Associations between observed time sitting at work and musculoskeletal symptoms: a repeated-measures study of manufacturing workers.

Time sitting at work is known to affect health overall, but its specific effects on musculoskeletal symptoms are unclear. We evaluated the relationship between observed time sitting at work and self-reported musculoskeletal symptoms among 195 manufacturing workers. Longer time sitting at work was significantly associated with lower prevalence of neck/shoulder (prevalence ratio [PR] = 0.70, 95% confidence interval [CI] [0.68, 0.72]; p < 0.001) and arm/wrist/hand (PR = 0.46, 95% CI [0.31, 0.69]; p < 0.001) musculoskeletal symptoms. Associations remained largely unchanged after adjusting for job type or occupational postures and load. Time sitting at work was associated with musculoskeletal symptoms, and should be taken into consideration as part of interventions to prevent musculoskeletal disorders (MSDs) and promote health of manufacturing workers.

Musculoskeletal disease and disability in dentists.

There is conflicting evidence on the extent that medical conditions, particularly musculoskeletal conditions related to work, cause disability and premature retirement in dentists. Reports based on data from disability insurance in the United States suggest dentists are not susceptible to work related musculoskeletal disability. Surveys of symptom rated debility suggest higher rates of dysfunction, however, as do compulsory employment injury reports from European countries. These data, including information on Swedish dentists, analyzed for this study, tend to put dentists at the higher end of health care professionals in terms of musculoskeletal injury and lost work time. Because compensation patterns and proprietorship vary between national systems, the relationship between exposure and injury and retirement from the active work force may include differing national characteristics.

Risk factors for lung cancer and for intervention effects in CARET, the Beta-Carotene and Retinol Efficacy Trial.

BACKGROUND: Evidence has accumulated from observational studies that people eating more fruits and vegetables, which are rich in beta-carotene (a violet to yellow plant pigment that acts as an antioxidant and can be converted to vitamin A by enzymes in the intestinal wall and liver) and retinol (an alcohol chemical form of vitamin A), and people having higher serum beta-carotene concentrations had lower rates of lung cancer. The Beta-Carotene and Retinol Efficacy Trial (CARET) tested the combination of 30 mg beta-carotene and 25,000 IU retinyl palmitate (vitamin A) taken daily against placebo in 18314 men and women at high risk of developing lung cancer. The CARET intervention was stopped 21 months early because of clear evidence of no benefit and substantial evidence of possible harm; there were 28% more lung cancers and 17% more deaths in the active intervention group (active = the daily combination of 30 mg beta-carotene and 25,000 IU retinyl palmitate). Promptly after the January 18, 1996, announcement that the CARET active intervention had been stopped, we published preliminary findings from CARET regarding cancer, heart disease, and total mortality. PURPOSE: We present for the first time results based on the pre-specified analytic method, details about risk factors for lung cancer, and analyses of subgroups and of factors that possibly influence response to the intervention. METHODS: CARET was a randomized, double-blinded, placebo-controlled chemoprevention trial, initiated with a pilot phase and then expanded 10-fold at six study centers. Cigarette smoking history and status and alcohol intake were assessed through participant self-report. Serum was collected from the participants at base line and periodically after randomization and was analyzed for beta-carotene concentration. An Endpoints Review Committee evaluated endpoint reports, including pathologic review of tissue specimens. The primary analysis is a stratified logrank test for intervention arm differences in lung cancer incidence, with weighting linearly to hypothesized full effect at 24 months after randomization. Relative risks (RRs) were estimated by use of Cox regression models; tests were performed for quantitative and qualitative interactions between the intervention and smoking status or alcohol intake. O'Brien-Fleming boundaries were used for stopping criteria at interim analyses. Statistical significance was set at the .05 alpha value, and all P values were derived from two-sided statistical tests. RESULTS: According to CARET's pre-specified analysis, there was an RR of 1.36 (95% confidence interval [CI] = 1.07-1.73; P = .01) for weighted lung cancer incidence for the active intervention group compared with the placebo group, and RR = 1.59 (95% CI = 1.13-2.23; P = .01) for weighted lung cancer mortality. All subgroups, except former smokers, had a point estimate of RR of 1.10 or greater for lung cancer. There are suggestions of associations of the excess lung cancer incidence with the highest quartile of alcohol intake (RR = 1.99; 95% CI = 1.28-3.09; test for heterogeneity of RR among quartiles of alcohol intake has P = .01, unadjusted for multiple comparisons) and with large-cell histology (RR = 1.89; 95% CI = 1.09-3.26; test for heterogeneity among histologic categories has P = .35), but not with base-line serum beta-carotene concentrations. CONCLUSIONS: CARET participants receiving the combination of beta-carotene and vitamin A had no chemopreventive benefit and had excess lung cancer incidence and mortality. The results are highly consistent with those found for beta-carotene in the Alpha-Tocopherol Beta-Carotene Cancer Prevention Study in 29133 male smokers in Finland.

