Indicators of long-term return to work after severe traumatic brain injury: A cohort study.

BACKGROUND: Return to work (RTW) is a major objective in the rehabilitation of individuals with severe traumatic brain injury (TBI). Implications for long-term occupational integration (beyond 5 years) have rarely been studied. OBJECTIVE: The objective was to assess long-term RTW and the associated factors after severe TBI. MATERIAL AND METHODS: Retrospective analysis of a cohort of individuals 16 to 60 years old admitted to hospital after severe TBI from 2005 to 2009 and followed prospectively. Medical and occupational data were collected from medical files and by systematic telephone interview to assess outcome at a minimum of 6 years post-trauma. Factors associated with RTW were investigated by multivariable regression analysis, estimating prevalence ratios (PRs) and 95% confidence intervals (CIs). A proportional hazards model was used to study RTW delay, estimating hazard ratios (HRs). RESULTS: Among the 91 individuals included (mean [SD] age 28.5 [11.3] years; 79% male), 63.7% returned to work after a mean of about 20 months, and 57.1% were still working at the time of the survey. Factors significantly associated with RTW on multivariable analysis were higher educational level (adjusted PR, 1.53; 95% CI, 1.15 to 2.03), absence of motor disability (adjusted PR, 1.82; 1.12 to 2.95) and behavioural disorder (adjusted PR, 1.26; 1.01 to 1.60), as well as disabled worker status (adjusted PR, 1.26; 1.01 to 1.60) (likelihood of the multivariate analysis model 53.1). Delayed RTW was associated with health insurance payments (adjusted HR, 0.40; 95% CI, 0.22 to 0.71), motor disability (adjusted HR, 0.34; 0.15 to 0.76), low educational level (adjusted HR, 2.20; 1.06 to 4.56) and moderate disability on the Extended Glasgow Outcome Scale (adjusted HR, 0.49; 0.27 to 0.91) (likelihood of the multivariate analysis model 335.5). CONCLUSION: Individuals with the most severe TBI are able to RTW and remain in work. This study highlights the multiple determinants involved in RTW and the role of socioenvironmental factors.

Road casualties in work-related and private contexts: occupational medical impact. Results from the ESPARR cohort.

BACKGROUND: Road accidents may impact victims' physical and/or mental health and socio-occupational life, notably including return to work. OBJECTIVES: To assess whether the occupational medical consequences sustained by subjects injured in road accidents occurring in a work-related context differ from those associated with private accidents. METHODS: 778 adults who were in work or occupational training at the time of their accident were included. Two groups were distinguished: 354 (45.5%) injured in road accidents occurring in a work-related context (commuting or on duty) and 424 (54.5%) injured in a private accident. The groups were compared on medical and occupational factors assessed on prospective follow-up at 6 months and 1 and 3 years. Multivariate analysis explored for factors associated at 6 months and 1 year with sick leave following the accident and duration of sick leave. RESULTS: There were no significant differences between groups for demographic data apart from a slightly higher injury severity in private accidents (32.5% of private accidents with MAIS3+(Maximum Abbreviated Injury Scale greater or equal to 3) vs. 23.7% for work-related accidents, p = 0.007). Victims of work-related accidents were more often on sick leave (OR = 1.8; 95% CI, 1.1-2.9). Although the length of sick leave is higher for work-related accidents that for private accidents, multivariate analysis showed that the injury severity and the post-traumatic stress disorder (PTSD) are significant factors to explain the time to return to work. There were no significant differences according to occupational impact during follow-up, notably including sick-leave duration, number of victims returning to work within 3 years and number of victims out of work due to incapacity. CONCLUSIONS: In the ESPARR (follow-up study of a road-accident population in the Rhône administrative county: Etude de Suivi d'une Population d'Accidentés de la Route dans le Rhône) cohort, the fact that a road accident occurred in a work-related context did not affect the occupational consequences.

Job Restrictions for Healthcare Workers with Musculoskeletal Disorders: Consequences from the Superior's Viewpoint.

