The World Federation of Neurology and the challenges in Environment Neurology.

Since its establishment the World Federation of Neurology (WFN) has manifested a keen interest in the environment and its relation to neurological diseases. Thus, in 2007 the WFN renamed the "Neurotoxicological Research Group" to "Environmental Neurology Research Group". In this short article, we review some recent events which illustrate the WFN involvement in Environmental Neurology as well its concerns about global health matters involving environmental issues.

[Standardization of spirometry: 2015 update. Published by German Atemwegsliga, German Respiratory Society and German Society of Occupational and Environmental Medicine]. / Leitlinie zur Spirometrie. Leitlinie der Deutschen Atemwegsliga, der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin und der Deutschen Gesellschaft für Arbeitsmedizin und Umweltmedizin zur Spirometrie.

Spirometry is a simple test and considered the gold standard in lung function. An obstructive ventilatory defect is a disproportionate reduction of maximal airflow from the lung in relation to the maximal volume that can be displaced from the lung. It implies airway narrowing and is defined by a reduced FEV1/FVC ratio below the 5th percentile of the predicted value (lower limit of normal, LLN). A restrictive disorder may be suspected when vital capacity (FVC) is reduced and FEV1/FVC is normal. It is definitely proven, however, only by a decrease in TLC below the 5th percentile of predicted value (LLN). The measurement of TLC by body plethysmography is necessary to confirm or exclude a restrictive defect or hyperinflation of the lung when FVC is below the LLN. 2012 a task force of the ERS published new reference values based on 74,187 records from healthy non-smoking males and females from 26 countries. The new reference equations for the 3-95 age range are now available that include appropriate age-dependent mean values and lower limits of normal (LLN). This presentation aims at providing the reader with recommendations dealing with standardization and interpretation of spirometry.

[Results of study concerning possible influence of rocket space activities on public health].

Using special medical examination results and specified criteria of objective evaluation, the authors summarized results of studies concerning health state of population dwelling in area possibly influenced by rocket space activities factors.

A critical appraisal of 2007 American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines for Interventional Pain Management: an independent review utilizing AGREE, AMA, IOM, and other criteria.

BACKGROUND: Today, with the growing interest of the medical community and others in practice guidelines, there is greater emphasis on formal procedures and methods for arriving at a widely scrutinized and endorsed consensus than ever before. Conflicts in terminology and technique are notable for the confusion that guidelines create and for what they reflect about differences in values, experiences, and interests among different parties. While public and private development activities continue to multiply, the means for coordinating these efforts to resolve inconsistencies, fill in gaps, track applications and results, and assess the soundness of particular guidelines continue to be limited. In this era of widespread guideline development by private organizations, the American College of Occupational and Environment Medicine (ACOEM) has developed guidelines that evaluate areas of clinical practice well beyond the scope of occupational medicine and yet fail to properly involve physicians expert in these, especially those in the field of interventional pain management. As the field of guidelines suffers from imperfect and incomplete scientific knowledge as well as imperfect and uneven means of applying that knowledge without a single or correct way to develop guidelines, ACOEM guidelines have been alleged to hinder patient care, reduce access to interventional pain management procedures, and transfer patients into a system of disability, Medicare, and Medicaid. OBJECTIVE: To critically appraise occupational medicine practice guidelines for interventional pain management by an independent review utilizing the Appraisal of Guidelines for Research and Evaluation (AGREE), American Medical Association (AMA), Institute of Medicine (IOM), and other commonly utilized criteria. METHODS: Revised chapters of ACOEM guidelines, low back pain and chronic pain, developed in 2007 and 2008 are evaluated, utilizing AGREE, AMA, IOM instruments, and Shaneyfelt et al's criteria, were independently reviewed by 4 appraisers. RESULTS: Critical appraisal utilizing the AGREE instrument found that both chapters scored less than 10% in 3 of the 6 domains, less than 20% in one domain, over 30% in one domain, and over 70% in one domain. Global assessment also scored below 30% with a recommendation from AGREE, "not recommended or suitable for use in practice." Based on AMA key attributes, both chapters of ACOEM guidelines met only one of the 6 key attributes, only 3 of the 8 attributes were met by IOM criteria, and based on the criteria described by Shaneyfelt et al, overall only 28% of criteria were met. CONCLUSION: Both the low back pain and chronic pain chapters of the ACOEM guidelines may not be ideal for clinical use based on the assessment by the AGREE instrument, AMA attributes, and criteria established by Shaneyfelt et al. They also scored low on IOM criteria (37.5%). These guidelines may not be applicable for clinical use.

Arsenic Exposure, Assessment, Toxicity, Diagnosis, and Management: Guidance for Occupational and Environmental Physicians.

