Metabolic genotype in relation to individual susceptibility to environmental carcinogens.

Earlier research indicates that within the human population there are considerable differences in the response to the carcinogenic activity of environmental carcinogens. Genetic polymorphism associated with several variants of the gene products participating in the biotransformation of various xenobiotics (including carcinogens) found in human populations constitutes a major cause of those differences. Enzymes coded by different variants of the same gene can differ in their catalytic activities. Up to the present time, most information on the effect of genetic polymorphism on the individual's ability to activate or deactivate environmental carcinogenic xenobiotics, and the associated risk of cancer, has been collected from studies of cytochromes P-450 belonging to gene families CYP1, CYP2 and CYP3, and of glutathione S-transferases and N-acetyltransferases. As carcinogen metabolism comprises a chain of chemical reactions involving numerous enzymes and enzyme-coding genes, research performed hitherto is able to offer only a very limited explanation of the associations between genetic polymorphism and the individual's susceptibility to cancer.

Ischaemic heart disease as an effect of obesity-related metabolic disturbances.

Obesity results from excessive accumulation of fats in adipose tissue and constitutes one of the essential sources of increased incidence of some diseases harassing the highly industrialized and urbanized societies. Obesity-related metabolic disorders may be associated with the risk of circulatory diseases. The mechanism causing that obesity enhances the incidence of the metabolic disorders have not been explained to the full extent. Hyperinsulinaemia is one of effects of obesity and of the associated presence of excessive blood fatty acid levels. Overloading of the organism with fatty acids changes the function pancreatic beta cells. Insulin resistance and hyperglycaemia caused by high peripheral fatty acid levels trigger increased insulin secretion. Hyperinsulinaemia affects hepatic metabolism so as to make it hyperanabolic. Liver increases triacylglycerol and cholesterol synthesis and raises the rate of very low density lipoproteins (VLDL) secretion to the blood. Increased VLDL concentration contributes to increased LDL and is associated with reduced HDL cholesterol concentrations. Atherogenic dyslipidemia in obese people results, to a large extent, from increased VLDL secretion. Data collected heretofore point to an undoubtedly essential role of the adipose tissue in the pathogenesis of metabolic disorders in obese people. There are many causes of disturbed adipose tissue function which result in high blood fatty acid levels, excessive fat accumulation in other tissues and organs, or both. Another factor which may aggravate the metabolic disorders is the diet. It is worth noting that genetic determinants may cause that some individuals reveal a specified set of factors increasing the risk of ischaemic heart disease.

Occupational health education in Poland: new needs, new requirements, new programmes.

The conditions of modern work environment in Poland generate new problems, new needs and new expectations in the area of occupational health. They are associated not only with the rapidly changing technologies and new professions but also with the psychosocial factors pertaining to extensive transformations of the political and economic systems. New needs and expectations determine a new approach: firstly, to the responsibilities of the occupational health specialists; secondly, to the organisation and management of the workers health care; and thirdly, to the general principles of the occupational health, including in particular relevant legislation. The new requirements concerning the operation of the occupational health system in all the three dimensions must be addressed in the design of the new training programmes in occupational health whether under- or postgraduate. Subjects to updating and modification should be not only the content of the training but also its forms and methodology. Competence-based learning should be accompanied by the modern methods of problem solving, distant learning, organised self-education and self-assessment. The growing interest in the quality of the training should be expressed, first of all, in the activities aiming at the development of procedures to assess the effectiveness of the training. It seems also necessary to adopt the active learning approach intensifying acquisition and verification of the knowledge and skills. This approach would also lead to deeper changes in the students' mentality and behaviour, e.g. to make them able to estimate their own and others' level of professional competence or shape the personal system of professional values under the conditions of the free-market economy in the health care which entails quality requirements for the services and the competition among its providers.

Self-assessment of competence in public health management as a measure of effectiveness of postgraduate training.