Objective Many workers suffer from musculoskeletal disorders. In France, occupational physicians are able to set job aptitude restrictions obliging employers to adapt the worker's job. The present study explored the impact of job restriction from the point of view of the employees' supervisors. Methods A qualitative study was conducted in 3 public hospitals. 12 focus groups were organized, involving 61 charge nurses and head nurses supervising 1 or more workers restricted for heavy lifting or repetitive movements. Discussions were recorded for qualitative thematic analysis. Results Charge and head nurses complained that aptitude restrictions were insufficiently precise, could not be respected and failed to mention residual capability. A context of personnel cuts, absenteeism and productivity demands entailed a need for polyvalence and reorganization threatening the permanence of adapted jobs. Job restrictions had several negative consequences for the charge and head nurses, including overwork, increased conflict, and feelings of isolation and organizational injustice. Conclusion Protecting the individual interests of workers with health issues may infringe on the interests of their supervisors and colleagues, whose perception of organizational justice may go some way to explaining the support or rejection they show toward restricted workers. This paradox should be explicitly explored and discussed.

[Follow-up after occupational asbestos exposure: terms and devices in foreign]. / Suivi après exposition professionnelle à l'amiante : modalités et dispositifs étrangers.

INTRODUCTION: Diseases, including cancer induced by asbestos, usually occur after many years of latency. The follow-up of employees must therefore continue after the end of their employment (retirement, redundancy, etc.) and such an arrangement has existed in France since 1996. This article reviews the literature on the post-employment monitoring arrangements that exist outside of France, particularly in other European countries, and their characteristics. STATE OF ART: This research has revealed a limited number of national experiences in Germany, Spain, Finland, Italy, Norway, Poland, and Switzerland. The medical protocols generally involve: algorithm decisions, questionnaire, physical examination, chest radiography, CT scan, and/or spirometry. PERSPECTIVES: Internationally, various methods exist to select employees for follow-up and to determine the frequency of subsequent examinations. Unlike Germany, which has a long experience of such medical follow-up, several of these programs are more recent. CONCLUSIONS: Post-occupational medical surveillance of asbestos-related disease is uncommon, monitoring arrangements vary and depend on medical and also on social factors. The French system of post-occupational monitoring can undoubtedly improve but it bears comparison with arrangements in other countries, where these are even present.

[Renal cell carcinoma and exposure to trichloroethylene: are the French limits of occupational exposure relevant?]. / Cancer du rein et expositions au trichloroéthylène: les valeurs limites d'exposition professionnelle françaises en vigueur sont-elles adaptées ?

BACKGROUND: Several studies have investigated the association between trichloroethylene (TCE) exposure and renal cell cancer (RCC) but findings were inconsistent. The analysis of a case control study has shown an increased risk of RCC among subjects exposed to high cumulative exposure. The aim of this complementary analysis is to assess the relevance of current exposure limits regarding a potential carcinogenic effect of TCE on kidney. METHODS: Eighty-six cases and 316 controls matched for age and gender were included in the study. Successive jobs and working circumstances were described using a detailed occupational questionnaire. An average level of exposure to TCE was attributed to each job-period in turn. The main occupational exposures described in the literature as increasing the risk of RCC were assessed as well as non-occupational factors. A conditional logistic regression was performed to test the association between TCE and RCC risk. Three exposure levels were studied (average exposure during the eight-hour shift): 35ppm, 50ppm and 75ppm. Potential confounding factors identified were taken into account at the threshold limit of 10% (p=0.10) (body mass index [BMI], tobacco smoking, occupational exposures to cutting fluids and to other oils). RESULTS: Adjusted for tobacco smoking and BMI, the odd-ratios associated with exposure to TCE were respectively 1.62 [0.77-3.42], 2.80 [1.12-7.03] and 2.92 [0.85-10.09] at the thresholds of 35ppm, 50ppm and 75ppm. Among subjects exposed to cutting fluids and TCE over 50ppm, the OR adjusted for BMI, tobacco smoking and exposure to other oils was 2.70 [1.02-7.17]. CONCLUSION: Results from the present study as well as those provided in the international literature suggest that current French occupational exposure limits for TCE are too high regarding a possible risk of RCC.

Optimizing a recycling process of SMC composite waste.

Investigations about the recycling of sheet moulding compounds (SMC) waste as incorporation material for thermoplastic polymer matrix are reported in this paper. A new efficient process is developed in order to strongly increase the reinforcement glass fraction of SMC leading to good mechanical performance of the new thermoplastic compounds. The overall process is composed of two main steps: mechanical and chemical. The second stage is characterised in terms of optimization and capability by means of experimental design and statistical process control techniques for finding the optimal chemical conditions and validating the process.

