Recognizing occupational illnesses and injuries.

Given the burden of occupational illnesses and injuries in the United States, family physicians should understand the role workplace exposures may play in patients' chief concerns. Incorporating employment screening questions into patients' intake questionnaires is an efficient means of identifying potential occupational causes of symptoms. Recommended questions include what kind of job patients have; whether their symptoms are worse at work; whether they are or have been exposed to dust, fumes, chemicals, radiation, or loud noise; and whether they think their health problems may be related to their work. These questions are especially important when the diagnosis or etiology is in doubt. Depending on patients' responses to the screening questions, a more detailed occupational history may be appropriate. It can be useful to ask about routine tasks performed during a typical work shift, as well as anything out of the ordinary (e.g., a change in routine, an injury or accident). The occupational history should include information about alcohol and tobacco use, second or part-time jobs, military service, hobbies, and home environment. Patients with suspected occupational illnesses or injuries may benefit from referral to an occupational medicine specialist for a more detailed assessment and follow-up.

Validation and modification of streptococcal pharyngitis clinical prediction rules.

OBJECTIVE: To validate a simplified version of the Walsh clinical prediction rules (CPRs) for the presence of streptococcal pharyngitis in an inner-city, ethnically diverse population. PATIENTS AND METHODS: This prospective study conducted in New York City, NY, from January 1,1997, to May 31,1997, consisted of 171 consecutive adult walk-in patients who presented with symptoms of upper respiratory tract infection and/or sore throat. The patients were assessed by using 5 clinical factors: cough, exposure to known streptococcal contact, temperature, tonsillar-pharyngeal exudates, and cervical lymphadenopathy. Throat cultures for group A beta-hemolytic streptococcus were obtained from all patients. Clinicians assessing the patients were unaware of throat culture results, and those processing the throat cultures were blinded to the clinical predictors. RESULTS: The prevalence of streptococcal pharyngitis was 24% (95% confidence interval, 18%-30%). The simplified version of the Walsh CPR for streptococcal pharyngitis predicted accurately the probability of a positive culture in our diverse population (area under the receiver operating characteristic curve, 0.71). The simplified CPR also showed clinically useful likelihood ratios and posterior probabilities. CONCLUSION: A simplified version of the Walsh CPR is accurate for diagnosing streptococcal pharyngitis in an inner-city population. This finding should provide clinicians more confidence in applying the CPR in similar clinical settings.

Work outcomes after benefits counseling among veterans applying for service connection for a psychiatric condition.

OBJECTIVE: This study's objective was to determine the efficacy of benefits counseling in a clinical trial. There has been concern that disability payments for psychiatric disorders reduce incentives for employment and rehabilitation. Benefits counseling, with education about opportunities to work and the financial implications of work on receipt of disability benefits, may counter these disincentives. METHODS: This single-blind, six-month randomized clinical trial enrolled 84 veterans who had applied for service-connected compensation for a psychiatric condition. Veterans were randomly assigned to either four sessions of benefits counseling or of a control condition involving orientation to the U.S Department of Veterans Affairs health care system and services. Days of paid work and work-related activities were assessed at follow-up visits by using a timeline follow-back calendar. RESULTS: Veterans assigned to benefits counseling worked for pay for significantly more days than did veterans in the control group (effect size=.69, p<.05), reflecting an average of three more days of paid employment during the 28 days preceding the six-month follow-up. Benefits counseling was associated with increased use of mental health services, but this correlation did not mediate the effect of benefits counseling on working. CONCLUSIONS: Barriers to employment associated with disability payments are remediable with basic counseling. More research is needed to understand the active ingredient of this counseling and to strengthen the intervention.

Separating deployment-related traumatic brain injury and posttraumatic stress disorder in veterans: preliminary findings from the Veterans Affairs traumatic brain injury screening program.

OBJECTIVE: Traumatic brain injury in returning Iraq and Afghanistan combat veterans has been the subject of numerous articles by the popular press and congressional inquires. Recent research has questioned the accuracy of the traumatic brain injury diagnosis in veterans with depression and/or posttraumatic stress disorder and the validity of the Veterans Affairs traumatic brain injury screening tool to identify traumatic brain injury in returning combat veterans. DESIGN: Medical records of all combat veterans in the Veterans Affairs Connecticut Healthcare System who both screened positive for traumatic brain injury and received clinical evaluation for traumatic brain injury during the first year of the Veterans Affairs traumatic brain injury screening program were reviewed to explore the relationship between posttraumatic stress disorder and self-reported symptoms attributed to deployment-related traumatic brain injury. RESULTS: Ninety-four combat veterans identified from positive traumatic brain injury screens were seen in the Veterans Affairs Connecticut Healthcare System from April 1, 2007, to March 30, 2008. Eighty-five percent of the veterans with positive screens met the American Congress of Rehabilitation Medicine definition of probable traumatic brain injury. Symptom reporting was similar for veterans with and without a history of traumatic brain injury. Veterans with both posttraumatic stress disorder and traumatic brain injury were more likely to report falling as a mechanism of injury and indicated that they had suffered a head injury during deployment (P