Evaluation of neurological testing for hand-arm vibration syndrome.

BACKGROUND: The neurological component of hand-arm vibration syndrome (HAVS) uses the Stockholm Workshop Scale sensorineural (SWS SN) stages for classification. Proximal compressive neuropathies are common in HAVS and the symptoms are similar to SN HAVS. The SWS may not be a valid staging tool if a patient has comorbid proximal compression neuropathy. AIMS: To evaluate the prevalence of proximal compression neuropathy in patients presenting for HAVS assessment and examine the association between compressive neuropathies and SWS SN. METHODS: A standardized assessment protocol was used to assess 431 patients for HAVS at St. Michael's Hospital, Toronto, Ontario. The prevalence of median and ulnar compressive neuropathies was determined. The association between proximal compression neuropathies and SWS SN stage (0/1 versus 2/3) was evaluated using Chi-square and Fisher's exact tests as well as multivariable logistic regression. RESULTS: Most patients (79%) reported numbness and 20% had reduced sensory perception (SWS SN Stage 2/3). Almost half (45%) had median neuropathy at the wrist and 7% had ulnar neuropathy. There was no association between the SWS SN stage and median or ulnar neuropathy. CONCLUSIONS: Two neurological lesions should be investigated in patients presenting for HAVS assessment: compressive neuropathy and digital neuropathy. The prevalence of compressive neuropathies is high in patients being assessed for HAVS and therefore nerve conduction studies (NCS) should be included in HAVS assessment protocols. Comorbid proximal neuropathy does not affect the SWS SN stage; therefore, NCS and SWS SN seem to be measuring different neurological outcomes in HAVS patients.

Evaluation of an occupational medicine patient consultation note assessment tool.

BACKGROUND: Medical education focuses on assessment, diagnosis and management of various clinical entities. The communication of this information, particularly in the written form, is rarely emphasized. Though there have been assessment tools developed to support medical learner improvement in this regard, none are oriented to occupational medicine (OM) practice. AIMS: This study was aimed to develop and evaluate an assessment tool for consultation letters, by modifying a previously validated assessment tool to suit practice in OM. METHODS: Using an iterative process, OM specialists added to the Consultation Letter Rating Scale (CLRS) of the Royal College of Physicians and Surgeons of Canada (henceforth abbreviated as RC) additional questions relevant to communication in the OM context. The tool was then used by two OM specialists to rate 40 anonymized OM clinical consultation letters. Inter-rater agreement was measured by percent agreement, kappa statistic and intraclass correlation. RESULTS: There was generally good percent agreement (>80% for the majority of the RC and OM questions). Intraclass correlation for the five OM questions total scores was slightly higher than the intraclass correlations for the five RC questions (0.59 versus 0.46, respectively), suggesting that our modifications performed at least as well as the original tool. CONCLUSIONS: This new tool designed specifically for evaluation of patient consultation notes in OM provides a good option for medical educators in a variety of practice areas in providing non-summative, low-stakes assessment and/or feedback to nurture increased competency in written communication skills for postgraduate trainees in OM.

Patient-centred care in an occupational medicine clinic.

BACKGROUND: Patient-centred care (PCC) has been associated with improved patient satisfaction outcomes in a variety of clinical settings. There is a paucity of research addressing the concept of PCC in an occupational medicine context. AIMS: To assess patient perception and compare physician and patient perceptions of patient centredness of the care at a specialty occupational medicine clinic. METHODS: An observational study design using the Patient Perception of Patient Centeredness Questionnaire (PPPC) at an ambulatory tertiary care occupational health clinic. Results were analysed using a standardized coding system. Summary scores were compared to results reported in a primary care setting. Patient and physician scores were compared to detect physician-patient differences in perceived patient centredness of care. RESULTS: Of 47 eligible patients 37 consented to participate and seven were excluded due to incomplete data. Summary scores of patient perceptions of patient centredness were similar but somewhat better than scores reported in a primary care setting. Perceived patient centredness of care was high and there was minimal discordance between patient and physician scores. CONCLUSIONS: This study demonstrated that PCC can be measured in an occupational health setting. In an ambulatory tertiary care occupational health clinic there was a high degree of patient centredness of care which may be explained by a variety of factors. Future research should consider whether similar findings exist in other occupational medicine practice settings.