[Cell Phones and Risk of brain and acoustic nerve tumours: the French INTERPHONE case-control study]. / Téléphone mobile, risque de tumeurs cérébrales et du nerf vestibuloacoustique: l'étude cas-témoins INTERPHONE en France.

BACKGROUND: Use of cell phones has increased dramatically since 1992 when they were first introduced in France. Certain electromagnetic fields (at extremely low frequency) have been recognized as possibly carcinogenic by the International Agency for Research on Cancer. Given the use of radiofrequency technology in cell phones, the rapid increase in the number of cell phones has generated concerns about the existence of a potential health hazard. To evaluate the relationship between the use of cell phones and the development of tumors of the head, a multicentric international study (INTERPHONE), coordinated by the International Agency for Research on Cancer, was carried out in 13 countries. This publication reports the results of the French part of the INTERPHONE study. METHODS: INTERPHONE is a case-control study focused on tumors of the brain and central nervous system: gliomas, meningiomas and neuromas of cranial nerves. Eligible cases were men and women, residents of Paris or Lyon, aged 30-59, newly diagnosed with a first primary tumor between February 2001 and August 2003. The diagnoses were all either histologically confirmed or based upon unequivocal radiological images. Controls were matched for gender, age (+/-5 years) and place of residence. They were randomly drawn from electoral rolls. Detailed information was collected for all subjects during a computer-assisted face-to-face interview. Conditional logistic regression was used to estimate the odds ratio (OR) for an association between the use of cell phones and risk of each type of cancer. RESULTS: Regular cell phone use was not associated with an increased risk of neuroma (OR=0,92; 95% confidence interval=[0.53-1.59]), meningioma (OR=0,74; 95% confidence interval=[0.43-1.28]) or glioma (OR=1.15; 95% confidence interval=[0.65-2.05]). Although these results are not statistically significant, a general tendency was observed for an increased risk of glioma among the heaviest users: long-term users, heavy users, users with the largest numbers of telephones. CONCLUSION: No significant increased risk for glioma, meningioma or neuroma was observed among cell phone users participating in Interphone. The statistical power of the study is limited, however. Our results, suggesting the possibility of an increased risk among the heaviest users, therefore need to be verified in the international INTERPHONE analyses.

Cancer mortality in a synthetic spinning plant in Besançon, France.

OBJECTIVES: To assess the mortality of a cohort of workers in a synthetic textile spinning plant and to evaluate the relationship between mortality from lung, liver and bladder cancer and the processes or the products used. METHODS: The study population consisted of male workers present for at least 6 months in the plant from 1968 to 1984. The cohort was followed until 1999. Vital status and the causes of death were determined by consulting national registries. The population of the Franche-Comté region was used for comparison. In total, 17 groups of exposure were assessed by the industrial hygienist, based on the consensus of an expert group that determined the exposure levels of each job to selected occupational hazards. Each worker was assigned to one or several groups, according to his occupational history. Confounding factors could not be assessed. Standardised mortality ratios (SMR) and 95% bilateral confidence intervals were calculated based on an assumed Poisson distribution of the number of cases to compare the plant mortality and the population mortality. Internal analyses were performed with Cox models in order to assess the risks of death related to the various exposures. RESULTS: In the whole cohort, mortality from all malignant neoplasms was lower than expected, but this was not significant. All the estimated SMRs were lower than or close to 1. The "hot -line fitters" (RR = 2.13; n = 9; 1.06 to 4.29) and the "fibre-drawing workers" (RR = 1.83; n = 20;1.09 to 3.07) experienced a statistically significant excess in mortality from lung cancer. A slightly elevated but not significant risk of death related to lung cancer (RR = 1.5; n = 41; 0.8 to 2.7) was observed in the groups with the highest exposure to mineral fibres. A statistically significant increase in cancer deaths was observed for workers with high exposure to dust (higher intensity: RR = 1.42; n = 79; 1.06 to 1.89). CONCLUSION: Some findings, mainly of lung cancer, justify further exploration in other plants in this industry.

