Musculoskeletal disorders and pain in agricultural workers in Low- and Middle-Income Countries: a systematic review and meta-analysis.

Agricultural workers constitute two-thirds of the population of Low- and Middle-Income Countries (LMIC) and are at increased risk of developing musculoskeletal disorders (MSD) due to high-risk activities. This systematic review and meta-analysis aim to synthesise the prevalence, predictors, and outcomes of musculoskeletal pain amongst agricultural workers to identify priority areas for prevention and development of early interventions. This systematic review and meta-analysis included Studies published from the inception of global electronic databases until 30 September 2022 were included. Prevalence estimates for MSDs among agricultural workers aged over 18 years in LMIC were extracted. Narrative synthesis summarized study findings and pooled estimates for 12-month pain prevalence were calculated. 7502 potential studies were identified. 64 studies (68,684 participants from 23 countries) were included in the systematic review; 33 studies were included in the meta-analysis. Low back pain was the most widely investigated symptom. The 12-month pooled prevalence of low back pain was highest in Africa [61.96% (45.69-76.22)] compared to Asia [54.16% (47.76-60.50)] and South/Central America [28.52%(10.91-50.33)]. Narrative synthesis found associations between MSDs, particular activities including heavy lifting and repetitive movements, and outcomes including reduced productivity. MSDs are common in agriculture workers in LMIC. Global prevalence of low back pain in farmers, particularly in Africa, is greater than in previously reported global prevalence in the general population. This may be attributed to environmental factors and high-risk activities which could be targeted for prevention and early intervention strategies to support individuals, prevent disability, and reduce loss of productivity.

[Analysis of symptoms and influencing factors of low back work-related musculoskeletal disorders among workers in a container manufacturing factory].

Objective: To investigate the occurrence of low back work-related musculoskeletal disorders (WMSDs) among workers in a container manufacturing factory, and to explore the influencing factors. Methods: In June 2022, 952 workers from a container factory were selected as the research objects by cluster random sampling. Through questionnaire survey, the incidence of low back WMSDs symptoms among workers in the past one year was collected, and the influencing factors of low back WMSDs were analyzed by logistic regression. Results: The incidence rate of low back WMSDs was 46.7% (445/952). The factors with higher exposure at work were frequent slight bending (77.0%, 733/952), frequent overtime (74.1%, 705/952), and the need to turn around while working (62.3%, 593/952). Multivariate logistic regression analysis showed that age over 40 years old, smoking, drinking, often bending over slightly, sitting for a long time, maintaining a large bending posture for a long time, often working overtime, limited operating space, and there was always a need to complete conflicting things in the container manufacturing factory workers were the risks of increasing the low back WMSDs (OR=1.68, 1.96, 2.47, 1.49, 1.84, 2.11, 1.90, 1.82, 2.00, P<0.05). Standing at work, always friendly colleagues, and always supportive and helpful leaders were protective factors for low back WMSDs (OR=0.60, 0.32, 0.40, P<0.05) . Conclusion: The incidence of low back WMSDs symptoms in container manufacturing workers is high, and work-related factors such as frequent slight bending, long time holding large bending posture and limited operating space are the focus of ergonomic intervention in container manufacturing enterprises.

[5 cases of occupational heat illness].

Objective: Through the analysis of five cases of occupational heat illness caused by high temperature, we expounded the pathogenesis and summarized the clinical characteristics of heat cramp and heat exhaustion of the newly revised diagnostic criteria for occupational heat illness (GBZ41-2019), in order to prevent the occurrence of occupational heat illness to put forward controllable countermeasures. Methods: According to the occupational history, clinical diagnosis and treatment and the other relevant data submitted by five patients, the diagnosis process was analyzed and summarized. Results: Five patients developed symptoms from July to August in summer, belonging to high-temperature operation. They improved by timely treatment. The symptoms, signs and laboratory tests of the five patients were different, but they were diagnosed as occupational heat illness. Conclusion: Employers should pay attention to the high temperature protection and cooling work, and strengthen the labor protection. If patients with heat cramp and heat exhaustion were timely treated, they could basically recover. Occupational disease diagnosticians should seriously study the new diagnostic criteria of occupational disease and constantly improve their diagnostic ability.

