Occupational skin diseases: actual state analysis of patient management pathways in 28 European countries.

BACKGROUND: Work-related skin diseases (WSD) are caused or worsened by a professional activity. Occupational skin diseases (OSD) need to fulfil additional legal criteria which differ from country to country. OSD range amongst the five most frequently notified occupational diseases (musculoskeletal diseases, neurologic diseases, lung diseases, diseases of the sensory organs, skin diseases) in Europe. OBJECTIVE: To retrieve information and compare the current state of national frameworks and pathways to manage patients with occupational skin disease with regard to prevention, diagnosis, treatment and rehabilitation in different European countries. METHODS: A questionnaire-based survey of the current situation regarding OSD patient management pathways was carried out with experts on occupational dermatology and/or occupational medicine from 28 European countries contributing to the European Cooperation in Science and Technology (COST) Action TD 1206 (StanDerm) (www.standerm.eu). RESULTS: Besides a national health service or a statutory health insurance, most European member states implemented a second insurance scheme specifically geared at occupational diseases [insurance against occupational risks (synonyms: insurance against work accidents and occupational injuries; statutory social accident insurance)]. Legal standards for the assessment of occupationally triggered diseases with a genetic background differ between different countries, however, in most European member states recognition as OSD is possible. In one-third of the countries UV light-induced tumours can be recognized as OSD under specific conditions. CONCLUSION: OSD definitions vary between European countries and are not directly comparable, which hampers comparisons between statistics collected in different countries. Awareness of this fact and further efforts for standardization are necessary.

Undergraduate teaching of occupational medicine in European schools of medicine.

PURPOSE: General practitioners play or should play a role in occupational medicine (OM), either in diagnosing occupational diseases or in counseling on return to work. Nevertheless, their training has been reported to be insufficient in most single country studies. AIMS: The objectives of this study were to analyze the content and extent of undergraduate teaching of OM in European medical schools. METHODS: An e-mail questionnaire survey of the teaching of OM to undergraduates was undertaken from December 2010 to April 2011 in all medical schools and medical faculties listed in 27 European countries (n = 305). RESULTS: Among the 305 universities identified, 135 answered to the questionnaire, giving a response rate of 44%. The mean number of hours given to formal instruction in occupational medicine to medical undergraduates was 25.5 h. Nevertheless, this number of hours varied widely between countries, but also within countries. Overall, 27% of medical schools gave their students 10 h of teaching or less, 52% 20 h or less and 69% 30 h or less. Whereas occupational diseases and principles of prevention were covered in most schools, disability and return to work were very poorly represented among the topics that were taught to students. CONCLUSION: Dedicated undergraduate teaching on occupational health or OM in European medical schools is present in most medical schools, usually at a low level, but is very variable between and within countries. Medical schools across Europe are very unequal to provide qualifying doctors education on the topics they will frequently come across in their working lives.

Further studies on delineating thyroid-stimulating hormone (TSH) reference range.

The aim of the study was to evaluate thyroid-stimulating hormone (TSH) concentration in a reference group and to compare it with the TSH in subjects with high probability of thyroid dysfunction. The study population consisted of 852 subjects. The reference group consisting of 316 subjects was obtained by the exclusion of the subjects having thyroid disease, taking thyroid influencing drugs, having increased thyroid peroxidase (TPO) antibodies, or having abnormal thyroid ultrasound. 42 high probability of thyroid dysfunction subjects were defined by the association of increased TPO antibody concentration, changed echogenicity, and changed echosonographic structure of thyroid parenchyma. In the reference group TSH reference range was 0.45 mU/l (95% CI 0.39-0.56 mU/l) to 3.43 mU/l (95% CI 3.10-4.22 mU/l). To distinguish reference and high probability of thyroid dysfunction group a TSH threshold was calculated. At a threshold value of 3.09 mU/l (95% CI 2.93-3.38 mU/l), specificity was 95% and sensitivity 38.1%. Using 2 different approaches to find upper limit of the TSH reference range we obtained similar results. Using reference group only a value of 3.43 mU/l was obtained. Using both reference group and subjects with the high probability of thyroid dysfunction we obtained 95% CI for the upper reference limit between 2.93 and 3.38 mU/l. Based on these premises, it could be argued that conservative estimate of the TSH upper reference range should be 3.4 mU/l for both sexes.

