Occupational and environmental medicine in a family medicine residency

Well-rounded instruction in occupational medicine as part of family medicine residency training is feasible through a program that balances a longitudinal curriculum of monthly occupational and environmental medicine (OEM) lectures, community-based OEM patient care, and worksite assessment. Such training would help equip family medicine residents to integrate occupational medicine into their practices, which, in light of a shortage of board-certified practitioners in OEM, would help fill community needs. The Intern-Resident Training Committee of Carson City Hospital in rural Michigan established both learner and institutional goals and objectives for such a program of instruction. A learner-needs assessment found appreciable interest among the residents for occupational medicine training. In addition, results of a survey of the occupational health community suggested there is inadequate coverage of OEM in medical schools and residencies. Furthermore, a focus group of occupational health managers revealed that clarity of communication and standardization of reporting were paramount concerns. Instruments for standardized OEM history and for OEM case management were developed for use within the residency continuity clinic. The curriculum was implemented with a variety of teaching strategies, including worksite assessment. Practice-based, case-oriented instruction was subsequently phased into the program as residents assumed responsibility for managing cases under the supervision of family medicine preceptors knowledgeable in OEM. An occupational medicine rotation was developed that included focused clinical exposure to OEM patients and studies that would lead to eligibility for a certificate of additional qualification in occupational medicine. Learner evaluations included chart reviews and patient satisfaction surveys. Program evaluations included interviews with occupational health managers. The residents were judged by their preceptors to have performed well. The responses of the health managers and the patients were positive. This program in occupational medicine was found to be educationally sound with demonstrated community benefit and patient satisfaction. Further, it is cost-effective, requiring no external funding.     

Occupational health as a priority]

The development of occupational health services in the Republic of South Africa has been limited by three factors. Firstly, occupational safety completely overshadowed occupational health. Secondly, about 8 state departments were active in its administration. Thirdly, occupational health was not interpreted as a preventable disease under the old Public Health Act No. 36 of 1919, and was hence excluded from the usual community health activities. The recommendations of the 1975 Commission of Inquiry that occupational health should fall under the scope of the Department of Health, and that the National Research Institute for Occupational Diseases should be transferred from the South African Medical Research Council to the Department of Health, have not yet been implemented. The advantages of such implementation and the estimated costs involved are discussed. A primary prerequisite is that all occupational diseases should be made notifiable diseases.     

Occupational and environmental epidemiology--similarities and contrasts.

There has been considerable growth in the disciplines of occupational and environmental epidemiology in recent years, with both fields having to deal with increasingly complex exposure profiles and adverse health outcomes. Environmental and occupational epidemiology as distinct from general epidemiology are compared and contrasted. Similarities and differences between the two fields are systematically discussed in terms of epidemiological peculiarities, study design characteristics, sampling procedures, exposure assessment, typical biases, problems in determining causation, ethical constraints, and implementation possibilities for research findings. There is a need in South Africa to provide adequate training to health professionals working in these fields, so that high-quality research, which has the potential to contribute significantly to improvements in the health of workers and the general public, can be undertaken.     

Occupational attainment and depressive symptoms in young adulthood

Past studies have shown that various aspects of occupational attainment (unemployment, job instability, low occupational status, and low earnings) are associated with poor mental health, but each of these studies focused on one or two aspects of occupational attainment. Consequently, it remains unclear whether their associations are independent of each other. Further, little is known about whether negative self‐assessments of occupational attainment are linked to poor mental health. We sought to overcome these limitations of past research while focusing on depressive symptoms as a mental health outcome and young adulthood as a life stage context. The study analysed U.S. data from the National Longitudinal Study of Adolescent to Adult Health (n = 13,178) using ordinary least square models. The analysis showed that all aspects of occupational attainment were associated with depressive symptoms in the expected directions. Further, unemployment, job instability, and negative self‐assessment of career progress showed stronger associations, and those associations were independent of other occupational attainment variables. Overall, the results suggested that understanding the association between occupational attainment and mental health requires close attention to the life stage context.     

Occupational history-taking in the RSA

Medical practitioners need to elicit a comprehensive occupational history from their patients, since this may play an integral part in establishing the diagnosis, may indicate the most appropriate form of management, and will ensure that claims for Workmen's Compensation are initiated when appropriate. This history can also assist in identifying undetected workplace hazards and in formulating and testing hypotheses concerning the relationship of work to health. The particular problems encountered in taking an occupational history effectively in the RSA are discussed.     