Vinculin Identified as a Potential Biomarker in Hand-Arm Vibration Syndrome Based on iTRAQ and LC-MS/MS-Based Proteomic Analysis.

Local vibration can induce vascular injuries, one example is the hand-arm vibration syndrome (HAVS) caused by hand-transmitted vibration (HTV). Little is known about the molecular mechanism of HAVS-induced vascular injuries. Herein, the iTRAQ (isobaric tags for relative and absolute quantitation) followed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) proteomics approach was applied to conduct the quantitative proteomic analysis of plasma from specimens with HTV exposure or HAVS diagnosis. Overall, 726 proteins were identified in iTRAQ. 37 proteins upregulated and 43 downregulated in HAVS. Moreover, 37 upregulated and 40 downregulated when comparing severe HAVS and mild HAVS. Among them, Vinculin (VCL) was found to be downregulated in the whole process of HAVS. The concentration of vinculin was further verified by ELISA, and the results suggested that the proteomics data was reliable. Bioinformative analyses were used, and those proteins mainly engaged in specific biological processes like binding, focal adhesion, and integrins. The potential of vinculin application in HAVS diagnosis was validated by the receiver operating characteristic curve.

Occupational variation in the incidence of lip cancer in the Nordic countries.

INTRODUCTION: While certain occupations, such as agriculture and fishery, have been associated with an increased risk of lip cancer, the occupational risk profile of lip cancer and its change over time remain poorly known. This study aims to evaluate the incidence of lip cancer across different occupations in the Nordic countries. METHODS: The Nordic Occupational Cancer Study (NOCCA) covers 14.9 million people and includes 45 years of cancer incidence data, from 1961 to 2005, linked to occupational categories for all the five Nordic populations. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were used to quantify the risk of lip cancer across occupational categories relative to the entire national populations. RESULTS: There were a total of 14,477 male and 3008 female lip cancer patients identified during follow up. The highest SIRs were observed among male fishermen (SIR 2.26, 95% CI: 2.04-2.50), gardeners (SIR 1.60, 95% CI: 1.48-1.72), and farmers (SIR 1.60, 95% CI: 1.55-1.66). A significantly reduced risk of lip cancer (SIR < 0.50) was observed among male physicians, teachers, religious workers, artistic workers, journalists, administrators, printers, waiters, and hairdressers. Among women, no occupations were associated with an increased risk of lip cancer. CONCLUSIONS: The incidence of lip cancer varies widely between outdoor and indoor occupations. Occupations involving outdoor activity and exposure to sunlight show the most elevated SIRs.

Certain outdoor occupations, such as agriculture and fishery, have been associated with an increased risk of lip cancer. However, the occupational risk profile of lip cancer and its change over time remain poorly known. This study highlights the excess risk of lip cancer among men with outdoor occupations and further corroborates previous studies. Efforts to counsel outdoor workers on the risk and prevention of lip cancer are needed to reduce the societal burden of the disease.

Occupational risk factors and exposure-response relationships for airway disease among health workers exposed to cleaning agents in tertiary hospitals.

