Improved protection of outdoor workers from solar ultraviolet radiation: position statement.

The vast majority of non-melanoma skin cancer (NMSC) is attributable to excessive exposure to ultraviolet radiation (UVR). Outdoor workers are exposed to an UVR dose at least 2 to 3 times higher than indoor workers and often to daily UVR doses 5 times above internationally recommended limits. The risk of UVR workplace exposure is vastly neglected, and the evident future challenges presented in this statement are contrasted with the current situation regarding legal recognition, patient care and compensation. While prevention is crucial to reduce cancer risks for outdoor workers, it is as much of relevance to better protect them through legally binding rules and regulations. Specific actions are outlined in five recommendations based on a Call to Action (table 1). The role of health professionals, including dermatologists, in this context is crucial.

Implementation of the integrated approach in different types of exposure scenarios.

The International Commission on Radiological Protection (ICRP) recognises three types of exposure situations: planned, existing, and emergency. In all three situations, the release of radionuclides into the natural environment leads to exposures of non-human biota, as well as the potential for exposures of the public. This paper describes how the key principles of the ICRP system of radiological protection apply to non-human biota and members of the public in each of these exposure situations. Current work in this area within ICRP Task Group 105 is highlighted. For example, how simplified numeric criteria may be used in planned exposure situations that are protective of both the public and non-human biota. In emergency exposure situations, the initial response will always be focused on human protection; however, understanding the potential impacts of radionuclide releases on non-human biota will likely become important in terms of communication as governments and the public seek to understand the exposures that are occurring. For existing exposure situations, there is a need to better understand the potential impacts of radionuclides on animals and plants, especially when deciding on protective actions. Understanding the comparative impacts from radiological, non-radiological, and physical aspects is often important in managing the remediation of legacy sites. Task Group 105 is making use of case studies of how exposure situations have been managed in the past to provide additional guidance and advice for the protection of non-human biota.

ICRP Publication 126: Radiological Protection against Radon Exposure.

In this report, the Commission provides updated guidance on radiological protection against radon exposure. The report has been developed considering the latest ICRP recommendations for the system of radiological protection, all available scientific knowledge about the risks of radon, and the experience gained by many organisations and countries in the control of radon exposure. The report describes the characteristics of radon exposure, covering sources and transfer mechanisms, the health risks associated with radon, and the challenges of managing radon exposure. The Commission recommends an integrated approach for controlling radon exposure, relying as far as possible on the management of buildings or locations in which radon exposure occurs, whatever the use of the building. This approach is based on the optimisation principle, and is graded reflecting the responsibilities of key stakeholders, notably in workplaces, and the intent of the national authorities to control radon exposure. The report also provides recommendations on managing radon exposure when workers' exposures are considered as occupational, and the appropriate requirements of the Commission should be applied.

Recycling harvest water to cultivate Chlorella zofingiensis under nutrient limitation for biodiesel production.

Harvest water recycling for Chlorella zofingiensis re-cultivation under nutrient limitation was investigated. Using 100% harvest water, four cultures were prepared: Full medium, P-limited medium, N-limited medium and N- and P-limited medium, while another full medium was also prepared using 50% harvest water. The results showed that the specific growth rate and biomass productivity ranged from 0.289 to 0.403 day(-1) and 86.30 to 266.66 mg L(-1) day(-1), respectively. Nutrient-limited cultures witnessed much higher lipid content (41.21-46.21% of dry weight) than nutrient-full cultures (26% of dry weight). The N- and P-limited medium observed the highest FAME yield at 10.95% of dry weight, while the N-limited culture and P-limited culture shared the highest biodiesel productivity at 20.66 and 19.91 mg L(-1) day(-1), respectively. The experiment on harvest water recycling times demonstrated that 100% of the harvest water could be recycled twice with the addition of sufficient nutrients.

Uranium mining industry views on ICRP statement on radon.