Risk of occupational blood exposure in a cohort of 24,000 hospital healthcare workers: position and environment analysis over three years.

Early and efficient prevention of occupational blood exposure at hospital requires knowledge of exposures and risks according to staff characteristics. Calculation of annual exposure rates and relative rates from personal and occupational data. The overall annual incidence was 3.5 per 100 workers per year; maximum for nurses and midwives (6.5); minimum for cleaners and paramedics (0.6). Exposures affected mainly nurses (57.81% of accidents, 12.12% of cohort) and occurred mostly in the surgical and the medical departments (26.34 and 25.20% of accidents). Men/women and students/physicians rate differences were not significant. Emergency and intensive care staffs had the highest relative rates (4.27 and 3.05) compared with maintenance staff. Nurses and laboratory staff were more exposed than physicians (3.76 and 2.30 times) were. Our results prompt prevention and training to be precisely focused and efficiently devised.

Noise in the postanaesthesia care unit.

BACKGROUND: Although the postanaesthesia care unit (PACU) can be noisy, the effect of noise on patients recovering from anaesthesia is unknown. We studied the sources and intensity of noise in the PACU and assessed its effect on patients' comfort. METHODS: We measured noise in a five-bed PACU with a sound level meter. Noise levels were obtained using an A-weighted setting (dBA) and peak sound using a linear scale (dBL). Leq (average noise level at 5-s intervals), maximum Leq (LeqMax), minimum Leq (LeqMin) and noise peaks (Lpc) were calculated. During recording, an independent observer noted the origin of sounds from alarms and noise above 65 dB intensity (P65dB). Two hours after leaving the PACU, patients were asked about their experience and to rank their complaints on a visual analogue scale (VAS) using unstructured and structured questionnaires. RESULTS: We made 20,187 measurements over 1678 min. The mean Leq, LeqMax and LeqMin were 67.1 (SD 5.0), 75.7 (4.8) and 48.6 (4.1) dBA respectively. The mean Lpc was 126.2 (4.3) dBL. Five per cent of the noise was at a level above 65 dBA. Staff conversation caused 56% of sounds greater than 65 dB and other noise sources (alarm, telephone, nursing care) were each less than 10% of these sounds. Five patients reported disturbance from noise. There was no significant difference in Leq measured for patients who found the PACU noisy and those who did not [59.5 (3.1) and 59.4 (2.4) dBA respectively]. Stepwise multiple logistic regression indicated that only pain was associated with discomfort. CONCLUSIONS: Even though sound in the PACU exceeded the internationally recommended intensity (40 dBA), it did not cause discomfort. Conversation was the most common cause of excess noise.

Work-related road accidents in France.

A descriptive analysis of all victims of road accidents recorded by the police in 1997 was carried out, distinguishing accidents occurring in the course of work, while commuting and for private reasons. The analysis concerned 105,816 drivers from 14 to 64 years of age; among these, 9.9% were injured during the course of work and 18.6% while commuting. The gender-ratio was maximal for accidents during the course of work (SR = 5.5) and minimal while commuting (2.1). Accidents in the course of work were generally less serious than the two other types aforementioned. Compared with the incidence rates for labourers, those of self-employed trades and services (SETS) and those of employees and executives were higher for accidents incurred during the course of work and lower for those incurred during commuting. Professional drivers had the highest risk during the course of work. Accidents while working were most serious for SETS and professional drivers. Although it was impossible to take into account the mileage travelled, this study points out the real share of work-related road accidents and shows the need to develop and adapt prevention to the groups at risk that we have identified.

Maternal occupational risk factors for oral clefts. Occupational Exposure and Congenital Malformation Working Group.