Epidemiology of occupational disorders of the upper extremity.

The rise in reports of occupational disorders of the upper extremity has been meteoric. This chapter examines the frequency and prevalence of upper extremity disorders, reviews the active surveys of upper extremity disorders in selected occupations, examines current surveillance systems, and discusses the problem of effective case definition.

A comparison of traditional electrodiagnostic studies, electroneurometry, and vibrometry in the diagnosis of carpal tunnel syndrome.

In 49 patients (98 hands), referred to an electrodiagnostic laboratory, assessments were made by conventional nerve conduction studies on the upper extremity and by two more portable modalities, namely electroneurometry (skin surface electrical stimulation of the motor nerve) and single-frequency (120 Hz) vibrometry. Tests were performed on median and ulnar nerves. Correlations with motor nerve conduction studies for each screening test on the median nerve were r = .81 for the electroneurometer and r = .48 for the vibrometer. When carpal tunnel syndrome was diagnosed either by clinical criteria only or by nerve conduction abnormality, the association with electroneurometry was characterized by high sensitivity and low specificity, while the opposite relationship prevailed with vibrometry. These associations were highly dependent on the methods used to select normal values from a reference population. While the manufacturer's recommended normal values offered good predictability, with thresholds that corresponded to nerve conduction studies, normal values generated in a more standard way produced much weaker and less useful associations. The selection of an appropriate electrical screening test for peripheral nerve injury, such as entrapment neuropathy, depends on the prevalence and seriousness of the target disease and the relative consequences of over- and underdiagnosis.

Raynaud's phenomenon associated with the use of pneumatically powered surgical instruments.

Five patients developed symptoms of Raynaud's phenomenon and upper extremity paresthesias after 7-32 months of exposure to air-powered surgical instruments used for the harvest of bone for bone banks. Results of cold challenge plethysmography, nerve conduction studies, vibrotactile thresholds, and quantitative sensory testing were as follows: all patients had significant reproducible vasospasm with nondetectable finger systolic blood pressure (FSBP = 0) after local digital cooling; nerve conduction abnormalities included delayed median nerve sensory conduction (< 48 m/s) across 5 of 10 wrists; and no ulnar nerve abnormalities were detected. Vibrotactile thresholds were only modestly elevated, an unexpected outcome given the frequently recognized association between vibrotactile tests and nerve conduction studies. These abnormalities occurred with exposures to frequencies previously thought to be too high to be harmful to medical personnel.

The beta-carotene and retinol efficacy trial (CARET) for chemoprevention of lung cancer in high risk populations: smokers and asbestos-exposed workers.

