Clinical characteristics of patients in a case control study of sarcoidosis.

Sarcoidosis may be affected by sex, race, and age. A Case Control Etiologic Study of Sarcoidosis (ACCESS) enrolled 736 patients with sarcoidosis within 6 mo of diagnosis from 10 clinical centers in the United States. Using the ACCESS sarcoidosis assessment system, we determined organ involvement for the whole group and for subgroups differentiated by sex, race, and age (less than 40 yr or 40 yr and older). The study population was heterogeneous in terms of race (53% white, 44% black), sex (64% female, 36% male), and age (46% < 40 yr old, 54% > or = 40 yr old). Women were more likely to have eye and neurologic involvement (chi(2) = 4.74, p < 0.05 and chi(2) = 4.60, p < 0.05 respectively), have erythema nodosum (chi(2) = 7.28, p < 0.01), and to be age 40 yr or over (chi(2) = 6.07, p < 0.02) whereas men were more likely to be hypercalcemic (chi(2) = 7.38, p < 0.01). Black subjects were more likely to have skin involvement other than erythema nodosum (chi(2) = 5.47, p < 0.05), and eye (chi(2) = 13.8, p < 0.0001), liver (chi(2) = 23.3, p < 0.0001), bone marrow (chi(2) = 18.8, p < 0.001), and extrathoracic lymph node involvement (chi(2) = 7.21, p < 0.01). We conclude that the initial presentation of sarcoidosis is related to sex, race, and age.

Familial aggregation of sarcoidosis. A case-control etiologic study of sarcoidosis (ACCESS).

Despite reports of familial clustering of sarcoidosis, little empirical evidence exists that disease risk in family members of sarcoidosis cases is greater than that in the general population. To address this question, we estimated sarcoidosis familial relative risk using data on disease occurrence in 10,862 first- and 17,047 second-degree relatives of 706 age, sex, race, and geographically matched cases and controls who participated in the multicenter ACCESS (A Case-Control Etiology Study of Sarcoidosis) study from 1996 to 1999. Familial relative risk estimates were calculated using a logistic regression technique that accounted for the dependence between relatives. Sibs had the highest relative risk (odds ratio [OR] = 5.8; 95% confidence interval [CI] = 2.1-15.9), followed by avuncular relationships (OR = 5.7; 95% CI = 1.6-20.7), grandparents (OR = 5.2; 95% CI = 1.5-18.0), and then parents (OR = 3.8; 95% CI = 1.2-11.3). In a multivariate model fit to the parents and sibs data, the familial relative risk adjusted for age, sex, relative class, and shared environment was 4.7 (95% CI = 2.3-9.7). White cases had a markedly higher familial relative risk compared with African-American cases (18.0 versus 2.8; p = 0.098). In summary, a significant elevated risk of sarcoidosis was observed among first- and second-degree relatives of sarcoidosis cases compared with relatives of matched control subjects.

The utility of Poison Control Center data for assessing toxic occupational exposures among young workers.

This study assessed the utility of Poison Control Center data for identifying and describing occupational toxic exposures to youth and the associated health outcomes of such exposures. The authors reviewed 1997 data from the American Association of Poison Control Centers' Toxic Exposure Surveillance System for occupational exposures to persons 6 to 19 years old. In 1997, there were 3442 reported occupational exposure cases among 6- to 19-year-olds. Exposure cases included underage workers, exposure to multiple substances, continuous or repeated exposure to the offending substance, and exposures occurring in the home. Poison Control Centers provide unique and valuable information on toxic workplace exposures to youth. Child labor laws may be violated in many cases, and risks exist with respect to industrial work done in the home. Prospective studies with immediate follow-back are needed.

A national survey of regional poison control centers' management of occupational exposure calls.

Regional poison control centers (PCCs) were surveyed nationally to assess their policies and practices in handling work-related exposures. A 24-item survey was mailed to the executive directors of 44 American Association of Poison Control Centers' certified PCCs nationwide. The survey also requested permission to call the PCC to conduct a blinded role-playing exercise of a case of work-related trichloroethane exposure. Responses on the management questionnaire were compared with the actual responses provided by information specialists in the role-playing exercise. Seventy-five percent of PCCs completed the survey; 43% completed the telephone role-playing exercise. Survey respondents generally overestimated what they thought was routinely done to assess work-related calls, compared with what actually occurred at the time of the work-related call in the role-playing exercise. For example, 32% indicated that their PCC asked about the activities of nearby workers, but none of the PCC staff actually did so. Eighty-nine percent of the PCC executive directors surveyed thought that their staff routinely advised callers to notify their employer about work-related exposure concerns, but this occurred in only 11% of the calls. We concluded that PCCs' responses to work-related calls are inadequate. Given the public health impact of work-related calls, PCCs should develop, implement, and monitor written protocols to better address the public health issues of workplace poisonings.