: Arsenic is ubiquitous in the environment and human exposure can occur from multiple possible routes including diet. Occupational medicine physicians asked to evaluate workers with elevated urine arsenic levels may be unaware that many sources of arsenic exposure are not work related. In this paper, we address arsenic exposure sources and pathways, adverse health effects of arsenic exposure and those subpopulations at increased risk, and the evaluation and treatment of those exposed to elevated arsenic levels.

Responsibilities of the Occupational and Environmental Medicine Provider in the Treatment and Prevention of Climate Change-Related Health Problems.

: Workers are uniquely susceptible to the health hazards imposed by environmental changes. Occupational and environmental medicine (OEM) providers are at the forefront of emerging health issues pertaining to working populations including climate change, and must be prepared to recognize, respond to, and mitigate climate change-related health effects in workers. This guidance document from the American College of Occupational and Environmental Medicine focuses on North American workers health effects that may occur as a result of climate change and describes the responsibilities of the OEM provider in responding to these health challenges.

Identification of core objectives for teaching sustainable healthcare education.

BACKGROUND: Physicians will be called upon to care for patients who bear the burden of disease from the impact of climate change and ecologically irresponsible practices which harm ecosystems and contribute to climate change. However, physicians must recognize the connection between the climate, ecosystems, sustainability, and health and their responsibility and capacity in changing the status quo. Sustainable healthcare education (SHE), defined as education about the impact of climate change and ecosystem alterations on health and the impact of the healthcare industry on the aforementioned, is vital to prevention of adverse health outcomes due to the changing climate and environment. OBJECTIVE: To systematically determine which and when a set of SHE objectives should be included in the medical education continuum. DESIGN: Fifty-two SHE experts participated in a two-part modified-Delphi study. A survey was developed based on 21 SHE objectives. Respondents rated the importance of each objective and when each objective should be taught. Descriptive statistics and an item-level content validity index (CVI) were used to analyze data. RESULTS: Fifteen of the objectives achieved a content validity index of 78% or greater. The remaining objectives had content validity indices between 58% and 77%. The preclinical years of medical school were rated as the optimal time for introducing 13 and the clinical years for introducing six of the objectives. Respondents noted the definition of environmental sustainability should be learned prior to medical school and identifying ways to improve the environmental sustainability of health systems in post-graduate training. CONCLUSIONS: This study proposes SHE objectives for the continuum of medical education. These objectives ensure the identity of the physician includes the requisite awareness and competence to care for patients who experience the impact of climate and environment on health and advocate for sustainability of the health systems in which they work. ABBREVIATIONS: CVI: Content validity index; SHE: Sustainable healthcare education.

Reducing the global environmental impacts of rapid infrastructure expansion.

Infrastructures, such as roads, mines, and hydroelectric dams, are proliferating explosively. Often, this has serious direct and indirect environmental impacts. We highlight nine issues that should be considered by project proponents to better evaluate and limit the environmental risks of such developments.

Applicability of a set of diagnostic tests in indoor air health research.

Following recommendations from literature, 22 diagnostic tests for the most frequent complaints of indoor air health problems were selected and assessed for their applicability in epidemiological studies. The tests were applied seven times during one year to 40 volunteers who to all appearances were not affected by indoor air health problems. Most psychophysical tests (e.g., Continuous Performance Test) turned out to be suitable, but physiological tests were either heavily disturbed by technical problems (e.g., portable electrogastrography), or biased by application techniques (e.g., acoustic rhinometry), or were simply too time-consuming (e.g., PC-based voice analysis). Hence, as standardized measurements and quantitative diagnostic tests in epidemiological indoor air health research may contribute to a better understanding of cause-effect relationships and yield new approaches for preventive and therapeutic strategies, more research is urgently needed to develop and evaluate suitable physiological tests and functional measurements.

Negative and non-positive epidemiological studies.

The aim of this study was to identify and discuss validity aspects on so called negative and non-positive studies. Arguments and examples are drawn from experiences in occupational health epidemiology regarding the interpretation of more or less equivocal study results. A negative study may be defined as showing a result that goes against the investigated hypothesis of an increased (or prevented) risk. Traditionally, studies with a risk estimate (relative risk or odds ratio) above, but close to unity are also referred to as negative, given a narrow confidence interval (CI) that includes unity. A risk estimate above unity with the CI including unity is non-positive, however, but an estimate below unity with upper CI bond exceeding unity might be seen as possibly negative or non-negative. A weaker "significance" than usually required should perhaps be accepted when evaluating serious hazards. In contrast to positive studies, the negative and non-positive studies tend to escape criticism in spite of questionable validity that may have obscured existing risks (or preventive effects). Even stronger arguments can be made in criticising negative and non-positive studies than positive studies, for example, regarding selection phenomena, and observational problems regarding exposure and outcome. Negative confounding should be considered although usually weak. In case-control studies, so called over-matching may obscure an existing risk as could the "healthy worker effect" in cohort studies. Small scale non-positive studies should be made available for meta-analyses and when considering studies that do not convincingly show a risk; those who are exposed should be given the "benefit of the doubt".

