Workplace reproductive problems

Occupational exposures can harm reproductive processes in men or women. Exposures may affect fertility, pregnancy outcomes or the child's health after delivery. The goal of patient management is to provide counseling at an appropriate level. Over-restricting the patient should be avoided while hazardous exposures should be identified and reduced. The occupational history can be used to estimate the magnitude of each exposure. If the exposure is a known reproductive hazard and the exposure level appears significant, there are several options for making the job safer. Modifications in work practices can be accomplished by advising the patient about changing work practices, writing formal work restrictions and talking with the employer. Temporary job transfers may be available. In some cases, a medical leave is needed. The primary care provider can play a key role in assisting patients to reduce reproductive risks.     

Occupational lung disease. Part 1. Identifying work-related asthma and other disorders

Lung disease is prevalent among workers. Occupational toxicant exposures have an important role in many cases of lung disease seen in workers. Most occupational lung diseases can be grouped into one of four categories that include asthma and the diffuse parenchymal lung diseases (also known as interstitial lung disease). Asthma is especially prevalent among workers, and occupational factors should be explored in all adults with asthma. A worker's visit to a primary care physician often represents the first opportunity to establish a link between lung disease and the workplace. Therefore, it is important to maintain a high level of suspicion about the potential etiologic role of workplace exposures, especially in new cases of lung disease among workers. Although accumulating absolute proof of work-relatedness may not be possible, a brief occupational history and physical evaluation can provide substantial evidence to effectively rule out, or begin to rule in, a link between work and lung disease.     

Occupationally related disorders

Occupational disease is responsible each year in the United States for 50,000 to 70,000 deaths and for approximately 350,000 new cases of illness. Occupational diseases affect all organ systems and include pulmonary disease, musculoskeletal injuries, occupational cancer, traumatic injuries, occupationally induced cardiovascular disease, disorders of reproduction, neurotoxic disorders, noise-induced hearing loss, dermatologic conditions, and psychological disorders. Occupational diseases may be very difficult to diagnose. Pathognomonic signs and symptoms are rare; most occupational diseases are clinically indistinguishable from disease of other etiologies. Diagnosis is complicated further by the long latency typical between a toxic occupational exposure and the appearance of illness. Further, there is widespread lack of information on the toxicity of most chemical substances in use in American workplaces, and workers frequently are not informed of the nature or the hazards of the materials with which they work. The occupational history is the principal clinical instrument for the diagnosis of occupational disease. All patients should undergo at least a brief occupational history that inquires about the current job, including both industry and occupation, the longest-held previous jobs, and any toxic occupational exposures to chemicals, fumes, gases, dust, noise, or radiation. Proper diagnosis of occupational disease permits proper treatment of the affected patient and also provides a basis for recognition of other similarly employed persons who may also be at risk of toxic exposure. Occupational diseases are highly preventable. Prevention is most efficiently achieved by removing hazardous materials from the workplace and replacing them with less hazardous substances. Other approaches to prevention include ventilation, alteration in work practices, and use of personal protective equipment. Physicians in the United States are for the most part not well trained to recognize occupational illness. At the same time, there is a great lack of qualified specialists in occupational medicine. The majority of care of patients with occupational disease will therefore continue to be the responsibility of primary care physicians, and these physicians must become more highly attuned to the possibility that their patients may have diseases induced by toxic exposures encountered at work. The development of a heightened sensitivity of primary care providers to occupationally induced disease is an urgent priority.     

Chest pain in children. Tip-offs to cause

The primary care physician can often delineate the cause of chest pain in a patient under 21 years of age after a thoughtful, careful, and thorough history and physical examination. Occasionally, an ECG and a chest x-ray film may be helpful. Noncardiac causes for the chest pain should be explored, and if found, the child and the parents should be assured that the problem is not serious. Occasionally, psychotherapy may be indicated. A pediatric cardiologist should be consulted when a strong family history of coronary artery disease or a personal history of coronary risk factors is present or a murmur is detected that may not be innocent. The specialist also should evaluate children who have organic cardiac disease. Finally, although the primary care physician may strongly suspect that the chest pain has little or no significance, reassurance by a pediatric cardiologist is frequently helpful to the child and the family.     