Functional limitations in workers with hand-arm vibration syndrome (HAVS).

BACKGROUND: Hand-arm vibration syndrome (HAVS) is a chronic occupational disease affecting workers exposed to hand-transmitted vibration. However, limited information exists on task-related disability experienced by workers with HAVS. AIMS: This study was conducted to characterize the impact of HAVS on task-related disability and daily life activities. METHODS: A retrospective chart review was undertaken of difficulty in carrying out activities reported by workers with HAVS who had been assessed in an Occupational Medicine clinic in 2015. Prior to their clinical assessment, the workers had been asked to complete an open-ended questionnaire regarding activities they were having difficulty performing in the domains of personal care, household activities and recreational activities or hobbies. RESULTS: Data from 107 workers diagnosed with HAVS were obtained through the retrospective chart review. The activities most affected included: getting dressed (n = 72), lawn maintenance (n = 61), fishing (including ice fishing) (n = 56), snow removal (n = 36), washing the car (n = 26) and doing the dishes (n = 25). CONCLUSIONS: These findings reported in an open-ended fashion by workers with HAVS provide a better understanding of the impact of HAVS on specific activities of daily living in comparison to highly structured questionnaires lacking any open-ended responses. Understanding the implications of HAVS on activities of daily living will contribute to the provision of patient-centred care, by enabling health care providers to effectively support HAVS patients, based on workers' actual experiences of functional limitations.

Skin-specific training experience of workers assessed for contact dermatitis.

Background: Contact dermatitis is a common and preventable work-related disease. Skin-specific training may be effective for preventing occupational contact dermatitis, but little information is available regarding actual workplace training and its effectiveness. Aims: To describe workplace skin-specific training among workers with suspected contact dermatitis. Methods: Patch test patients being assessed for suspected contact dermatitis at an occupational health clinic in Toronto, Canada, completed a questionnaire on training experiences, workplace characteristics, exposures and skin protection practices. Results: Of 175 patients approached, 122 (71%) workers completed questionnaires. Many (80%) had received general occupational health and safety and hazardous materials training (76%). Fewer (39%) received skin-specific training. Of those with work-related contact dermatitis, 52% did not receive skin-specific training. Skin-specific training was commonly provided by health and safety professionals or supervisors using video, classroom and online techniques. Content included glove use, exposure avoidance and hand washing information. Workers that received skin-specific training found it memorable (87%), useful (85%) and common sense in nature (100%). Conclusions: This study indicates gaps in workplace training on skin disease prevention for workers with contact dermatitis. Workers perceived skin-specific training to be useful. Understanding worker training experiences is important to prevention programme development and reducing work-related skin disease.

Awareness of occupational skin disease in the service sector.

BACKGROUND: Occupational skin disease (OSD) is a common occupational disease. Although primary prevention strategies are known, OSDs remain prevalent in a variety of work environments including the service sector (restaurant/food services, retail/wholesale, tourism/hospitality and vehicle sales and service). AIMS: To obtain information about awareness and prevention of OSD in the service sector. METHODS: Focus groups and a survey were conducted with two groups. The first consisted of staff of the provincial health and safety association for the service sector and the second group comprised representatives from sector employers. Focus groups highlighted key issues to inform the survey that obtained information about perceptions of awareness and prevention of OSD and barriers to awareness and prevention. RESULTS: Both provincial health and safety association staff and sector employer representatives highlighted low awareness and a low level of knowledge of OSD in the sector. Barriers to awareness and prevention included a low reported incidence of OSD, low priority, lack of training materials, lack of time and cost of training, lack of management support and workplace culture. CONCLUSIONS: A starting point for improving prevention of OSD in the service sector is increased awareness. Identification of the barriers to awareness and prevention will help to shape an awareness campaign and prevention strategies. Building on existing experience in Europe will be important.