The main goal of the postgraduate training in public health is to make already experienced students develop appropriate competence to deal with health problems existing and emerging within different spheres of social reality. The task involves the checking on and evaluation of the students' learning process and the didactic qualifications of teaching personnel. A serious problem is posed here by the specificity of the postgraduate training in the course of which new competences have to be transmitted in the context of competence already possessed, which should be also improved refreshed, revised etc. Moreover, the influence of the experience and attitude components is here stronger than in the case of undergraduate studies. All these need to be reflected in the curricula, teaching methods, and assessment procedures. In the introductory part of the paper the authors discuss briefly an approach to and the adopted definition of professional competence. The body is devoted to the assessment of competence acquired and the methods applied after a 2-year postgraduate studies for public health managers. Seventeen types of competence transmitted to the students were made the points of reference in a special self-assessment questionnaire. The respondents were asked to assess the contribution of particular courses to the acquisition or improvement of each type of competence. The results obtained in a group of students suggest that some modifications and improvements in the educational objectives and programmes should be introduced.

The biomarkers detecting early changes in the human organism exposed to occupational carcinogens.

Epidemiological studies and clinical data confirm that occupational exposure to carcinogenic agents plays an important role in cancer etiology. Recent tremendous progress in understanding of the mechanisms of carcinogenesis, and also introduction of new tests to recognize changes occurring in the exposed organism have made it possible for the occupational medicine to detect the earliest cancer stages which occur during the latent phase of the disease. Detecting pre-neoplastic changes which precede an overt form of cancer and identification of measurable indicators of those changes has been one of the fundamental aims of molecular biology research. Biomarkers may serve as a research tool which makes it possible to achieve this aim. Suitably selected biomarker sets can provide information on the extent of the exposure to carcinogenic agents (biomarkers of exposure), detect early changes produced by the agents in the exposed organism (biomarkers of effects), and identify people with particularly high cancer risk (biomarkers of susceptibility). It will soon be possible to use molecular biomarkers, capable of detecting increased cancer risk at the molecular level of cell structure, in prophylactic action intended to reduce cancer incidence. Molecular biomarkers are capable of recording very early health effects of exposure to carcinogens, thus making it possible to determine cancer risk at a very early stage of cancer development.

Medical causes of female sickness absence during economic transition in Poland.

The current transformation of property relations and economic restructuring, along with many other factors, influence the health condition of workers. The present study was undertaken to investigate the trends in the rate and causes of female sickness absence during the period of economic transition in Poland, based on the absence analysis in one of the largest (before the process of restructuring) plants of the motor car industry. Vital for the current trends in the workers' absenteeism is the reduction in the rate of employment. The group investigated was composed of 3215 women and 5373 men employed during the years 1989-94. The main variable examined was the reason for the worker's discharge: (1) quitting the job because of health problems, (2) retirement, (3) termination of work contract due to economic problems of the plant, (4) change of affiliation agreed between the former and present employers. The structural transformations in the plant under study brought about the discharge of about 77% of workers during the period between 1989 and 1994, mostly owing to the termination of work contracts for economic reasons, and earlier retirement. The increase in the rate of sickness absence involved to a higher extent female workers; it amounted to 30% compared to 12% for male workers. Among the workers quitting employment, the rate of sickness absence was twice as high as that for the workers still under employment. The largest differences were noted for the female population; they concerned cardiovascular diseases, neoplasms and complications of pregnancy, delivery and the puerperium. The economic transformation processes make a considerable impact on the occurrence of sick absenteeism in workplaces. Workers leaving their jobs because of health problems, as well as those discharged for economic reasons belong to the highest risk group.

Polish approach to the quality assurance system in occupational health services.

The most important factors which influence the quality of Occupational Health Services in Poland are discussed. The legal regulations, the system of specialist education, guidelines and standards in occupational medicine, and the role of regional specialists supervision system are presented. The audit of medical documentation revealed the 'sub-populations' of doctors who are concerned about the quality and those who are not. Keeping relatively moderate prices of services by some OHS units, even at the cost of their quality, has become a side-effect of competition. The establishment of an accreditation system in OHS is postulated, basing on the existing elements of such a system.