In 2009, the International Commission on Radiological Protection issued a statement on radon which stated that the dose conversion factor for radon progeny would likely double, and the calculation of risk from radon should move to a dosimetric approach, rather than the longstanding epidemiological approach. Through the World Nuclear Association, whose members represent over 90% of the world's uranium production, industry has been examining this issue with a goal of offering expertise and knowledge to assist with the practical implementation of these evolutionary changes to evaluating the risk from radon progeny. Industry supports the continuing use of the most current epidemiological data as a basis for risk calculation, but believes that further examination of these results is needed to better understand the level of conservatism in the potential epidemiological-based risk models. With regard to adoption of the dosimetric approach, industry believes that further work is needed before this is a practical option. In particular, this work should include a clear demonstration of the validation of the dosimetric model which includes how smoking is handled, the establishment of a practical measurement protocol, and the collection of relevant data for modern workplaces. Industry is actively working to address the latter two items.

Forced fluid removal in critically ill patients with acute kidney injury.

PURPOSE: The aim was to test the feasibility of protocol-driven fluid removal with continuous renal replacement therapy (CRRT) in patients in whom standard fluid balance prescription did not result in substantial negative fluid balances. MATERIALS AND METHODS: In 10 mechanically ventilated patients with sepsis or signs of inflammation and acute kidney injury [age 65 (48-78 years; median, range), simplified acute physiology score II 66 (39-116)], fluid removal was guided by mean arterial pressure (MAP), cardiac index (CI), mixed venous oxygen saturation (SvO(2)), lactate/base excess, peripheral circulation, and filling pressures, and adjusted hourly with the goal to maximize volume removal for up to 3 days. RESULTS: Fluid removal rates during the 3 days before and during the study period [66 (36-72) h] were 11 (-30 to +36) ml/kg/day and -59 (-85 to -31) ml/kg/day, respectively (P = 0.002). In 12% of a total of 594 fluid removal rate evaluations, fluid removal had to be decreased or stopped. Most frequent reasons leading to decreasing fluid removal were (n, % of all instances, median lowest value from all patients): SvO(2) (44, 28%, 59%), MAP (36, 23%, 57 mmHg), CI (26, 17%, 2.4 l/min/m(2)), low peripheral temperature (22, 14%, 'cold'). Overall, systemic hemodynamics remained stable throughout the study period. CONCLUSIONS: In these patients, protocolized fluid removal with CRRT was associated with large negative fluid balances.

Oxygen transport and mitochondrial function in porcine septic shock, cardiogenic shock, and hypoxaemia.

INTRODUCTION: The relevance of tissue oxygenation in the pathogenesis of organ dysfunction during sepsis is controversial. We compared oxygen transport, lactate metabolism, and mitochondrial function in pigs with septic shock, cardiogenic shock, or hypoxic hypoxia. METHODS: Thirty-two anaesthetized, ventilated pigs were randomized to faecal peritonitis (P), cardiac tamponade (CT), hypoxic hypoxia (HH) or controls. Systemic and regional blood flows, lactate, mitochondrial respiration, and tissue hypoxia-inducible factor 1 alpha (HIF-1α) were measured for 24 h. RESULTS: Mortality was 50% in each intervention group. While systemic oxygen consumption (VO(2) ) was maintained in all groups, hepatic VO(2) tended to decrease in CT [0.84 (0.5-1.3) vs. 0.42 (0.06-0.8)/ml/min/kg; P = 0.06]. In P, fractional hepatic, celiac trunk, and portal vein blood flows, and especially renal blood flow [by 46 (14-91)%; P = 0.001] decreased. In CT, renal blood flow [by 50.4 (23-81)%; P = 0.004] and in HH, superior mesenteric blood flow decreased [by 38.9 (16-100)%, P = 0.009]. Hepatic lactate influx increased > 100% in P and HH, and > 200% in CT (all P < 0.02). Hepatic lactate uptake remained unchanged in P and HH and converted to release in CT. Mitochondrial respiration remained normal. Muscle adenosine triphosphate (ATP) concentrations decreased in P (5.9 ± 1.4 µmol/g wt vs. 2.8 ± 2.7 µmol/g wt, P = 0.04). HIF-1α expression was not detectable in any group. CONCLUSION: We conclude that despite shock and renal hypoperfusion, tissue hypoxia is not a major pathophysiological issue in early and established faecal peritonitis. The reasons for reduced skeletal muscle tissue ATP levels in the presence of well-preserved in-vitro muscle mitochondrial respiration should be further investigated.

Wegener's granulomatosis in Finland in 1981-2000: risk of dialysis-dependent renal disease.

