The HEAT-SHIELD project - Perspectives from an inter-sectoral approach to occupational heat stress.

OBJECTIVES: To provide perspectives from the HEAT-SHIELD project (www.heat-shield.eu): a multi-national, inter-sectoral, and cross-disciplinary initiative, incorporating twenty European research institutions, as well as occupational health and industrial partners, on solutions to combat negative health and productivity effects caused by working on a warmer world. METHODS: In this invited review, we focus on the theoretical and methodological advancements developed to combat occupational heat stress during the last five years of operation. RESULTS: We outline how we created climate forecast models to incorporate humidity, wind and solar radiation to the traditional temperature-based climate projections, providing the basis for timely, policy-relevant, industry-specific and individualized information. Further, we summarise the industry-specific guidelines we developed regarding technical and biophysical cooling solutions considering effectiveness, cost, sustainability, and the practical implementation potential in outdoor and indoor settings, in addition to field-testing of selected solutions with time-motion analyses and biophysical evaluations. All recommendations were adjusted following feedback from workshops with employers, employees, safety officers, and adjacent stakeholders such as local or national health policy makers. The cross-scientific approach was also used for providing policy-relevant information based on socioeconomic analyses and identification of vulnerable regions considered to be more relevant for political actions than average continental recommendations and interventions. DISCUSSION: From the HEAT-SHIELD experiences developed within European settings, we discuss how this inter-sectoral approach may be adopted or translated into actionable knowledge across continents where workers and societies are affected by escalating environmental temperatures.

[Risk assessment and its appropriateness supporting the physician in the certification of a suspected occupational disease.] / La valutazione dei rischi e la sua appropriatezza a supporto del medico nella certificazione di sospetta tecnopatia.

OBJECTIVES: The topic of appropriateness was defined as the new frontier of development of health interventions. RH Brook in an Editorial published in the BMJ in 1994 defines the appropriateness "… an intervention for which the expected benefits are greater (with a sufficient margin) the possible negative consequences … excluding economic considerations". In workplaces the goal of appropriateness should cover not only the actions of health surveillance and health protocols, but also and primarily all stages of the risk assessment process. METHODS: Only through an assessment of occupational risks that aims to identify, evaluate and measure the real professional risk factors in specific working environments, it is possible to meet the requirements of effectiveness, efficiency and protection of ethical principles in the identification of priorities (according to values of person, community and society) that represent the size of the appropriateness of an intervention. At the same time, the risk assessment should provide to the occupational pyisician instruments to study with scientific, justifiable and reproducible criteria the possible correlation between damage to the worker's health and the occupational risk factors. RESULTS: In the process of reporting of suspected technopathy, both for prevention purposes (according to art. 139 of Presidential Decree 1165/68, art. 10 of Legislative Decree 38/00 and DM 10 June 2014), both for insurance purposes (according to art. 53 of Presidential Decree 1165/68 and Ministerial Decree 9 April 2008), it should be considered two indispensable judgment elements to study the correlation between the disease and the work: on the one hand the level (measured or estimated) of the occupational risk factors; on the other hand the appropriateness of the risks assessment compared to the best and most current scientific evidence (Evidence Based Medicine - EBM), according to technical standards and specific guidelines. CONCLUSIONS: Our study underlines the importance of appropriateness in the risk assessment process to analyze the correlation between the exposure to specific occupational hazards and the suspected technopathy.

[Challenges to occupational medicine in view of the problem of work-related diseases and the aging of workforce. Directions for further development and intentional changes in preventive care of employees in Poland]. / Wyzwania medycyny pracy wobec problemu chorób zwiazanych z praca oraz starzenia sie populacji osób pracujacych. Dalszy kierunek rozwoju i celowe zmiany w opiece profilaktycznej nad pracujacymi w Polsce.

