A Comprehensive Obesity Benefit as a Guide for Employers on the Core Components of Obesity Care: Guidance From the American College of Occupational and Environmental Medicine (ACOEM) Roundtable on Obesity.

OBJECTIVE: The need to confront the obesity epidemic and its impact on employers requires a serious look at how we address the treatment of obesity. This article focuses on the core components of obesity care and the need for employers to offer a comprehensive obesity benefit (COB) as part of employee insurance coverage. METHODS: In May 2022, the American College of Occupational and Environmental Medicine convened a roundtable meeting, which brought together five corporate medical directors and representatives from aerospace/defense and energy industries to learn about the disease of obesity and provide clinical insights regarding health and safety in their respective industries. The goals of the program were to provide awareness of benefits for the treatment of obesity and identify the feasibility for employers of implementing a COB for their employees. Participants learned how a comprehensive approach to covering obesity treatments is necessary, and what benefits should be offered to employees. RESULTS: Participants were invited to review the insurance benefits they currently offer to employees and compare them to the COB. Outcomes were limited by a lack of participation by the employers invited to participate. Participants identified actions that need to be addressed for employers to develop a more comprehensive approach to obesity care. CONCLUSION: Implementing a COB can help employers increase access and utilization of comprehensive obesity care by employees.

Health Promotion Interventions in Occupational Settings: Fact-finding Survey among Italian Occupational Physicians.

BACKGROUND:  Occupational Physicians (OPs) are essential for health promotion (HP) at the workplace, although their HP knowledge and perception are still under-searched. METHODS: Between September and December 2022, the Italian Society of Occupational Medicine (SIML) - HP working group performed a cross-sectional survey on SIML-OPs aimed to address their approach, experience, strategies, and needs concerning HP plans. RESULTS: A total of 336 OPs completed the questionnaire. Regarding HP's OP perception, this was reported as a social investment (34.45%) and shared responsibility for all the company's preventive figures (30.18%). Over half of the enrolled OPs declared to have been involved as HP plans' organizers (57.30%) or collaborators (54.80%) in the previous 5 years. The greatest percentage of organizers were in the younger age groups (40-59 years; 50%). Additionally, following a more limited number of companies, prevalently of medium-high dimensions, and more than 500 workers were positively associated with greater OP participation in HP initiatives. Promoting healthy lifestyles was the main target of the HP plans (88.64%). Interdisciplinary collaboration, OP training on HP procedures and information on the targeted population have been reported as effective issues to support an active engagement of OPs in HP. CONCLUSIONS: A general interest of the Italian OPs with respect to HP was demonstrated, however, information on the potential benefits of HP in workplace aligned with OP perceptions and needs seem necessary to successfully implement HP interventions.

Notified occupational mental disorders: associations with health and income.

BACKGROUND: Studies indicate that workers' compensation claim processes may affect patients' health negatively. However, few studies focus on patients with mental health claims, and the claim process varies between countries. AIMS: The aims of this study were to examine whether being notified to the Danish Labour Market Insurance with an occupational mental health condition was associated with changes in visits to the general practitioner (GP), use of medicine and annual income. METHODS: Study participants were 965 patients with a mental disorder examined at a department of occupational medicine. Of these, 669 patients were notified with an occupational mental disorder, 296 were not. Health-related outcomes, including GP visits and prescriptions of psychotropic drugs, were estimated at baseline during the year of medical examination, while annual income was estimated a year before the examination. The follow-up was the year after the year of examination for all outcomes. Outcomes were collected from the Danish National Bureau of Statistics. Analyses were conducted using Poisson regression and conditional logistic regression. RESULTS: All measured outcomes decreased from baseline to follow-up in both groups. These changes were not significantly different depending on notification status at baseline. CONCLUSIONS: This study suggests that being notified with an occupational mental disorder does not significantly affect health-related outcomes. A significant decrease in annual income over time was seen in both groups, the notified and the unnotified group, highlighting the importance of providing support to all employees with a mental disorder.

Assessment of workplace bullying in Italy by INAIL: forensic and occupational medicine considerations.