OBJECTIVES: This study investigated the role of maternal exposures at work during pregnancy in the occurrence of oral clefts. METHODS: The occupational exposures of 851 women (100 mothers of babies with oral clefts and 751 mothers of healthy referents) who worked during the first trimester of pregnancy were studied. All the women were part of a multicenter European case-referent study conducted using 6 congenital malformation registers between 1989 and 1992. In each center, the mother's occupational history, obtained from an interview, was reviewed by industrial hygienists who were blinded to the subject's status and who assessed the presence of chemicals and the probability of exposure. Odds ratios (OR) were estimated by a multivariate analysis including maternal occupation or occupational exposures during the first trimester of pregnancy and possible confounding factors such as center of recruitment, maternal age, urbanization, socioeconomic status, and country of origin. RESULTS: After adjustment for confounding factors, cleft palate only was significantly associated with maternal occupation in services such as hairdressing [OR 5.1, 95% confidence interval (95% CI) 1.0-26.0] and housekeeping (OR 2.8, 95% CI 1.1-7.2). The analysis suggests that the following occupational exposures are associated with orofacial clefts: aliphatic aldehydes (OR 2.1, 95% CI 0.8-5.9) and glycol ethers (OR 1.7, 95% CI 0.9-3.3) for cleft lip with or without cleft palate and lead compounds (OR 4.0, 95% CI 1.3-12.2), biocides (OR 2.5, 95% CI 1.0-6.0), antineoplastic drugs (OR 5.0, 95% CI 0.8-34.0), trichloroethylene (OR 6.7, 95% CI 0.9-49.7), and aliphatic acids (OR 6.0, 95% CI 1.5-22.8) for cleft palate only. CONCLUSIONS: Due to the limited number of subjects, these results must be interpreted with caution. However, they point out some chemicals already known or suspected as reproductive toxins.

[Chemical-induced cancers]. / Cancers chimio-induits.

Most chemical carcinogenic agents are industrial. About 4% of all cancers have an occupational origin, but the percentage is higher in exposed populations. Evidence of carcinogenicity is provided by epidemiological studies, animal experiments and other biological sources like experimental mutagenesis. The IARC (International Agency for Research on Cancer) classification and the European Union classification of carcinogenic agents for humans are useful for prevention and regulation. Some cancers are classified as occupational diseases but only a few persons receive compensation given the difficulties of aetiologic diagnosis and the frequent absence of declaration.

[Social impact of screening and of medical surveillance on people exposed to asbestos]. / L'impact social du dépistage et de la surveillance médicale chez les personnes exposées à l'amiante.

A medical screening program has collective and individual impact. The collective benefit of medical screening for people exposed to asbestos would be financial (better compensation of occupational diseases related to asbestos). The cost of compensation would be attributed to the special assurance fund for occupational diseases. A medical screening of asbestos diseases would set an example for other Public health problems. It would be important for admission of social damage for the French nation. For individuals, social benefits would be better (compensation during work stop and annuities). But screening can have a negative psychological impact for asymptomatic persons. Persons exposed to asbestos and patients with asbestos diseases are able to quit their job for anticipated retirement. Is it a benefit for patients with mesothelioma or lung cancer? It is a very important benefit for asbestosis. The risk is to change the objective of medical screening into a social screening. The financial and medical benefits of screening for hyaline plaques is very poor. Awarding social damage is important for individuals.

[Mortality in the French paper and pulp industry]. / Une étude de mortalité dans l'industrie française du papier et de la pâte à papier.

BACKGROUND: The objective was to describe a possible cancer mortality risk in relation with the occupational exposure within an International study co-ordinated by the International Agency for Research on Cancer. METHODS: An epidemiological cohort study was set up to assess the mortality in four French pulp and paper companies. The four cohorts were followed up from January 1st 1968 to December 31st 1992. The causes of death were ascertained by matching with the national file of causes of death. RESULTS: The full cohort consisted in 5,529 men and 876 women. The total numbers of subjects deceased between 1968 and 1992 were respectively 708 and 34. Causes of death could be traced for 98%. The observed mortality was significantly lower than the expected for all causes of deaths (SMR = 0.86) as well for all deaths by cancer (SMR = 0.87). The analysis by departments showed an excess mortality by cancer of the pancreas in the wood preparation department (SMR = 3.14) as well as in the paper production department (SMR = 2.04). CONCLUSIONS: In absence of any prior hypothesis, it is difficult to assign an occupational origin to these observed excesses. The future results of the international study will enable us to interpret these results more precisely.

Congenital malformation and maternal occupational exposure to glycol ethers. Occupational Exposure and Congenital Malformations Working Group.

