Occupational allergic respiratory diseases in garbage workers: relevance of molds and actinomycetes.

Exposures to molds and bacteria (especially actinomycetes) at workplaces are common in garbage workers, but allergic respiratory diseases due to these microorganisms have been described rarely. The aim of our study was a detailed analysis of mold or bacteria-associated occupational respiratory diseases in garbage workers. From 2002 to 2011 four cases of occupational respiratory diseases related to garbage handling were identified in our institute (IPA). Hypersensitivity pneumonitis (HP) was diagnosed in three subjects (cases 1-3, one smoker, two non-smokers), occupational asthma (OA) was diagnosed in one subject (case 4, smoker), but could not be excluded completely in case 2. Cases 1 and 2 worked in composting sites, while cases 3 and 4 worked in packaging recycling plants. Exposure periods were 2-4 years. Molds and actinomycetes were identified as allergens in all cases. Specific IgE antibodies to Aspergillus fumigatus were detected exclusively in case 4. Diagnoses of HP were essentially based on symptoms and the detection of specific IgG serum antibodies to molds and actinomycetes. OA was confirmed by bronchial provocation test with Aspergillus fumigatus in case 4. In conclusion, occupational HP and OA due to molds occur rarely in garbage workers. Technical prevention measures are insufficient and the diagnosis of HP is often inconclusive. Therefore, it is recommended to implement the full repertoire of diagnostic tools including bronchoalveolar lavage and high resolution computed tomography in the baseline examination.

[Skin and occupational artificial UV-radiation]. / Haut und berufliche UV-Strahlung künstlicher Quellen.

In various areas of professional activity, exposure of skin to ultraviolet radiation coming from artificial sources may occur. These UV rays differ from the solar UV radiation due to their intensity and spectrum. We review current developments with the introduction of statutory exposure limit values for jobs with UV radiation from artificial sources, a selection of relevant activities with artificial UV exposure and an overview of the occurrence of skin disorders and dermatologically relevant skin diseases caused by these specific occupational exposures. The latter is relevant for medical advice in occupational dermatology and occupational medicine. On the basis of existing studies on welders and studies regarding occupations with "open flames" (using the example of the glassblower) it is evident that so far no reliable data exist regarding the chronic photodamage or the occurrence of UV-typical skin cancers, but instead clear evidence exists regarding the regular occurrence of acute light damage in these occupations.

[Cutaneous malignancies in occupationally-induced scars]. / Maligne Hauttumoren in beruflich verursachten Narben.

BACKGROUND: The occurrence of neoplasms in injury scars--as consequence of occupational accidents--may lead to compensation according to the statutory accident insurance regulations. According to newer regulatory attempts in occupational dermatology, certain criteria have to be met before the diagnosis of a neoplasm induced by a scar is accepted and compensation is due. MATERIAL AND METHODS: Based on a retrospective analysis of 217 dermatological claim files between 2007 and 2009 of the IPA (including 22 follow-ups), medical opinions on neoplasms developing in possible occupational scars were re-evaluated using criteria of the German social accident insurance and the Bamberg medical bulletin, part II (Bamberger Merkblatt, BM II) to see how well they qualified for recognition as an occupational or accident-related disorder. RESULTS: Three cases were identified where a neoplasm was suspected of having developed in an occupationally-related scar. One of the insured events entitled for compensation. Following the guidelines of the BM II, this case was approved as an occupational disease secondary to injuries with resultant reduction in earning capacity, whereas the others did not meet the requirements. CONCLUSIONS: Two problems in evaluating malignant tumors in occupational scars are the long latency period and the documentation of a scar. The tumor excision specimen should be histologically re-examined to document the presence of an associated scar.

[Induction of occupational leucoderma and vitiligo. Can butylated hydroxytoluene induce vitiligo similarly to p-tert-butylphenol?]. / Beruflich bedingte Leukoderme und Vitiligo. Kann Butylhydroxytoluol ähnlich dem p-tert.-Butylphenol eine Vitiligo auslösen?