Abstract: The Authors, after a broad examination of the operating methods of inail (National Institute for Accident Insurance at Work) for the correct assessment and indentification of workplace bullying, carried out a comparative evaluation on the various diagnostic tests in the forensic psychiatric field for this occupational problem.

Assessment of clinical consultations in an academic occupational medicine clinic.

BACKGROUND: Occupational medicine clinical consultation services are relatively under-recognized and under-utilized in Canada. AIMS: To describe clinical consultations in a university-affiliated general occupational medicine clinic. METHODS: All of the charts of patients seen in referral to our general occupational medicine clinic over a 2-year period were reviewed to extract information to provide a descriptive summary of the nature of these consultations. We evaluated patient demographic factors and work- and exposure-related information, as well as the source of referral and the nature of the presenting clinical problem. RESULTS: The 131 patients had a mean (SD) age of 50.6 (14.0) years, 55% were men and 62% were referred by their family physicians. They presented with a broad spectrum of clinical problems, with neurological problems (29%) and multisystem problems (24%) being the most prevalent. The patients worked in a variety of occupational sectors, with manufacturing and the service sector being the most frequent. Seventy-two per cent of patients came for investigation of an occupational problem and 28% came for an environmental issue. Only 36% of patients were found to have their presenting problem due to an exposure, which highlights the need for in-depth clinical assessment before making a causal attribution. CONCLUSIONS: This study provides information about the nature of clinical problems seen in an academic general occupational medicine referral clinic. The results might assist in increasing awareness and utilization of occupational medicine clinical services, which are beneficial for patient education, diagnosis and management.

[Directions of organizational and economic changes in occupational health services as a response to the COVID-19 pandemic - challenges to the health crises]. / Kierunki organizacyjno-ekonomicznych zmian ochrony zdrowia nad osobami pracujacymi jako odpowiedz na pandemie COVID-19 ­ wyzwania wobec kryzysów zdrowotnych.

The COVID-19 pandemic caused not only short-term organizational and economic changes in the functioning of occupational health services, but also enforced to include them in the formulation of a strategic systemic approach to this link of the health care system. The aim of the article is to identify and describe the organizational and economic changes in occupational health services during the pandemic. On this basis, the directions of further research on the improvement of the activities of health care entities of working people in response to future health crises have been formulated. The review covered legal acts relating to organizational and economic changes, Polish and foreign expert publications, full-text Polish and English-language scientific articles included in the PubMed database, publications beyond the specified period, consistent and useful in explaining the concepts of organization, management and economics. The changes in occupational health services presented in the literature during the pandemic consisted of: introducing additional organizational forms of providing health care to employees including occupational medicine leaders, strengthening supervision over working conditions, interdisciplinary cooperation for managing the health of working people, participation in pro-vaccination campaigns, activities in the field of rehabilitation after COVID-19 and new-quality cooperation with public and private health stakeholders. As the result of the review, problems were formulated for future research, which included ensuring the security of occupational medicine entities in terms of resource availability, adjusting the allocation of resources to new financial needs during and after a pandemic, evaluation of organizational and economic changes introduced during the pandemic and the legitimacy of their maintenance in subsequent periods, the development of economic and organizational instruments for the time of crisis, the scope and principles of cooperation with health care stakeholders and the introduction of medical technologies based on a medical and economic assessment according to Health Technology Assessment. Med Pr. 2022;73(6):471-83.

Occupational Medicine and Total Worker Health®: from preventing health and safety risks in the workplace to promoting health for the total well-being of the worker.

The COVID-19 pandemic has highlighted the importance of Public Health interventions for global social and economic development. Still, the community's well-being depends on each individual's health. In addition to pandemics, health conditions can be altered by chronic degenerative diseases, aging, disabilities, and work. Personal behaviors such as poor nutrition, lack of physical activity, tobacco use, excessive alcohol consumption, and drug use can also affect health and safety at work. In the last twenty years, we have witnessed rapid changes in the nature of work, workplace and workforce. In parallel, there is increasing attention to fatigue, psychosocial risks and the achievement of decent, sustainable and healthy work as societal goals. Consequently, in 2011, NIOSH developed Total Worker Health®, a holistic approach to worker well-being to help improve worker health and safety. More recently, in Italy, the Ministry of Health has provided for the preparation of projects according to the "Total Worker Health (TWH)" approach in the National Prevention Plan for the five years 2020-2025. As indicated by the Ministry, the strategic role of the occupational physician is fundamental, being the only figure of occupational safety and health professionals able to integrate the health and safety of workers with their well-being to reach the Total Worker Health.