CARET is a multicenter, two-armed, double-masked randomized chemoprevention trial in Seattle, Portland, San Francisco, Baltimore, Connecticut, and Irvine, to test whether oral administration of beta-carotene (30 mg/day) plus retinyl palmitate (25,000 IU/day) can decrease the incidence of lung cancer in high risk populations, namely, heavy smokers and asbestos-exposed workers. The intervention combines the antioxidant action of beta-carotene and the tumor suppressor mechanism of vitamin A. As of April 30, 1993, CARET had randomized 1,845 participants in the 1985-1988 pilot phase plus 13,260 "efficacy" participants since 1989; of these, 4,000 are asbestos-exposed males and 11,105 are smokers and former smokers (44% female). Accrual is complete everywhere except Irvine, which was the last center added (1991), and the safety profile of the regimen to date has been excellent. With 14,420 smokers, 4,010 asbestos-exposed participants, and 114,100 person-years through February 1998, we expect CARET to be capable of detecting a 23% reduction in lung cancer incidence in the two populations combined and 27, 49, 32, and 35% reductions in the smokers, female smokers, male smokers, and asbestos-exposed subgroups, respectively. CARET is highly complementary to the alpha-tocopherol-beta-carotene study in Finland and the Harvard Physicians Health Study (beta-carotene alone) in the National Cancer Institute portfolio of major cancer chemoprevention trials.

Diseases of unusual occupations: an historical perspective.

A compilation of conditions deemed unusual from previous eras serves to highlight now obsolete jobs and remind that even relatively prevalent occupational disorders of today will be viewed retrospectively as strange in the proximate future. Discussed are coal miners' nystagmus, scrotal cancer in chimney sweeps, phossy jaw, hatters' shakes, painters' colic, potters' rot, chauffeurs' knee, glanders, caisson disease, and others.

A cross sectional epidemiological survey of shipyard workers exposed to hand-arm vibration.

The hand-arm vibration syndrome, widely known as vibration white finger, is a disorder of nerves and blood vessels that occurs in workers exposed to segmental vibration. A cross sectional symptom survey was performed on a sample of workers employed by a large shipyard in the north eastern United States. Random samples were drawn from departments composed of full time dedicated pneumatic grinders, workers with part time exposure to vibration, and other workers not exposed to vibratory tools. Of the 375 workers sampled, 79% responded. The prevalence of white finger symptoms was 71%, 33%, and 6% among the three exposure groups respectively. Similarly, the prevalence of numbness and tingling in the hands and fingers in the three exposure groups was 84%, 50%, and 17%. Workers were classified according to the Stockholm Workshop staging systems for vascular and sensorineural symptom severity. Exposure-response analyses of both vascular and sensorineural stage showed monotonically increasing prevalence of higher disease stages with increasing duration of exposure. Logistic regression analysis, performed to control for potential confounding factors including age and current smoking state, produced highly significant (p less than 0.001) associations between cumulative duration of exposure and prevalence of symptoms. In these analyses smoking state was significantly related to vascular and sensorineural symptoms and age was not. Average latency to onset of symptoms was less than five years of full time equivalent work with vibratory tools. Logistic regression analyses were performed to assess the effect of use of particular work practices on reported symptoms. Further study of this workforce with objective, quantitative measures of peripheral neurological and vascular function is required to characterise the clinical and subclinical effects of vibration exposure.

Detailed clinical assessment of neurological function in symptomatic shipyard workers.

Forty eight patients with extensive occupational exposure to pneumatic grinding tools were evaluated at a university sponsored occupational health clinic. All patients were interviewed and examined by a physician and assessed neurologically with standard clinical, functional motor, quantitative vibrotactile, and electrodiagnostic tests. Sensorineural symptoms were nearly universal; 47 patients (98%) reported numbness and tingling of the hands and fingers. Among clinical tests, two point discrimination and 30 Hz vibration perception were most frequently abnormal. In order to evaluate associations between quantitative test results and sensorineural symptoms, patients were stratified into two groups of symptom severity according to a consensus sensorineural staging system. The tests that discriminated best between the groups of more and less symptomatic patients were hand strength dynamometry, and vibrotactile thresholds. Age standardised 120 Hz vibrotactile thresholds were significantly raised in digit II in 41% of hand measurements. Nerve conduction studies were neither significantly different between more and less symptomatic groups nor correlated with clinical and quantitative sensory tests. Twenty five per cent of the patients had slowing of sensory conduction velocities in the median nerve at the wrist (less than 48 m/s). Of this subset of patients only two showed abnormal slowing of the median nerve distal to the wrist, but half also showed ulnar nerve slowing (less than 47 m/s). This observation highlights the difficulty of differentiating median nerve entrapment from diffuse distal neuropathy in workers exposed to vibration and points to the need for concomitant quantitative sensory and functional motor assessment.

