[Exposome: from an intuition to a mandatory research field in occupational and enviromental medicine.] / Esposoma: da intuizione a linea di ricerca obbligata nelle Scienze Mediche Occupazionali e Ambientali.

OBJECTIVES: As Genomics aims at the collective characterization and quantification of genes, exposomics refers to the totality of lifetime environmental exposures, consisting in a novel approach to studying the role of the environment in human disease. The aim is to assess all human environmental and occupational exposures in order to better understand their contribution to human diseases. The "omics" revolution infact mostly regards the underlying method: scientific knowledge is expected to come from the analysis of increasingly extensive databases. METHODS: The primary focus is on air pollution and water contaminants, but all the determinants of human exposure are conceptually part of the idea of exposome, including physical and psychological factors. Using 'omic' techniques the collected exposure data can be linked to biochemical and molecular changes in our body. RESULTS: Since the first formulation of the idea itself of Exposome many efforts have been made to translate the concept into research, in particular two important studies have been started in Europe. CONCLUSIONS: We herein suggest that Occupational Medicine could be a precious contributor to the growth of exposure science also in its omic side thanks to the methods and to the knowledges part of our background.

The U.S. Army Occupational and Environmental Medicine Residency at Aberdeen Proving Ground, Maryland: 1960-1996.

BACKGROUND: Reorganization of the Army and critical assessment of Army Graduate Medical Education programs prompted the Occupational and Environmental Medicine (OEM) Consultant to the Army Surgeon General to initiate a review of current Army OEM residency training. Available information indicated the Army OEM residency at Aberdeen Proving Ground, MD, was the first and longest operating Army OEM residency. Describing this residency was identified as the first step in the review, with the objectives of determining why the residency was started and sustained and its relevance to the needs of the Army. METHODS: Records possibly related to the residency were reviewed, starting with 1954 since certification of physicians as Occupation Medicine specialists began in 1955. Interviews were conducted with selected physicians who had strong affiliations with the Army residency and the practice of Army OEM. FINDINGS: The Army OEM residency began in 1960 and closed in 1996 with the transfer of Army OEM residency training to the Uniformed Services University of the Health Sciences, Bethesda, MD. Over 36 years, 47 uniformed residency graduates were identified; 44 were from the Army. Forty graduated between 1982 and 1996. The OEM residency was part of a dynamic cycle. Uniformed OEM leaders identified the knowledge and skills required of military OEM physicians and where these people should be stationed in the global Army. Rotations at military sites to acquire the needed knowledge and skills were integrated into the residency. Residency graduates were assigned to positions where they were needed. Having uniformed residents and preceptors facilitated the development of trust with military leaders and access to areas where OEM physician skills and knowledge could have a positive impact. Early reports indicated the residency was important in recruiting and retaining OEM physicians, with emphasis placed on supporting the Army industrial base. The late 1970s into the 1990s was a more dynamic period. There was heightened interest in environmental protection and restoration of military installations, and in the threats posed by nuclear, biological and chemical weapons. Additionally, President Reagan initiated a military buildup that brought new health risks to soldiers who would use and maintain modern equipment. Army OEM physicians were required to possess competencies in many areas, to include depots in the Army industrial base, occupational health for the soldier for exposures like carbon monoxide in armored vehicles, military unique exposures like those from chemical threat agents, and environmental medicine to assess health risks on contaminated U.S. military sites and from exposures of deployed forces. These offered interesting OEM training opportunities that challenged residents in the program and helped recruit new residents. DISCUSSION: The strength of the first Army OEM residency was that it was part of a dynamic cycle that consisted of identifying and defining Army OEM needs, training physicians to meet those needs and assigning residency graduates to positions where they would have a positive impact. This paradigm can be used as the basis for contemporary assessments of the Army's need for uniformed OEM physicians and a uniformed OEM residency program.

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.

Implementation of a novel occupational and environmental medicine specialty teleconsultation service: the VHA experience.

OBJECTIVE: Occupational and environmental medicine (OEM) physician specialty practices continue to grow in scope and intensity across the Veterans Health Administration. This study characterizes the implementation of a novel, nationwide telemedicine program that provides OEM specialty consultation to providers across the Veterans Health Administration. METHODS: We examined provider requests and specialist responses for a 6-month pilot from May to October 2013. Characteristics of consult users, determinants of case complexity, and specific applications of OEM specialty expertise were identified. RESULTS: Over a 6-month period, employee occupational health providers consulted the OEM telemedicine pilot a total of 65 times. Employee occupational health providers without formal training repeatedly identified complex cases related to work and disability. CONCLUSIONS: The program has created a new system management solution to deliver expert, in-depth consultation and real-time provider education in OEM.

[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.

[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.

[Identification of the effects of certain determinants on the results of pension prevention in the locomotor dysfunction]. / Identyfikacja wplywu niektórych uwarunkowan na wyniki prewencji rentowej w dysfunkcjach narzadu ruchu.