OBJECTIVES: This study investigated occupational risk factors and exposure-response relationships for airway disease among health workers (HWs) exposed to cleaning agents in two tertiary hospitals in South Africa and Tanzania. METHODS: In this cross-sectional study, 697 participants completed questionnaire interviews while 654 underwent fractional exhaled nitric oxide (FeNO) testing. Asthma Symptom Score (ASS) was computed based on the sum of answers to five questions on asthma-related symptoms in the past 12 months. For exposure-response analyses, cleaning agent-related self-reported exposure variables were categorised into three levels (cleaning product not used; use of a cleaning product for up to 99 min per week and use of a cleaning product for ≥100 min per week). RESULTS: Asthma-related outcomes (ASS and FeNO) demonstrated positive associations with medical instrument cleaning agents (orthophthalaldehyde and enzymatic cleaners) and tasks (instruments precleaning and changing sterilisation solutions) as well as patient care activities (disinfection prior to procedures and disinfecting wounds). A particularly pronounced dose-response relationship was observed between work-related ocular-nasal symptoms and medical instrument cleaning agents (orthophthalaldehyde, glutaraldehyde, enzymatic cleaners, alcohols and bleach) (OR range: 2.37-4.56) and tasks (OR range: 2.92-4.44). A strong association was also observed between ASS and use of sprays for fixed surface cleaning (mean ratio 2.81; 95% CI 1.41 to 5.59). CONCLUSIONS: Specific agents for medical instrument disinfection for example, orthophthalaldehyde and enzymatic cleaners, patient care activities and use of sprays are important occupational risk factors for airway disease among HWs.

Chronic Obstructive Pulmonary Disease and Work: The Continuing Narrative.

It has long been recognized that harmful inhaled workplace exposures can contribute to the development of chronic obstructive pulmonary disease (COPD). This article, intended for the clinician, summarizes some of this evidence and some areas of controversy. Current estimates based on pooled epidemiological analyses of population-based studies identify that approximately 14% of the burden of COPD (and 13% of the burden of chronic bronchitis) is attributable to such exposures. In addition to these approaches, various studies implicate specific exposures as contributing. Certain of these relating to cadmium, coal, and respirable crystalline silica are discussed in more detail. Despite this amassed evidence to date supporting associations between COPD and workplace exposures, there have been surprisingly few studies that have attempted to assess the attribution by experts of an occupational cause in cases of COPD. One study, using hypothetical cases of COPD, noted that while expert physicians were willing to make such an occupational link, this was only likely in cases with light smoking histories and a priori defined heavy occupational exposures. Relatively recent data relating to computed tomography (CT) scan appearances may give the clinician a further guide. Several studies from populations have now linked potentially harmful occupational exposures specifically with the presence of emphysema on CT scanning. It will be of interest to see if this finding, along with other clinical attributes of cases such as smoking and family histories, exclusion of asthma, genetic data, and the nature of workplace exposures, will increase the future diagnosis by clinicians of occupational COPD. In the interim, while better diagnostic approaches are developed, we suggest that consideration of an occupational cause is an important part of the clinical investigation of cases of COPD. Finally, we suggest that evidence-based workplace preventive strategies for occupational COPD should be informed by knowledge of which exposures are most important to reduce, and whether and when intervention to reduce exposure at an individual worker level is warranted.

Occupational asthma, rhinitis and contact urticaria from greenhouse work.

BACKGROUND: The current knowledge about occupational allergic diseases among greenhouse workers is scant. AIMS: To describe greenhouse workers' occupational allergic diseases. METHODS: We identified 28 greenhouse workers with occupational allergic diseases in 2002-2020 by conducting a systematic search in the patient register of the Finnish Institute of Occupational Health. All the patients worked in tomato- or cucumber-growing greenhouses and showed immunoglobulin-E-mediated sensitization to occupational agents. Specific inhalation challenges or workplace peak expiratory flow monitoring confirmed occupational asthma (OA), nasal allergen challenges confirmed occupational rhinitis (OR) and open skin tests confirmed occupational contact urticaria (OCU). RESULTS: Most patients had more than one occupational disease and were sensitized to several workplace agents. Tomato plants were the most common cause of occupational diseases and induced 22 allergic diseases in 14 patients. Cucumber plants caused occupational diseases in 10 patients (3 OA, 7 OR and 6 OCU). The pest control mite Amblyseius swirskii and a mixture of parasitic wasps Encarsia formosa and Eretmocerus eremicus both induced two OA cases. Three patients had an occupational disease caused by storage mites and three others had a work-related systemic reaction to a bumblebee sting. CONCLUSIONS: The greenhouse workers typically suffered from several occupational allergic diseases and were sensitized to cultivated plants, various pest control organisms and storage mites. All these can cause OA and OR, but in this study, OCU was only induced by cultivation plants. Cucumber plant is a novel cause of OA and OR, and A. swirskii is a novel cause of OA.