The Capability Gap in Occupational Health Information Management.

The lack of an integrated approach to data capture, information management, and analysis limits the contribution of occupational and environmental medicine to protecting 2.3 million uniformed and civilian DoD workers. Despite an abundance of military information systems that include the terms "Safety" and "Occupational Health" in their names, none of these systems provide capabilities needed to aggregate and analyze the results of occupational medicine exams, use medical surveillance to mitigate exposure incidents, provide enterprise-level management of occupational medicine services, or comply with privacy and recordkeeping law and regulation. Instead, they provide a patchwork of data that meets most regulatory compliance requirements but fails to achieve the true objectives of occupational health programs. Bridging these capability gaps will improve the occupational health care of the DoD workforce, improve the quality of occupational medicine services, increase public trust in the DoD management of exposure incidents, and potentially generate hundreds of millions of dollars through cost-avoidance on workers' compensation claims and through identification and elimination of non-value-added medical certification exams. The ongoing Military Health System transformation represents a unique opportunity to bridge these long-recognized but persistent capability gaps.

Confidencialidade em medicina ocupacional: protegendo informações / Confidentiality in occupational medicine: protecting information / Confidencialidad en medicina del trabajo: protección de información

Resumo A confidencialidade é elemento central da relação médico-paciente e está associada à boa qualidade do atendimento. Contudo, pode ser rompida em conformidade com as normas éticas e legais estabelecidas no país. Este estudo objetiva mostrar os principais aspectos da confidencialidade em medicina ocupacional. Para isso, realizou-se revisão narrativa de literatura sobre o tema, utilizando bases de dados de livre acesso e embasando-se nos códigos de ética médica. A atuação do médico do trabalho envolve o trabalhador, outros profissionais não médicos e o empregador, situação capaz de desencadear conflitos, requerendo que o médico conheça suas obrigações e limites ético-legais. A proteção da confidencialidade respeita os direitos humanos, mas dilemas podem surgir, não bastando obedecer aos ditames éticos, mas sendo necessário essencialmente seguir as normas legais. Este estudo busca mostrar os principais aspectos éticos e legais atualizados referentes à saúde ocupacional.

Abstract Confidentiality is a central element of the physician-patient relationship and is associated with good quality of care. However, it may be broken in accordance with the ethical and legal standards established in the country. This study aims to show the main aspects of confidentiality in occupational medicine. For this, a narrative review of the literature on the subject was carried out, using free access databases and based on the codes of medical ethics. The occupational physician's performance involves the worker, other non-medical professionals and the employer, a situation that may trigger conflicts, requiring physicians to know their obligations and ethical-legal limits. The protection of confidentiality respects human rights, but dilemmas may arise, not only to obey ethical precepts, but to follow legal norms. This study seeks to show the main and updated ethical and legal aspects regarding occupational health.

Resumen La confidencialidad es clave en la relación médico-paciente y está asociada a buena calidad de la atención. Sin embargo, está sujeta a una quiebra de conformidad a lo establecido en las normas éticas y legales en el país. Este estudio pretende mostrar los principales aspectos de confidencialidad en la medicina del trabajo. Para ello, se realizó una revisión narrativa de la literatura en las bases de datos de acceso abierto basándose en códigos de ética médica. El actuar del médico del trabajo involucra al trabajador, a profesionales no médicos y al empleador, lo que puede desencadenar conflictos requiriendo que el médico conozca sus obligaciones y límites ético-legales. La protección de la confidencialidad respeta los derechos humanos, pero pueden surgir dilemas y no solo bastará atenerse a los dictámenes éticos, sino seguir fundamentalmente las normas legales. Los resultados mostraron los principales aspectos éticos y legales actualizados relacionados con la salud laboral.

