Arsenic Exposure, Assessment, Toxicity, Diagnosis, and Management: Guidance for Occupational and Environmental Physicians.

: Arsenic is ubiquitous in the environment and human exposure can occur from multiple possible routes including diet. Occupational medicine physicians asked to evaluate workers with elevated urine arsenic levels may be unaware that many sources of arsenic exposure are not work related. In this paper, we address arsenic exposure sources and pathways, adverse health effects of arsenic exposure and those subpopulations at increased risk, and the evaluation and treatment of those exposed to elevated arsenic levels.

Improving the assessment of occupational diseases by occupational physicians.

BACKGROUND: The prevention of occupational diseases is limited by a lack of insight into occupational exposure to risk. We developed a six-step approach to improve the diagnosis and reporting of occupational diseases and the selection of subsequent preventive actions by occupational physicians (OPs). AIMS: To evaluate the effect of the six-step approach on the transparency and quality of assessing occupational diseases and the usability of the six-step approach according to OPs and their satisfaction with it. METHODS: A randomized controlled trial. OPs in the control group used the standard information available. OPs in the intervention group used the six-step approach and accompanying educational materials. The actions and decisions of OPs in both groups were analysed using 17 performance indicators. To address the second issue, OPs used the six-step approach over 6 weeks and rated its usability and their satisfaction in relation to several aspects. RESULTS: The average score of the OPs in the intervention group (n = 110) was statistically significantly higher (11/17 performance indicators, 62% of the maximum score) than that of the OPs in the control group (n = 120, 5/17 performance indicators, 30% of the maximum score, P < 0.001). The usability aspects of the six-step approach had mean scores of 7 and 8. Mean satisfaction with the six-step approach was 8. CONCLUSIONS: The six-step approach resulted in better evidence-based and transparent decision-making about occupational diseases by OPs. Usability and satisfaction were rated as satisfactory by the OPs.

[New regulations for inpatient treatment of the statutory accident insurance: From the perspective of a university medical center]. / Neuordnung des stationären Heilverfahrens der Gesetzlichen Unfallversicherung: Aus Sicht einer Universitätsklinik.

BACKGROUND: New regulations of the German statutory accident insurance for inpatient treatment have been introduced. The aims of the new regulations are to improve cost-effectiveness and the quality of medical care. The introduction of the injury type catalogue and the severe injuries type procedure (SAV) has led to a concentration of resources. The purpose of these innovations is an increase in the quality of treatment of patients with complex injuries. CONCLUSION: The introduction of the new regulations resulted in a centralization of medical care in order to optimize the quality of treatment of complex injuries from occupational accidents. Hence, the high demands concerning infrastructure and human resources expected of a level one university medical center are taken into account.

[The new treatment procedure of the German statutory accident insurance: From the perspective of a community hospital]. / Die neuen Heilverfahren der DGUV: Aus der Sicht eines Städtischen Krankenhauses.

The requirements of the German statutory accident insurance (DGUV) for the new treatment procedure were presented on 1 January 2013 in a new catalogue. The implementation of the certification of hospitals for the very severe injury procedure (SAV) by the DGUV should have been completed by 2014. These requirements placed high demands on trauma-oriented hospitals because of the high structural and personnel prerequisites. The background to the new organization was the wish of the DGUV for quality improvement in patient treatment in hospitals for patients with very severe occupational and occupation-related trauma by placement in qualified centers with high case numbers. No increase in income was planned for the hospitals to cope with the necessary improvements in quality. After 2 years of experience with the SAV we can confirm for a community hospital that the structural requirements could be improved (e.g. establishment of departments of neurosurgery, plastic surgery and thoracic surgery) but the high requirements for qualification and attendance of physicians on duty are a continuous problem and are also costly. The numbers of severely injured trauma patients have greatly increased, particularly in 2015. The charges for the complex treatment are not adequately reflected in the German diagnosis-related groups system and no extra flat rate funding per case is explicitly planned in the DRG remuneration catalogue. The invoicing of a center surcharge in addition to the DRG charges has not been introduced.

Shoulder Conditions: Diagnosis and Treatment Guideline.

The following guideline covers a wide array of shoulder conditions seen in the workers' compensation, as well as the nonworkers' compensation, population. The guideline is intended to help establish work relatedness and aid in making the diagnosis of shoulder injuries and degenerative conditions. It also provides a nonoperative and operative guideline for the treatment of several shoulder conditions, not limited to rotator cuff tears, subacromial impingement syndrome, acromioclavicular arthritis and dislocations, as well as glenohumeral arthritis.

Work-Related Carpal Tunnel Syndrome: Diagnosis and Treatment Guideline.

