDCs, respectively. Many of these exposures can be modified through safe and simple behavioral changes supported by proactive government action to both limit known hazardous exposures and to proactively screen new industrial chemicals prior to their use. Routine healthcare maintenance should include guidance to reduce EDC exposures, and a recent report by the Institute of Medicine suggests that testing be conducted, particularly in populations heavily exposed to perfluoroalkyl substances-chemicals used in nonstick coatings as well as oil- and water-resistant clothing.

Severe allergic systemic reaction to personal protective equipment during the COVID-19 pandemic.

Our case describes a hospital worker who suffered a severe reaction to personal protective equipment (PPE) during the COVID-19 pandemic. After researching the excipient list of her PPE and completing a literature review, we postulated that isocyanates used in the production of the polyurethane band of the N95 mask was the cause for her reaction. In the absence of standardised testing, we tested this hypothesis by replicating her reaction to PPE by using a commercially available isocyanate patch, identifying diphenylmethane-4, 4-diisocyanate as the culprit agent.We recommended caution in the use of polyurethane containing N95 masks- for people reporting allergic reaction- and testing for sensitivity for polyurethane. The patient was able to tolerate non-polyurethane containing standard surgical masks, providing an option for PPE in some clinical circumstances. Since avoiding N95 masks, she has not had any further reactions.

FAIR environmental and health registry (FAIREHR)- supporting the science to policy interface and life science research, development and innovation.

The environmental impact on health is an inevitable by-product of human activity. Environmental health sciences is a multidisciplinary field addressing complex issues on how people are exposed to hazardous chemicals that can potentially affect adversely the health of present and future generations. Exposure sciences and environmental epidemiology are becoming increasingly data-driven and their efficiency and effectiveness can significantly improve by implementing the FAIR (findable, accessible, interoperable, reusable) principles for scientific data management and stewardship. This will enable data integration, interoperability and (re)use while also facilitating the use of new and powerful analytical tools such as artificial intelligence and machine learning in the benefit of public health policy, and research, development and innovation (RDI). Early research planning is critical to ensuring data is FAIR at the outset. This entails a well-informed and planned strategy concerning the identification of appropriate data and metadata to be gathered, along with established procedures for their collection, documentation, and management. Furthermore, suitable approaches must be implemented to evaluate and ensure the quality of the data. Therefore, the 'Europe Regional Chapter of the International Society of Exposure Science' (ISES Europe) human biomonitoring working group (ISES Europe HBM WG) proposes the development of a FAIR Environment and health registry (FAIREHR) (hereafter FAIREHR). FAIR Environment and health registry offers preregistration of studies on exposure sciences and environmental epidemiology using HBM (as a starting point) across all areas of environmental and occupational health globally. The registry is proposed to receive a dedicated web-based interface, to be electronically searchable and to be available to all relevant data providers, users and stakeholders. Planned Human biomonitoring studies would ideally be registered before formal recruitment of study participants. The resulting FAIREHR would contain public records of metadata such as study design, data management, an audit trail of major changes to planned methods, details of when the study will be completed, and links to resulting publications and data repositories when provided by the authors. The FAIREHR would function as an integrated platform designed to cater to the needs of scientists, companies, publishers, and policymakers by providing user-friendly features. The implementation of FAIREHR is expected to yield significant benefits in terms of enabling more effective utilization of human biomonitoring (HBM) data.

Blood pressure and hypertension in relation to lead exposure updated according to present-day blood lead levels.

Lead is an environmental hazard that should be addressed worldwide. Over time, human exposure to lead in the Western world has fallen drastically to the levels comparable to those in humans living in the pre-industrial era, who were mainly exposed to natural sources of lead. To re-evaluate the health risks possibly associated with present-day lead exposure, a three-pronged approach was applied. First, we critically assessed the recently published population metrics describing the adverse health effects associated with lead exposure at the population level. Next, we summarized the key results of the Study for Promotion of Health in Recycling Lead (SPHERL; NCT02243904) and analyzed these results in the context of the published population metrics. Last but not least, we performed a brief literature review on the present-day lead exposure level in Poland. To our best knowledge, SPHERL is the first prospective study that accounted for interindividual variation in vulnerability to the toxic effects of lead exposure by assessing the participants' health status before and after occupational lead exposure, with blood pressure and hypertension as the primary outcomes. The overall conclusion of this comprehensive review on blood pressure and hypertension is that mainstream ideas about the public and occupational health risks related to lead exposure need to be urgently updated because a large part of the available literature has become obsolete given present-day exposure levels that sharply declined over the past 40 years.