Requirements for occupational medicine training in Europe postulated by Polish professionals.

In order to determine common key competences required for occupational medicine specialists across Europe, a questionnaire has been developed and disseminated in several European countries. The questionnaire contained 115 subjects relating to eight fields of activity of an occupational medicine physician (occupational hazards to health, assessment of disability and fitness for work, communications, research methods, management, environmental medicine, occupational health law and ethics, and health promotion). Items in each part were classified into three categories: knowledge, experience and skills. For each of the subjects respondents were asked to allocate a score from 0 to 5, where 0 = not necessary, 1 = of minimal importance and 5 = most important or essential. In Poland the questionnaire was distributed between two groups of specialists: group I--chief administrators of occupational health services, and group II--relatively younger occupational medicine physicians participating in a specialist training. A comprehensive analysis of the completed questionnaires had three dimensions: (a) substantive (classification of the importance of particular key competences, as perceived by Polish specialists in occupational medicine), (b) personal (differences in opinions among occupational medicine physicians and an attempt to explain these differences in sociological terms), (c) comparative (evaluation and interpretation of similarities and differences between two groups). A hierarchy of requirements for occupational medicine training in Poland was constructed, with one set of competences recognized by the respondents as needless and others as useful with different grade of importance. Surprisingly, a wide diversity of opinions among respondents has given rise to the explanation hypotheses, some of them being verified using the material gathered.

[Limitations in using international occupational disease statistics for comparative analysis]. / Ograniczenia w wykorzystywaniu miedzynarodowych statystyk chorób zawodowych do analiz porównawczych.

The comparability of international statistical data on the incidence of occupational disease is discussed. The examples of some countries served to present the reasons why the relevant data available in publications cannot be often used as a frame of reference to comparative studies. The problem results mainly from different definitions of the term "occupational disease" as they frequently include in their context also these pathologies which are numbered among work-related diseases. In addition, the authors highlighted the steps undertaken by international organizations (World Health Organization, International Labour Organization, and European Union) to unify both the diagnostic procedures and the system of collecting and publishing of statistical data on occupational diseases.

Excess mortality in working age males in Poland: general patterns.

Since the second World War, excess mortality of males has been steadily growing in Poland. The aim of this paper was to analyze the basic relationships between excess male mortality and some social and economic factors, with special reference to both age and place of residence. Data published in Demographic Yearbooks and included in reports produced by the Government Population Council were used in the analysis. The excess male mortality is expressed in terms of male/female mortality ratio, and also in terms of the difference between the average female and male life expectancy. In the early 1990s the general male mortality rate in Poland was by 23% higher than the general female mortality rate, whereas in males at younger working age (20-44 years) mortality was three times higher, and in the older age (45-64 years) groups 2.7 times higher than the female mortality. Compared with the majority of European countries, Poland is characterised by high rates of excess male mortality, which points to a deteriorated health status of the population. At present, excess mortality of the working age males is much higher than in the 1960s and 1970s. Our analysis of the 1960-1994 trends revealed that the highest excess male mortality occurs in the 20-24 age group. Although recently a falling trend has been observed in the infant, juvenile and post working age groups, a continuous increase is noted in the working age population of Poland. Causes of death were also included in our analysis. Among circulatory diseases, the highest excess mortality was due to acute myocardial infarction (the risk of death from this disease was 8 times higher for males than for females). Accidents, injuries and poisoning constitute another leading group of causes responsible for excess mortality (6/1 male/female death risk ratio). The excess male mortality rates are higher in the rural than in the urban areas. The excess male mortality was also reflected in the indices of average life expectancy. In 1995, the average life expectancy was 67.6 years for males and 76.4 years for females. Thus, in Poland males live 8.6 years shorter than females on average. Increased excess mortality among the working age males, a considerable difference between male and female average life expectancy, disturbed demographic male/female balance, these are at least some of the reasons why further in depth studies of excess male mortality in Poland should continue.