Blood and urine cadmium and bioelements profile in nickel-cadmium battery workers in Serbia.

Although cadmium (Cd) is extensively used for nickel-cadmium battery production, few recent reports are available on the effect of this toxic metal on the imbalance of biometals in occupational exposure. The current study was carried out to determine the Cd level and its effect on the content of bioelements: zinc, cooper, magnesium, and iron in blood and urine of workers exposed to Cd during nickel-cadmium battery production. beta(2)-microglobulins (beta(2)-MG), as indicators of kidney damage, were determined in urine.The study group comprised 32 male nickel-cadmium battery workers, and the control group had 15 male construction workers with no history of Cd exposure. Levels of Cd and bioelements were determined in blood and urine by atomic absorption spectrophotometry.Cd concentration in blood of exposed workers was around 10 microg/L and in urine ranged from 1.93 to 8.76 microg/g creatinine (cr). Urine Cd concentration was significantly higher in exposed workers than in the controls, although no statistical difference in beta(2)-MG content was observed in urine between the two groups. Blood Zn and Mg level were significantly reduced and urine Zn level was increased in Cd-exposed group when compared with controls.The mean Cd concentrations in blood and urine did not exceed the recommended reference values of 10 microg/L in blood and 10 microg/g cr in urine. Cd exposure resulted in disturbances of Zn in blood and urine and Mg in blood but had no effect on Cu and Fe content in biological fluids.

Occupational health and safety in agriculture: situation and priorities at the beginning of the third millennium.

Agriculture is a human activity, which includes a number of different tasks and occupies a huge number of people worldwide. Estimates of World Bank for 2003 suggest that 51% of globalpopulation lives in rural areas. ILO estimates that 1.3 billion of workers are engaged in agriculture, and they represent almost a half of the total number of economically active subjects (2,838,897,404). In developed countries, agriculture workers are only a small fraction of the whole work force (up to 9% according to ILO data), while in developing countries, especially in Asia, agriculture workers represent up to the 60% of the total work force. Most agriculture workers reside in Asia, in the Pacific (74%) and in Africa (16%). ILO estimates suggest that half of fatal occupational injuries in the world are attributable to agriculture. This means that around 170,000 agriculture workers die every year as a consequence of occupational injuries. Using the same estimate, half of the fatal accidents could be linked to agricultural activities (more than 130 million). Comparing this estimate with the 6.328.217 people injured in war in 2002 or with the 20-50 million injured victims of road accidents, one has a much clearer picture about the importance of preventing agricultural injuries. In a complicated situation such as occupational health and safety problems in agriculture, it is not so easy to select priorities clearly. But "legalization" of agriculture workers could be a key to solving all the other problems. Actual data on fatal and non-fatal occupational injuries in agriculture show that occupational health and safety issues are among the top priorities for that discipline.

Cardiovascular effects in viscose rayon workers exposed to carbon disulfide.

The objectives of this study were to investigate the cardiovascular effects in workers currently exposed to carbon disulfide (CS2) below the threshold limit value (TLV) of 31 mg/m3 and to determine the prevalence of coronary heart disease (CHD) after long-term exposure. 172 men (91 workers exposed to CS2 in a viscose rayon factory and 81 referent workers) were examined using a medical and job history questionnaire, Rose's questionnaire, and electrocardiography at rest, and by measuring blood pressure and serum lipids and lipoproteins. Personal exposures were monitored simultaneously with active sampling and findings were analyzed according to the NIOSH 1600 method. As a result of technical and organizational improvements, personal CS2 exposures were well below the TLV (5.4-13.02 mg/m3). No significant effect of CS2 on blood pressure or lipids (total cholesterol, HDL and LDL cholesterol, triglycerides, and apolipoproteins AI and B) was found, even after allowance for confounding factors. The prevalence of CHD (ECG abnormalities and chest pain) was higher in the viscose rayon workers than in the workers with no exposure but reached statistical significance for men with exposure histories often years and more only (cumulative CS9 index > or = 150 mg/m3, the most highly exposed group). The findings suggest that the coronary risk is increased in workers previously exposed to high CS2 concentrations but not in those exposed to CS2 levels below the current TLV.