Association of ambient PM1 exposure with maternal blood pressure and hypertensive disorders of pregnancy in China.

Evidence concerning PM1 exposure, maternal blood pressure (BP), and hypertensive disorders of pregnancy (HDP) is sparse. We evaluated the associations using 105,063 participants from a nationwide cohort. PM1 concentrations were evaluated using generalized additive model. BP was measured according to the American Heart Association recommendations. Generalized linear mixed models were used to assess the PM1-BP/HDP associations. Each 10 µg/m3 higher first-trimester PM1 was significantly associated with 1.696 mmHg and 1.056 mmHg higher first-trimester SBP and DBP, and with 11.4% higher odds for HDP, respectively. The above associations were stronger among older participants (> 35 years) or those educated longer than 17 years or those with higher household annual income (> 400,000 CNY). To conclude, first-trimester PM1 were positively associated with BP/HDP, which may be modified by maternal age, education level, and household annual income. Further research is warranted to provide more information for both health management of HDP and environmental policies enactment.

Soft tissue infection and follow-up for an unsheltered patient: the role of Street Medicine providers in bridging gaps in care.

Street Medicine is a volunteer-run initiative for low-resource healthcare settings. Formed to bridge gaps in care for persons experiencing homelessness, these organisations work to provide preventative medicine through maintenance care and follow-up. However, there are limits to what Street Medicine can accomplish given the geographical radius covered, lack of available transportation options and vulnerable sleeping locations night to night for the patients served. The subject of this case report is a middle-aged Spanish-speaking unsheltered man who began his care with a Street Medicine team. He was unable to attend medical appointments due to relocation, complicating his disease course and resulting in hospital intervention for cellulitis. Post-discharge, he stayed within radius and was treated by the street team. Increased emphasis on the effects of housing insecurity and addressing social determinants of health could prevent deterioration of manageable diseases and should be an area of active interest for Street Medicine team expansion.

UV radiation and air pollution as drivers of major autoimmune conditions.

Autoimmune diseases comprise a very heterogeneous group of disorders characterized by disruptive immune responses against self-antigens, chronic morbidity and increased mortality. The incidence and prevalence of major autoimmune conditions are particularly high in the western world, at northern latitudes, and in industrialized countries. This study will mainly focus on five major autoimmune conditions, namely type 1 diabetes, multiple sclerosis, inflammatory bowel diseases, rheumatoid arthritis, and autoimmune thyroid disorders. Epidemiological and experimental evidence suggests a protective role of sunlight exposure on the etiology of major autoimmune conditions mediated by the endogenous production of vitamin D and nitric oxide. A historical perspective shows how the rise of anthropogenic air pollutants is temporally associated with dramatic increases in incidence of these conditions. The scattering caused by ambient particulate matter and the presence of tropospheric ozone can reduce the endogenous production of vitamin D and nitric oxide, which are implicated in maintaining the immune homeostasis. Air pollutants have direct detrimental effects on the human body and are deemed responsible of an increasingly higher portion of the annual burden of human morbidity and mortality. Air pollution contributes in systemic inflammation, activates oxidative pathways, induces epigenetic alterations, and modulates the function and phenotype of dendritic cells, Tregs, and T-cells. In this review, we provide epidemiological and mechanistic insights regarding the role of UV-mediated effects in immunity and how anthropic-derived air pollution may affect major autoimmune conditions through direct and indirect mechanisms.

Thinking "Green" When Treating "Pink Puffers" and "Blue Bloaters"-Reducing Carbon Footprint When Prescribing Inhalers.

The impact of man-made climate change is already affecting millions of people worldwide. The health care sector in the US is a relevant contributor, accounting for about 8 to 10% of national greenhouse gas emissions. This special communication describes the harmful impact of propellant gases in metered dose inhalers (MDI) on the climate and summarizes and discusses current knowledge and recommendations from European countries. Dry powder inhalers (DPI) are a good alternative to MDIs and are available for all inhaler drug classes recommended in current asthma and COPD guidelines. Changing an MDI to PDI can significantly reduce carbon footprints. The majority of the US population is willing to do more to protect the climate. Primary care providers can engage in this by addressing the impacts of drug therapy on climate change in medical decision making.