[Attitudes of Polish occupational medicine physicians towards a proposal of requirements for occupational medicine training in Europe]. / Postawy polskich lekarzy medycyny pracy wobec europejskiego projektu wymagan szkoleniowych w tej dziedzinie.

In order to determine key competences required of occupational medicine specialists, common throughout Europe, a questionnaire has been developed and distributed among several European countries. The questionnaire contained 115 subjects related to 8 fields of activities carried out by occupational medicine physicians (occupational hazards to health, assessment of disability and fitness for work, communications, research methods, management, environmental medicine, occupational health law and ethics, and health promotion). In each of these fields, competences were classified into three following categories: knowledge, experience and skills. Respondents were asked to allocate a score from 0 to 5 for each subject, where 0 = not necessary; 1 = of minimum importance, and 5 = most important or essential. In Poland the questionnaire was distributed among two groups of specialists: group I--experienced specialists in occupational medicine (leading representatives of occupational health care management), and group II--relatively younger and less experienced occupational medicine physicians, participating in the specialist training, organised by The Nofer Institute of Occupational Medicine. A comprehensive analysis of the completed questionnaires was carried out in two dimensions: substantive (the importance of individual competences as perceived by Polish specialists in occupational medicine), and comparative (evaluation and interpretation of similarities and differences between two groups of respondents). A hierarchy of requirements, occupational medicine training in Poland is to satisfy, was reconstructed with two sets of competences, one recognised by respondents as needless and the other recognised as useful with different grades of importance. Some characteristic differences in opinions between two groups studies were highlighted.

Molecular epidemiology: cancer risk assessment using biomarkers for detecting early health effects in individuals exposed to occupational and environmental carcinogens.

Detecting changes that precede the overt symptoms of cancer and identifying measurable indices of such changes in persons exposed to occupational and environmental carcinogens constitutes one of the primary objectives of molecular epidemiology research. Biomarkers represent a valuable research tool that makes it possible to attain that objective. Suitably selected biomarker sets may provide information on the extent of exposure to carcinogenic agents (internal dose, biologically effective dose), detect early changes caused by those agents in the exposed organism, and identify individuals with a particularly high risk of cancer development. The tremendous progress in research on the mechanisms of cancer initiation and promotion has enabled the assessment of cancer risk in healthy individuals by examining specific results from determinations of suitably selected biomarkers. The finding that gene defects (gene mutations and changes of their expression) constitute the background of carcinogenesis has resulted in molecular biology becoming focused on detecting defective genes or proteins synthesized under control of the defective genes.

Occupational medicine at the verge of the twenty first century: evaluation of accomplished and expected changes in the preventive approach.

The World Bank in its document under the title 'Investing in Health' (1993) states that the health status of the population, including the working population, and working conditions in individual countries depend essentially on the value of gross national product per capita. The attitudes towards the role and objectives of occupational medicine have changed significantly over the last three decades. A high priority given to primary prevention reflects the mainstream of a new approach to preventive measures. Advancements in technology, production and services, common use of computers and flattening of work organisation structures have brought about the need for workers' active participation in planning of activities and shaping working conditions in own enterprise. At the same time, workers are required to possess much higher qualifications facilitating their participation in applying new technologies and using new information systems, which resulted in a fierce competition on the labour market. In the countries in the political, social and economic transition, the conditions for introducing a new system of sustained development, described by Gustavsen at the 25th International Congress on Occupational Health have not as yet been established. A procedure-based system involving negotiations between employers and workers' representatives failed to be successful in improving working conditions as the roles of the state, employers and trade unions had not been defined precisely. It is expected that further health promotion at the worksites in these countries will depend mainly on the economic progress and the reformed system of education.

[Analysis of education processes in areas of public health and occupational medicine. Introductory premises and hypotheses]. / Analiza procesów ksztalcenia w zakresie medycyny pracy i ochrony zdrowia pracujacych. Wstepne zalozenia i hipotezy.