OBJECTIVE: To determine the risk of renal insufficiency requiring transient or chronic dialysis and its contributing factors in patients diagnosed with Wegener's granulomatosis (WG) between 1981 and 2000 in Finland. PATIENTS AND METHODS: A retrospective cohort study using hospital discharge registers with a review of hospital case reports. Data were complemented with files from the Finnish Registry for Kidney Diseases. All files were reviewed by 8 October 2005. RESULTS: A total of 492 patients received a verified diagnosis of WG in 1981-2000. Of these, 84 (17%) needed dialysis by the end of follow-up. Of the 84 dialysed patients, 32 (38%) recovered initially, 32 (38%) needed chronic dialysis (dialysed > 3 months), and 19 (23%) received a kidney transplant. Forty-one (49%) of the dialysed patients were alive at the end of follow-up: 16 with a kidney transplant, 14 on dialysis, and 11 without dialysis. The cumulative rate of developing renal involvement leading to dialysis was 14.6% [95% confidence interval (CI) 11.6-18.2] at 5 years and 29.6% (95% CI 21.5-40.0) at 20 years after onset of WG symptoms. Elevated creatinine levels at presentation were associated with an increased rate of renal insufficiency requiring chronic dialysis. Age, gender, and involvement of any particular organ system had no significant effect. CONCLUSIONS: WG patients are at great risk of developing renal insufficiency, and this risk increases as the disease progresses. Elevated creatinine levels at presentation are associated with an increased risk of dialysis-dependent end-stage renal disease.

Muscle membrane dysfunction in critical illness myopathy assessed by velocity recovery cycles.

OBJECTIVE: To test the hypothesis that muscle fibers are depolarized in patients with critical illness myopathy by measuring velocity recovery cycles (VRCs) of muscle action potentials. METHODS: VRCs were recorded from brachioradialis muscle by direct muscle stimulation in 10 patients in intensive care with evidence of critical illness myopathy (CIM). Two sets of recordings were made, mean 3.9 d apart, and compared with those from 10 age-matched controls. RESULTS: Muscle supernormality was reduced in the patients by 50% compared with controls (P<0.002) and relative refractory period was increased by 59% (P<0.01). Supernormality was correlated with plasma potassium levels (R=-0.753, P<0.001), and the slope of this relationship was much steeper than previously reported for non-critically ill patients with renal failure (P<0.01). CONCLUSIONS: The abnormal excitability properties indicate that the muscle fibers in CIM were depolarized, and/or that sodium channel inactivation was increased. The heightened sensitivity to potassium is consistent with the hypothesis that an endotoxin reduces sodium channel availability in depolarized muscle fibers. SIGNIFICANCE: VRCs provide a practicable means to monitor muscle membrane changes in intensive care and to investigate the pathogenesis of CIM.

Effect of site of lactate infusion on regional lactate exchange in pigs.

BACKGROUND: The rate of extra-hepatic lactate production and the route of influx of lactate to the liver may influence both hepatic and extra-hepatic lactate exchange. We assessed the dose-response of hepatic and extra-hepatic lactate exchange during portal and central venous lactate infusion. METHODS: Eighteen pigs randomly received either portal (n=5) or central venous (n=7) lactate infusion or saline (n=6). Sodium lactate was infused at 33, 66, 99, and 133 µmol kg⁻¹ min⁻¹ for 20 min each. Systemic and regional abdominal blood flows and plasma lactate were measured at 20 min intervals until 1 h post-infusion, and regional lactate exchange was calculated (area under lactate uptake-time curve). RESULTS: Total hepatic lactate uptake [median (95% confidence interval)] during the experimental protocol (140 min) was higher during portal [8198 (5487-12 798) µmol kg(-1)] than during central venous lactate infusion [4530 (3903-5514) µmol kg⁻¹, P<0.05]. At a similar hepatic lactate delivery (∼400 µmol kg⁻¹ min⁻¹), hepatic lactate uptake [mean and standard deviation (sd)] was higher during portal [118 (sd 55) µmol kg⁻¹ min⁻¹] than during central venous lactate infusion [44 (12) µmol kg⁻¹ min⁻¹, P < 0.05]. Time courses of arterial lactate concentrations and lactate uptake at other measured regions were similar in both groups. CONCLUSIONS: Higher hepatic lactate uptake during portal compared with central venous lactate infusion at a similar total hepatic lactate influx underlines the role of portal vein lactate concentration in total hepatic lactate uptake capacity. Arterial lactate concentration does not depend on the site of lactate infusion. At higher arterial lactate concentrations, all regions participated in lactate uptake.