Comparison of clinic models for patients with work-related asthma.

BACKGROUND: Work-related asthma (WRA) is a prevalent occupational lung disease that is associated with undesirable effects on psychological status, quality of life (QoL), workplace activity and socioeconomic status. Previous studies have also indicated that clinic structure may impact outcomes among patients with asthma. AIMS: To identify the impact of clinic structure on psychological status, QoL, workplace limitations and socioeconomic status of patients with WRA among two different tertiary clinic models. METHODS: We performed a cross-sectional analysis between two tertiary clinics: clinic 1 had a traditional referral base and clinical staffing while clinic 2 entirely comprised Worker's Compensation System referrals and included an occupational hygienist and a return-to-work coordinator. Beck Anxiety and Depression II Inventories (BAI and BDI-II), Marks' Asthma Quality of Life Questionnaire (M-AQLQ) and Work Limitation Questionnaire (WLQ) were used to assess outcomes for patients with WRA. RESULTS: Clinic 2 participants had a better psychological status across the four instruments compared with clinic 1 (for Beck 'Anxiety': P < 0.001 and 'Depression': P < 0.01, 'Mood' domain of M-AQLQ: NS and 'Mental Demands' domain of WLQ: P < 0.01). Clinic 2 had a greater proportion of participants with reduced income. CONCLUSIONS: Our study indicates that clinic structure may play a role in outcomes. Future research should examine this in larger sample sizes.

Workplace screening for hand dermatitis: a pilot study.

BACKGROUND: Health care workers (HCWs) are at increased risk for developing occupational skin disease (OSD) such as dermatitis primarily due to exposure to wet work. Identification of risk factors and workplace screening can help early detection of OSD to avoid the condition becoming chronic. AIMS: To determine risk factors and clinical findings for hand dermatitis using a workplace screening tool. METHODS: Employees at a large teaching hospital in Toronto, Canada, were invited to complete a two-part hand dermatitis screening tool. Part 1 inquired about hand hygiene practices and Part 2 comprised a visual assessment of participants' hands by a health professional and classification as (i) normal, (ii) mild dermatitis or (iii) moderate/severe dermatitis. Risk factors were determined using chi-square and Cochran-Armitage analysis on a dichotomous variable, where Yes represented either a mild or moderate/severe disease classification. RESULTS: There were 183 participants out of 643 eligible employees; response rate 28%. Mild or moderate/severe dermatitis was present in 72% of participants. These employees were more likely to work directly with patients, have worked longer in a health care setting, wash hands and change gloves more frequently, wear gloves for more hours per day, have a history of eczema or dermatitis and report a current rash on the hands or rash in the past 12 months. CONCLUSIONS: There was a high percentage of HCWs with dermatitis and risk factors for dermatitis. These findings argue for increased attention to prevention and early identification of hand dermatitis and support further testing of the workplace screening tool.

Health-care barriers for workers with HAVS in Ontario, Canada.

BACKGROUND: Hand-arm vibration syndrome (HAVS) becomes irreversible unless it is identified early and progression prevented. AIMS: To describe the health-care-seeking behaviours of workers with HAVS and barriers to health care. METHODS: We invited all patients assessed for HAVS between 15 January and 27 March 2013 at a hospital-based occupational health clinic (OHC) in Ontario, Canada, to complete a questionnaire asking why and from whom they sought health care, reasons they waited to seek care and barriers they encountered in accessing care. We analysed the data using descriptive statistics. RESULTS: Forty-one (82%) patients agreed to participate. Thirty-seven had confirmed HAVS; 30 (84%) were Stockholm workshop vascular stage 2 or greater and 35 (97%) were sensorineural stage 1 or greater. The commonest employment sectors were construction [21 (57%)] and mining [6 (17%)]. The main reasons for seeking treatment were pain [11 (30%)], finger numbness [8 (22%)] and functional limitations [5 (14%)]. The commonest initial point of health care was the family physician [23 (66%)]. The mean wait between symptom onset and seeking treatment was 3.4 years, while the mean time between onset and OHC assessment was 9 years. Reasons for delay in seeking care were ignorance of the seriousness and irreversibility of HAVS and ability to continue to work. Family physicians suspected HAVS in 17% of cases and recommended job modification in 34%. CONCLUSIONS: Workers with HAVS in Ontario delay seeking health care. Primary care physicians often fail to recognize HAVS. Barriers to health care include ignorance of HAVS and of the importance of prevention.