Rabies prevention in primary care. A four-step approach

Although most physicians in the United States have not seen a person with rabies, the primary care physician is often confronted with a patient who has been bitten by an animal capable of transmitting rabies virus. Rabies is almost always transmitted by a bite; licks and other nonbite exposures hardly ever cause the disease. The control of rabies in domestic animals has greatly reduced the risk of human disease following the bite of a dog or cat, but rabies in wild animals (especially skunks and raccoons) remains a constant threat. By obtaining epidemiologic information about animal rabies in the area where the exposure occurred, the physician can determine whether the animal in question may have been rabid. If any question remains, owned dogs and cats should be observed for ten days and any other animal should be killed and its brain examined for rabies virus. When postexposure prophylaxis is indicated, it should be administered exactly as recommended herein.     

Occupational lung disease. Part 2. Discovering the cause of diffuse parenchymal lung disease

Diffuse parenchymal lung disease (also known as interstitial lung disease) and acute irritant reactions are much less commonly managed by primary care physicians than asthma. Acute irritant reactions are typically readily recognized because of the immediate exposure-response relationship. As with asthma, a diagnosis of diffuse parenchymal lung disease should prompt a careful review of the patient's work history. Findings from history taking and radiography provide most of the data needed to establish a diagnosis of asbestosis or silicosis. A pulmonologist should be consulted about lung disease that eludes diagnosis. In cases in which a link between work and illness is strongly suspected, an occupational medicine specialist may be consulted for assistance with preparing reports for a workers' compensation claim as well as characterizing and quantifying impairment. Various government agencies provide extensive information about specific toxic exposures and occupational lung diseases by telephone and on the World Wide Web.     

Cardiovascular evaluation of adolescents and young adults. Salient aspects of the examination

Cardiac findings in adolescents and young adults are usually normal, and most murmurs and other abnormalities that are found are benign. However, the primary care physician needs to obtain a complete personal and family history and perform a thorough physical examination to rule out cardiovascular disease and its precursors. Of primary concern are a personal or family history of syncope, family history of sudden death, and several pathologic murmurs such as those caused by mitral valve prolapse and hypertrophic cardiomyopathy. The physician may need to reassure the patient until a definitive diagnosis is made and can also provide accurate information on cardiac disease prevention.     

Sexual problems in chronic respiratory disease. Achieving and maintaining intimacy

Chronic obstructive pulmonary disease (COPD) may be linked to several types of sexual dysfunction, but presence of the disease does not preclude enjoyment of sexual activity. A thorough medical and biopsychosocial evaluation of the patient with sexual dysfunction will help the physician to ascertain the cause of dysfunction and to assess contributory physical and psychological factors. In addition to appropriate medical and psychiatric treatment, management should include patient education and supportive psychotherapy. Open communication between the physician, patient, and partner is essential to a successful outcome. The patient and partner may need to alter their attitudes and develop new approaches to sex. The primary care physician can serve as a source of reassurance, information, and recommendations to help the patient live a full life, including a satisfying sex life.     

