Medical surveillance in work-site safety and health programs.

Businesses frequently call on family physicians to provide employee health services at the work site or in the clinician's office. These services include medical screening (detection of dysfunction or disease before an employee would ordinarily seek medical care) and medical surveillance (analysis of health information to identify workplace problems that require targeted prevention). Such services can transform acute care and routine screening activities into opportunities for primary prevention when they are integrated into the broader framework of work-site safety and health programs. Components of these programs include management commitment, employee participation, hazard identification and control, employee training and program evaluation. For optimal program success, family physicians must communicate with frontline safety officers and have first-hand knowledge of the workplace and its hazards. Professional and technical resources are available to guide the family physician in the role of medical surveillance program coordinator.

Lead levels in Maryland construction workers.

A cross-sectional study of unionized construction workers not currently known to be performing lead work was conducted. Participants completed an interviewer-administered questionnaire obtaining information about demographics, work history, other possible sources of lead exposure and health status (including hypertension, noise-induced hearing loss and renal disease). Blood was then obtained via venipuncture for whole blood lead level, hematocrit and free erythrocyte protoporphyrin determination. Two hundred and sixty-four Maryland construction workers had median whole blood lead determinations of 7 micrograms/dl and mean values of 8.0 micrograms/dl, with a skewed distribution ranging from 2 to 30 micrograms/dl. None were currently engaged in known lead work. Blood lead levels were significantly higher for the 124 who had 'ever' worked in demolition (8.8 micrograms/dl vs. 7.2 micrograms/dl, p = .004), and for the 79 who had ever burned paint and metal and welded on outdoor structures compared to the 48 who had done none of these activities (8.6 micrograms/dl vs. 6.8 micrograms/dl, p = .01). The 58 workers who had ever had workplace lead monitoring performed had higher lead levels (9.7 vs. 7.5 micrograms/dl, p = .003). Blood lead levels increased with age, and cigarette smoking. African Americans (N = 68) had higher lead levels (9.1 vs. 7.5 micrograms/dl, p = .01). There were only two women in the study, one with a lead level of 21 micrograms/dl and one, 7 micrograms/dl. Blood lead levels did not predict either systolic or diastolic blood pressure in this population. However, there was a significant interaction between race and lead as predictors of blood pressure, with blacks demonstrating a trend-significant correlation, and whites showing a nonsignificant but negative association. Demolition and hotwork on outdoor structures are known to cause acute episodes of lead poisoning. They also appear to cause slight but persistent increases in blood lead levels. Future workplace regulation should recognize and seek to maintain the low baseline now apparent even in urban, East Coast, construction workers.

Noise-induced hearing loss, nationality, and blood pressure.

Noise exposure has been associated with increased catecholamine production and blood pressure elevation in laboratory studies and in human volunteers. Epidemiologic studies have given conflicting results. In order to determine whether noise-induced hearing loss predicts a rise in blood pressure, we reviewed occupational medicine records in an occupational health center serving three companies where noise exposure is commonly found. Height, weight, blood pressure, and screening audiometry are obtained as part of routine occupational health screening, and the results of the screening visit are abstracted from written clinical records. The results of pure tone screening audiometry are reported in nonstandardized fashion (Normal, WNL, NAD, for example, for normal). We reviewed records from 1990 and 1991 inclusive. One investigator, blind to blood pressure status, assigned each record to "no hearing loss," "not codable," or "hearing loss assumed to be due to noise" on the basis of the written audiometry report. Hearing loss due to causes other than noise was considered not codable. No attempt was made to quantify severity of hearing loss. Two hundred and sixteen charts were excluded as "not codable," 1,535 were classified as having no hearing loss, and 610 had some degree of hearing loss, most probably due to noise exposure. To adjust for confounding covariates, multiple regression analysis was used and indicated that hearing status improves the regression model for predicting diastolic blood pressure (p = 0.04), following age, nationality, body mass index (BMI), and month of testing, although the effect is small. Stratification by age and BMI revealed increased diastolic pressure in the group with hearing loss under age 45, regardless of obesity.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of lead stores in male veterans.