Variability in the classification of radiographs using the 1980 International Labor Organization Classification for Pneumoconioses.

This study describes the extent of agreement in classification of chest radiographs using the International Labor Organization (ILO) classification among six readers from the United States and Canada. A set of 119 radiographs was created and read by three Canadian and three US readers. The two ratings of interest were profusion (scored from 0/- to 3/+) and pleural abnormalities consistent with pneumoconiosis (scored with the ILO system, then collapsed into a yes/no). We used a number of approaches to evaluate interreader agreement on profusion and pleural changes, determining concordance, observed agreement, kappa statistic, and a new measure to approximate sensitivity and specificity. This study found that five of six readers had good fair to good agreement for pleural findings and for profusion as a dichotomous variable (> or = 1/0 vs < or = 0/1) using the kappa statistic, while a sixth reader had poor agreement. We found that concordance, expressed as percent agreement, was higher for normal radiographs than for ones that showed disease, and describe the use of the kappa statistic to control for this finding. This analysis adds to the existing literature with the use of the kappa statistic, and by presenting a new measure for "underreading" and "overreading" tendencies.

Epidemiology of advanced lung disease in the United States.

ALD affects a large segment of the population in the United States, both old and young, and men and women of all races and ethnicities. Many chronic diseases inevitably advance to a stage that results in significant respiratory impairment and disability. Although the causes of some of the diseases are known and the diseases may be preventable, the overall absolute burden of illness in the population is rising because of an enlarging population and newer therapeutic approaches. This is evident despite the lack of consistent and comparable data estimates for all diseases from national database resources. Where the data exist, it is evident that the cost related to the morbidity and mortality of these illnesses is substantial and consumes a significant proportion of health care expenditures. Both morbidity and mortality estimates, as well as cost estimates, are conservative and are likely underestimates of the true overall impact of ALD on the US economy.

Occupational history as the key to the recognition and prevention of workplace-related lung disease.

Occupational and environmental exposures cause substantial lung disease morbidity and mortality. A detailed exposure history is the key to detecting and treating these largely preventable illnesses and deaths. Components of an exposure history include details of the current and past work histories as well as of nonoccupational exposures. Identification of a sentinel health event requires a public health approach to the follow-up of affected individuals. This approach includes industrial hygiene sampling and monitoring, engineering and administrative controls, institution of proper work practices, education, and medical monitoring.

Occupational impairment and disability among applicants for Social Security disability benefits in Pennsylvania.

OBJECTIVE: The study goal was to assess the extent of workplace-related disease and injury among Social Security Disability Insurance applicants. METHODS: A convenience sample of 240 consecutive applicants to the Pennsylvania Bureau of Disability Determination was studied to assess the prevalence of work-related disorders. An applicant had a work-related condition if there was a clear statement of a workplace illness or injury associated with the impairment, or if the applicant had worked at an occupation with a high likelihood of exposures known or suspected to contribute to the condition of interest. RESULTS: Of the 240 applicants, 166 (69%) were awarded disability insurance benefits; a total of 27 (11%) had work-related conditions, including 14 of the 166 (8%) who were found to be disabled. Forty percent of the 27 had a disorder that was musculoskeletal in origin. Of 59 applicants with cancer, 10.2% had some work-related etiological component. Of an estimated 71,680 adult disability insurance applicants in Pennsylvania in 1990, 5134 new insurance beneficiaries had a projected occupationally related disability. CONCLUSIONS: A substantial number of applicants for disability insurance benefits suffer from an impairment caused or exacerbated by prior workplace exposures. These individuals may serve as sentinel events for initiating follow-up surveillance and prevention activities.

Epidemiology of obstructive sleep apnea.