[A case of dimethylformamide poisoning caused by skin contact].

In this paper, the clinical data of a case of accidental poisoning of dimethylformamide in a traffic accident was analyzed. The patient was trapped in the driving room, his limbs were soaked in dimethylformamide for a long time, and dimethylformamide was inhaled at the same time. After 4 days of treatment in a local hospital, he was transferred to the Department of Poisoning & Occupational Diseases, Emergency Medicine of Qilu Hospital of Shandong University for treatment. The main clinical manifestation of the patient was liver damage and intractable abdominal pain, which was cured by active treatment.

[A case of occupational explosive deafness caused by non explosive strong noise].

Occupational explosive hearing loss is often caused by close exposure to blasting operations or the impact waves and strong pulse noise generated by explosions of flammable and explosive chemicals, pressure vessels, etc. in the workplace. This article analyzes the diagnosis of a case of occupational explosive hearing loss caused by non explosion, in order to improve the flexible application of diagnostic standards by occupational disease diagnosis physicians.

Lifetime occupational exposures and chronic obstructive pulmonary disease risk in the UK Biobank cohort.

BACKGROUND AND AIM: Occupational exposures are important, preventable causes of COPD. We previously found an increased risk of COPD among six occupations by analysing lifetime job histories and lung function data in the population-based UK Biobank cohort. We aimed to build on these findings and elucidate the underlying potential causal agents to focus preventive strategies. METHODS: We applied the ALOHA+job exposure matrix (JEM) based on the International Standard Classification of Occupations V.1988 codes, where exposure to 12 selected agents was rated as 0 (no exposure), 1 (low) or 2 (high). COPD was spirometrically defined as FEV1/FVC less than the lower limit of normal. We calculated semiquantitative cumulative exposure estimates for each agent by multiplying the duration of exposure and squared intensity. Prevalence ratio (PR) and 95% CI for COPD were estimated using robust Poisson regression adjusted for centre, sex, age, smoking and coexposure to JEM agents. Only associations confirmed among never-smokers and never-asthmatics were considered reliable. RESULTS: Out of 116 375 participants with complete job histories, 94 514 had acceptable/repeatable spirometry and smoking data and were included in the analysis. Pesticide exposure showed increased risk of COPD for ever exposure (PR=1.13, 95% CI 1.01 to 1.28) and high cumulative exposure (PR=1.32, 95% CI 1.12 to 1.56), with positive exposure-response trends (p trend=0.004), which were confirmed among never-smokers (p trend=0.005) and never-asthmatics (p trend=0.001). CONCLUSION: In a large population-based study, occupational exposure to pesticides was associated with risk of COPD. Focused preventive strategies for workers exposed to pesticides can prevent the associated COPD burden.

Lung cancer risk in relation to jobs held in a nationwide case-control study in Iran.

BACKGROUND: Globally, lung cancer is the most frequent occupational cancer, but the risk associated with the occupations or occupational environment in Iran is not clear. We aimed to assess occupations with the risk of lung cancer. METHODS: We used the IROPICAN nationwide case-control study data including 658 incident lung cancer cases and 3477 controls. We assessed the risk of lung cancer in relation to ever working in major groups of International Standard Classification of Occupations, high-risk occupations for lung cancer and duration of employment and lung cancer subtype among construction workers and farmers while controlling for cigarette smoking and opium consumption. We used unconditional regression logistic models to estimate ORs for the association between increased lung cancer risk and occupations. RESULTS: We observed elevated ORs for lung cancer in male construction workers (OR=1.4; 95% CI: 1.0 to 1.8), petroleum industry workers (OR=3.2; 95% CI: 1.1 to 9.8), female farmers (OR=2.6; 95% CI: 1.3 to 5.3) and female bakers (OR=5.5; 95% CI: 1.0 to 29.8). A positive trend by the duration of employment was observed for male construction workers (p< 0.001). Increased risk of squamous cell carcinoma was observed in male construction workers (OR=1.9; 95% CI: 1.2 to 3.0) and female farmers (OR=4.3; 95% CI: 1.1 to 17.2), who also experienced an increased risk of adenocarcinoma (OR=3.8; 95% CI: 1.4 to 9.9). DISCUSSION: Although we observed associations between some occupations and lung cancer consistent with the literature, further studies with larger samples focusing on exposures are needed to better understand the occupational lung cancer burden in Iran.