Carpal tunnel syndrome is the most common entrapment neuropathy, and its risk of occurrence in the presence of repetitive, forceful angular hand movements, or vibration, is common. It is critical to make the diagnosis based on appropriate clinical history and findings and with corroborating electrodiagnostic studies. Conservative management should be undertaken with the goal of maintaining employment; surgical decompression can be highly effective, particularly if undertaken early on.

[Risk assessment comparison of biomechanical overloading of the musculoskeletal system: 10 years' applied experience]. / Metodi di valutazione del rischio da sovraccarico biomeccanico all'apparato muscolo scheletrico a confronto: esperienza applicativa di dieci anni.

UNLABELLED: Risk assessment for upper extremity work related muscoloskeletal disorders by applying six methods of ergonomic: a ten years experience. The objective of this research was to verify and validate the multiple step method suggested by SIMLII guidelines and to compare results obtained by use of these methods: Washington State Standard, OCRA, HAL, RULA, OREGE and STRAIN INDEX. METHODS: 598 workstations for a total of 1800 analysis by different methods were considered, by adopting the following multiple step procedure: prelinminary evaluation by Washington State method and OCRA checklist in all the working stations, RULA or HAL as first level evaluation, OREGE or SI as second level evaluation. RESULTS: The preliminary evaluation resulted negative (risk absent) in the 75% of examined work stations and by using checklist OCRA optimal-acceptable condition was found in 58% by HAL in 92% of analysis, by RULA in 100%, by OREGE in 64%; by SI in 70% of examined working positions. We observed similar evaluation of strain among methods and main differences have been observed in posture and frequency assessment. DISCUSSION AND CONCLUSION: The preliminary evaluation by State of Washington method appears to be an adequate instrument for identify the working condition at risk. All the adopted methods were in a good agreement in two estreme situations: high risk or absent risk, expecially in absent risk conditions. Level of accordance varied on the basis of their rationale and of the role of their different components so SIML indications about the critical use of biouzechanical methods and about the possible use of more than one of them (considering working chlaracteristics) have been confirmed.

Value of occupational medicine board certification.

OBJECTIVE: To assess the impact of occupational medicine board certification and career stage on practice characteristics. METHODS: Two hundred sixty occupational medicine physicians completed a questionnaire and 25 activity log descriptions about 72 items in 9 major domains. For each item, the percentage of activities involving the item and the percentage of physicians conducting the item at least once were calculated. Results were analyzed by board certification status and career stage. RESULTS: Board-certified physicians had more-diverse practice activities and skills. They were more involved in management and public health-oriented activities, with greater emphasis on toxicology and less on musculoskeletal disorders. The noncertified physicians received more payment from workers' compensation. Early-career physicians spent more time in direct injury/illness treatment, being paid by workers' compensation, and addressing musculoskeletal problems. CONCLUSIONS: Formal training confers advantages in practice diversity and population medicine orientation.

[Market oriented occupational medicine]. / Piaci viszonyok a foglalkozás-egészségügyben.

The history and the recent state of occupational medicine in Hungary, and its relation with governmental labor organizations are analyzed. In the past 20 years, large "socialist" factories were replaced by smaller companies employing fewer workers. They have been forced to establish contract with occupational health providers. Many of them offer primary care services, whereas family physicians having a board examination in occupational medicine are allowed to work in this field as well. The market of occupational medicine is less regulated, and ethical rules are not always considered. Undercutting prices is a common practice. The recent system could be improved by some regulations which should be respected. There is no reason to make rough changes establishing a new market for profit oriented insurance companies, and to allow employees and employers to work without specification neglecting international agreements. Occupational medicine should be supervised again by the health authorities instead of economists who have quite different, short-term priorities.

A comparison of the recognition of overwork-related cardiovascular disease in Japan, Korea, and Taiwan.

In Japan, Korea, and Taiwan, cerebrovascular and cardiovascular diseases (CVDs) caused by overwork are recognized by government as work-related. These three countries are the only countries in the world that officially recognize CVDs caused by psychosocial factors (e.g., overwork) as work-related cerebrovascular and cardiovascular diseases (WR-CVDs), and compensate employees accordingly. The present study compared the similarities and differences among the recognition of overwork-related CVDs in Japan, Korea, and Taiwan. The criteria by which WR-CVDs are identified are very similar in the three countries. However, in the interval surveyed (1996-2009), Korea had a remarkably larger number of recognized WR-CVD patients than did Japan or Taiwan. Recognition of occupational diseases is influenced by various factors, including socio-cultural values, the nature of occupational health care schemes, the extent of the social security umbrella, national health insurance policy, and scientific evidence. Our results show that social factors may be very different among the three countries studied, although the recognition criteria for WR-CVDs are quite similar.