BACKGROUND: While vitiligo is usually idiopathic, some cases are caused by chemicals. If occupational exposure to p-tert-butylphenol (ptBP) leads to vitiligo, the legal requirements for occupational disease Nr. 1314 can be fulfilled in Germany. Chemicals of similar structure can induce local and more widespread symmetrical depigmentation with genital involvement, making the differential diagnosis more complicated. Occupationally caused depigmentation from other chemicals can also be treated according to § 9 sec. 2 of the occupational disease regulations. MATERIALS AND METHODS: Some substances can cause leukoderma only in animals; others in animals and humans; in some cases systemic vitiligo-like changes develop. The effects on human skin cannot always be predicted from the structural analogies of the involved chemicals. RESULTS: Based on a case of occupational exposure to butyl hydroxytoluene with possible induction of vitiligo, a careful updated literature analysis of substances inducing depigmentation is presented. CONCLUSION: The literature contains discrepancies in the evidence for the ability of some substances-especially BHT-to cause vitiligo. A more exact analysis indicates that BHT does not cause vitiligo or leukoderma.

[Workplace health promotion in network structures - the Erlangen Model of "enterprises in motion"]. / Betriebliche Gesundheitsförderung in Netzwerkstrukturen am Beispiel des Erlanger Modells - "Bewegte Unternehmen."

INTRODUCTION: Evidence-based health promotion and prevention are the only means to meet the future economic challenges in health care. Since preventive measures do not penetrate all strata of society alike, the workplace is a probable platform for health education and promotion. Against this background, the network of the 'Erlangen Model' attempts to include health promotion as an integral part of enterprise policy; the present paper evaluates preliminary results of this programme. METHOD: Questionnaires and interviews were conducted among employees of 6 companies and authorities forming the network "Agitating Enterprises". A total of 1,748 subjects were included and answered questions about their professional and health-related situation, physical activities, and expectations in connection with the programme. RESULTS: Almost half of the subjects (48%) had no intention to participate in one of the programme's courses. Most frequent mentioned reasons in favour of participation were the expectation of positive effects on general health (75%), well-being (78%), team work (32%) and enjoyment of sports (70%). Factor analysis extracted 5 dimensions of occupational burden out of over 50 items: "Co-operation with colleagues and superiors", "safety at work", "workflow organisation", "individual complaints" and "workplace design". Between participating companies the expression of these dimensions varied substantially; employees of the university hospital in general reported a higher-than-average burden. In contrast, differences regarding the health status, satisfaction with employment conditions and individual activity scores were minor. CONCLUSION: Health promotion at the workplace is meaningful, especially for health-care employees. Differential analyses of reasons for non-participation may reveal starting points for an improvement of attendance in health-promotion programmes.

Comparison of wheat and rye flour solutions for skin prick testing: a multi-centre study (Stad 1).

BACKGROUND: Skin prick testing (SPT) is the basic method for diagnosing IgE-mediated allergies. However, skin reactivity is related to the quality of allergen extracts, which are often poorly defined for occupational allergens. OBJECTIVE: To compare wheat and rye flour SPT solutions from different producers. MATERIALS AND METHODS: Standardized SPTs were performed in seven allergy centres with wheat and rye flour solutions from four producers in 125 symptomatic bakers. Optimal cut-off levels for weal sizes were assessed with the Youden Index. Comparisons between SPT results of different solutions were made with flour-specific IgE (sIgE) as the gold standard. Sensitivities, specificities, positive and negative predictive values, and test efficiencies were calculated and compared with McNemar and chi(2)-tests. The influence of the choice of the gold standard (sIgE or challenge) test was examined for 95 subjects. Additionally, SPT solutions were analysed for protein and antigen content. RESULTS: The optimal cut-off level for all SPT solutions was a weal size of >or=1.5 mm. While differences between wheat and rye flours were small, differences between producers were important. Variability of sensitivities (0.31-0.96), negative predictive values (0.42-0.91), and test efficiencies (0.54-0.90) were higher than variations of specificities (0.74-1.00) and positive predictive values (0.88-1.00). Similar results were obtained when using challenge test results as the gold standard. Variability could be explained by the different antigen contents of the SPT solutions. CONCLUSION: There is a wide variability of SPT solutions for wheat and rye flour from different producers, mainly with respect to sensitivities, negative predictive values, and test efficiencies. Improvement and standardization of SPT solutions used for the diagnosis of baker's asthma are highly recommended.