Mortality of workers employed in refractory ceramic fiber manufacturing: An update.

This study evaluates the possible association between refractory ceramic fiber (RCF) exposure and all causes of death. Current and former employees (n = 1,119) hired from 1952 to 1999 at manufacturing facilities in New York (NY) state and Indiana were included. Work histories and quarterly plant-wide sampling from 1987 to 2015 provided cumulative fiber exposure (CFE) estimates. The full cohort was evaluated as well as individuals with lower and higher exposure, <45 and ≥45 fiber-months/cc. The Life-Table-Analysis-System was used for all standardized mortality rates (SMRs). Person-years at risk were accumulated from start of employment until 12/31/2019 or date of death. There was no significant association with all causes, all cancers, or lung cancer in any group. In the higher exposed, there was a significant elevation in both malignancies of the "urinary organs" (SMR = 3.59, 95% confidence interval [CI] 1.44, 7.40) and "bladder or other urinary site" (SMR = 4.04, 95% CI 1.10, 10.36), which persisted in comparison to regional mortality rates from NY state and Niagara County. However, six of the nine workers with urinary cancers were known smokers. In the lower exposed, there was a significant elevation in malignancies of the lymphatic and hematopoietic system (SMR = 2.54, 95% CI 1.27, 4.55) and leukemia (SMR = 4.21, 95% CI 1.69, 8.67). There was one pathologically unconfirmed mesothelioma death. A second employee currently living with a pathologically confirmed mesothelioma was identified, but the SMR was non-significant when both were included in the analyses. The association of these two mesothelioma cases with RCF exposure alone is unclear because of potential past exposure to asbestos.

Risk of breast cancer in Danish women occupationally exposed to organic solvents, including ethanol.

BACKGROUND: Organic solvents have been suggested to increase the risk of breast cancer although the epidemiologic evidence is limited. This study explored the association between organic solvents and breast cancer. METHODS: This nested population-based case-control study comprised 845 women with primary breast cancer initially identified in the Danish Cancer Registry between 2000 and 2003, and 1500 controls matched on year of birth who were randomly selected from the Danish Civil Registration System. Information on occupational exposure to organic solvents, and specifically ethanol, as well as risk factors for breast cancer was collected through structured interviews. RESULTS: For organic solvents, an increased risk was indicated for ever-exposure (odds ratio = 3.20, 95% confidence interval: 2.27-4.52), however, no noteworthy risk patterns were detected when exploring duration of exposure and cumulative exposure. Ever-exposure to organic solvents was associated with an increased risk of estrogen receptor negative and positive tumors as well as pre- and postmenopausal breast cancer. No associations were detected between occupational exposure to ethanol and breast cancer. CONCLUSIONS: This study indicates a positive association between organic solvents and breast cancer.

Silicosis: enlarged cervical lymph nodes, pericardial effusion and lung abnormalities.