Ethical thinking in occupational and environmental medicine: Commentaries from the Selikoff Fund for Occupational and Environmental Cancer Research.

A tribute to Dr. Irving J. Selikoff MD, the founder of this journal, is indeed welcome now more than two decades after his passing. He was known during his lifetime as the US Father of Environmental Medicine which at the time encompassed occupational medicine and much more as industry also polluted the general environment. The 1970s were a busy time as OSHA and the EPA were newly formed and high exposures to workers were no exception. Dr. Selikoff was a brave pioneer examining workers throughout the country and Canada, publicizing their exposures, and writing and presenting the scientific results. Industry was not always receptive and controlled an astounding amount of narrative, with the creation of the American Journal of Industrial Medicine filling a void of scientific need. We four authors write about the ethics of occupational health, the plight of nuclear energy workers, the climate crisis and opportunity for unions to engage workers, and the global march toward educating medical students on workers' health and safety. All four of us interacted with Dr. Selikoff during his tenure at Mount Sinai, and over the years joined each other in promoting his legacy. Toward that end we have written articles honoring his memory.

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.

Towards a toxic-free environment: perspectives for chemical risk assessment approaches.

Regulatory frameworks to control chemical exposure in general living and occupational environments have changed exposure scenarios towards a widely spread contamination at relatively low doses in developed countries. In such evolving context, some critical aspects should be considered to update risk assessment and management strategies. Risk assessment in low-dose chemical exposure scenarios should take advantage of: toxicological investigations on emerging substances of interest, like those recognised as endocrine disruptors or increasingly employed nanoscale materials; human biological monitoring studies aimed to identify innovative biomarkers for known chemical exposure; "omic" technologies useful to identify hazards of chemicals and their modes of action. For updated risk assessment models, suitable toxicological studies, analyses of dose-responses at low-concentrations, environmental and biological monitoring of exposure, together with exposome studies, and the proper definition of susceptible populations may all provide helpful contributions. These may guide defining preventive measures to control the exposure and develop safe and sustainable chemicals by design. Occupational medicine can offer know-how and instruments to understand and manage such evolution towards a toxic-free environment to protect the safety and health of the workforce and, in turn, that of the general population.

Proposed Mitigation and Adaptation Strategies Related to Climate Change: Guidance for OEM Professionals.

Climate change is an urgent challenge amplified by socioeconomic factors that demands thoughtful public health responses from OEM professionals. This guidance statement from the American College of Occupational and Environmental Medicine focuses on the different strategies that these health professionals can implement to protect workers from health impacts associated with climate change hazards, foster workplace resilience in the face of rapidly changing environments, and take the necessary steps to mitigate the effects of global climate change.

Reconstruction of asbestos exposure in workers suffering from pleural neoplasms and employed in sectors not generally associated with high exposure levels: the importance of an accurate standardized assessment of occupational medicine.

INTRODUCTION: Malignant pleural mesothelioma onset in workers exposed to asbestos is well known with reference to multiple working sectors. In some cases, occurring among workers of sectors characterized by a presumed lower relevance of asbestos exposure, the absence of a well-defined correlation can prevent their emergence and compensation. To improve definition of these cases, this article underlines the importance of a standardized approach to occupational anamnesis. METHODS: Thorough standardized occupational health assessment method application in a case of pleural malignant neoplasm occurred in a hauler, a job generally not associated with high levels of exposure to asbestos fibres. RESULTS: Assessment of malignant pleural mesothelioma diagnosis and dual mode relevant occupational exposure to asbestos during both truck driving and loading and unloading operations of asbestos-containing goods. CONCLUSIONS: Systematic occupational medicine assessment with accurate standardized approach is essential for reconstruction of asbestos exposure, in order to highlight every aspect useful to establish causal link between cases of pleural mesothelioma and possible occupational and non-occupational exposure to the mineral, even in cases where the first-level occupational history does not appear to be suggestive.