Sleep-disturbed breathing, which includes apneas, hypopneas, and oxygen desaturations, occurs in asymptomatic individuals and increases with age. Obstructive apnea is the most frequent type of respiratory disturbance documented by polysomonography, the gold standard test for assessing sleep-disturbed breathing. Many of the prevalence studies done to date have had one or more methodological weaknesses, including selection biases, varying definitions of obstructive sleep apnea, failure to distinguish types of apneas, failure to control for confounding variables, and small sample size. Although there is consensus on the definitions of sleep-disturbed breathing, the appropriate number of apneas and hypopneas for diagnosing clinically significant obstructive sleep apnea is uncertain. While the cutoff of five or more apneas and hypopneas per hour is historically considered abnormal, the origins of this number are vague, and the longevity of those who have this value on polysomnography is not necessarily reduced. This is particularly true among those without symptoms of obstructive sleep apnea syndrome, which include excessive daytime sleepiness, snoring, nocturnal awakenings, and morning headaches. Investigators should be careful to distinguish symptomatic study subjects from asymptomatic subjects, and to exclude central apneas in calculating their estimates. In addition, various studies have used different definitions of sleep apnea syndrome, making comparisons of point estimates difficult. It would be more appropriate for researchers to estimate morbidity and mortality indices with confidence intervals, using several different cutoff points. Subject selection in all studies should follow a two-stage sampling procedure. All subjects with symptoms compatible with obstructive sleep apnea syndrome and a subsample of asymptomatic individuals should be studied with all-night polysomnography. If portable monitoring is used, the validity and reproducibility of this diagnostic method should be assessed. Subjects with significant comorbidity should be excluded from prevalence studies. Factors that clearly increase the risk of sleep-disturbed breathing and obstructive sleep apnea and its related symptoms include age, structural abnormalities of the upper airway, sedatives and alcohol, and probably family history. Although endocrine changes such as growth hormone, thyroid hormone, and progesterone deficiency also have been suggested as risk factors for exacerbating obstructive sleep apnea syndrome, there is minimal epidemiologic evidence to support this. Case-control studies are recommended to assess the relation of endocrine factors to obstructive sleep apnea syndrome in a rigorous fashion. A limited number of mortality studies have suggested decreased survival in persons with the obstructive sleep apnea syndrome, possibly primarily due to vascular-related disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Asbestos-related radiographic abnormalities in elevator construction workers.

Elevator construction workers are exposed to asbestos dust during construction and refurbishment work on older buildings. We screened a cohort of workers, all with greater than 20 yr of employment in the industry, with clinical examinations, chest radiography ("B" reader interpretations), and routine spirometry. Twenty of the 91 workers (22%) had evidence of pleural disease, but none of them had an interstitial process consistent with asbestosis. Of those with pleural thickening, 15 had bilateral circumscribed plaques and five had unilateral plaque formation. There were no cases of diffuse pleural thickening, benign pleural effusions, or mesothelioma identified in our cohort. The difference in the mean body mass index of those with pleural abnormalities (29.18 +/- 3.95) and those without (27.7 +/- 3.86) was not statistically significant (p = 0.135). We conclude that elevator construction workers have an increased risk for the development of asbestos-related pleural disease.

A randomized trial to evaluate a computer-based learning program in occupational lung disease.

Computer based learning (CBL) is a recent educational innovation that may supplement the limited formal education typically offered to medical students in occupational health-related issues. The authors conducted a randomized trial among sophomores to evaluate a Macintosh-based application on occupational lung disease (OH-CBL). The program emphasizes interactive learning and skills practice through a case-based approach. Students taking an OH block in the Preventive Medicine course were assigned either to the OH-CBL or to the lecture group. 35 students completed the OH-CBL; 45 attended the lecture. Of four study-relevant multiple-choice questions, substantial differences were found in favor of the OH-CBL group over the lecture group on one question as well as on the study-relevant multiple choice total score. There was no difference on mean overall grade or on the three study-relevant essay items. The grade on study-relevant questions exhibited a weak relationship with microcomputer experience (r = .29, P = .04). Students' ratings of the CBL program using Likert scales were generally favorable. These findings suggest that CBL programs can be designed to be both acceptable to students and educationally effective. Each new program needs to be individually assessed to meet these standards. The authors identify several components of CBL that are necessary for successful implementation into a medical curriculum.

Morbidity among municipal waste incinerator workers.