Glycol ethers are found in a wide range of domestic and industrial products, many of which are used in women's work environments. Motivated by concern about their potential reproductive toxicity, we have evaluated the risk of congenital malformations related to glycol ether exposure during pregnancy as part of a multicenter case-control study, conducted in six regions in Europe. The study comprised 984 cases of major congenital malformations and 1,134 controls matched for place and date of birth. Interviews of the mothers provided information about occupation during pregnancy, sociodemographic variables, and other potential risk factors (medical history, tobacco, alcohol, drugs). A chemist specializing in glycol ethers evaluated exposure during pregnancy, using the job description given by the mother, without knowledge of case or control status. We classified malformations into 22 subgroups. The overall odds ratio (OR) of congenital malformation associated with glycol ether exposure was 1.44 [95% confidence interval (CI) = 1.10-1.90], after adjustment for several potential confounders. The association with exposure to glycol ethers appeared particularly strong in three subgroups: neural tube defects (OR = 1.94; 95% CI = 1.16-3.24), multiple anomalies (OR = 2.00; 95% CI = 1.24-3.23), and cleft lip (OR = 2.03; 95% CI = 1.11-3.73). In this last subgroup, risk, especially of an isolated defect, tended to increase with level of exposure.

[Occupational exposure and malignant hemopathies: a case-control study in Lyon (France)]. / Expositions professionnelles et hémopathies malignes: une enquête cas-témoins réalisée à Lyon (France).

A hospital based case-control study was carried out in Lyon with the aim of assessing the association between haematologic malignancies and occupational exposures to 320 compounds. Job histories were obtained by questionnaire for 118 cases (52 non Hodgkin lymphomas, 48 acute myeloid leukemia, 18 others leukaemias), and 118 controls with diseases other than cancer from the same general hospital; controls were matched for sex, age and nationality. Systematic coding of exposures based on a blind analysis of job histories, was done by a team of experts in chemistry and occupational health. Mantel-Haenszel analysis was performed. Significantly elevated odds-ratio were observed for non Hodgkin lymphomas and exposure to mineral oils (14.86; 2.76-80.0), excavation dusts (3.91; 0.94-15.95), alkali compounds (2.90; 1.09-7.68), inks (2.47; 1.09-5.17). For inks, a dose-response relation was observed. Elevated odds-ratios appeared for acute myeloid leukaemias and arsenic compounds (3.02; 0.90-10.13) and lead compounds (3.70; 1.09-13.44). When regarding industrial activities, two of them are more frequently found: food industries (14 cases/5 controls), public works (12 cases/0 control). When regarding jobs, winding (6 cases/0 control), glass workers (8 cases/1 control) and warehousemen (10 cases and 4 controls) are more often seen among cases.

Bladder cancer and occupational exposures.

OBJECTIVES: A hospital-based case-referent study was carried out in Lyon with the purpose of generating hypotheses about the role of occupational exposures to 320 compounds in bladder carcinogenesis. METHODS: Job histories were obtained by questionnaire for 116 cases and 232 reference patients with diseases other than cancer (one referent from the same hospital ward and one from another ward of the same hospital per case); the referents were matched for gender, hospital, age, and nationality. Systematic coding of exposures, with a blind analysis of job histories, was carried out by a team of experts in chemistry and occupational health. RESULTS: Significantly elevated odds ratios were observed for exposure to pyrolysis and combustion products [odds ratio (OR) 2.3, 95% confidence interval (95% CI) 1.0-4.0] when the general referents were used and for cutting fluids (OR 2.6, 95% CI 1.2-5.4) when tobacco consumption was adjusted for. The latter was highest among the category consisting of blue-collar and unskilled workers, supervisors, and agricultural workers (OR 4.6 95% CI 2.0-10.6), while the odds ratio for the other category was 0.8 (95% CI 0.3-2.7). An elevated odds ratio for exposure to inks was observed for the women (OR 14.0, 95% CI 1.8-106.5) on the basis of 14 exposed cases, but confounding factors could have been responsible for this result. Odds ratios for several other exposures (rubber: OR 5.7, nitrates: OR 8.2, coke dust: OR 3.5, meat additives: OR 3.8) were also elevated, but not significantly so when based on a small number of exposed cases. CONCLUSION: The observations of this investigation should be tested in future studies, in particular since exposures to agents such as cutting fluids or pyrolysis products are ubiquitous in industrial settings and may present an important public health hazard.