The system of occupational health care in Poland, based on occupational medicine service, takes care of almost 12.5 million employees subjected to over 4.5 million obligatory periodic medical check ups. This form of providing prophylactic care comes down to examinations dictated by legal regulations, whose scope is not oriented towards a comprehensive workers' health assessment, but to the examination of the systems and organs critical to work-related dangers. Simultaneously, epidemiological data indicate a large number of chronic diseases, which may influence the professional activity, like hypertension or diabetes and a high percentage of patients not aware of their illness. Since patients participating in obligatory examinations usually feel healthy and do not use health care services on a daily basis, an occupational medicine physician has a unique opportunity to detect health disorders at an early stage, which can prevent the development of health complications affecting the condition of the patient, limiting their professional activity, but also causing additional costs of the health care system. The authors have proven the need to involve occupational medicine services in the prevention of chronic diseases and the need to introduce additional sources of financing for procedures enabling early detection of diseases the patient may not be aware of or control of the effectiveness of already diagnosed illnesses. They addressed the need to change the current legal form of establishing and announcing the range of examinations and directives for certifying the lack or presence of health contraindications to work to the specified and updated standards prepared by scientific research institutes and occupational medicine societies. Med Pr 2016;67(5):691-700.

Álcool e drogas no trabalho: conhecimento do candidato ao título de especialista em medicina do trabalho em relação ao tema / Alcohol and drug use at work: required knowledge for the title of specialist in occupational medicine

Contexto: O conhecimento teórico do médico do trabalho em relação ao gerenciamento dos casos de uso, abuso e dependência de álcool e drogas no local de trabalho é um fator preocupante, tendo em vista o grande crescimento desta prática no Brasil. Objetivos: O presente artigo visa avaliar o conhecimento dos médicos do trabalho sobre o tema, objetivando ações de melhoria nesta área de atuação. Tais ações podem ser realizadas pelos cursos de formação e por instituições ligadas à área. Métodos: Foi realizada uma questão aberta em relação ao tema na Prova de Título de Especialista em Medicina do Trabalho de 2012, cujos resultados foram estudados e discutidos através de metodologia de correção desenvolvida pelos autores. Resultados: A média de conhecimento sobre o tema ficou em 4,26, em uma escala de 0 a 10. Conclusões: O estudo sugere que o conhecimento pericial sobre o tema é precário, exigindo urgentemente ações das instituições formadoras e demais órgãos em relação a este grande problema que ocorre na prática diária.

Context: Theoretical knowledge of the occupational physician on the management of cases of use, abuse and dependence on alcohol and drugs in the workplace is a concern, given the strong growth of this practice in Brazil. Objectives: This article aims to assess physicians' knowledge on the subject, seeking improvement actions in this field. Such actions can be achieved by training courses and institutions related to the field. Methods: An open question on the topic was included in the Test for Certification in Occupational Medicine, 2012, the results of which have been studied and discussed using a correction methodology developed by the authors. Results: The average knowledge on the subject was 4.26 on a scale from 0-10. Conclusions: The study suggests that the expert knowledge on the subject is precarious, requiring urgent educational actions from institutions and other bodies in relation to this major problem that occurs in daily practice.

[Occupational exposure to biological agents intentionally used in Polish enterprises]. / Zawodowa ekspozycja na czynniki biologiczne stosowane w sposób celowy w Polsce.