Occupational contact allergens: are they also associated with occupational asthma?

BACKGROUND: Workplace exposures that can potentially cause both allergic occupational contact dermatitis (AOCD) and occupational asthma (OA) are not clearly identified. METHODS: Occupational contact allergens (OCAs) were identified using North American Contact Dermatitis Group (NACDG) data. Reference documents and systematic reviews were used to determine whether each OCA had been reported to potentially cause OA. The presence or absence of a sensitizer notation in occupational hygiene reference documents was also examined. RESULTS: The 10 most common OCAs were: epoxy resin*, thiuram, carba mix, nickel sulfate*, cobalt chloride*, potassium dichromate*, glyceryl thioglycolate, p-phenylenediamine*, formaldehyde* and glutaraldehyde*. Seven (indicated by *) were determined to be possible causes of OA. Information on sensitizing potential from OH reference materials contained conflicting information. CONCLUSIONS: Several common OCAs can also potentially cause OA. Inhalation and dermal exposures to these agents should be controlled and both OA and AOCD should be considered as possible health outcomes. Increased consistency in sensitizer notations is needed.

Workers with occupational contact dermatitis: workplace characteristics and prevention practices.

BACKGROUND: There are many gaps in knowledge related to prevention practices in place for workers who subsequently develop occupational contact dermatitis (OCD). AIMS: To describe the workplace characteristics and the prevention practices in workplaces where workers developed hand dermatitis. METHODS: Consecutive cases of probable OCD were enrolled from a specialist occupational health clinic. At the time of the initial assessment, questionnaires were administered to collect information about clinical presentation, workplace characteristics and prevention practices at work. RESULTS: 100 workers with hand dermatitis were enrolled in the study and 78 were considered to have OCD. Two-thirds of these had had some occupational health and safety or Workplace Hazardous Materials Information System (WHMIS) training in their workplace, however, training related to glove use and skin care was less common. Unionized workers were more likely to have received training. Workers involved in wet work were less likely to report training. CONCLUSIONS: These findings suggest that there are gaps in prevention programs for work-related skin disease. Research is needed on effective strategies that are sustainable in the workplace.

Educational intervention among farmers in a community health care setting.

BACKGROUND: Farmers are at increased risk of developing work-related respiratory diseases including asthma, but little is known about their occupational health and safety (OHS) knowledge and exposure prevention practices. Educational interventions may improve knowledge and practice related to prevention. AIMS: To determine the feasibility of an educational intervention for farmers in a community health centre setting. METHODS: This was a pilot study. Farmers were recruited by the community health centre and completed a questionnaire on symptoms, OHS knowledge and exposure prevention practices. The intervention group received education on work-related asthma and exposure control strategies, and was offered spirometry and respirator fit testing. All subjects were asked to repeat the questionnaire 6 months later. RESULTS: There were 68 study participants of whom 38 formed the intervention group. At baseline, almost 60% of farmers reported having received OHS training and were familiar with material safety data sheets (MSDSs); fewer (approximately 40%) reported knowledge of OHS legislation and availability of MSDSs. Approximately, two-thirds of subjects reported using respiratory protection. The response rate for repeating the questionnaire was 76% in the intervention group and 77% in the controls. Among the intervention subjects, statistically significant increases were observed in reported safety training, familiarity and availability of MSDSs and knowledge of OHS legislation. CONCLUSIONS: Gaps in OHS knowledge were observed. The educational intervention on OHS knowledge and exposure prevention practices in the community health centre setting was feasible. Larger, more-controlled studies should be undertaken as this study suggests a positive effect on OHS knowledge and prevention practices.