Outcomes of an Intervention to Increase Physicians Underrepresented in Medicine in Occupational Medicine Training.

CONTEXT: Diversity in the US physician workforce is important. Physicians Underrepresented in Medicine (UIM) are more likely to serve poor, uninsured, and vulnerable populations. OBJECTIVE: To increase the number of UIM physicians in Occupational Medicine. PROGRAM: An Inclusion and Diversity Committee, consisting of the program director, trainees, and graduates, was created with the goal of recruiting and developing UIM residents and increasing Occupational and Environmental Medicine awareness. Outreach to UIM residents and medical students at local, regional, and national meetings, creation and distribution of descriptive brochures, and supervised 1-day observerships were some of the interventions. RESULTS: Only 4 Underrepresented Minorities physicians out of 65 (6%) graduated during the first decade of the program 1997-2007; this increased to (16/70) 23% during the following decade subsequent to establishing the Inclusion and Diversity Committee. CONCLUSION: A multifaceted strategic approach can help increase UIM physician participation in graduate training programs, helping address health equity.

Adolf Thierry and the first pharmaceutical factory in Southeast Europe.

The paper explores the beginnings of pharmaceutical industry development in Croatia and the establishment of the first pharmaceutical factory in Southeast Europe. Adolf Thierry de Chateauvieux (St. Pölten, 1854 - Pregrada, 1920), a nobleman hailing from France, immigrated to Croatia at the end of the 19 th century. He bought the Angjelu cuvaru ( Guardian Angel ) pharmacy (1892) in the small town of Pregrada and established the first pharmaceutical factory (1894) in this part of Europe. The factory had an equipped laboratory, a production facility, a storage room for raw materials and balsams, a room for packaging and shipping finished products and a commercial office. Production was mainly based on herbal remedies. The most famous were Thierry's Balsam and Thierry's Centifolia Ointment, both registered and patented in London (1900). By virtue of Adolf Thierry's entrepreneurial spirit and skilful product advertisement, his medicinal preparations were distributed across Europe, America, India and Africa, a testament to which is the well-preserved and researched documentation.

Valoración del desempeño ocupacional: factor integrador en la calificación de la pérdida de capacidad laboral y ocupacional / Assessment of occupational performance: An integrating factor of the loss of work and occupational capacity

Resumen Introducción: El desempeño ocupacional (DO) como concepto integrador permite la valoración holística de la persona e identifica el potencial para el retorno a la actividad productiva a través del concepto ocupacional, como insumo para la valoración de la pérdida de la capacidad laboral y ocupacional (PCLO), esto permite una calificación objetiva de los aspectos que constituyen el Manual único para la calificación de la pérdida de la capacidad laboral y ocupacional (MUCPCLO). Métodos: Estudio transversal analítico con aplicación de una escala de evaluación del DO a una muestra de trabajadores seleccionados a conveniencia, con alteraciones en funciones o estructuras corporales, participación o restricción a nivel ocupacional. Se realizaron comparaciones analíticas con el estándar de calificación del MUCPCLO y se identificaron factores diferenciales e integradores. Resultados: La muestra estuvo integrada por seis sujetos, cuatro presentaron un accidente de trabajo y dos, enfermedades laborales. En cuanto a la evaluación del desempeño, se evidenció que el 66 % presentó dependencia leve en actividades específicas; producto de ello, se logró realizar un análisis diferencial con énfasis en la calificación del MUCPCLO. Se reconocen factores específicos en el proceso como la objetividad de la valoración del DO, los múltiples aportes del concepto de DO y las posibilidades de articulación con el manual MUCPCLO. Conclusiones: La valoración previa del DO y el concepto integral del terapeuta ocupacional se constituyen como un eje fundamental que aporta al proceso de la valoración PCLO.

