Is postal postoperative follow-up in urogynaecology feasible?

Postoperative follow-up after urogynaecological surgery has been little investigated. Traditionally, it is done in hospital but there is wide variation in the assessments and timing. We aimed to determine the viability of postal follow-up in women undergoing urogynaecological surgery. This is a retrospective review of prospectively collected data. All women who underwent prolapse and/or urinary incontinence surgery between January and June 2010 were included. Validated ICIQ questionnaires for prolapse and/or incontinence, as appropriate, were used, before surgery and at 6 months postoperatively. The primary outcome was the response rate to postal follow-up. A total of 70 women had urogynaecology surgery during the study period; 65 (93%) women returned the questionnaires (95% CI 84-97%, p < 0.0001). The postoperative questionnaires scores showed a statistically significant improvement compared with the preoperative scores. This results in only a small proportion of women needing hospital attendance for follow-up (10%). We conclude that postal follow-up is feasible.

Value based interpretation of pulmonary function tests.

Two contrasting errors in spirometric interpretation are the inappropriate conclusion of "normality" (type I) and of "abnormality" (type II). A survey of 67 health professionals showed major interpersonal and intersituational differences in opinion about the optimal relative proportions of type I and type II errors. This suggests the need for caution in the commonly employed practice of interpretation based on a 5 percent false positive rate.

Estimation of the exertion requirements of coal mining work.

The work requirements of coal mining work were estimated by studying a group of 12 underground coal miners. A two level (rest, 300 kg X m/min) test was performed to estimate the linear relationship between each subject's heart rate and oxygen consumption. Then, heart rates were recorded during coal mining work with a Holter type recorder. From these data, the distributions of oxygen consumptions during work were estimated, allowing characterization of the range of exertion throughout the work day. The average median estimated oxygen consumption was 3.3 METS, the average 70th percentile was 4.3 METS, and the average 90th percentile was 6.3 METS. These results should be considered when assessing an individual's occupational fitness.

Work placement and worker fitness. Implications of the Americans with Disabilities Act for pulmonary medicine.

Pulmonary physicians have a significant role in assessing the ability of individuals with respiratory impairments to be placed in jobs or retain current jobs. The Americans with Disabilities Act mandates a high level of rational thought and justification for any recommendation against placement or work retention. This article reviews criteria for determining if an individual with a respiratory impairment or disability can currently and safely perform a job and if there is substantial direct threat of future risk. In addition, methods of modifying the workplace to accommodate individuals with respiratory disabilities are discussed.

Veracity of disability claimants' self-reports of current smoking status. Comparison of carboxyhemoglobin levels from disability claimant and reference population.

Carboxyhemoglobin level (%COHB) obtained during pulmonary function testing was used as a measure of recent tobacco smoking among persons claiming to be nonsmokers and ex-smokers. Asbestos disability applicants and reference routine clinical patients had similar mean %COHB (2.09 +/- 1.34 and 1.99 +/- 0.88, respectively) and proportions with abnormally elevated %COHB (35 and 46 percent, respectively, had %COHB greater than 2 percent). However, comparisons of persons claiming to be ex-smokers and nonsmokers showed that the ex-smokers had higher mean %COHB (p less than 0.001 by analysis of variance) and proportions with elevated %COHB. This study suggests that disability applicants and routine clinical patients do not differ in veracity of self-stated smoking information, but many persons claiming to be ex-smokers are actually not.

Is the MVV:FEV1 ratio useful for assessing spirometry validity?

The ratio between the maximal voluntary ventilation (MVV) and the forced expiratory volume in one second (FEV1) has been proposed as an indicator of the adequacy of a subject's efforts in disability determinations and other spirometry applications. Data from a large population of industrial workers tested in a university pulmonary function laboratory were examined and a smaller clinical population was used to validate the conclusions. The MVV:FEV1 ratio was not affected to a clinically significant degree by age, degree of functional abnormality, or administration of an aerosolized bronchodilator. The ratio was too variable to be of use in determining whether an individual's results are reliable, but the determination of the average ratio for a large group of subjects may be useful in evaluating the overall performance of a spirometry laboratory.

Physiologic categorization of asbestos-exposed workers.

Categorization of the pattern of physiologic abnormalities in patients with asbestos-associated disease may be important for clinical, compensation, and epidemiologic reasons. A population of 658 asbestos-exposed workers was divided into six groups (restrictive, mixed restrictive-obstructive, obstructive, abnormal diffusing capacity, small airway disease, and normal) based upon pulmonary function test results. Use of two commonly employed prediction equations for diffusing capacity produced divergent results. Adjustment of the forced vital capacity for airtrapping based upon measurement of residual volume or of total lung capacity can improve the accuracy of categorization, particularly in smokers. Hence, the process of interpretation of pulmonary function testing should be chosen carefully.

Artificial intelligence-assisted occupational lung disease diagnosis.