BACKGROUND: The paper presents the intentional use of biological agents for industrial, diagnostic and research purposes in Polish enterprises. MATERIAL AND METHODS: The National Register of Biological Agents (Krajowy Rejestr Czynników Biologicznych - KRCB) is an online database that collects the data on the intentional use of biological agents at work in Poland. RESULTS: As of December 2013 there were 533 notifications in KRCB, mainly for diagnostic (73%), research (20%) and industrial purposes (7%). Mostly there were hospital diagnostic laboratories (37%), and other laboratories (35%), as well as higher education and research institutions (11%). In total, 4015 workers (91.7% of women, 8.3% of men) were exposed tobiological agents. Agents classified in risk group 2 were used in 518 enterprises, and in risk group 3 in 107 enterprises. Of those agents the following bacteria were the most frequently used: Escherichia coli except for non-pathogenic strains (455 enterprises and 3314 exposed workers); Staphylococcus aureus (445 and 3270); and Pseudomonas aeruginosa (406 and 2969, respectively). In 66 enterprises there were used biological agents recognized by the International Agency for Research on Cancer (IARC) as carcinogens. They are viruses: Epstein-Barr (7 enterprises, 181 exposed workers); hepatitis B (16 and 257); hepatitis C virus (15 and 243); human immunodefi- ciency virus (8 and 107); human papillomaviruses (2 and 4); parasites: Clonorchis viverrini (1 and 2 ); Clonorchos sinensis (1 and 2); Schistosoma haematobium (1 and 2) and bacteria Helicobacter pylori; (15 and 230, respectively). CONCLUSIONS: The National Register of Biological Agents at Work permits to evaluate the situation of occupational exposure to biological agents used intentionally in enterprises in Poland.

Commentary on the contributions and future role of occupational exposure science in a vision and strategy for the discipline of exposure science.

Exposure science is a holistic concept without prejudice to exposure source. Traditionally, measurements aimed at mitigating environmental exposures have not included exposures in the workplace, instead considering such exposures to be an internal affair between workers and their employers. Similarly, occupational (or industrial) hygiene has not typically accounted for environmental contributions to poor health at work. Many persons spend a significant amount of their lifetime in the workplace, where they maybe exposed to more numerous chemicals at higher levels than elsewhere in their environment. In addition, workplace chemical exposures and other exogenous stressors may increase epigenetic and germline modifications that are passed on to future generations. We provide a brief history of the development of exposure science from its roots in the assessment of workplace exposures, including an appendix where we detail current resources for education and training in exposure science offered through occupational hygiene organizations. We describe existing successful collaborations between occupational and environmental practitioners in the field of exposure science, which may serve as a model for future interactions. Finally, we provide an integrated vision for the field of exposure science, emphasizing interagency collaboration, the need for complete exposure information in epidemiological studies, and the importance of integrating occupational, environmental, and residential assessments. Our goal is to encourage communication and spur additional collaboration between the fields of occupational and environmental exposure assessment. Providing a more comprehensive approach to exposure science is critical to the study of the "exposome", which conceptualizes the totality of exposures throughout a person's life, not only chemical, but also from diet, stress, drugs, infection, and so on, and the individual response.

[Rehabilitation in the German statutory accident insurance. Guide to the new outpatient and inpatient structures]. / Rehabilitation in der Deutschen Gesetzlichen Unfallversicherung. Leitfaden durch die neuen ambulanten und stationären Strukturen.

BACKGROUND: The German statutory accident insurance (DGUV) has the statutory mandate to eliminate or to prevent an aggravation of the consequences of accidents by all appropriate means and is based on the principle of rehabilitation before pension. For this, special methods have been developed in recent decades, such as employer's mutual insurance inpatient further treatment (BGSW, Berufsgenossenschaftliche Stationäre Weiterbehandlung) and extended outpatient physiotherapy (EAP, Erweiterte Ambulante Physiotherapie). In 2012 the workplace-related musculoskeletal rehabilitation (ABMR, Arbeitsplatz-bezogene muskuloskelettale Rehabilitation) was added to these complex treatments. SPECIAL REHABILITATION MEASURES: For complex injuries and delayed healing these methods approach their limits. The accident clinics of the Association of Clinics in Statutory Accident Insurance (KUV, Klinikverbund der gesetzlichen Unfallversicherung) provide a number of specialized rehabilitation measures in order to ensure an optimal seamless rehabilitation of the severely injured. In addition to complex inpatient rehabilitation (KSR, Komplexe Stationäre Rehabilitation) integrated special rehabilitation procedures, such as neurorehabilitation for severely traumatic brain injured patients and rehabilitation after spinal cord injury and other special rehabilitation methods, such as occupation-oriented rehabilitation (TOR, Tätigkeitsorientierte Rehabilitation) and pain rehabilitation, ensure that the German Society for Trauma Surgery (DGU) phase model of trauma rehabilitation is implemented. This provides an early start in the context of acute treatment as so-called early rehabilitation. After a specialized post-acute rehabilitation, additional therapeutic options are often required. CONCLUSION: An appropriate treatment of severely injured patients is important, for example through rehabilitation managers, which must not end with discharge from the rehabilitation hospital. The aim of all efforts is the reintegration into the working and social environment in addition to the best possible quality of life.