Thirty-two male veterans participated in a study to determine cumulative lead exposure in an urban population. Subjects were chosen on the basis of blood pressure status in order to attempt to compare lead exposure between patients with and without hypertension. Patients currently enrolled in hypertension clinic and on treatment were recruited and matched with controls for age, race, and socioeconomic status. Each subject underwent provocative chelation via slow intravenous infusion of CaNa2 EDTA and 6-h urinary lead measurement and completed an interviewer-administered questionnaire. Twenty blacks and 12 whites participated, with a median age of 52 years (range: 27 to 72). Urinary lead excretion ranged from below detection limits to frankly toxic levels in an individual with heavy moonshine ingestion. Lead levels were higher than reported in other non-workplace populations. The distribution of lead values was skewed, as expected, with a median excretion of 75 mcg lead/6 h (corresponding to a median 24 degrees post-chelation urinary lead excretion of 286 mcg) and modal values between 50 and 75 micrograms lead. Levels of 95 mcg lead/6 h (corresponding to 24 degrees levels of 333 mcg lead) and above were considered "high" (N = 11) and the remainder were "low" (N = 21). Among those able to recall various characteristics of their first childhood dwellings, the presence of flaking paint in a multiple family dwelling was strongly associated with "high" lead excretion (X2 = 9.32, p = 0.009). Hypertensives excreted slightly more lead than nonhypertensives, although the difference was not statistically significant in this small sample. Lead excretion was not associated with current (treated) blood pressure determinations among hypertensives. However, lead excretion was associated with systolic pressure as recorded on entry to the hypertension clinic (N = 21, R2 = 0.24, p = 0.03).

The effect of blood lead on blood pressure in children.

The effect of elevated blood lead levels on the blood pressure of children has not been clearly described. In order to define this association better, we conducted a cross-sectional study, evaluating the association between lead and high blood pressure. Using a Dinamap monitor to measure blood pressures, blood pressures and blood lead levels were measured in 149 children (ages 1-10 years) receiving medical care at the General Medical and Lead Poisoning Clinics at Children's Hospital of Philadelphia. Blood lead levels ranged from 7 to 70 mg/dL with a mean of 27 mg/dL. The mean systolic blood pressure was 108 mmHg and the mean diastolic reading was 63 mmHg. Higher systolic blood pressure was significantly correlated with increased weight, age, and height. Diastolic pressure was significantly associated with weight and height. There was a small, negative correlation between blood lead levels and systolic blood pressure, and a positive but insignificant correlation between lead levels and diastolic blood pressure. Our study population had both higher mean lead levels and a higher prevalence of hypertension than is true of the U.S. population as a whole. We concluded that elevated blood lead levels are not associated with elevated blood pressure in children.

Environmental medicine: its introduction into a medical school primary care requirement.

One hundred and twelve medical students participating in a required 6-week primary-care rotation completed a pretest of environmental medicine knowledge and attitudes at the start of the rotation and a similar posttest on the last day of the rotation. Control group students were to participate in the usual weekly didactic sessions of the clerkship. Intervention students were given a booklet describing environmental considerations in clinical medicine and introducing them to the concept of risk assessment, three computer-assisted instruction cases, and a problem-based learning (PBL) exercise involving role-play. Because voluntary compliance with evaluation forms was poor during year one, during the second year students in the intervention group were required to return evaluation forms in order to sit for the course final examination. Knowledge and attitudes of both intervention and control groups were compared at baseline and at the end of the rotation. Students in the intervention group also completed process evaluations of the intervention materials. Students in both intervention and control groups increased knowledge gains significantly during the second year of the intervention, while neither group improved during year 1. This may have been due to a 'spill-over' effect among primary-care teachers implementing the intervention. Students ranked both environmental and occupational medicine of least importance in their training compared with eight other aspects of medicine, and this ranking did not improve with intervention. The PBL exercise was well received by the students. Of 28 evaluations, 27 ranked the session in the highest 3 of a 5-part Likert scale for worthwhile content, and 24 would recommend the session to a friend.(ABSTRACT TRUNCATED AT 250 WORDS)

A training program in universal precautions for second-year medical students.