Prediction of challenge test results by flour-specific IgE and skin prick test in symptomatic bakers.

BACKGROUND: Wheat and rye flours are among the most important allergens causing occupational asthma. Usually, the diagnosis of baker's asthma is based on inhalation challenge tests with flours. AIMS OF THE STUDY: To evaluate the relevance of flour-specific serum immunoglobulin E (IgE) and skin prick test (SPT) in the diagnosis of baker's asthma and to define flour-specific IgE concentrations and wheal sizes that allow a prediction of the outcome of challenge testing. METHODS: Bronchial and nasal challenge tests with wheat (rye) flour were performed in 71 (95) symptomatic bakers. Determinations of flour-specific IgE as well as SPTs were performed in all subjects. Analyses included the calculation of sensitivity, specificity, positive (PPV) and negative predictive values (NPV) at different IgE concentrations and different wheal sizes, and receiver-operating characteristics (ROC) plots with the challenge result as gold standard. RESULTS: Thirty-seven bakers were positive in the challenge with wheat flour, while 63 were positive with rye flour. Depending on the flour-specific IgE concentrations (wheal size), PPV was 74-100% (74-100%) for wheat and 82-100% (91-100%) for rye flour, respectively. The minimal cut-off values with a PPV of 100% were 2.32 kU/l (5.0 mm) for wheat flour and 9.64 kU/l (4.5 mm) for rye flour. The shapes of the ROC plots were similar for wheat and rye flour. CONCLUSION: High concentrations of flour-specific IgE and clear SPT results in symptomatic bakers are good predictors for a positive challenge test. Challenge tests with flours may be avoided in strongly sensitized bakers.

Dimethyl sulphate; a hidden problem in occupational medicine.

BACKGROUND: In a chemical plant, alkylating agents (mainly ethylene oxide and propylene oxide, but also dimethyl sulphate) are utilised for the production of special surfactants. AIMS: To determine possible uptakes of dimethyl sulphate by workers using N-methylvaline. METHODS: Sixty two workers in a chemical plant (38 smokers, 24 non-smokers) with potential exposure to dimethyl sulphate were monitored with respect to their blood levels of N-methylvaline. Ten laboratory workers without exposure to methylating agents were controls. Blood samples of eight workers from a specific working area were analysed for N-methylvaline in a follow up investigation four months later. RESULTS: The 95th centile for N-methylvaline was 80.7 microg/l blood in the exposed workers compared to 12.4 microg/l blood in controls. In a hot spot area, 10 workers exceeded the German exposure equivalent value for dimethyl sulphate (40 microg/l blood) up to fourfold. In contrast, dimethyl sulphate has not been detectable in workplace air in this area. In a follow up investigation of eight of these 10 workers, N-methylvaline levels were significantly lower, but still increased. CONCLUSIONS: The present study is to our knowledge the first to report increased N-methylvaline levels after occupational exposure to dimethyl sulphate. As ambient monitoring values in the plant could not explain this exposure, skin contact was considered to be the main route of uptake for this substance. Dimethyl sulphate may therefore represent an occupational problem that has been generally underestimated in the past.

Skin strain and its influence on systemic exposure to a glycol ether in offset printing workers.

Under workplace conditions, it is difficult to prove the influence of skin lesions on skin penetration by chemical substances. The aim of the present study was to show whether systemic exposure to glycol ether increases due to lesions of the skin in printing workers. 28 male printers, exposed to 2-(2-butoxyethoxy)ethanol (BEE), were interviewed about the workplace exposure by a standardized questionnaire. The systemic exposure in printers was determined by biological monitoring of the main metabolite of BEE butoxyethoxyacetic acid (BEAA) in urine. Furthermore, clinical examination of the skin, transepidermal water loss, capacitance and skin surface pH measurements were carried out. Erythema and scaliness were the most important factors showing an effect on dermal absorption. The mean urinary BEAA excretions for printers with skin lesions on the hands were higher (20.62 mg/l for scaliness and 14.40 mg/l for erythema) compared to that for printers without detectable skin lesions (12.08 mg/l for scaliness and 13.03 mg/l for erythema). Bioengineering measurements to predict skin strain and percutaneous absorption were only supportive. We were able to show that by using a multiple spectrum of methods an enhancement of percutaneous absorption of BEE could be demonstrated in workers with skin lesions.