Occupational respiratory diseases in South Africa--results from SORDSA, 1997-1999.

OBJECTIVES: To describe the nature and extent of work-related respiratory diseases reported to the national Surveillance of Work-related and Occupational Respiratory Diseases in South Africa (SORDSA) reporting scheme. The causative agents and industrial categories in which they occurred are also characterised. DESIGN: Voluntary monthly reporting of newly diagnosed cases by pulmonologists, occupational medicine practitioners and occupational health nurses. SETTING: Medical and occupational health referral centres in the nine provinces of South Africa. SUBJECTS: Cases were workers from non-mining industries or ex-miners, suffering from a newly diagnosed occupational respiratory disease, reported to SORDSA between October 1996 and December 1999. OUTCOME MEASURES: Frequencies of reported occupational respiratory disease by year, reporting source, province and sex. Frequencies of short- and long-latency diseases by industry and causative agent. RESULTS: There was incomplete reporting coverage of the nine provinces in the first 3 years. Reporting was most comprehensive from Gauteng, KwaZulu-Natal and the Western Cape. Diseases with long latency periods made up 76.2% of the cases. Pneumoconiosis, even in non-mining industries, was the most frequently reported disease, followed by inhalation accidents. Occupational asthma was the fourth most reported disease. Apart from the prominence of pneumoconiosis, the results obtained by SORDSA are similar to those from a British occupational lung disease surveillance scheme. This study showed that newly diagnosed cases of occupational lung disease occurred in many industries and were caused by a variety of agents. CONCLUSION: SORDSA has contributed insight into the nature, extent and distribution of occupational respiratory diseases in South Africa. It has also highlighted important causes of occupational respiratory diseases in South Africa, as well as hazardous industries. The data indicate that South Africa has a widespread occupational lung disease problem, and provide a platform for targeted prevention strategies.     

高等护理专业学生的职业价值观研究

目的了解当代高等护理专业学生（高护生）的职业价值观，为我国高等护理院校有效地开展大学生职业价值观教育提供依据。方法使用职业价值观调查问卷对508名高护生进行调查。结果在职业价值问卷的3个维度中，分数由高到低依次为保健，发展，声望、地位。不同年级高护生声望、地位维度评分比较，差异有显著性意义（P〈0．05）；不同学历高护生保健及声望、地位维度比较，差异有显著性意义（P〈0．05，P〈0．01）。结论当代高护生的职业价值观反映了时代特征，尚需加强教育以使他们具有更多的职业奉献精神。     

Occupational stress in health service workers in the UK

Levels of occupational stress were examined in 1176 employees of all occupational groups within one large UK health authority. In comparison with the most recently established normative group of workers from non-health care sectors, health workers reported significantly greater pressure at work but scored lower on measures of Type A behaviour pattern and employed coping strategies more frequently. The health care workers reported, in contrast with previous studies, fewer symptoms of mental ill-health and similar levels of job satisfaction. Job satisfaction and psychosomatic ill-health were related to sickness absence among health workers. Approximately one in 12 health workers had stress symptoms of equal magnitude to patients attending clinical psychology outpatient clinics. The major occupational groups within the health worker sample were compared on stress measures. General managers were found to report the lowest levels of pressure, were high on Type A (nearly as high as doctors), were found to be the most ‘internal’ in their perceived locus of control, had the lowest levels of ill-health symptoms, the highest levels of job satisfaction and the lowest sickness absence rate. Nurses reported the highest levels of pressure. Ancillary staff and scientists and technicians, on the other hand, had very low levels of job satisfaction and high sickness absence.     

Occupational hazards to the pregnant orthopaedic surgeon

The number of female orthopaedic residents and orthopaedic surgeons has increased substantially. Concerns have been raised regarding the effect of the work environment on the health of the female orthopaedic surgeon and her fetus or neonate. Occupational risks, and specifically risks to the pregnant orthopaedic surgeon, are becoming an important issue in medicine. Such risks include exposure to methylmethacrylate (MMA), anesthetic gases, blood-borne pathogens, radiation, emotional stress, and physical stress. Awareness of and knowledge about such exposures are needed for the pregnant orthopaedic surgeon to make informed decisions about her occupational exposures and to be proactive about her own and her child's health.     