BACKGROUND: A training program in universal precautions was developed and implemented in 1991-92 for second-year students at the George Washington University School of Medicine and Health Sciences. The students were required to participate in a three-hour session that consisted of lecture, demonstration, and practice components focused on the risks of bloodborne-disease exposure and the techniques of phlebotomy and intravenous insertion using universal precautions. METHOD: All 135 second-year students participated in the lecture component, but only 120 students, who were unfamiliar with the procedures, were required to participate in the demonstration and practice components. Each of these students was asked to answer pre- and postsession knowledge questions and to rate his or her preparedness on a five-point Likert scale, ranging from 1, "not prepared at all," to 5, "well prepared." Paired t-tests were used to compare the pre- and postsession knowledge scores and self-assessed preparedness scores. At the end of the training program, the students were offered the opportunity to volunteer for additional, individualized training with the hospital phlebotomy service. Unpaired t-tests were used to compare differences between the postsession knowledge scores of the volunteers and nonvolunteers. RESULTS: A total of 103 students completed both pre- and posttests. The students' knowledge scores increased from means of 64.7% to 88.5% (p = .001). Their self-assessed preparedness scores also increased, ranging from a low of means of 1.6 presession and 3.4 postsession for intravenous insertion to a high of means of 3.19 presession and 4.26 postsession for addressing personal concerns about possible exposure. The 43 students who volunteered for additional training scored significantly better on the postsession knowledge questions than did the nonvolunteers, suggesting that those who may have needed it most failed to sign up for additional training. CONCLUSION: The training session significantly improved the students' knowledge and sense of their own competency.

Body fluid exposure in an urban tertiary care medical center.

The increasing prevalences of the human immunodeficiency (HIV) and hepatitis B viruses have focused attention on the risks that health care workers face when exposed to potentially infective body fluids. This study establishes a profile of 320 parenteral exposure incidents and 47 exposure incidents to mucous membranes or abraded skin, reported in our medical center between July 1988 and July 1990. We found that 102 (27.8%) of the incidents involved an HIV-positive patient, that 130 (35.4%) of the reporting employees had completed their hepatitis B vaccination at the time of the incident, and that, although the majority of incidents involved employees with patient contact, unfortunately, service workers also were represented (4.6%, n = 17). Factors contributing to incidents included recapping (10.9%, n = 40), full needle-boxes (7.6%, n = 28), and inappropriate disposal (13.1%, n = 48). A health fair featuring walk-in hepatitis B immunization attracted 260 participants, 90% of whom completed the entire immunization series. This significantly improved the immunization rate of employees subsequently reporting body fluid exposure.

Integrating occupational health into the medicine clerkship using problem-based learning.

OBJECTIVE: To improve medical students' ability and willingness to obtain occupational histories from their patients. PARTICIPANTS: General medicine faculty and internal medicine teaching residents, who participated as instructors, and medical students during their required internal medicine clerkships. SETTING: The primary teaching hospitals of two medical schools. DESIGN: During alternate months, students participated in problem-based sessions that included occupational health objectives (intervention) or attended the standard small-group didactic sessions (control). Process evaluations were collected from students and faculty in the intervention group following each session. Outcome evaluation was performed using chart audit and multiple-choice testing to compare the intervention and control groups. INTERVENTION: Intervention students participated in at least one problem-based session incorporating occupational aspects of disease into clinical internal medicine. Instructors received information packets and materials but had no other expertise in occupational medicine. MEASUREMENTS AND MAIN RESULTS: The great majority of ratings on the process evaluations showed that the students were "moderately" to "extremely" interested in the session attended. No student rated any session to be a "waste of time," and over 90% of students would recommend the session being evaluated to a friend. Chart audit showed that students in the intervention group recorded slightly more occupational information than did those in the control group (an average of 2.97 vs. 2.37 pieces of information, p = 0.06). When the most commonly documented data (employment status and job title) were ignored, the difference between group means (1.1 vs. 0.91) was significant (p = 0.03), suggesting that intervention students were more likely to probe further into a patient's occupational history. Both groups of students collected less occupational information from women than from men (t = 3.22, p = 0.0035). Multiple-choice tests revealed no difference between the two groups in overall medical knowledge or occupational medicine knowledge. CONCLUSIONS: Problem-based learning with specific occupational content is well accepted by students and modestly improves their occupational history taking.

Sensitivity of in vivo X-ray fluorescence determination of skeletal lead stores.