Occupational health nursing as a component of baccalaureate nursing education

Much can be gained by the nursing profession and by society by having well-prepared, professional occupational health nurses. Furthermore, conceptual knowledge about occupational health will better prepare the non-specialized nurse for her or his nursing practice. Lastly, knowledge about the hazards and risks that may accompany one's occupation will increase the nurse's awareness of the hazards that she/he may face in her/his own occupational setting. For these reasons the incorporation of occupational health content in the baccalaureate nursing programs would be a singular achievement for the nursing profession. It is clear that work-related injuries and illnesses pose a major challenge to today's health care providers. Most occupational health problems are preventable. It is fitting and indeed imperative that members of the nursing profession be leaders in a concerted effort to reduce the many risks in the workplace. The U.S. Public Health Service (1983) states that it is their goal that "by 1990 at least 70% of primary health care providers should routinely elicit occupational health exposures as part of the patient (health) history and should know how to interpret the information in an understandable manner." It is only through the introduction of important occupational health concepts in baccalaureate schools of education that this goal will be accomplished. Knowledge about occupational health nursing is fragmented. Furthermore, an occupational health curriculum, when it does exist, is varied in its content and its emphasis. this stems in part from a dearth of knowledge and experience by educators in the field of occupational health.(ABSTRACT TRUNCATED AT 250 WORDS)     

Occupational skin disease

Contact dermatitis, the most common occupational skin disease, is characterized by clearly demarcated areas of rash at sites of exposure. The rash improves on removal of the offending agent. In allergic contact dermatitis, even minute exposures to antigenic substances can lead to a skin rash. Common sensitizing agents include nickel and members of the Rhus genus (e.g., poison ivy, poison oak). Severe skin irritants tend to cause immediate red blisters or burns, whereas weaker irritants produce eczematous skin changes over time. An occupational cause should be suspected when rash occurs in areas that are in contact with oil, grease, or other substances. Direct skin testing (patch or scratch) or radioallergosorbent testing may help to identify a specific trigger. Skin cancer can have an occupational link in workers with prolonged exposure to sunlight and certain chemicals, although it can take decades for lesions to develop. In workers with occupational skin disease, workplace changes and protective measures are important to prevent future exposure.     

Cancer surveillance. Who stands to benefit?

Currently, surveillance or risk-oriented follow-up of patients in the individual practice setting may be the most efficacious means of reducing the morbidity and mortality associated with selected types of cancer. Intervention into carcinogenesis or alteration of the natural history of cancer requires a clear understanding of the pathogenesis of the disease and patient acceptance of interval surveillance. Because etiologic information and patient compliance are frequently limited, careful scrutiny of recommendations for cancer screening or prevention is essential. It is through taking detailed family, occupational, and carcinogen-exposure histories and doing a thorough physical examination that the primary care physician can best utilize information regarding the risk of cancer and the benefits of available methods of prevention and treatment.     

Environmentally related disorders of the cardiovascular system

The patient's level of activity is typically the only work-related concern considered in clinical medicine. This article discusses why it is important for clinicians to expand their concern to include the possibility of exposure to various gases, metals, and chemicals when evaluating a patient with cardiovascular disease. Both at the time of diagnosis and when deciding whether a patient can return to work, the workplace exposures need to be reviewed for their potential to exacerbate or cause cardiac symptoms or even death. An appropriate exposure history with confirmatory laboratory tests will allow the clinician to diagnose and manage environmentally related cardiovascular disease.     

Key issues in nutrition. During childhood and adolescence

Good nutrition is important between ages 2 and 18, because growth and maturation are taking place and because future eating habits are being established. The primary care physician can assist children and adolescents by evaluating high-risk factors, such as a family history of cardiovascular disease or hypercholesterolemia, and by recommending supplemental nutrients as indicated. Possibly more important, though, is the counseling the physician can give these patients and their parents to promote a life-style that may prevent disease.     

Selected topics related to occupational exposures. Part III. Occupational dermatology

Occupational skin disorders are very common and are a surprisingly frequent cause of lost work time. Failure to suspect an occupational cause can lead to repeated treatment failure and needlessly prolong patient misery and frustration. Primary care providers play a key role in recognizing possible occupational causes and arranging appropriate education, preventive measures, and treatment. Occupational skin conditions often occur in nonindustrial settings in workers such as hairdressers, health care personnel, and food handlers. Irritant contact dermatitis is by far the most prevalent occupational skin condition and is emphasized in this article. Allergic contact dermatitis, infections, skin cancers, and acneform eruptions may also have significant occupational associations. We will present criteria that suggest on occupational exposure, list common offending agents, and review the clinical presentations and relevant pathophysiology. We provide guidance on a directed history and physical examination and suggest when diagnostic testing is most likely to have value. Finally we outline preventive measures such as contact avoidance, barrier creams, and protective gloves and address therapy and indications for referral.     