The European influence on workers' compensation reform in the United States.

Workers' compensation law in the United States is derived from European models of social insurance introduced in Germany and in England. These two concepts of workers' compensation are found today in the federal and state workers' compensation programs in the United States. All reform proposals in the United States are influenced by the European experience with workers' compensation. In 2006, a reform proposal termed the Public Health Model was made that would abolish the workers' compensation system, and in its place adopt a national disability insurance system for all injuries and illnesses. In the public health model, health and safety professionals would work primarily in public health agencies. The public health model eliminates the physician from any role other than that of privately consulting with the patient and offering advice solely to the patient. The Public Health Model is strongly influenced by the European success with physician consultation with industry and labor.

[Immigration, work and health--social, cultural and best practices in occupational medicine: the views of union patronage]. / Immigrazione, lavoro e salute--aspetti sociali, culturali e buone pratiche in Medicina del Lavoro: il punto di vista del patronato sindacale.

Observations from the trade union patronages report that migrants more often that before seek for their assistance, for various reasons, including health and safety at work. We have noticed, besides the "healthy migrant effect" (now decreasing), a certain mobility within occupations, as well as autonomous enterprise developments. Occupational injuries that we see in migrant workers tend to be less serious, potentially because of the greater instability and fear at work (and quick return to work), with informal patterns of health care. Under notification, greater frequency of temporary compensations are also present, likely related to higher vulnerability of migrant worker and to different access and quality of health services. As for the occupational diseases, we have observed an increase in notifications for migrant workers, mainly related to a greater knowledge and exercise of health care and insurance rights and options. Our Patronage experience enables to state that migrants are prone to accept uncomfortable conditions, high rhythm and heavy workloads and that health and safety at work is perceived as a factor not immediately necessary as compared to other issues such as work itself, residence permit, housing. On one side, society at large has to take care of such issues; on the other side, the occupational health system should proceed to a new cultural approach, using also appropriate indicators of process and outcome today available, while integrating the well known motto from Ramazzini, considering questions proper for migrant workers.

[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.

Quality measures for the diagnosis and non-operative management of carpal tunnel syndrome in occupational settings.

INTRODUCTION: Providing higher quality medical care to workers with occupationally associated carpal tunnel syndrome (CTS) may reduce disability, facilitate return to work, and lower the associated costs. Although many workers' compensation systems have adopted treatment guidelines to reduce the overuse of unnecessary care, limited attention has been paid to ensuring that the care workers do receive is high quality. Further, guidelines are not designed to enable objective assessments of quality of care. This study sought to develop quality measures for the diagnostic evaluation and non-operative management of CTS, including managing occupational activities and functional limitations. METHODS: Using a variation of the well-established RAND/UCLA Appropriateness Method, we developed draft quality measures using guidelines and literature reviews. Next, in a two-round modified-Delphi process, a multidisciplinary panel of 11 U.S. experts in CTS rated the measures on validity and feasibility. RESULTS: Of 40 draft measures, experts rated 31 (78%) valid and feasible. Nine measures pertained to diagnostic evaluation, such as assessing symptoms, signs, and risk factors. Eleven pertain to non-operative treatments, such as the use of splints, steroid injections, and medications. Eleven others address assessing the association between symptoms and work, managing occupational activities, and accommodating functional limitations. CONCLUSIONS: These measures will complement existing treatment guidelines by enabling providers, payers, policymakers, and researchers to assess quality of care for CTS in an objective, structured manner. Given the characteristics of previous measures developed with these methods, greater adherence to these measures will probably lead to improved patient outcomes at a population level.

[Collaboration of the occupational physician for risk assessment activities in work environment]. / La collaborazione del medico competente alle attività di valutazione dei rischi in azienda.

In Italy, the legislative Decree n. 81/2008 (and further modifications) foresee the obligation, with relative sanction, for the "competent physician" to collaborate with the employer and the person responsible of the service of prevention and protection to the evaluation of the risks in the places of job. Objective of the present job is to give indications that allow the physician to acquit with correctness the obligation, looking for an equilibrium among the dictated normative and the resources to his/her disposition. For small and medium-sized companies, some activities developed by the physician can determine the real collaboration to the evaluation of the risks: periodic inspections; recording of the evaluations of the workers; planning of the biological monitoring; execution of the sanitary overseeing; epidemiological elaboration of the data of the sanitary overseeing; you meet with the employer etc. In the great farms the collaboration of the competent physician to the evaluation of the risks should culminate in the predisposition of a specific document Such document could compose him some followings sections: indication of the working risks; evaluation of the risks for the pregnant workers; evaluation of the risk job-correlated stress; analysis on the problem list alcohol and job; collaboration to the organization of the service of first help; analysis of the accident coarse; collaboration to the realization of programs of information; collaboration to the realization of programs of promotion of the health; layout of the sanitary plan; measures of prevention and protection necessary.