Preliminary external quality assessment for the biological monitoring of carbon disulfide with urinary 2-thiothiazolidine-4-carboxylic acid.

Four laboratories have participated in an external quality control assessment for the determination of 2-thiothiazolidine-4-carboxylic acid (TTCA). TTCA is used as a biomarker for exposure to CS2. Thirteen different urine samples were analyzed by each laboratory. Ten of these were spiked with known amounts of TTCA, and had either a high or intermediate creatinine content. Two samples without any TTCA were used as controls and one sample was a pool of samples of urine from five employees occupationally exposed to CS2. The latter had unknown TTCA content. For each sample, TTCA and creatinine concentration were determined. The samples were supplied in three consecutive deliveries. Several samples were offered more than once. Thus, within-laboratory variability could be established for creatinine and TTCA determination and accuracy could be determined for TTCA analysis. Within-laboratory variability was low for all laboratories for creatinine, although laboratory D seemed to have a slight downward bias. Accuracy for TTCA was good for all laboratories. No significant mean deviation from the expected TTCA value was encountered. There does not seem to be any clear influence of the TTCA concentration level of the samples on the accuracy and within-laboratory variability. Two of the four laboratories (A and C) showed lower within-laboratory variability than the other two for TTCA, although coefficients of variation between replicated samples are high for these two laboratories as well. The laboratory giving the best accuracy, gave the highest within-laboratory variability. A non-systematic, random error is probably the source of this. The results of this preliminary study indicate that analysis of TTCA, although regarded as an established biomarker, can give biases and thus negatively interfere with inferred dose-effect or dose-response relationships in occupational epidemiology.

Activity of glutathione peroxidase and superoxide dismutase in workers occupationally exposed to mercury.

According to previous research the lipid peroxidation process has a significant role in mercury toxicity. Since glutathione peroxidase (GPX) and superoxide dismutase (SOD) play a significant role in erythrocyte antioxidative defence, it is very important to determine their activity in occupationally exposed workers. The aim of this study was to assess the activity of antioxidative enzymes in the erythrocytes of workers occupationally exposed to mercury. We compared a group of 42 workers exposed to elemental mercury in a chloralkali plant (Hg group). The control group (C group) consisted of 75 subjects employed in lime production who had never been exposed to mercury or any toxic substance. The GPX activities in erythrocytes were significantly lower in the Hg group than in the control group (Hg group, 9.05 +/- 7.52 IU/gHb; C group 15.54 +/- 4.85 IU/gHb; p < 0.001). Also, SOD activity in the erythrocytes of workers occupationally exposed to mercury was significantly lower than in the control group (Hg group, 1280.7 +/- 132.3 IU/gHb; C group, 1377.9 +/- 207.5 IU/gHb; p < 0.006). The concentrations of mercury in blood were significantly higher in the Hg group compared to the control group (Hg group, 0.179 +/- 0.040 micromol/l; C group, 0.023 +/- 0.011 micromol/l; p < 0.001). Urine mercury concentrations were also significantly higher in the Hg group than in the control group (Hg group, 23.2 +/- 11.3 nmol/mmol creatinine; C group, 2.7 +/- 0.6 nmol/mmol creatinine; p < 0.001). The concentrations of selenium in erythrocytes were almost equal in both groups examined (Hg group, 62.9 +/- 8.72 microg/l; C group, 65.8 +/- 10.57 microg/l). Also, in the Hg group there were increased levels of erythrocyte malondialdehyde (Hg group, 138.58 +/- 33.85 micromol/l; C group 105.21 +/- 49.62 micromol/l; p < 0.001). On the basis of previous results, it can be concluded that occupational exposure to elemental mercury leads to increased lipid peroxidation in erythrocytes. Also, it can be postulated that this exposure leads to decreased activity of GPX and SOD in erythrocytes.

Occupational profile and cardiac risks: mechanisms and implications for professional drivers.