An artificial intelligence expert-based system for facilitating the clinical recognition of occupational and environmental factors in lung disease has been developed in a pilot fashion. It utilizes a knowledge representation scheme to capture relevant clinical knowledge into structures about specific objects (jobs, diseases, etc) and pairwise relations between objects. Quantifiers describe both the closeness of association and risk, as well as the degree of belief in the validity of a fact. An independent inference engine utilizes the knowledge, combining likelihoods and uncertainties to achieve estimates of likelihood factors for specific paths from work to illness. The system creates a series of "paths," linking work activities to disease outcomes. One path links a single period of work to a single possible disease outcome. In a preliminary trial, the number of "paths" from job to possible disease averaged 18 per subject in a general population and averaged 25 per subject in an asthmatic population. Artificial intelligence methods hold promise in the future to facilitate diagnosis in pulmonary and occupational medicine.

Role of chest physicians in detection and treatment of occupational and environmental respiratory disease. A practice survey.

A survey of American College of Chest Physicians (ACCP) members was conducted to determine their degree of involvement in the diagnosis and prevention of occupational and environmental respiratory disease (OERD). Although the response rate was relatively low, the results are likely to be representative. Calculations based on the data estimate that in the prior year, chest physicians on the average saw 15 patients with OERD caused by work, 13 worsened by work, and 28 affected by the home environment. Asthma appears to be a more common occupational or environmental concern than pulmonary fibrosis. Chest physicians clearly perceived a need for more education in OERD. The survey also demonstrated that although many chest physicians perform routine industrial surveillance testing, it is often done without using standardized methods. Furthermore, chest physicians are actively involved with medical/legal aspects of OERD. Overall, the survey documents the role of chest physicians in the area of OERD and emphasizes significant educational needs.

Respiratory disability. The uncoupling of oxygen consumption and disability.

In the past it was believed that respiratory disability could be objectively assessed by comparing the measured O2 consumption requirement of the job with the subjects' measured or estimated maximal oxygen consumption. More recently, it has become clear that this "classic" paradigm does not completely apply to all situations. This article reviews recent aspects of respiratory disability assessment.

Prevention and control of occupational lung disease.

Prevention is the ultimate purpose of efforts to identify and understand occupational lung diseases. A major challenge for this decade will be the effective implementation of preventive programs which allow utilization of the developing information base on incidence and pathogenesis. Much of the basic methodology for prevention has yet to be developed, and many basic social and philosophic decisions will be forthcoming. It is clear that prevention of occupational lung disease will require a cooperative effort among pulmonary physicians, occupational physicians, epidemiologists, industrial hygienists, basic researchers, toxicologists, government regulators and members of many other disciplines.

Medical causation analysis heuristics.

Medical causation analysis determines whether or not a specific patient's illness is the result of a work site or an environmental exposure. In the past, this has been conducted implicitly with little analysis of the process per se. Our review suggests that there are several distinct heuristics that may be utilized; these include probability-based models, application of group-based data (epidemiology) to individuals, Bayesian analysis, a priori assumptions about which conclusions are better, and others. Some methods consider only work causes, whereas others explicitly consider alternative explanations. There are considerable differences among the methods in process, outcome, and fundamental assumptions. Formal assessment of the medical causation analysis process can provide insight and may ultimately lead to its standardization and improvement.

Time and knowledge barriers to recognizing occupational disease.

Traditionally, inadequate training has been considered the major barrier to recognition of occupational disease. A survey of 136 practitioners was conducted to determine which barriers were actually considered most relevant. The sample included three subgroups: primary care, occupational medicine-oriented, and Mexican. Four aggregate indices were derived: Knowledge, Time, Unpleasant aspects, and Importance. Inadequate Time was as important as inadequate Knowledge, whereas perceived lack of Importance and Unpleasant aspects were less relevant. Patterns among the subgroups were generally comparable. This study implies that training more occupational medicine specialists in increasing recognition is not sufficient unless specific strategies to overcome time constraints are also implemented. For example, emphasizing a "complete occupational history" may be counterproductive. Limiting histories to selected patients; use of focused, brief histories; and, perhaps, computer-based methods are needed.

Decision model for optimizing respirator protection.

Respirators are widely used for protection against inhaled toxins. The emphasis of research and implementation effort has evolved through several stages: the respirator device itself, use situation, respirator program factors under employer control, individual worker factors not under employer control, and occupational health systems. For this study, a computer-simulation decision assistance model was developed to assess the impact of various factors on the number of workers receiving adequate protection. Factors include the respirator protection factor, identification of sites needing respirator protection, selection of proper device, availability when needed, frequency of ever use, regularity of use among users, and variability in personal susceptibility or other factors. This analysis demonstrates that for both moderate-risk and high-risk (i.e., IDLH, immediately dangerous to life and health) exposures under current circumstances, the actual protection afforded depends upon the optimization of program factors and detection of atypical outlier persons and worksites. Therefore, programs and research must focus on these areas. Occupational medicine specialists should help optimize these areas and, in addition, use each case of respiratory protection failure as an index case to improve the overall programs.

An "atomic" approach to dis/ability assessment.