Silicosis is an occupational lung parenchymal disease caused by inhaling silica. It requires differentiation from a malignant tumour and granulomatous disease. We describe the case of a woman with silicosis who exhibited enlargement of bilateral cervical lymph nodes, pericardial effusion and lung abnormalities. She was diagnosed with silicosis based on histological examination of a resected cervical lymph node, lung tissue biopsy and history of silica exposure. She underwent glucocorticoid therapy during hospitalization. The lung abnormalities, enlarged cervical lymph nodes and pericardial effusion were ameliorated by glucocorticoid therapy, but she relapsed shortly thereafter. In conclusion, silicosis with cervical lymph node enlargement and pericardial effusion is rare and should be differentiated from a malignant tumour and granulomatous disease. Some patients may respond well to steroids in the short term.

Trends in pneumoconiosis in Brazil, 1979-2019.

BACKGROUND: Pneumoconiosis is a lung disease related to exposure to dust in the workplace. The disease can induce irreversible damage to health, especially in lung tissue, and can cause progressive and permanent physical disabilities. AIMS: This study evaluated the temporal and spatial distribution of mortality rates (1979-2019) and hospital admissions (1995-2019) for pneumoconiosis in Brazil. METHODS: The outcomes were hospitalization and death due to pneumoconiosis: codes 500-506 according to the ICD-9 and J60-J66 according to the ICD-10. Data from this retrospective ecological study were collected from the Brazilian Ministry of Health database. RESULTS: Hospitalization for pneumoconiosis has decreased in all regions of Brazil. Hospitalizations occurred predominantly in men aged over 40 years. Death rates showed a temporal increase in all regions. Deaths occurred predominantly in men aged over 50 years. The highest hospitalization and death rates were in the states of the Midwest and South Regions. CONCLUSIONS: Pneumoconiosis is a preventable occupational disease, and ongoing occurrences of hospitalizations and deaths highlight the importance of inspecting industries and controlling occupational and environmental exposures.

[Noise exposure and its impact on health in an auto parts manufacturing enterprise].

Objective: To learn about the noise exposure and health status of workers and analyze factors that may affect the health outcomes of workers in an auto manufacturing enterprise in Tianjin City. Methods: In September 2020, occupational hygiene survey, noise exposure level detection and occupational health examination data collection were carried out in an auto parts manufacturing enterprise. Chi square test and unconditional logistic regression analysis were used to analyze the health effects of noise exposure and hearing loss of 361 noise exposure workers. Results: The rates of over-standard noise exposure, hearing loss and hypertension were 69.39% (34/49) , 33.24% (120/361) and 11.36% (41/361) , respectively. There were upward trends on age and noise-working years for hearing loss and hypertension rates (χ(2)=-5.95, -6.16, -2.81, -2.74, P<0.05) . Unconditional logistic regression analysis showed that age>35 years old, noise exposure length of service >10 years and noise L(EX, 8 h)>85 dB (A) were risk factors for hearing loss (OR=3.57, 95%CI: 1.09, 11.75; OR=4.05, 95%CI: 1.97, 8.25; OR=1.75, 95%CI: 1.00, 3.05; P=0.036, 0.001, 0.047) . Conclusion: This company has a high rate of job noise exceeding the standard, and noise-exposed workers have more serious hearing loss. Age, noise exposure and high noise exposure are risk factors for hearing loss.

[A case-control study of occupational noise exposure induced high-frequency hearing loss and the risk of hypertension].