Eighteen patients with known past occupational lead exposure underwent parenteral diagnostic chelation with ethylenediaminetetraacetic acid and x-ray fluorescent determination of in vivo skeletal lead stores at the distal styloid process of the ulna and at the temporal base bone using a cobalt 57 source and measuring lead Ka x-rays. X-ray fluorescent lead measurements in both locations correlated with results of diagnostic chelation. Using a post-chelation urinary excretion of greater than 600 micrograms lead/24 h as the definition of "high-" lead stores, sensitivity of x-ray fluorescence at the wrist and temple was 56% and 39%, respectively.

Self-reported musculoskeletal complaints among garment workers.

One hundred forty-four sewing machine operators answered questionnaires concerning occupational history and musculoskeletal symptoms adapted from the National Health and Nutrition Examination Survey. They were matched for age within 5 years, race, and sex with persons completing the HANES I Augmentation Survey, and the prevalence of self-reported musculoskeletal morbidity was compared. Operators complained significantly more often of knee pain (prevalence odds ratio [POR] = 1.84, p = .0001) and knee swelling (POR = 9.98, p less than .00001), although they were no more likely to have had knee surgery. Similar increases were reported for upper-back pain (POR = 2.13, p = .002) joint ache, and joint swelling (both were significant for fingers, wrists, elbows, and shoulders at p less than .05 levels). No differences in low-back pain or in hospitalization for joint conditions were noted. Ergonomic redesign of sewing machines needs to address knee and upper-back movements as well as the arm, wrist, and finger movements.

Kaposi's sarcoma in an elderly man with Wegener's granulomatosis treated with cyclophosphamide and corticosteroids.

The association of Kaposi's sarcoma with malignant lymphoreticular diseases and immunosuppressive therapy is well documented. This report describes an elderly man who presented with fulminant Wegener's granulomatosis that responded to treatment with cyclophosphamide and corticosteroids. Rapidly progressing cutaneous Kaposi's sarcoma developed ten weeks after the start of immunosuppressive therapy yet regressed on discontinuation of the corticosteroid therapy, despite continuation of cyclophosphamide therapy. To our knowledge, this is the first reported case of Kaposi's sarcoma occurring in association with Wegener's granulomatosis. The literature on Kaposi's sarcoma in immunosuppressed patients is reviewed.

Shortened forms of provocative lead chelation.

Shortened urinary lead collections following provocative chelation have been standardized for pediatric patients, but have not been considered adequate for adults. This study compared shortened urine collections for lead excretion post chelation with standard 24-hour collections. Thirty-five patients without known current lead exposure and with serum creatinine measurements less than 2 mg/dL were hospitalized and had provocative chelation performed as follows: One gram of CaNa2-ethylenediaminetetraacetic acid (EDTA) was administered in 250 mL of a 5% dextrose in water solution intravenously over one hour; the same dose was repeated 12 hours later. A 24-hour urine collection for lead excretion was begun at the time of initiation of the first dose. At three hours and six hours from start of first dose, each patient was instructed to void, total volume to that point was recorded, and a 10-mL aliquot was withdrawn for lead measurement. Both three-hour and six-hour urinary lead excretion following a single dose of EDTA correlated linearly with 24-hour lead excretion post chelation (r = .89 and .94, respectively). When a 24-hour level of 600 micrograms was defined as "true positive" the three-hour collection had a sensitivity of 76% and specificity of 95% and six-hour urinary lead excretion had 82% sensitivity and 100% specificity. Mild renal insufficiency (reflected by serum creatinine levels between 1.5 and 2.1 mg/dL) did not significantly alter the correlation between three-, six-, and 24-hour urinary post-chelation lead excretion.

Using review of medical clinic charts to teach occupational health.

The authors evaluated the effectiveness of chart audit with written feedback as a tool for encouraging second- and third-year residents to obtain and record occupational information during history-taking. Baseline information was obtained by reviewing the charts of 20 residents of patients who presented for complete history-taking and physical examination and scoring for various aspects of occupational history-taking. Intervention was directed at 10 of the residents; the other 10 served as controls. Between five and 12 charts were reviewed for each of the 10 residents in the intervention group; the scoring sheet, scoring criteria, results, and a brief discussion of potentially relevant occupational concerns for the given patient were returned to the resident, along with copies of the relevant pages of the patient's record. Chart review showed no difference in total scores for occupational history-taking between the two groups before intervention. The postintervention scores improved insignificantly for the intervention group; however, the scores deteriorated significantly for the control group (1.38 to 0.92, .05 greater than p greater than .025).