[Need for occupational and environmental allergology in occupational health - the 45th Japanese society of Occupational and Environmental Allergy Annual Meeting 2014 in Fukuoka].

The 45th Japanese Society of Occupational and Environmental Allergy (OEA) Annual Meeting 2014 was held in Fukuoka city in conjunction with a technical course for occupational health physicians to learn occupational and environmental diseases more deeply. Allergic reaction due to low concentrations of chemical and biological materials is important in toxicological diseases due to highly concentrated chemical materials in the field of occupational and environmental medicine. In this paper we describe the activities of the OEA, which was established in 1970 and has completely cured patients with severe occupational asthma, such as the regional Konjac asthma in Gunma prefecture and Sea Squirt asthma in Hiroshima prefecture. Regard for the occupational environment will prevent the onset and/or exacerbation of allergic occupational disease in individual employees with allergy. Occupational cancer of the bile duct and asbestosis are also current, serious issues that should be resolved as soon as possible. It is desirable for the occupational health physician to have a large stock of knowledge about toxicological and allergic diseases in various occupational settings to maintain the health and safety of workers.

Occupational medicine--then and now: where we could go from here.

Occupational medicine has a long-standing history in the region of the former Yugoslavia with seminal contributions to the theory and practice of this discipline. This tradition should be expanded to incorporate psychosocial stressors. We review the sociological work stress models and empirical evidence gleaned thereby, and then the occupational stressor index, an additive burden model developed from a cognitive ergonomics perspective. In numerous studies, the occupational stressor index is significantly associated with risk behaviors: smoking, obesity and sedentariness and clinical outcomes: hypertension, ischemic heart disease, dyslipidemia and type 2 diabetes. The occupational stressor index characterizes the work conditions of physicians including surgeons and anesthesiologists; professional drivers and other groups at elevated risk for stress-related disorders. Much of these empirical data are from this region. Work-stress related health disorders are a major public health problem, with enormous human and economic costs. A more proactive role for physicians is needed vis-à-vis our working environment and that of patients. We physicians face a heavy job stressor burden strongly implicated with adverse health outcomes. The challenge is to identify effective strategies to lower the risk of work-stressor related illness. The critical gap is the lack of evidence-based guidelines. Intervention studies are needed in which job stressors are ameliorated as a therapeutic/preventive modality; the logical starting point is within our own profession. We also suggest how the relevant clinical competence could be enhanced. Alongside clinical enhancement should be the full restoration of physician empowerment to implement work-related recommendations. A participatory action research perspective by physicians for physicians and for our patients is needed.

[Rheumatic diseases and work ability]. / Malattie reumatiche e capacità lavorativa.

Musculoskeletal diseases are tile most frequent cause of pain in the working population. Rheumatic diseases are chronic illnesses, cause of functional impairnment, relevant working disability and absence from work; however, affected patients maintain a significant functional ability. In this context, the "Fit for work" project, operating in Italy since 2012, promotes the management of chronic musculoskeletal conditions through the realization, also in our country, of a rheumatic medical assistance network in behalf of workers affected by rheumatic diseases and other musculoskeletal disabiliting conditions.