The association between early hemodynamic variables and outcome in normothermic comatose patients following cardiac arrest.

BACKGROUND: Currently, few data exist on the association between post-cardiac arrest hemodynamic function and outcome. In this explorative, retrospective analysis, the association between hemodynamic variables during the first 24 h after intensive care unit admission and functional outcome at day 28 was evaluated in 153 normothermic comatose patients following a cardiac arrest. METHODS: Medical records of a multidisciplinary intensive care unit were reviewed for comatose patients (Glasgow Coma Scale < or = 9) admitted to the intensive care unit after successful resuscitation from an in- or an out-of-hospital cardiac arrest. The hourly variable time integral of hemodynamic variables during the first 24 h after admission was calculated. At day 28, outcome was assessed as favorable or adverse based on a Cerebral Performance Category of 1-2 and 3-5, respectively. Bi- and multivariate regression models adjusted for relevant confounding variables were used to evaluate the association between hemodynamic variables and functional outcome. RESULTS: One hundred and fifty-three normothermic comatose patients were admitted after a cardiac arrest, of whom 64 (42%) experienced a favorable outcome. Neither in the adjusted bivariate models (r(2), 0.61-0.78) nor in the adjusted multivariate model (r(2), 0.62-0.73) was the hourly variable time integral of any hemodynamic variable during the first 24 h after intensive care unit admission associated with functional patient outcome at day 28 in all patients as well as in patients after an in- or an out-of-hospital cardiac arrest. CONCLUSION: Commonly measured hemodynamic variables during the first 24 h following intensive care unit admission due to a cardiac arrest do not appear to be associated with the functional outcome at day 28.

Survival of patients with Wegener's granulomatosis diagnosed in Finland in 1981-2000.

OBJECTIVE: To determine the survival of and contributing factors in patients diagnosed with Wegener's granulomatosis (WG) between 1981 and 2000 in Finland. METHODS: A retrospective cohort study using hospital discharge registers with a review of hospital case records. Analysis of causes of death in Finland up to 30 July 2005. RESULTS: A total of 492 patients received a verified diagnosis of WG between 1981 and 2000. Of these, 203 died before the end of June 2005. The overall 1-year survival rate was 83.3% and the 5-year survival rate was 74.2%. The standardized mortality ratio (SMR) for all WG patients was 3.43 [95% confidence interval (CI) 2.98-3.94], for women 4.38 (95% CI 3.59-5.61) and for men 2.80 (95% CI 2.28-3.41). The most frequent causes of death were WG or another connective tissue disease, cardiovascular events and neoplasms. The prognosis did not change markedly over the 20-year period. Older age and elevated creatinine level at presentation were associated with poorer prognosis, whereas primary ear, nose, and throat (ENT) involvement and prompt treatment with cyclophosphamide predicted longer survival. CONCLUSIONS: WG patients had increased mortality compared with the rest of the population. Older age and elevated creatinine level at diagnosis predicted poor prognosis, but ENT involvement initially and cyclophosphamide treatment resulted in a better outcome.

Incidence of Wegener's granulomatosis in Finland 1981-2000.

OBJECTIVE: To determine the incidence and clinical presentation of Wegener's granulomatosis (WG) in Finland during the 20-year period 1981-2000. METHODS: We performed a study with retrospective data retrieval using the hospital discharge register in Finland. All available hospital case reports were reviewed. We included those patients diagnosed with and treated for WG. Demographic and clinical data at diagnosis were recorded. RESULTS: Of the 492 patients diagnosed with WG, 49% were male. Mean age at diagnosis was 53.2 years (SD 18.1). The highest rate of incidence occurred in men and women aged 65-74 years. The annual incidence per million of the population increased from 1.9 (95% CI 1.4 to 2.6) during 1981-1985 to 9.3 (95% CI 8.1 to 10.6) during 1996-2000 with gender age-adjusted incidence rate ratio 4.5 (CI 3.6 to 5.7). Only minor changes in the signs and symptoms at diagnosis occurred during the 20-year span. In 83% of cases, the ACR criteria (>or=2 criteria) were fulfilled. The mean age at diagnosis rose from 45.8 to 55.0 years and the median diagnostic delay decreased from 17 to 4 months during the two decades. CONCLUSION: The incidence of WG has increased during the last two decades with little change in clinical symptoms at presentation. At the same time, the mean age of the patients has increased and the diagnostic delay has considerably shortened.