Objective: To investigate the relationship between high frequency hearing loss caused by occupational noise and the risk of hypertension. Methods: In March 2020, a case-control study was conducted. All noise exposed workers who participated in occupational health examination in Wuxi City in 2019 were selected as the study subjects (95432 cases in total) . The hypertension group was defined as the case group, and the normotensive group was defined as the control group. According to the hearing threshold, they were divided into the non high frequency hearing loss group (<40 dB) and the high frequency hearing loss group (≥ 40 dB) . Univariate statistical method and binary logistic regression were used to evaluate the relationship between high-frequency hearing loss and hypertension risk. Stratified analysis was used to compare the risk of hypertension among workers with high-frequency hearing loss of different ages and length of service. Results: There were significant differences in gender, age, length of service, enterprise scale, economic type and high-frequency hearing loss between control group and hypertension group (P<0.05) . Binary logistic regression analysis showed that after adjusting for gender, age, length of service, enterprise scale and economic type, the risk of hypertension in the high-frequency hearing loss group was still increased (OR=1.062, 95%CI: 1.007~1.121, P=0.027) . The risk of hypertension in high-frequency hearing loss patients was higher than that in non high-frequency hearing loss patients in 20-39 years old and 40-59 years old age groups (OR=1.536, 95%CI: 1.353~1.743; OR=1.179, 95%CI: 1.111~1.250; P<0.05) . The risk of hypertension in high-frequency hearing loss patients in <5years, 5-9years, 10-14 years, 15-19 years and ≥20 years working age groups were higher than that in non high-frequency hearing loss groups (OR=1.926, 95%CI=1.007-1.121; OR=1.635, 95%CI=1.478-1.810; OR=1.312, 95%CI=1.167-1.474; OR=1.445, 95%CI=1.238-1.686; OR=1.235, 95%CI=1.043-1.463; P<0.05) . Conclusion: There is a certain relationship between high-frequency hearing loss caused by occupational noise and the risk of hypertension, and the risk of hypertension is different among high-frequency hearing loss patients of different ages and working years.

Submarine medicine: An overview of the unique challenges, medical concerns, and gaps.

Submariners face many challenges. For example, they "live where they work" and can be called to duty anytime. They have limited access to open space, natural settings, fresh air, fresh food, sunlight, privacy, exercise, and outside communication. They support a wider range of missions than occur aboard most other Navy vessels. At sea or on shore, submariners work long hours under conditions with little margin for error. They may traverse remote or disputed areas of the ocean far from rescue assets, and must remain vigilant for potential encounters with hostile forces, onboard fires, anomalies in the breathing atmosphere, leaks, undersea collisions, or radiation exposures. If any of these factors cause casualties, the Independent Duty Corpsman (with intermittent advice from shore-based medical personnel), must be ready to provide aid as long as necessary. The challenges of submarine service led to the growth of the unique field of submarine medicine, which has maintained an excellent record of health and safety. This review introduces the field of submarine medicine as practiced in the U.S. Navy, describing its major concerns, giving an overview of the operation of a submarine medical department, and identifying several medical gaps that researchers are working to fill. Submarine medicine already has a stellar record in terms of radiation and atmospheric safety and has made strides in fatigue management. Ongoing work will deliver improved psychological screening and support tools. This report summarizes developments in these and other areas of submarine medicine.

Fluorine detection in the lung tissue of a worker with interstitial pulmonary fibrosis and long-term occupational exposure to polytetrafluoroethylene and perfluorooctanoic acid.

Exposure to polytetrafluoroethylene (PTFE), a compound used in nonstick cookware coating and a variety of other applications, is known to cause acute lung injury and granulomatous pneumonitis. It is uncertain whether PTFE and compounds used in its manufacture, such as perfluorooctanoic acid (PFOA), cause chronic lung disease. Here we report a case of interstitial pulmonary fibrosis in a 71-year-old man who died following a brief illness clinically suspected to be acute respiratory distress syndrome. He had a 25-year history of occupational exposure to PTFE and PFOA. At postmortem examination, the lungs demonstrated diffuse alveolar damage (DAD) superimposed on interstitial pulmonary fibrosis. The interstitial fibrosis lacked fibroblast foci and exhibited basilar and subpleural accentuation with focal microscopic honeycombing. Within the fibrotic lung parenchyma were scattered giant cells containing birefringent translucent particles. Scanning electron microscopy and energy-dispersive x-ray spectroscopy (SEM-EDS) were performed. A majority of the birefringent particles demonstrated a prominent peak for fluorine by EDS analysis. This is the first report to document the presence of fluorine, an elemental constituent of PTFE and PFOA, in fibrotic lung tissue. Careful evaluation of other individuals with long-term exposure to PTFE and/or PFOA appears warranted to better elucidate the spectrum of pulmonary disease associated with these compounds.