[Overdiagnosis and defensive medicine in occupational medicine]. / Overdiagnosis e medicina difensiva in Medicina del Lavoro.

In clinical medicine since some years overdiagnosis is giving rise to growing attention and concern. Overdiagnosis is the diagnosis of a "disease" that will never cause symptoms or death during a patient's lifetime. It is a side effect of testing for early forms of disease which may turn people into patients unnecessarily and may lead to treatments that do no good and perhaps do harm. Overdiagnosis occurs when a disease is diagnosed correctly, but the diagnosis is irrelevant. A correct diagnosis may be irrelevant because treatment for the disease is not available, not needed, or not wanted. Four drivers engender overdiagnosis: 1) screening in non symptomatic subjects; 2) raised sensitivity of diagnostic tests; 3) incidental overdiagnosis; 4) broadening of diagnostic criteria for diseases. "Defensive medicine" can play a role. It begs the question of whether even in the context of Occupational Medicine overdiagnosis is possible. In relation to the double diagnostic evaluation peculiar to Occupational Medicine, the clinical and the causal, a dual phenomenon is possible: that of overdiagnosis properly said and what we could define the overattribution, in relation to the assessment of a causal relationship with work. Examples of occupational "diseases" that can represent cases of overdiagnosis, with the possible consequences of overtreatment, consisting of unnecessary and socially harmful limitations to fitness for work, are taken into consideration: pleural plaques, alterations of the intervertebral discs, "small airways disease", sub-clinical hearing impairment. In Italy the National Insurance for occupational diseases (INAIL) regularly recognizes less than 50% of the notified diseases; this might suggest overdiagnosis and possibly overattribution in reporting. Physicians dealing with the diagnosis of occupational diseases are obviously requested to perform a careful, up-to-date and active investigation. When applying to the diagnosis of occupational diseases, proper logical criteria should be even antecedent to a good diagnostic technique, due to social outcome for the worker.

[Efficacy--appropriateness]. / Efficacia - Appropriatezza.

I discuss the meaning and differences between the Appropriateness and Efficacy in the prevention of occupational risks and damage. It is argued that to be "appropriate" an intervention should be suitable, keeping with the circumstances, while the intervention that achieves the goal is "effective". In practice, the appropriateness is very used in the field of clinical medicine, with reference to the treatment, while in the prevention it is usual to use with greater frequency the term of effectiveness.

Twenty year development of occupational diseases in the Czech Republic: medical and geographical aspects.

The study analysed occupational diseases in the Czech Republic from the viewpoint of occupational medicine and medical geography. It used a dataset consisting of 32,646 cases of occupational diseases reported during the period of 1994-2013. The descriptive part of the study analysed occupational diseases according to their spatial distribution, occurrence in different branches of economic activities, employees' gender, and according to chapters of the List of occupational diseases. The incidence of occupational diseases showed an overall decreasing trend, which can be related to several factors--transformation of the national economy (shift from heavy industry to manufacturing industry and services), an improvement in access to occupational healthcare services, increased responsibility of employers for safe working conditions, but also a concealment of health problems by employees for fear of losing job. An exception to the decreasing trend is the automotive industry, in which the upward trend in occupational diseases occurrence was noted. The analytical part of the study focused on the relation between unemployment and occupational diseases incidence rates in different regions of the Czech Republic. In most regions, a statistically significant inverse association was shown between the rate of unemployment and occupational disease incidence. The situation is described in more detail for the Moravia-Silesia and Ustí nad Labem Regions and the Capital City of Prague, wherein a statistically significant inverse association was shown between the rate of unemployment and occupational disease incidence. The theory of marginal utility can explain the phenomenon. To certain degree of health problems, employees tend to prefer employment stability, especially if the unemployment is on rise in their region. On the other hand, if losing their job, they often try to claim benefits connected with occupational diseases.