Wegener's granulomatosis in Finland in 1981-2000: clinical presentation and diagnostic delay.

OBJECTIVE: To determine the features of clinical presentation and the diagnostic delay of Wegener's granulomatosis (WG) in Finland in 1981-2000. METHODS: A retrospective cohort study using hospital discharge registers with review of hospital case reports. We determined the spectrum of WG symptoms in relation to individual organ groups and ELK (Ear, nose, throat, Lung, Kidney) score within the first 6 months from disease onset. Diagnostic delay and contributing factors were analysed. RESULTS: Of 513 WG patients treated at Finnish specialized medical care hospitals, 489 patients had sufficient information in the first 6 months of their disease. The ENT (Ear, Nose, and Throat) system was involved in 63%; the pulmonary system in 59%, and 60% had general symptoms. Over time, the general symptoms became more common at presentation. The diagnostic delay had decreased from 17 to 4 months. CONCLUSIONS: The initial symptoms of WG remained essentially unchanged. The proportion of general symptoms increased. A considerable shortening of diagnostic delay occurred, mostly between the 5-year periods of 1981-1985 and 1986-1990, when anti-neutrophil cytoplasmic antibody (ANCA) tests were brought into routine use. ELK scores of 2 and 3 and the presence of pulmonary and general symptoms predicted a shorter diagnostic delay.

Time- and dose-related regional fluxes of tissue-type plasminogen activator in anesthetized endotoxemic pigs.

BACKGROUND: Acute endotoxinemia elicits an early fibrinolytic response. This study analyzes the effects of the dose and duration of endotoxin infusion on arterial levels of tissue-type plasminogen activator (tPA) and pulmonary, mesenteric and hepatic plasma tPA fluxes. METHODS: Pigs were randomized to receive an acute, high-dose (for 6 h, n=13, high ETX) or a prolonged, low-dose (for 18 h, n=18, low ETX) infusion of endotoxin or saline vehicle alone (for 18 h, n=14, control). All animals were fluid resuscitated to maintain a normodynamic circulation. Systemic and regional blood flows were measured and arterial, pulmonary arterial, portal and hepatic venous blood samples were analyzed to calculate regional net fluxes of tPA. Plasma tumor necrosis factor (TNF-alpha) levels were analyzed. RESULTS: Mesenteric tPA release and hepatic uptake increased maximally at 1.5 h in ETX groups related to dose. Maximal mesenteric tPA release [high ETX 612 (138-1185) microg/min/kg, low ETX 72 (32-94) microg/min/kg, median+/-interquartile range] and hepatic tPA uptake [high ETX -1549 (-1134 to -2194) microg/min/kg, low ETX -153 (-105 to -307) microg/min/kg] correlated to TNF-alpha levels. Regional tPA fluxes returned to baseline levels at 6 h in both ETX groups and also remained low during sustained low ETX. No changes were observed in control animals. CONCLUSIONS: Endotoxemia induces an early increase in mesenteric tPA release and hepatic tPA uptake related to the severity of endotoxemia. The time patterns of changes in mesenteric and hepatic tPA fluxes are similar in acute high-dose endotoxemia and sustained low-dose endotoxemia.

The contribution of occupational risks to the global burden of disease: summary and next steps.