Quality assurance in occupational and environmental laboratory medicine.

In a medical laboratory service, quality assurance (QA) concerns all those actions necessary to provide confidence that the results of laboratory tests will satisfy defined standards for quality. Taking into account the type of testing concerned and the techniques involved, quality assurance will encompass all steps taken to ensure that laboratory results are reliable. It covers the use of scientifically and technically sound practices for laboratory investigations, including selection, collection, transport, identification, storage, preparation and manipulation of specimens and recording, reporting and interpretation of the results. QA refers also to other activities designed to improve the reliability of investigations such as staff training and management, evaluation of the adequacy of the laboratory environment, maintenance and calibration of instruments and the use of technically validated and properly documented methods. All these activities should be described in a quality manual. This document is a prerequisite to obtain certification of the quality system or laboratory accreditation, according to the International Standard ISO 29000 series or the European Standard EN 45001, respectively.

Comparison of some European external quality assessment schemes in the field of occupational and environmental medicine.

In most European countries an increasing number of external quality assessment schemes (EQAS) are organized, and it seems appropriate to reinforce collaboration at the European level between organizers of EQAS related to occupational and environmental medicine. Since differences between these EQAS have been recognized, a collaborative project was set up focused on the ways the present occupational and environmental medicine EQAS evaluate results obtained by the same pool of laboratories analysing identical control samples for blood lead. The results confirmed that the samples delivered to the laboratories were homogeneous. Considering the performance as judged by five different schemes the study revealed that laboratories were not ranked identically. For laboratories, which either had a very bad or a very good performance, however, the ranking were comparable. The statistical design of the evaluated EQAS poses problems and requires attention.

Prospects of harmonisation of European external quality assessment schemes in occupational and environmental laboratory medicine.

Since 1979, twelve external quality assessment schemes (EQAS) in occupational and environmental laboratory medicine (OELM) have been developed in nine European countries. These schemes cover a broad range of analytes and matrices and have developed differing procedures for the evaluation of laboratories' performances. Collaboration among EQAS in OELM and harmonisation of methods for evaluation of laboratory performance would be advantageous to cope with the demand for assessment of quality of analytical results for an increasing number of analytes and the need to guarantee comparability and consistency of conclusions on health and regulatory issues in different countries and at an international level. This paper compares the different features of the existing EQAS, to highlight critical points for further discussions, and to make some suggestions for possible further collaboration.

[Estimate of uncertainty of measurements in clinical laboratories and in environmental, occupational, and preventive medicine]. / Stima dell'incertezza di misura nel laboratorio clinico e in medicina ambientale, occupazionale e preventiva.

According to recently issued (UNI CEI EN ISO/IEC 17025, UNI CEI ENV 13005 and prEN ISO 15189) standards, to assure the quality of analytical results and their comparability in time and in different places, testing and clinical laboratories must demonstrate to use validated methods, guarantee the traceability of their measurements and state the measurement uncertainty associated with each result. For some SI quantities, such as the mass, the traceability to SI and the estimate of measurement uncertainty are warranted by established methods. In the clinical laboratory and especially in preventive, environmental and occupational laboratory medicine, specific difficulties arise to warrant the traceability to the mole. On one hand, the whole concept of measurement uncertainty is new in laboratory medicine, on the other hand, its application faces practical difficulties, because of the wideness and the complexity of the analytical repertory, the lack of officially validated methods and matrix-specific reference materials traceable to SI. In this paper we discuss briefly the concept of measurement uncertainty and its meaning in comparison with other parameters used to define the performance of analytical methods. In addition, we describe the procedures recommended by international organisations for estimating measurement uncertainty and interpreting analytical results with an associated measurement uncertainty in comparison with limit values.

ACOEM practice guidelines: opioids and safety-sensitive work.

OBJECTIVE: ACOEM has updated the treatment guidelines concerning opioids. This report highlights the safety-sensitive work recommendation that has been developed. METHODS: Comprehensive literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel to develop evidence-based guidance. A total of 12 moderate-quality studies were identified to address motor vehicle crash risk, and none regarding other work among opioid-using patients. RESULTS: Acute or chronic opioid use is not recommended for patients who perform safety-sensitive jobs. These jobs include operating motor vehicles, other modes of transportation, forklift driving, overhead crane operation, heavy equipment operation and tasks involving high levels of cognitive function and judgment. CONCLUSION: Quality evidence consistently demonstrates increased risk of vehicle crashes and is recommended as the surrogate for other safety-sensitive work tasks.