Abstract Introduction: Occupational performance (OP) as an integrating concept allows the holistic assessment of the person and identifies the potential for the return to productive activity through the occupational concept as an input for the assessment of the loss of work and occupational capacity (LWOC), allowing an objective qualification of the aspects that constitute the Manual único para la calificación de la pérdida de la capacidad Laboral y Ocupacional (MUCPCLO, Spanish acronym for Manual for the qualification of the loss of labor and occupational capacity). Methods: A cross-sectional study was conducted with application of an OP evaluation scale to a sample of conveniently selected workers with alterations in body functions or structures, participation, or restriction at the occupational level. Analytical comparisons were made with the MUCPCLO scoring standard, and differential and integrating factors were identified. Results: Six subjects made up the sample, four had an occupational accident and two occupational diseases. In performance evaluation, 66% of the sample presented slight dependence on specific activities that lead to a differential analysis with emphasis on the MUCPCLO score. Specific factors were recognized, such as, objectivity of the assessment of occupational performance, multiple contributions of the concept of occupational performance, and possibilities of articulation with the manual. Conclusions: The prior assessment of occupational performance and the integral concept of the occupational therapist are constituted as a fundamental axis that contributes to the process of the assessment of the LWOC.

[Evaluation of medical insurance consultant reports within the German Statutory Accident Insurance-Methodology and results of a peer review procedure]. / Evaluation der Durchgangsarztberichte in der Deutschen Gesetzlichen Unfallversicherung ­ Methodik und Ergebnisse eines Peer-Review-Verfahrens.

BACKGROUND: Accident insurance consultants (D-physicians) are qualified specialists with particular expertise in occupational medicine. Within the medical treatment procedure of the German Statutory Accident Insurance (DGUV), D­physicians must make a report on the medical care after occupational accidents. This nationwide evaluation aimed to systematically measure the quality of documentation of these medical reports. Peer review is a common method to ensure process quality. MATERIAL AND METHODS: For each included D­physician 30 reports of more severe cases from 2017 were randomly selected. The reports were anonymized and randomly assigned to a peer reviewer. Peer reviewers used a web-based checklist with nine rating categories and dichotomous response format (deficiency/no deficiency). To evaluate overall quality each report was rated with an overall grade from 1 (very good) to 6 (insufficient). RESULTS: A total of 30,384 reports were evaluated by 82 peer reviewers. One third of the reports contained no deficiencies. Most deficiencies were found in the category on information about the accident. The mean overall grade for each D­physician was 2.6 and ranged from 1.5 (best) to 4.1 (worst). All evaluated D­physicians were given an individual quality report which described the main findings. CONCLUSION: The first nationwide peer review of the DGUV proved to be a practical and valid quality assurance procedure to evaluate the medical reports of D­physicians. The quality of the reports was in general good. The DGUV plans to repeat the peer review process taking further groups of D­physicians into consideration.

Impact of chronic constipation on health-related quality of life and work productivity in Japan.

BACKGROUND AND AIM: The impact of chronic constipation on health-related quality of life (HRQoL), work productivity, and healthcare resource use in Japan is not well understood. This study aimed to evaluate and compare the humanistic burden of respondents with chronic constipation to respondents without chronic constipation and to respondents with type 2 diabetes mellitus (T2DM), irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD), respectively. METHODS: This cross-sectional study collected demographic and general health data and HRQoL data as measured by the Short Form 12-Item (Version 2) Health Survey and EuroQol 5-dimension health surveys. Health impacts on employment-related activities and indirect costs were measured using the Work Productivity and Activity Impairment questionnaire. Propensity score matching was used to identify a control group without chronic constipation. Multivariate generalized linear models were used to identify potential factors that may impact the outcomes of respondents. RESULTS: A total of 30 001 individuals responded to the Japan National Health and Wellness Survey 2017, whereof 3373 (11.2%) reported having chronic constipation; 963 were physician diagnosed. Compared with matched controls, patients with physician-diagnosed chronic constipation had lower mean HRQoL scores and higher mean absenteeism, presenteeism, total Work Productivity and Activity Impairment, and indirect costs. Physician-diagnosed chronic constipation was associated with a higher health burden than T2DM, IBS, and GERD. CONCLUSIONS: Chronic constipation is associated with a considerable health burden, which is higher compared with T2DM, IBS, and GERD. These results suggest an urgent need for effective treatment of Japanese patients with chronic constipation to improve their quality of life.