Raynaud's phenomenon of occupational origin.

Vibration delivered to the hand and arm by industrial pneumatic tools is a common cause of vascular and neurovascular problems, including cold-induced vascular spasm (vibration white finger) and peripheral neuropathies with paresthesias, dysesthesias, and sensory abnormalities. A decade ago, the US Public Health Service estimated that 1.2 million American workers were at risk. Differentiation of primary and secondary Raynaud's phenomenon from the thoracic outlet syndrome and from the carpal tunnel syndrome pose potential diagnostic difficulties. Despite growing public recognition of upper extremity problems caused by repetitive trauma, there have been few investigations of vibration-induced disorders in the United States. This is not true worldwide, particularly in Northern Europe, where there has been significant intervention in medical surveillance and tool design. There does appear to be, however, frequent misdiagnosis and misdirected surgery. This has particular significance for the clinician, since in the 1990s, cumulative trauma injuries are expected to exceed all other work-related injuries.

Historical perspectives in occupational medicine. Pancoast and the image of silicosis.

In the two decades following the First World War, American occupational medicine was consumed in cataloguing the pneumoconioses, and no physician was more prominent than Henry K. Pancoast of the University of Pennsylvania. In a landmark trial following the worst silicosis outbreak in the United States at Gauley Bridge, West Virginia, Pancoast testified for the defense, attributing the disease to tuberculosis. Pancoast was not an isolated commentator, as the prominence of the cases attracted some of the country's leading authorities on occupational medicine. Pancoast's error, as well as the accuracy of some of his colleagues, clarifies an important occupational disease in its epidemic period. There is also a less historically specific exposition of the impact of professional involvement in social policy, liability, and compensation.

Spectrum of occupational disease in an academic hospital-based referral center in Connecticut from 1979 to 1987.

The inability to characterize the extent of occupational disease in the United States limits clinical diagnosis and public health interventions. We present an 8-year (1979 to 1987) experience with clinic-based reporting in Connecticut. Altogether, 3566 cases were sequentially coded for demographics, diagnoses, workplace identification, and exposures at two academic occupational medicine clinics. The lungs were the principal organs of diagnosed effect, with asbestos-related disorders predominating, whereas the urinary tract, endocrine organs, and cardiovascular systems were rarely involved. Of all diseases, 64.8% were diagnosed as chronic and irreversible. Three common disorders, lead intoxication (acute and chronic), asbestosis, and occupational asthma were selected for illustration. Patients with lead poisoning and asbestosis, although collectively numerous (40 and 504, respectively), came from a small number of worksites and industries. Occupational asthma was more variable: 141 diagnosed cases came from 56 different trades and industries and were caused by 28 recognized agents. While we recognize that clinic-based reporting suffers from obvious problems with referral bias and misclassification, our experience shows that it provides an important index of disease burden. Our data document the effects of legislation and litigation on lead poisoning and asbestosis, and correspondingly helps characterize diseases that will respond to broad intervention. On the other hand, occupational asthma is more pervasive and would require a more specialized, partially clinical approach.

Toxicological screening for organophosphorus-induced delayed neurotoxicity: complications in toxicity testing.

The acute biocidal effects of organophosphorus pesticides are a central feature of modern agricultural chemistry, and also define the concerns of regulatory toxicology. Less well known, but more complex and idiosyncratic, is the potential for some agents to produce a delayed and progressive polyneuropathy--Organophosphorus Induced Delayed Neurotox-icity (OPIDN). On three occasions during the past ten years, the National Institute for Occupational Safety and Health (NIOSH) had been asked to evaluate human delayed neurotoxicity from three commercially available pesticides. These were leptophos, fenthion, and isofenphos. In each case, human disease was either observed or suggested by specialized toxicity testing. The reasons that federally recommended screening measures failed to identify a potential for human neurotoxicity were not accidental, but stem from a systematic approach that focuses on a traditional definition of acute lethal toxicity. The oral single dose study on one species appears to be insufficient for recognizing the delayed neurotoxic hazard of many representatives of this chemical class. The recent addition of a recommended biochemical assay--neurotoxic esterase (NTE)--to federal guidelines potentially improves sensitivity, but it is purely adjunctive and does not amend underlying ambiguities in selecting the dose and route of administration. It is also quite probable that human neurotoxicity may be a potential hazard from exposure to more than the handful of organophosphorus pesticides that have been described in the literature.