Incinerator workers are exposed to many toxic compounds, most notably heavy metals. We evaluated medical and exposure monitoring data of an actively employed cohort of Philadelphia incinerator workers following an Agency for Toxic Substances and Disease Registry site survey and National Institute for Occupational Safety and Health (NIOSH) health hazard evaluation (HHE). Of the many airborne samples taken by NIOSH, only four of the personal breathing zone samples were above OSHA or ACGIH standards: one for lead, one for phosphorous, and two for total particulates. Because samples were taken during limited operations (only one of the two incinerators were operating), the results may underestimate historical exposures at this site. We limited our medical analysis to the 86 male workers who participated in the HHE out of the 105 active employees. The 86 employees were divided into potential high and low exposure groups based on a work site analysis done by an independent industrial hygienist. Eight individuals had at least one elevated biological index indicating exposure to a heavy metal. These elevations, however, were unrelated to the workers' exposure categories. Furthermore, no clinically significant mean blood or serum measurements were noted. Thirty-four percent of the workers had evidence of hypertension which increased the risk of significant proteinuria. Neither hypertension nor proteinuria were related to exposure group. Changes in pulmonary function related only to smoking status. Although there was some evidence of an increased risk of exposure to products of incinerator waste, we could not relate the few elevated biological tests to exposure classification. Additional studies are needed to assess the potential health effects of municipal waste incinerator by-products.

Costs of occupational injury and illness in Pennsylvania.

A variety of state and federal data sources are used to estimate two critical components of the annual economic costs of occupational injuries and illnesses in Pennsylvania: foregone earnings of affected workers and medical costs. Foregone earnings costs resulting from occupational injuries and illnesses are estimated at between $1.22 billion and $2.02 billion in 1988. A number of potential adjustments to these estimates widen the range considerably. Estimates of medical costs range from $740 million to $797 million. Combining these two estimates gives total estimated costs of $1.96 billion to $2.82 billion.

Poison Control Center follow-up of occupational disease.

We followed up 73 of 372 calls to a Regional Poison Control Center (RPCC) that involved workplace disease/exposure(s); most other calls were not made by the workers. An average of 12 additional people per workplace were potentially exposed. Six of the 73 contacted a government agency for investigation of the hazard/illness. Twenty-five percent of callers were still exposed an average of seven months after the original call. The results indicate that poison control centers should develop a public health component to calls about possible workplace poisonings.

A model system for occupational disease surveillance activities applying Centers for Disease Control guidelines to poison control centers.

Each year, poison control centers (PCCs) receive more than 25,000 calls related to workplace exposures to hazardous substances. Recent studies indicate that each caller may be a sentinel contact representing other exposed or ill workers. Although PCCs traditionally focus their follow-up efforts on the treatment of the index case alone, with minimal attention to the public health implications of other exposed or ill workers, PCCs could serve as a national surveillance system for occupational illnesses, a system with both passive and active attributes.

Clinical experiences: development of a medical surveillance protocol for hazardous waste workers.

Medical surveillance of hazardous waste workers is essential for the health of these workers, who have unique, complex exposures. In order for this preventive tool to be effective, the supervising and/or examining physician must be educated about the specific health risks of hazardous waste workers and also must perform a comprehensive examination. Results of testing should be evaluated both for remarkable abnormalities as well as longitudinal subtle changes in individuals, and also for trends in workers with similar exposures. Fitness for duty determinations should be then made with appropriate communication of abnormalities and follow-up recommendations to both employers and employees. To date, clinical and research findings from clinical centers performing surveillance examinations on hazardous waste workers have not revealed remarkable abnormalities related to their potential exposures. The possible causes for these results include: (1) the workers have been well protected; (2) the current diagnostic methodologies are not sensitive enough to detect pathophysiologic changes; and (3) disease may not yet be manifest due to latency or cumulative effects of long-term low-dose exposure. In addition, one must keep in mind that previous clinical and research data were collected from test results of workers who were mainly involved in feasibility, as opposed to remediation, activities. With the prospective change of more clean-up involvement of hazardous waste workers, their potential for exposure may increase. Therefore, periodic collaborative evaluation of existing surveillance programs' results (e.g., every 5 years) is advised. This would allow determination of the efficacy of the current diagnostic methods in detecting disease, as well as the possible inclusion of more sensitive and/or specific newer technologies for use on a more routine basis.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of occupational health professionals in academic environments.

We surveyed American and Canadian medical schools to assess the extent to which occupational health professionals provided services to their own institutions. Ninety-two of 155 schools (60 percent) responded to a mailed questionnaire. Forty-six (51 percent) of the respondents had an occupational health service distinct from an employee health service. Two thirds of the respondents provided occupational health services to business and industry. Such professionals based in nonclinical departments were more likely to provide educational and epidemiologic services for hospital employees than were professionals based in clinical departments. In those institutions with risk management, biohazards, or health and safety committees, less than one half of the occupational health professionals in those institutions were members of those committees. Five respondents felt that there were financial disincentives to providing occupational health services to their institution's employees. We conclude that academic-based occupational health professionals have inadequate input into the provision of such services at their own institutions.