Of the population of 900 drivers, 419 drivers with changes in the circulatory system were enrolled in the study, and the control group consisted of 150 healthy drivers. In both groups there were professional and non-professional drivers. Traffic accidents caused by these drivers were registered over a five-year period. Drivers with cardiovascular diseases and professional drivers were more frequently responsible for accidents than healthy and non-professional drivers. The comparison between the group studied and the controls indicated over a two-fold increase in the number of accidents caused by sick drivers.

Preventability of malpractice claims in emergency medicine: a closed claims study.

We conducted a retrospective study of 262 malpractice claims against emergency physicians insured in Massachusetts by the state-mandated insurance carrier; these 262 claims were closed in the years 1980 through 1987. A total of $11,800,156 in indemnity and expenses was spent for these 262 claims. In 211 cases, the allegation was failure to diagnose a medical or surgical problem. One hundred eighty-four of these cases were included in the following eight diagnostic categories: chest pain, abdominal pain, wounds, fractures, pediatric fever/meningitis, aortic aneurysm, central nervous system bleeding, and epiglottitis. These eight categories accounted for 66.44% of the total dollars spent for the 262 claims. Because of the high incidence and dollar losses attached to these eight diagnostic categories, the Massachusetts Chapter of the American College of Emergency Physicians (MACEP) has developed clinical guidelines for the evaluation of these high-risk areas. Of the 184 high-risk claims, 99 claim files were reviewed; 45 of these reviewed claims were judged by physician reviewers as preventable by the application of the MACEP high risk clinical guidelines. From 22.26% to 46.4% of the $11,800,156 spent on the 262 claims could have been saved by the application of the MACEP clinical guidelines.

Retropharyngeal calcific tendinitis: report of five cases and review of the literature.

Retropharyngeal calcific tendinitis is an inflammation of the longus colli muscle tendon, which is located on the anterior surface of the vertebral column extending from the atlas to the third thoracic vertebra. Five cases of acute retropharyngeal calcific tendinitis seen in the emergency department (ED) over a 15-month period are reported. In addition, a retrospective review of four cases diagnosed as retropharyngeal abscess and admitted to the hospital revealed that two of these cases actually represented retropharyngeal calcific tendinitis. A review of the literature and potential differential diagnoses are presented. For those primary care physicians who must evaluate patients with acute cervical pain, sore throat, or odynophagia, an x-ray study of the neck revealing retropharyngeal calcium deposition should raise the question of the diagnosis of acute retropharyngeal tendinitis. Clinical characteristics of this entity include a painful condition which is treatable and is often mistaken for retropharyngeal abscess, pharyngitis, or peritonsillar abscess. In our opinion, this condition may be more prevalent than the literature suggests.

Partition of catalase and its peroxidase activities in human red cell membrane: effect of ATP depletion.

Partititon of catalase (hydrogen-peroxide:hydrogen-peroxide oxidoreductase EC 1.11.1.6) and peroxidase (donor:hydrogen-peroxide oxidoreductase EC 1.11.1.7) activities between the red cell membrane and the cytosol were studied under various experimental conditions. A small but significant amount of catalase (1.6%) was retained on human red cell membranes prepared by hemolysing washed red cells with 30 volumes of 10 mM Tris buffer, pH 7.4. Membrane -bound catalase had a relatively higher peroxidase activity than the soluble enzyme fraction. Polyacrylamide gel electrophoresis in sodium dodecyl sulfate of the solubilized membranes demonstrated catalase to be a single band with a molecular weight of 60 000. Membranes prepared from adenosine triphosphate-depleted red cells depicted a two to three-fold increase in catalase activity, as well as an increase in 60 000 molecular weight band on polyacrylamide gel electrophoresis. The extra amount of retained catalase was a less efficient peroxidase than found in fresh membranes. The binding of catalase to ATP-depleted red cell membranes was dependent upon both pH and hemolysing ratio. Red cells incubated at pH 7.1 demonstrated a decrease in bound catalase, as did membranes prepared from red cells hemolysed at 1:100 dilution. beta-Mercaptoethanol decreased the catalase activity in the membranes and increased the odianisidine peroxidase activity without any significant effect on the 60 000-dalton band.