Disability assessment is a complex process that requires consideration of both work demands and clinical conditions. It is commonly practiced in two very distinct fashions. First, poorly specified processes are used to reach decisions about highly specific situations; second, broad generalizations are often applied, which may be poorly applicable to specific situations. A new approach allows the integration of these two methods. The "atomic" approach has two phases: "disaggregation" into the smallest possible meaningful knowledge units (atoms) and then "reintegration" (reassembly). Individual information units may be applicable to a wide variety of different situations, providing an efficient system. The atomic approach includes two tracks that merge to produce the dis/ability assessment: Clinical track (diagnosis-->confirmation test; diagnosis-->impact assessment test-->test result-->physiologic/anatomic limitation; and the job demand track (job-->task-->sub task-->functional work demand index-->empiric data). The approach describe offers advantages of rationality, empiric and face validity, and efficiency. The logic is fully explicable, and most information units (atoms) can be used in many ways to cover new situations. It is applicable to both individual case situations and to large-scale system development.

Environmental health response clinics. A survey of program options.

Environmental Health Response Clinics are established in response to concerns about community exposures to hazardous situations (chemical, biological, radiological). They are developed in response to a demand for "clinical services" and operate outside the usual health care financing and delivery mechanisms. Prompted by their experience in California, the authors formed a focus group to identify possible goals and services. A mail survey of occupational-environmental health professionals was then conducted to evaluate the feasibility and priority of representative goals. The analysis suggests that services should focus on the specific hazard of concern and that communication and education are essential components. The tendency to "do a general physical examination" should be eschewed. Ratings for priority and feasibility were disparate for several possible goals. In some instances, a "hands-on examination" may not be the best use of resources. Environmental health professionals may serve by direct clinical service or by advising community-based practitioners. Providing routine clinical services alone cannot meet the expectations for an environmental health response clinic.

Frequency of occupational health concerns in general clinics.

Studies have suggested that occupational disease and injury are under-recognized by clinicians. To estimate the frequency of occupational factors in disease and injury, 108 patients in a general (not occupational) health care facility were interviewed about the frequency and types of workplace-health interactions. Thirty-nine percent reported possible causation by work, and 66% reported a possible increase in symptoms by work, even if not caused by work. Twenty-seven percent reported changing jobs and/or tasks because of work-health interactions. The majority of men and women reported that worksite changes could improve their functional ability at work. This study therefore indicates that (1) occupational health concerns are common in primary care clinics, even if not addressed by clinicians; (2) the definition of occupational health concerns should be broadened to include disease caused by work, disease symptoms worsened by work, and the need for occupational accommodation even if the disease itself is not caused by work; and (3) inquiring about patient concerns about workplace-health interactions can provide clinicians with significant opportunities for primary, secondary, and tertiary prevention.

Radiographic and spirometric findings in diatomaceous earth workers.

Diatomaceous earth is a noncrystalline form of silica; in processing, calcining leads to formation of cristobalite, a form of crystalline silica. Four hundred ninety-two currently employed diatomaceous earth workers in a large mine and processing facility had chest radiographs performed and interpreted by the International Labour Office (ILO) system. Two hundred sixty-seven subjects underwent spirometry testing. Exposure indices for total dust (largely diatomaceous earth) and cristobalite were reconstructed for each individual based upon personnel records. Analysis demonstrated the following prevalences of radiographic findings: 5% had ILO scores > or = 1/0, and 25% had scores of 0/1 or higher. Regression analyses showed that there was a relationship between both total cristobalite exposure and total dust (largely diatomaceous earth) exposure and the ILO score. Radiographic patterns are not typical of those of classic silicosis. Linear regression analyses for forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio did not demonstrate a relationship between cumulative exposure and lung function. Such analyses were performed using all subjects and stratified by smoking status. There were differences in spirometric data according to radiographic ILO category, but the results were inconsistent and did not permit determining if physiologic changes are associated with radiographic change or if this is due to confounding. Overall, the study suggests that diatomaceous earth pneumoconiosis (radiographically defined) is an entity distinct from silicosis. Recent exposure levels may produce radiographic abnormalities but do not lead to demonstrable physiologic effect. The prevalence of the disorder has diminished markedly in response to modern dust control measures. Ongoing medical surveillance is recommended in workers with potential exposure to significant quantity of material.

Chest radiography in Portland cement workers.

To investigate the prevalence of pneumoconiosis in Portland cement workers, a controlled cross-sectional survey was conducted. Chest radiographs of approximately 2640 Portland cement workers showed prevalence rates of about 1% for rounded and for irregular small opacities and about 2% for pleural abnormalities. After age and smoking adjustment, the overall prevalences were still significantly elevated over controls, but when examined separately by smoking status, the significant increases were confined to smokers. Although statistically significant, the prevalences were only elevated about 1% in cement workers, compared with controls. A statistically significant relationship with exposure was found for pleural abnormalities but not for rounded or irregular small opacities. Thus a weak association exists between pulmonary radiographic abnormalities and employment in US Portland cement plants, and there appears to be a dose-response relationship between exposure and pleural abnormalities.