BACKGROUND: The Comparative Risk Assessment (CRA) project of the World Health Organization (WHO) assessed worldwide mortality and morbidity in the year 2000 resulting from exposures to selected occupational hazards. This article summarizes findings of the WHO CRA project, presents the estimates of the International Labor Organization (ILO) for total deaths due to workplace risks, and calls for action. OBJECTIVES: Global burden estimates and counts of deaths assist ministers and other decision and policy makers to make informed decisions and to take action regarding risk reduction. METHODS: The WHO CRA methodology combined the proportions of the population exposed to five occupational hazards (excluding numerous risks due to inadequate global data) with relative risk measures to estimate attributable fractions of the selected health outcomes for both morbidity and mortality. ILO estimates of total numbers of global work-related injury deaths apply national fatality rates to employment data for the particular country; for disease deaths ILO uses an attributable risk approach. RESULTS: In 2000, the selected occupational risk factors were responsible worldwide for 37% of back pain, 16% of hearing loss, 13% of chronic obstructive pulmonary disease (COPD), 11% of asthma, 8% of injuries, 9% of lung cancer and 2% of leukemia, and about 100% of pneumoconioses and mesothelioma. These selected risks at work resulted in the loss of about 24 million years of healthy life and caused 850,000 deaths worldwide, about 40% of the ILO estimate of 2.2 million total deaths. CONCLUSIONS: These global and regional analyses have identified areas where specific preventive actions are required.

Practical sources of error in measuring pulmonary artery occlusion pressure: a study in participants of a special intensivist training program of The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI).

BACKGROUND: Physiological data obtained with the pulmonary artery catheter (PAC) are susceptible to errors in measurement and interpretation. Little attention has been paid to the relevance of errors in hemodynamic measurements performed in the intensive care unit (ICU). The aim of this study was to assess the errors related to the technical aspects (zeroing and reference level) and actual measurement (curve interpretation) of the pulmonary artery occlusion pressure (PAOP). METHODS: Forty-seven participants in a special ICU training program and 22 ICU nurses were tested without pre-announcement. All participants had previously been exposed to the clinical use of the method. The first task was to set up a pressure measurement system for PAC (zeroing and reference level) and the second to measure the PAOP. RESULTS: The median difference from the reference mid-axillary zero level was - 3 cm (-8 to + 9 cm) for physicians and -1 cm (-5 to + 1 cm) for nurses. The median difference from the reference PAOP was 0 mmHg (-3 to 5 mmHg) for physicians and 1 mmHg (-1 to 15 mmHg) for nurses. When PAOP values were adjusted for the differences from the reference transducer level, the median differences from the reference PAOP values were 2 mmHg (-6 to 9 mmHg) for physicians and 2 mmHg (-6 to 16 mmHg) for nurses. CONCLUSIONS: Measurement of the PAOP is susceptible to substantial error as a result of practical mistakes. Comparison of results between ICUs or practitioners is therefore not possible.

Changes in respiratory mechanics and gas exchange during the acute respiratory distress syndrome.

BACKGROUND: The time course of impairment of respiratory mechanics and gas exchange in the acute respiratory distress syndrome (ARDS) remains poorly defined. We assessed the changes in respiratory mechanics and gas exchange during ARDS. We hypothesized that due to the changes in respiratory mechanics over time, ventilatory strategies based on rigid volume or pressure limits might fail to prevent overdistension throughout the disease process. METHODS: Seventeen severe ARDS patients {PaO2/FiO2 10.1 (9.2-14.3) kPa; 76 (69-107) mmHg [median (25th-75th percentiles)] and bilateral infiltrates} were studied during the acute, intermediate, and late stages of ARDS (at 1-3, 4-6 and 7 days after diagnosis). Severity of lung injury, gas exchange, and hemodynamics were assessed. Pressure-volume (PV) curves of the respiratory system were obtained, and upper and lower inflection points (UIP, LIP) and recruitment were estimated. RESULTS: (1) UIP decreased from early to established (intermediate and late) ARDS [30 (28-30) cmH2O, 27 (25-30) cmH2O and 25 (23-28) cmH2O (P=0.014)]; (2) oxygenation improved in survivors and in patients with non-pulmonary etiology in late ARDS, whereas all patients developed hypercapnia from early to established ARDS; and (3) dead-space ventilation and pulmonary shunt were larger in patients with pulmonary etiology during late ARDS. CONCLUSION: We found a decrease in UIP from acute to established ARDS. If applied to our data, the inspiratory pressure limit advocated by the ARDSnet (30 cmH2O) would produce ventilation over the UIP, with a consequent increased risk of overdistension in 12%, 43% and 65% of our patients during the acute, intermediate and late phases of ARDS, respectively. Lung protective strategies based on fixed tidal volume or pressure limits may thus not fully avoid the risk of lung overdistension throughout ARDS.