Conditions that mimic inflammatory bowel disease. Diagnostic clues and potential pitfalls

Many of the features that identify idiopathic inflammatory bowel disease are also found with other colorectal conditions that are often encountered by the primary care physician. Although, initially, symptoms of these disorders may appear to be caused by ulcerative colitis or Crohn's disease, the cause could be bacterial, viral, parasitic, or fungal infection. Ischemic colitis and radiation colitis are other conditions that are similar in presentation to ulcerative colitis. In most cases, the physician should be able to make a differential diagnosis from a thorough history and physical examination, anoscopy or sigmoidoscopy, rectal biopsy, stool examination, and serology. An occasional patient, in whom diagnosis is not made by these methods, may require a barium enema study, colonoscopy, or referral to a gastroenterologist.     

Evaluation of suspected dementia

As the proportion of persons in the United States older than 65 years increases, the prevalence of dementia will increase as well. Risk factors for dementia include age, family history of dementia, apolipoprotein E4 genotype, cardiovascular comorbidities, chronic anticholinergic use, and lower educational level. Patient history, physical examination, functional assessment, cognitive testing, laboratory studies, and imaging studies are used to assess a patient with suspected dementia. A two-visit approach is time-effective for primary care physicians in a busy outpatient setting. During the first visit, the physician should administer a screening test such as the verbal fluency test, the Mini-Cognitive Assessment Instrument, or the Sweet 16. These tests have high sensitivity and specificity for detecting dementia, and can be completed in as little as 60 seconds. If the screening test result is abnormal or clinical suspicion of another disease is present, appropriate laboratory and imaging tests should be ordered, and the patient should return for additional cognitive testing. A second visit should include a Mini-Mental State Examination, Geriatric Depression Scale, and verbal fluency and clock drawing tests, if not previously completed.     

Muscle contraction headache. Overview and update of a common affliction

Muscle contraction headache usually can be correctly diagnosed on the basis of a thorough patient history and physical examination, although diagnostic tests may be necessary to exclude structural or inflammatory disease. Often, symptoms are directly related to emotional conflicts. In most cases, the primary care physician can provide treatment, which includes understanding and emotional support. Pharmacologic therapy and biofeedback are effective in controlling symptoms. Depression should be suspected in patients with chronic headache. Referral for neurologic or psychiatric consultation should be considered if the diagnosis is unclear or therapy is unsatisfactory.     

Cardiovascular effects of antidepressants. Avoiding cardiotoxicity in the elderly

Elderly patients are at high risk for both depression and cardiovascular disease. Withholding antidepressant therapy from an elderly patient who has a stable cardiac condition is usually unjustified. Knowledge of the cardiac side effects of commonly used antidepressants enables the primary care physician to prescribe these agents safely for depressed elderly patients.     

Impact of tobacco smoking and smoking cessation on cardiovascular risk and disease

Despite declines in smoking prevalence in many Western countries, tobacco use continues to grow in global importance as a leading preventable cause of cardiovascular disease. Tobacco smoke is both prothrombotic and atherogenic, increasing the risks of acute myocardial infarction, sudden cardiac death, stroke, aortic aneurysm and peripheral vascular disease. Even very low doses of exposure increase the risk of acute myocardial infarction. However, smoking cessation and second-hand smoke avoidance swiftly reduce this risk. While promising new agents are emerging, proven cost-effective and safe cessation interventions already exist, such as brief physician advice, counseling and nicotine replacement therapy. These should be routinely offered, where available, to all smokers. This is especially important for those at risk of, or with established and even acute, cardiovascular disease. Clinicians must play a more active role than ever before in supporting complete cessation in patients who smoke and in advocating for stronger tobacco control measures.