[Rare cardiovascular diseases in the context of occupational health care]. / Rzadkie choroby ukladu krazenia w kontekscie opieki profilaktycznej nad pracownikiem.

In Poland like in other European countries a favorable trend towards reducing morbidity and mortality from cardiovascular disease has been observed. Nevertheless they are still one of the most important health problems in the population, responsible for nearly half of all deaths, including premature deaths. They also affect the quality of life in terms of health and socio-economic development, limiting the possibility of taking and/or continuing employment. Nowadays, cardiovascular diseases have become more common among young, professionally active people. Their professional activity, work organization and exposure to a broad range of occupational factors and environmental conditions may significantly influence the development and course of the cardiovascular disease. The aim of the study was to present the relationship between occupation and some rarer diseases and cardiovascular pathologies, as well as those in which this relationship has not as yet been fully evidenced, however, they may play an important role in workers' health care. In this paper tako-tsubo cardiomyopathy, aortic aneurysm, aortic dissection, pericardial tamponade, Brugada syndrome and sudden cardiac death are discussed. In addition, the authors indicate new issues emerging along with the development of modern diagnostic and therapeutic techniques in cardiology, such as the care of patients with implanted pace-maker and the use of automated external defibrillators. These issues are presented in the context of their relationship with the occupation, taking into account the activities possibly to be undertaken under preventive care programs.

Antimicrobial therapy of febrile complications after high-dose chemotherapy and autologous hematopoietic stem cell transplantation--guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO).

More than 18,000 autolgous transplantation were performed in Europe in the year 2009. It as a routine procedure in experienced centres. Even if there is a low mortality rate, infections are a major issue after transplantation, occurring in more than 60 % of the patients. In this review we discuss all aspects of infections after autologous stem transplantation, including epidemiology, diagnostics, therapeutic algorithms, prophylaxis and supportive therapy.

Persistent failure of the COIDA system to compensate occupational disease in South Africa.

Cases of occupational disease, solvent encephalopathy and occupational asthma are used to exemplify failings of the workers' compensation system in South Africa, that include delays in processing claims, non-response to requests for information, and inadequate assessment of disability. These and other systemic deficiencies in administration of the Compensation for Occupational Injuries and Diseases Act of 1993 (COIDA) reduce access by workers with occupational disease to private medical care, and shift costs to workers and to public sector medical care. Another unintended effect is to promote underreporting of occupational disease by employers and medical practitioners. Reforms have been tried or proposed over the years, including decentralisation of medical assessment to specialised units, which showed promise but were closed. Improved annual performance reporting by the Compensation Commissioner on the processing of occupational disease claims would promote greater public accountability. Given the perennial failings of the system, a debate on outsourcing or partial privatisation of COIDA's functions is due.

[The contribution of surveillance systems of occupational diseases and mesothelioma in environmental health studies]. / Il contributo dei sistemi di registrazione delle malattie professionali e dei mesoteliomi negli studi su ambiente e salute.

National surveillance systems of occupational diseases may contribute to evaluate the work-related component of diseases investigated in SENTIERI Project. For a description of SENTIERI, refer to the 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI Project. The National Workers Compensation Authority (INAIL) archives all occupational diseases claims (more than 230 000 in the period 2000-2007) and is in charge of their compensation. The Italian National Mesothelioma Register (ReNaM) and the Sinonasal Cancer Register (ReNaTuNS) record high occupational etiological fraction neoplasms (i.e. mesothelioma and sinonasal cancers). The former has identified more than 10 000 mesothelioma cases until now, and covers almost the whole country; the latter is active only in three Italian regions, Piemonte, Lombardia and Toscana. The monitoring of cancer sites at lower occupational etiological fraction is based on a record-linkage procedure between population-based cancer registries and employment history data, available at the Italian National Institute for Social Security (INPS). Finally, the informative system Mal.Prof collects and classifies all the diseases possibly related to the work environment reported by the Prevention Services of the Local Health Units.