Chronic beryllium disease in a precious metal refinery. Clinical epidemiologic and immunologic evidence for continuing risk from exposure to low level beryllium fume.

Five workers at a precious metal refinery developed granulomatous lung disease between 1972 and 1985. The original diagnosis was sarcoidosis, but 4 of the workers were subsequently proved to have hypersensitivity to beryllium by in vitro proliferative responses of lymphocytes obtained by bronchoalveolar lavage. Review of medical records of coworkers and extensive industrial hygiene surveillance of the plant demonstrated that 4 cases occurred in the furnace area where air concentrations of beryllium fume were consistently below the permissible exposure limit of 2 micrograms/M3. A single case has been recognized from parts of the refinery where exposures to cold beryllium dust often exceeded the standard by as much as 20-fold. These data demonstrate that chronic beryllium disease still occurs and confirm the importance of specific immunologic testing in patients suspected of having sarcoidosis but with potential exposure to beryllium. The data raise concern about the adequacy of modern industrial controls, especially in the setting of exposure to highly respirable beryllium fume.

Silicosis in a grey iron foundry. The persistence of an ancient disease.

An industrial hygiene and medical survey was conducted in an iron foundry to study the occurrence of silicosis. Breathing zone exposures to respirable crystalline silica had been very high in 1977 [1 045 micrograms/m3 (geometric mean) for coremakers and 198 micrograms/m3 for fettlers]; exposures in 1980 and 1982 were substantially lower. A radiographic evaluation of 188 workers revealed silicosis in 18 (9.6%). Eight had category 1 profusion of small rounded pulmonary lesions (by the 1980 classification of the International Labour Office); two had category 2; and eight had category 3. Two had progressive massive fibrosis. Four workers without silicosis in 1977 had developed lesions by 1980. The prevalence increased from 1.5% among workers employed less than 20 years to 53% among longer term workers. No association was found between the prevalence of silicosis and cigarette smoking. Chronic cough was more common in workers with heavy current dust exposure than in those with light exposure, more common in smokers than in nonsmokers, and more common in silicotics than in nonsilicotics. A multiplicative interaction existed between dust exposure and smoking in the etiology of cough. Silicosis continues to exist in American foundries. Cigarette smoking does not contribute to the causation of silicosis, but it aggravates the attendant respiratory symptoms.

Review of the biodistribution and toxicity of the insect repellent N,N-diethyl-m-toluamide (DEET).

A review of the biodistribution and toxicity of the insect repellent N,N-diethyl-m-toluamide (DEET) is presented. Workers using repellent containing this compound may be exposed to greater than 442 g in 6 mo. In human studies, variable penetration into the skin of from 9 to 56% of a topically applied dose and absorption into the circulatory system of approximately 17% have been reported. Excretion of DEET by humans was initially rapid but not as complete as in animal models. Only about one-half of the absorbed DEET was excreted by humans over 5 d. Depot storage of DEET in the skin was also documented. Skin irritant effects, including scarring bullous dermatitis in humans, were reported. One animal study that reported embryotoxicity could not be confirmed by other investigators. The limited testing for mutagenicity and carcinogenicity provided negative results. Neurotoxic effects were observed in workers exposed to 4 g or more per week. Six young girls developed encephalopathies after exposure to unspecified amounts of DEET ranging from small to massive doses. Three of these girls later died. The cause of their death has not been resolved. Because of the lack of information, further research into the absorption, carcinogenicity, and neurotoxic effects is needed.