Skin and respiratory symptoms among workers with suspected work-related disease.

BACKGROUND: Many workers are exposed to chemicals that can cause both respiratory and skin responses. Although there has been much work on respiratory and skin outcomes individually, there are few published studies examining lung and skin outcomes together. AIMS: To identify predictors of reporting concurrent skin and respiratory symptoms in a clinical population. METHODS: Patients with possible work-related skin or respiratory disease were recruited. An interviewer- administered questionnaire collected data on skin and respiratory symptoms, health history, smoking habits, workplace characteristics and occupational exposures. Predictors of concurrent skin and respiratory symptoms were identified using multiple logistic regression models adjusted for age, sex and atopy. RESULTS: In total, 204 subjects participated; 46% of the subjects were female and the mean age was 45.4 years (SD = 10.5). Most subjects (n = 167, 82%) had possible work-related skin disease, compared with 37 (18%) subjects with possible work-related respiratory disease. Subjects with a history of eczema (OR 3.68, 95% CI 1.7-7.8), those from larger workplaces (OR 2.82, 95% CI 1.8-7.4) and those reporting respirator use at work (OR 2.44, 95% CI 1.2-4.8) had significantly greater odds of reporting both work-related skin and respiratory symptoms. Current smoking was also associated with reporting concurrent skin and respiratory symptoms (OR 2.57, 95% CI 1.2-5.8). CONCLUSIONS: Workers reported symptoms in both systems, and this may be under-recognised both in the workplace and the clinic. The association between history of eczema and concurrent skin and respiratory symptoms suggests a role for impaired barrier function but needs further investigation.

Testing the joint health and safety committee assessment tool in the education sector.

Joint Health and Safety Committee (JHSC) effectiveness has been identified as an area of concern for Ontario's education sector. The JHSC Assessment Tool has been previously tested in hospitals with positive results. This study assessed the feasibility and usability of the JHSC Assessment Tool in the education sector. Members of multi-workplace JHSCs from Ontario school boards used the tool to assess their committees' effectiveness before, during and after a committee meeting with usability testing conducted pre and post meeting. Results suggested that the JHSC Assessment Tool was feasible to use during a regular JHSC meeting, groups were able to come to consensus on the majority of items, and usability scores were high overall. Participant feedback provided insight that informed the development of a version relevant to multi-workplace committees.

Who cares? The impact on caregivers of suspected mining-related lung cancer.

Background: In the present study, we investigated the emotional, physical, financial, occupational, practical, and quality-of-life impacts on caregivers of patients with mining-related lung cancer. Methods: This concurrent, embedded, mixed-methods study used individual in-depth qualitative interviews and the 36-item Short Form Health Survey (version 2: RAND Corporation, Santa Monica, CA, U.S.A.) quality-of-life measure with 8 caregivers of patients with suspected mining-related lung cancer who had worked in Sudbury or Elliot Lake (or both), and sometimes elsewhere. Individuals who assist workers in filing compensation claims were also interviewed in Sudbury and Elliot Lake. Interviews (n = 11) were transcribed and analyzed thematically. Results: Caregiver themes focused on the long time to, and the shock of, diagnosis and dealing with lung cancer; not much of a life for caregivers; strong views about potential cancer causes; concerns about financial impacts; compensation experiences and long time to compensation; and suggestions for additional support. Quality-of-life scores were below the norm for most measures. Individuals who assist workers in preparing claims were passionate about challenges in the compensation journey; the requirement for more and better family support; the need to focus on compensation compared with cost control; the need for better exposure monitoring, controls, resources, and research; and job challenges, barriers, and satisfaction. Conclusions: Caregivers expressed a need for more education about the compensation process and for greater support. Worker representatives required persistence, additional workplace monitoring and controls, additional research, and a focus on compensation compared with cost control. They also emphasized the need for more family support.