[Identification of the most common problems and mistakes in the medical certification of inability to work for disability pension provision based on the expertise carried out by the Out-Patient Clinic of Occupational Diseases, Nofer Institute of Occupational Medicine, Lódz, 2005-2007]. / Identyfikacja najczesciej wystepujacych problemów w orzekaniu o niezdolnosci do pracy dla celów rentowych na podstawie dzialalnosci ekspertyzowej Przychodni Chorób Zawodowych w latach 2005-2007.

BACKGROUND: The definition of "inability to work" and principles of medical certification of disabilities, determining the entitlement to an ill-health pension provision are regulated by law. However, the term ,,"inability to work" is not precisely defined and the standards of its assessment are not accurately formulated. This refers not only to the term "loosing ability to work to considerable degree", but also to the criteria of occupational qualifications. OBJECTIVES: The aim of this study was to identify the most common problems and mistakes in the medical certification that entitles to disability pension provision. MATERIALS AND METHODS: The study, based on medical consultations provided for the president of the Social Insurance Company (ZUS) in the years 2005-2007, was carried out in the Out-Patient Clinic of Occupational Diseases, Nofer Institute of Occupational Medicine, Lódz. In total, 293 medical cases were analyzed, of which 61 concerned consequences of occupational diseases, 44--accidents at work and 188--idiopathic diseases. RESULTS: Men formed the majorityof the study group (66%) and the mean age of the examined individuals was 49. The predominant causes of medical certification of patient's inability to work, both in men and female, were musculoskeletal disorders, cardio-vascular diseases, diabetes and mental health problems. Significant discrepancies in the medical statements on inability to work were observed between ZUS and the Nofer Institute of Occupational Medicine. They concerned the evaluation of people's inability to work in general, as well as the degree (partial or complete) of lost capability for work. A consensus of medical statements was found in 153 cases, and differences in other 140 (47.8%) cases. Most differences were found in the evaluation of inability to work caused by consequences of occupational diseases. CONCLUSIONS: Lack of certification guidelines, excessive preference of medical criteria used for defining body fitness disturbances and insufficient consideration of occupational and economic aspects of certified inability to work in terms of assuming work in future) are the main reasons for difficulties in inability to work certification. The scheme of certification procedure was also suggested.

[Occupational physician's decisions on the basis of legislation, ethics and scientific evidence]. / La decisione del medico del lavoro: tra norme, valori etici e prove scientifiche.

BACKGROUND: In the dynamic context of occupational medicine an increasing number of occupational health problems requires a high-quality standard practice supported by decisions consistent both with ethics and legislation. OBJECTIVES: This paper examines the relationship between legal requirements, ethical values and scientific evidence issues in occupational health practice. RESULTS: i) Legal requirements. Italian law states that practice must be evidence-based and comply with the code of ethics for occupational health professionals of the ICOH. ii) Ethical values. The code itself emphasizes that practice should be relevant, knowledge-based, sound and appropriate to occupational risks. Furthermore, the objectives and methods of health surveillance and biological monitoring must be clearly defined and indicator must be chosen according to their relevance and predictive value. Any dilemma arising from the practice should be dealt with according to the ethical principles of health benefit, independence and justice. iii) Scientific evidence. Both the law and the code of ethics require that practice be based on available evidence. CONCLUSIONS: Decisions made on the basis of a comprehensive process founded on scientific evidence should result in effective and high-quality outcomes that respect both the law and the rights of individuals and society.

[Efficacy and appropriateness in updating and validating the activities of the occupational health physician]. / Strumenti di aggiornamento ed orientamento delle attività del medico del lavoro, efficacia ed appropriatezza.

BACKGROUND: We reviewed the Italian tools for updating and validating the activities of occupational health physicians (guidelines, consensus documents, technology assessment, good practices, etc.) from the point of view of efficacy and appropriateness. RESULTS AND CONCLUSIONS: We examined more than 20 guidelines produced since 2003 by the Italian Society of Occupational Health and Industrial Hygiene (SIMLII), the procedures issued by the National System of Guidelines in Medicine/SNLG) by the Italian National Health Institute (ISS) and the new law on occupational safety and health "Decreto Legislativo 81/08", which for the first time includes and defines in specific legislation the different possible instruments for guiding the activities of the occupational health physician, not only to improve the effectiveness of interventions but also aimed at constantly adopting rigorous methodologies based on evidence.