Tackling climate change and health inequalities in primary care.

The Climate Emergency is now widely accepted as the biggest public health crisis facing humanity. Previous research has highlighted how social and health inequalities shape the health impacts of climate change in the UK, but there has been little attention to the role of general practice in deprived areas. This Brief Report summarises a roundtable discussion of Scottish 'Deep End' GPs - family doctors working in the most socio-economically deprived areas - which took place weeks before the 26th UN Climate Change Conference (COP26), held in Glasgow in November 2021. The report highlights the need for urgent action to make general practice more sustainable, including recommendations for community engagement, (de)prescribing, medical education, digital inclusion, and investment in premises and capacity building.

Public and occupational health risks related to lead exposure updated according to present-day blood lead levels.

Lead is an environmental hazard that should be addressed worldwide. Over time, human lead exposure in the western world has decreased drastically to levels comparable to those among humans living in the preindustrial era, who were mainly exposed to natural sources of lead. To re-evaluate the potential health risks associated with present-day lead exposure, a two-pronged approach was applied. First, recently published population metrics describing the adverse health effects associated with lead exposure at the population level were critically assessed. Next, the key results of the Study for Promotion of Health in Recycling Lead (SPHERL; NCT02243904) were summarized and put in perspective with those of the published population metrics. To our knowledge, SPHERL is the first prospective study that accounted for interindividual variability between people with respect to their vulnerability to the toxic effects of lead exposure by assessing the participants' health status before and after occupational lead exposure. The overall conclusion of this comprehensive review is that mainstream ideas about the public and occupational health risks related to lead exposure urgently need to be updated because a large portion of the available literature became obsolete given the sharp decrease in exposure levels over the past 40 years.

Thiamethoxam intoxication due to occupational inhalational exposure.

Neonicotinoid is a new class of systemic insecticides that are selectively toxic to insects. However, cases of human toxicity have been reported. A man in his 60s, who worked as a pest control operator (which required the use of thiamethoxam), presented with fever and headache. We investigated the levels of thiamethoxam and clothianidin in the blood and urine. Our results suggested that chronic thiamethoxam intoxication was caused by occupational inhalation exposure and environmental pollution. After cessation of insecticide use, the patient remained asymptomatic but had persistent oral dysesthesia and postural finger tremor, even at undetectable levels of thiamethoxam and clothianidin. This case report is the first to describe human thiamethoxam intoxication after occupational inhalation exposure. When similar symptoms are encountered and a history of insecticide use is confirmed, clinicians should consider the diagnosis of neonicotinoid intoxication.

The amount of SARS-CoV-2 RNA in wastewater relates to the development of the pandemic and its burden on the health system.

Virus surveillance in wastewater can be a useful indicator of the development of the COVID-19 pandemic in communities. However, knowledge about how the amount of SARS-CoV-2 RNA in wastewater relates to different data on the burden on the health system is still limited. Herein, we monitored the amount of SARS-CoV-2 RNA and the spectrum of virus variants in weekly pooled wastewater samples for two years from mid-February 2020 and compared them with several clinical data. The two-year monitoring showed the weekly changes in the amount of viral RNA in wastewater preceded the hospital care needs for COVID-19 and the number of acute calls on adult acute respiratory distress by 1-2 weeks during the first three waves of COVID-19. Our study demonstrates that virus surveillance in wastewater can predict the development of a pandemic and its burden on the health system, regardless of society's test capacity and possibility of tracking infected cases.

Environmental Medicine: Exploring the Pollutome for Solutions to Chronic Diseases.

Environmental toxicant exposure, according to many researchers in the field, is the leading cause of chronic disease and premature death globally. For the purposes of this review, we will use obesity and type 2 diabetes as examples of toxicant-induced chronic diseases. Endocrine Disrupting chemicals (EDCs) such as phthalates and bisphenols, per- and polyfluoroalkyl substances (PFAS), and persistent organic pollutants (POPs) have been linked to increased risk for obesity and type 2 diabetes in both animal and large epidemiologic studies. These two conditions are well-documented examples of evidence for mechanisms of both adipose metabolism disruption and pancreatic cell dysfunction. The implications for health care directives to both identify, prevent, and treat these exposures are reviewed.