Occupational health services in Johannesburg and Randburg

Questionnaires were posted to 760 manufacturing organisations sampled from the 1986 Workmen's Compensation tape in the Johannesburg and Randburg areas. A response rate of 51% was obtained. The results indicate a general deficiency in the quantity of occupational health services offered. For example, only 57 factories (18%) offered a medical service on the premises, while pre-employment examinations were provided by 59. More larger factories than smaller ones provided occupational health services. There were also variations in the occupational health benefits provided, and salaried employees were generally better off than wage earners. For example, 62 factories (25%) did not provide medical schemes for wage earners, while only 5 (2%) did not provide medical schemes for salaried employees. Since the Erasmus Commission's findings were published in 1976, there does not appear to have been a substantial change in the provision of occupational health services in the manufacturing industry. With increasing urbanisation it is important that something be done to improve this situation.     

Occupational risks of blood exposure in the operating room

Bloodborne pathogens continue to be a source of occupational infection for healthcare workers, but particularly for surgeons. Over 1 per cent of the U.S. population has one or more chronic viral infections. Hepatitis B is the infection that has the longest known role as an occupational pathogen, but infection with this virus is largely preventable with the use of the effective hepatitis B vaccine. Hepatitis C affects the largest number of people in the United States, and there is no vaccine available for the prevention of this infection. HIV infection still has not been associated with a documented transmission in the operating room environment, but six cases of probable occupational transmission have been reported. A total of 57 healthcare workers have had documented occupational infection since the epidemic of HIV infection began. Infection of blood-borne pathogens to patients from infected surgeons remains a concern. Surgeons who are e-antigen-positive for hepatitis B have been well documented to be an infection risk to patients in the operating room. Only four surgeons have been documented to transmit hepatitis C, although other transmissions have occurred in the care of patients when practices of infection control have been violated. No surgical transmission of HIV to a patient has been identified at this time. Prevention of occupational infection requires use of protective barriers, avoidance of exposure risk by modification of techniques, and a constant awareness of sharp instruments in the operating room. Blood exposure in the operating room carries risk of infection and should be avoided. It is likely that other infectious agents will emerge as operating room threats. Surgeons must maintain vigilance in avoiding blood exposure and percutaneous injury.     

Occupational blood-borne diseases in surgery

BACKGROUND: Human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV) infections are transmitted by blood exposure. Surgeons have been concerned about the risks of blood exposure in the operating room as a potential source of occupational infections from these viruses. The actual risk and frequency of operating room transmission remains poorly understood by many surgeons. METHODS: The pertinent recent literature on the pathophysiology, diagnosis, prevention, and treatment of HIV, HBV and HCV were reviewed to address the current understanding of these viruses as occupational risks to surgeons. RESULTS: HIV transmission to surgeons has not been documented in the United States by the Centers for Disease Control. HIV transmission from a surgeon to a patient in the environment of the operating room, as well as transmission from an HIV-infected surgeon to a patient, has not been documented. HBV infection of surgeons has declined with the general acceptance of the HBV vaccine. HCV infection remains a real risk for transmission in the operating room, given that no vaccine is currently available and that the overall number of chronically infected patients remains quite high. CONCLUSION: The risk of occupational infection from known viral pathogens for surgeons is low, but it is not zero. Effective barriers, modified patterns of behavior, and prompt responses to blood exposure events are the best methods for prevention.     

Occupational hazards in plastic surgery

The occurrence of occupational disorders among plastic surgeons has not had much attention in the literature thus far. A case of a plastic surgeon with distal interphalangeal arthrosis, considered to represent an occupational disorder, is presented. In a review of the literature, possible occupational hazards in plastic surgery are discussed.     

Presidential address: Knowledge,know-how,and vascular surgeons

Vascular surgeons know vascular disease and its treatment, yet uncertainties about the future of their specialty require an examination of its two basic components: knowledge and know-how. Knowledge, or understanding, flows from research efforts, and expands the scientific basis of our medical knowledge. It is imperative that new knowledge through funded research continues so that vascular surgical science progresses. Know-how, or skill, is a crucial component of the vascular surgeon's armamentarium and has been recognized through our history as a criterion of a surgeon's proficiency. The vascular fellowship program provides the vascular surgical trainee with the knowledge and know-how necessary to become accomplished and qualified for certification in this specialty. Future progress in vascular surgery depends on new knowledge and know-how and their innovative application to human vascular disease. This may involve a formal cooperative relationship between the two national vascular societies and our colleagues in interventional radiology to develop a comprehensive vascular health care program. The societies together must continually evaluate the forces for change that are prevalent in the health care environment to expand this program. This will ensure a healthy forecast for our dynamic specialty in the twenty-first century. (J VASC SURG 1995;21:169-73)     