In the first section of the work the premise encouraging the analysis of educational systems in the areas of public health and occupational medicine is presented. There is an urgent need for the education of highly personnel in these two fields, and the adhering of educational systems to the current needs requires an in-depth historical and sociological analyses as well as the evaluation and comparative studies. The model analysis and the research hypothesis are subject of the two other sections.

[Environmental factors which impair male fertility]. / Czynniki srodowiska uposledzajace plodnosc mezczyzn.

Introduction of new technologies involving many chemicals does not remain free from the effect on the human health. Occupational acute poisoning is rare now-a-days, but we often face many problems arising out of the late sequel to exposures, such as mutations, neoplasms or reproduction disorders. Numerous research institutes of occupational medicine are involved in the evaluation of the effect of environmental factors on the workers' health. Many recent publications emphasise that the quality of the human semen is gradually decreasing which is manifested by the lower number of spermatozoons (1 cm3) semen, a higher proportion of morphologically impaired spermatozoons and a higher per cent of motile spermatozoons. The quality of the semen is affected not only by the hazards present in the general environment, but also by the factors occurring in the work environment. Occupational exposure induces sometimes infertility of couples but more often impairs the reproduction, and this is one of important issues which be addressed by occupational medicine.

System for analysing sickness absenteeism in Poland.

The National System of Sickness Absenteeism Statistics has been functioning in Poland since 1977, as the part of the national health statistics. The system is based on a 15-percent random sample of copies of certificates of temporary incapacity for work issued by all health care units and authorised private medical practitioners. A certificate of temporary incapacity for work is received by every insured employee who is compelled to stop working due to sickness, accident, or due to the necessity to care for a sick member of his/her family. The certificate is required on the first day of sickness. Analyses of disease- and accident-related sickness absenteeism carried out each year in Poland within the statistical system lead to the main conclusions: 1. Diseases of the musculoskeletal and peripheral nervous systems accounting, when combined, for 1/3 of the total sickness absenteeism, are a major health problem of the working population in Poland. During the past five years, incapacity for work caused by these diseases in males increased 2.5 times. 2. Circulatory diseases, and arterial hypertension and ischaemic heart disease in particular (41% and 27% of sickness days, respectively), create an essential health problem among males at productive age, especially, in the 40 and older age group. Absenteeism due to these diseases has increased in males more than two times.

[Evaluation of training quality in the field of occupational medicine. Methodologic principles and a perspective of assessment tool development]. / Ocena jakosci ksztalcenia w zakresie medycyny pracy. Zalozenia metodologiczne i perspektywa opracowania narzedzi.

Bearing in mind a growing interest in the quality of educational processes the authors stressed the need for addressing this issue in the field of occupational medicine. They discussed major principles of the internal system of quality assessment and the possibility of adopting two instruments for evaluating (controling) the quality of teaching and learning: a questionnaire for self-assessment of acquired/transmitted competences and a test for assessing the progress in acquiring knowledge and skills necessary to solve problems.

[Biomarkers of hepatotoxic effects: their usefulness in occupational medicine]. / Biomarkery skutków hepatotoksycznych: przydatnosc dla medycyny pracy.

Medical screening and the resultant monitoring of health effects induced by hepatotoxins present in workplaces become of still greater importance in the assessment of occupational health and safety. Health effects of occupational and nonoccupational hepatotoxic factors may be acute, subacute or chronic. Laboratory tests (biomarkers) used in screening for detection of asymptomatic damages of the liver should satisfy the following three criteria: 1. they should provide positive or negative predictive information, namely the information about possible development of clinically evident hepatopathy; 2. they should be very sensitive and specific in order to ensure a correct identification of the developing disease; and 3. they should provide information which of clinical biomarkers should be applied subsequently in order to confirm and facilitate the diagnosis of hepatopathy related to exposure to occupational hepatotoxins or to eliminate such a relationship. It should be also remembered that for assessing disorders in hepatic functions those biomarkers should be selected which are most effective in identifying both persons with hepatopathy induced by environmental hepatotoxins and those who are free from the liver damages. It should be stressed that to date none of the existing biomarkers is sensitive and specific enough to assess alone all the functional systems of the liver.