Hypersensitivity pneumonitis and airways hyperreactivity induced by occupational exposure to penicillin.

A patient with penicillin-induced hyperreactive airways in association with hypersensitivity pneumonitis is described. Patch tests and intradermal tests to penicillin were positive. Bronchoalveolar lavage demonstrated a relative lymphocytosis and mild neutrophilia. Symptoms and physiologic abnormalities of pulmonary function and gas exchange resolved on cessation of exposure to penicillin.

Asthmatic subjects symptomatically worse at work: prevalence and characterization among a general asthma clinic population.

STUDY OBJECTIVES: To assess the prevalence of a historical occupational component to asthma in an adult asthma clinic and to compare characteristics of asthmatic subjects with and without work-attributed symptoms. DESIGN: A retrospective review of data obtained from a physician-administered questionnaire, answers to which were obtained at the initial patient visit of asthmatic subjects, and which included specific questions regarding the relationship of work to symptoms. Chart review data were used to supplement information on workplace exposures and investigations. SETTING: A university-based secondary- and tertiary-referral asthma clinic. PATIENTS: Seven hundred thirty-one adult asthmatic subjects who were referred for assessment and management of asthma. INTERVENTIONS: Statistical analyses of asthmatic subjects with and without work-attributed symptoms and a determination, from chart review, of the likelihood of causes for symptomatic worsening of asthma at work. MEASUREMENTS AND RESULTS: Sixty percent of the patients (435) had adult onset of asthma, among whom 310 patients (71%) were employed at the time of their visit. Fifty-one patients reported their asthma to be worse at work (ie, 16% of adult-onset working asthmatic subjects). Sixteen of these patients (31%) had likely or possible sensitizer-induced occupational asthma (OA), and 49% likely had aggravation of underlying asthma. The other 20% of patients had possible OA or aggravation of underlying asthma at work. CONCLUSIONS: Adult-onset asthmatic subjects commonly report a worsening of asthma at work, more commonly on the basis of likely aggravation of underlying asthma than on the basis of likely or possible OA.

Scabies in chronic health care institutions.

BACKGROUND: The diagnosis and management of outbreaks of scabies in health care facilities may be difficult. As there is little information available regarding the extent of this problem we conducted a questionnaire study to provide an indication of the occurrence of scabies in chronic health care facilities in the province of Ontario, Canada. It also documented the facilities' approach to the management of the disease. OBSERVATIONS: Two outbreaks of scabies in chronic health care facilities are described. The questionnaire study revealed that 25% of the institutions reported that they had problems with scabies over a 1-year period. A minority had a written policy with respect to dealing with the management of scabies, particularly in the setting of a mass outbreak. CONCLUSIONS: Scabies is a common problem in chronic health care facilities; however, diagnosis and management may be difficult. The development of a specific protocol for the management of such outbreaks by the appropriate public health agencies would be useful.

Characteristics of occupational medicine practitioners and practice in Canada.

To obtain baseline information with respect to occupational medicine practice in Canada, a questionnaire survey of members of the Occupational and Environmental Medical Association of Canada was carried out by mail in 1993. One hundred eighty-six responses were received (56% of the membership). The average age of the respondents was 49.5, 12% were female, and 55% worked full-time in occupational medicine. Practice types included corporate settings (58%), clinics (23%), government agencies (14%), worker's compensation boards (7%) and academic settings (5%). Sixty percent had some formal training in occupational medicine, and 46% had occupational medicine certification by either the Royal College of Physicians and Surgeons of Canada, the Canadian Board of Occupational Medicine, or the American Board of Preventive Medicine. Younger physicians were more likely to be female and have gone directly into occupational medicine. Women were more likely to be working full-time in occupational medicine but worked fewer hours per week. Those physicians with specialty qualifications were older and more likely to be working full-time in occupational medicine and be active in professional activities. The Association intends to continue surveying its members on a triennial basis, identifying trends in the practice profiles and continuing education needs.