Chlorinated dibenzo-p-dioxins and dibenzofurans and the human immune system: 3. Plasma immunoglobulins and cytokines of workers with quantified moderately-increased body burdens.

The concentrations of immunoglobulins (IgA, IgD, IgG, IgM) and of several cytokines were measured in the plasma of volunteers with clearly, but moderately, increased body burdens of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/PCDF), using monoclonal antibodies and an enzyme-linked immuno-sorbant assay. Two groups of workers with different body burdens of PCDD/PCDF were studied: (trial I) persons with mainly 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), and (trial II) persons with mainly penta- and hexachlorinated dibenzofurans (P5CDF/H6CDF) in their blood fat. Including the reference group, 158 volunteers were investigated. A slight but statistically significant decrease was observed in the plasma concentration of IgG1 in persons exposed to TCDD, but not in persons exposed to P5CDF/H6CDF. When the data of both groups were pooled and a multi-regression analysis against international TCDD toxicity equivalencies (I-TEq, NATO/CCMS) was performed, taking several confounding factors into account, no influence of the dioxin exposure could be revealed. There were no changes in the plasma concentrations of the other immunoglobulins studied. In the same volunteers, no deviation from the reference range was found for the concentrations of the cytokines: IL-1alpha, IL-1beta, IL-6 and TNFalpha in blood plasma.

[Pilot project for evaluation of lung function reference values]. / Pilotprojekt zur Uberprüfung von Lungenfunktionssollwerten.

Lung function tests were performed in this study on 139 adults (mean age 36 years), as well as on 91 female persons between 16 and 18 years of age (the latter just starting on their professional careers), the lungs being healthy in each case in both groups. The findings were compared with the currently accepted reference value formulae after Quanjer et al., and Zapletal as well as further developed reference value formulae after Brändli et al., Most of the measurement data obtained by spirometry for the BGFA group of probands are between the two recommended reference values for adults with better coincidence with Brändli's predictions (exceptions being MMEF25-75 MEF 50 and MEF 25). In our studies we obtained higher values than the reference median values after Quanjer and Zapletal for IVC, FVC, FEV1 and PEF by 6-8% and 5-15%, respectively, whereas the values for adults differ from the predictions made by Brändli et al. by -4% to +5%. The flow data MMEF 75-25, MEF 50 and especially MEF 25 are set at too low levels (by 5-23%) by Zapletal's and Brändli's values. Comparatively, the values predicted by Quanjer et al. for the above mentioned flow-volume parameters (with the exception of MEF 75) are too high by 4% to 12%. There are also considerable differences in respect of the reference values for IGV to the tune of +15% in the BGFA group compared to Quanjer et al.; in the BAFAM group the values differ from those of Zapletal et al. by +17%. RV yields results in the BGFA group which are higher by 11% than according to Quanjer's formulae, whereas in the BAFAM group they are higher by 15% compared to Zapletal's predictions. In respect of Rt there are differences to the predictions by Rühle and Matthys by +16% (BGFA group) and +13% (BAFAM group), respectively. The BAFAM group differs from Zapletal's predictions by +11%. Looking at the reference limit values the overall impression is confirmed that the predictions after Quanjer et al. and mostly also those by Zapletal are too low in respect of the abovementioned lung function parameters (in the majority of cases not 5% of the examined probands, as expected, are below those levels, but only about 2%). Females, who had been underrepresented in the previous healthy proband groups, show larger deviations than males in respect of most of the parameters.(ABSTRACT TRUNCATED AT 400 WORDS)