Occupational hazards of inhalational anaesthetics

Occupational exposure to inhalational anaesthetics has often been associated with health hazards and reproductive toxicity, but the available evidence is weak and comes mostly from epidemiological studies that have been criticized. Studies based on registered data generally showed no association between occupational exposure to inhalational anaesthetics and reproductive effects. Animal studies also showed a lack of carcinogenicity, organ toxicity and reproductive effects with trace concentrations, as observed in operating rooms. The exception may be nitrous oxide, which in some, but not all, studies showed teratogenicity in rats chronically exposed to concentrations of 1000 p.p.m. and higher, such as may occur in unscavenged operating rooms lacking a mechanical ventilation system. Occupational exposure has also been associated with impairment of psychological functions, but these effects do not occur with trace concentrations. All in all, the scientific evidence for hazards is weak. Nonetheless, it is good practice to limit levels of exposure.     

Occupational asthma due to chrome and nickel electroplating

BACKGROUND: Exposure to chromium during electroplating is a recognised though poorly characterised cause of occupational asthma. The first series of such patients referred to a specialist occupational lung disease clinic is reported. METHODS: The diagnosis of occupational asthma was made from a history of asthma with rest day improvement and confirmed by specific bronchial provocation testing with potassium dichromate and nickel chloride. RESULTS: Seven workers had been exposed to chrome and nickel fumes from electroplating for eight months to six years before asthma developed. One subject, although exposed for 11 years without symptoms, developed asthma after a single severe exposure during a ventilation failure. This was the only subject who had never smoked. The diagnosis was confirmed by specific bronchial challenges. Two workers had isolated immediate reactions, one a late asthmatic reaction, and four a dual response following exposure to nebulised potassium dichromate at 1-10 mg/ml. Two of the four subjects were also challenged with nebulised nickel chloride at 0.1-10 mg/ml. Two showed isolated late asthmatic reactions, in one at 0.1 mg/ml, where nickel was probably the primary sensitising agent. Four workers carried out two hourly measurements of peak expiratory flow over days at and away from work. All were scored as having occupational asthma using OASYS-2. Breathing zone air monitoring was carried out in 60 workers from four decorative and two hard chrome plating shops from workers with similar jobs to those sensitised. No measurement exceeded the current occupational exposure standard for chromate or nickel, the mean levels of chromate exposure for jobs similar to those of the affected workers were 9-15 micrograms/m3. CONCLUSION: Chrome used in electroplating is a potential cause of occupational asthma. Sensitivity to chrome in electroplaters may occur in situations where exposure levels are likely to be within the current exposure standards. There may be cross reactivity with nickel. Inhalation challenge with nebulised potassium dichromate solution is helpful in making the specific diagnosis where doubt exists.


     

Occupational eosinophilic bronchitis in a foundry worker exposed to isocyanate and a baker exposed to flour

Eosinophilic bronchitis without asthma may occur as a consequence of occupational exposure. The cases of a foundry worker and a baker who developed symptoms, respectively, due to exposure to isocyanate and flour, are reported. Cough was not associated with variable airflow obstruction or with airway hyper-responsiveness and was responsive to inhaled corticosteroids. The eosinophilia detectable in their sputum was causally related to the occupational exposure in the workplace. The examination of induced sputum should be used in addition to the objective monitoring of lung function for workers who have asthma-like symptoms in an occupational setting.     

Occupational asthma due to latex in health care workers.

Immediate hypersensitivity reactions ranging from mild urticaria to life threatening anaphylaxis after exposure to natural rubber latex have been reported frequently in health care workers while occupational asthma due to latex exposure is less well studied. The results of specific challenge tests and immunological tests in four health care workers with work related respiratory and skin disorders induced by the use of latex gloves are described. Occupational asthma was confirmed in three subjects by specific challenge tests. All had a positive skin test reaction to the latex extract; specific IgE antibodies were detected in only one subject. The fourth subject had a negative specific inhalation and skin test reaction to the latex extract. Peak expiratory flow monitoring at work and away from work showed a pattern consistent with work related asthma. These findings confirm that latex is a cause of occupational asthma in health care workers.     

Occupational skin diseases of the feet

Although dermatoses account for the vast majority of occupational disease, the role played by foot disorders is uncharted. Often, protective footgear has an etiologic rather than a therapeutic effect. The environmental, chemical, physical, and biologic causes of pedal skin disease in the workplace are described, with emphasis on the need for their recognition and control.