BACKGROUND: A large group of patients of Ladek Zdrój spa consists of people with disabilities confirmed by objective tests performed under the pension prevention program of the Social Insurance Institution (ZUS). The purpose of disability prevention is to improve the health conditions to the extent required to continue work. The aim of the study was to identify the differences in the assessment of the treatment and its results between patients referred by the Social Insurance Institution and by the National Health Fund (NFZ). MATERIAL AND METHODS: A group of 780 people referred to the spa treatment because of different locomotor dysfunctions participated in a questionnaire-based voluntary anonymous survey. The control group consisted of 215 persons with similar illnesses referred by the National Health Fund. The questionnaire included nine specific questions concerning important socio-medical issues of spa rehabilitation. RESULTS: Following the mathematical analysis, the survey data, presented in the percentage form in 10 tables, allowed us to identify differences in the evaluation of treatment of patients referred by ZUS and NFZ. CONCLUSIONS: Satisfactory results of rehabilitation were reported more often by patients referred by NFZ than by those treated under the ZUS disability prevention program. The latter group of patients frequently reported anger, fear or despair associated with rehabilitation declaring at the same time active participation in the treatment process. This observation provides evidence that the pension prevention based on the holistic model, preferred by the Social Insurance Institution, is more useful.

Optimizing health care delivery by integrating workplaces, homes, and communities: how occupational and environmental medicine can serve as a vital connecting link between accountable care organizations and the patient-centered medical home.

In recent years, the health care reform discussion in the United States has focused increasingly on the dual goals of cost-effective delivery and better patient outcomes. A number of new conceptual models for health care have been advanced to achieve these goals, including two that are well along in terms of practical development and implementation-the patient-centered medical home (PCMH) and accountable care organizations (ACOs). At the core of these two emerging concepts is a new emphasis on encouraging physicians, hospitals, and other health care stakeholders to work more closely together to better coordinate patient care through integrated goals and data sharing and to create team-based approaches that give a greater role to patients in health care decision-making. This approach aims to achieve better health outcomes at lower cost. The PCMH model emphasizes the central role of primary care and facilitation of partnerships between patient, physician, family, and other caregivers, and integrates this care along a spectrum that includes hospitals, specialty care, and nursing homes. Accountable care organizations make physicians and hospitals more accountable in the care system, emphasizing organizational integration and efficiencies coupled with outcome-oriented, performance-based medical strategies to improve the health of populations. The ACO model is meant to improve the value of health care services, controlling costs while improving quality as defined by outcomes, safety, and patient experience. This document urges adoption of the PCMH model and ACOs, but argues that in order for these new paradigms to succeed in the long term, all sectors with a stake in health care will need to become better aligned with them-including the employer community, which remains heavily invested in the health outcomes of millions of Americans. At present, ACOs are largely being developed as a part of the Medicare and Medicaid systems, and the PCMH model is still gathering momentum and evolving among physicians. But, the potential exists for implementation of both of these concepts across a much broader community of patients. By extending the well-conceived integrative concepts of the PCMH model and ACOs into the workforce via occupational and environmental medicine (OEM) physicians, the power of these concepts would be significantly enhanced. Occupational and environmental medicine provides a well-established infrastructure and parallel strategies that could serve as a force multiplier in achieving the fundamental goals of the PCMH model and ACOs. In this paradigm, the workplace-where millions of Americans spend a major portion of their daily lives-becomes an essential element, next to communities and homes, in an integrated system of health anchored by the PCMH and ACO concepts. To be successful, OEM physicians will need to think and work innovatively about how they can provide today's employer health services-ranging from primary care and preventive care to workers' compensation and disability management-within tomorrow's PCMH and ACO models.

[Structure of human resources and activities of occupational medicine service in Poland in 2009 and dynamics and trends in recent years]. / Struktura kadr i dzialalnosc sluzby medycyny pracy w Polsce w 2009 r. oraz dynamika i kierunki zmian w ostatnich latach.

BACKGROUND: The main objective of the study was to provide the most important results concerning the state of human resources and activities of occupational medicine services in Poland in 2009 and their dynamics and trends in the recent years. MATERIALS AND METHODS: Information about the state of human resources and activities of occupational medicine services has been obtained from statistical forms (more than 10,000) filled by occupational physicians carrying out the preventive g care of workers, and health care centers (or their separate parts), which are the primary occupational medicine units and regional occupational medicine centers (forms: MZ-35A, MZ-35B and MZ-35). RESULTS: In 2009, essential changes were noted in the structure of the primary occupational medicine units. 'Ihere was a significant decrease in the number of public health care centers. This phenomenon has resulted from the transformation of public health care centers into non-public structures. CONCLUSIONS: The range of occupational medicine services has reached the level sufficient enough to achieve the objectives of the occupational health care mandatory assignment. However, the structure of the tasks actually performed by regional occupational medicine centers greatly varies, from focusing on the statutory tasks to their marginalization.

Treatment of music performance anxiety via psychological approaches: a review of selected CBT and psychodynamic literature.

Performance anxiety, or stage fright, is anxiety aroused about potential mishaps in performance that expose feared inadequacies before an audience and which evoke feelings of embarrassment and humilation. For affected musicians, performance anxiety can be emotionally devastating, as their career choice in music may be terminated or severely compromised. This paper focuses on the cognitive and psychodynamic literature about music performance anxiety, with the emphasis that for treatment "one size does not fit all." It reviews the factors underlying performance anxiety and those factors which can exacerbate the condition in musicians. The two major clinical treatment modalities within contemporary psychology, cognitive behavior therapy (CBT) and psychodynamic treatments, are reviewed. While there are more empirical studies of CBT in various populations in the literature, until recently there was an indifference to empirical research by psychodynamic investigators. However, meta-analyses show strong efficacy for psychodynamic psychotherapy (in various disorders, not specifically music performance anxiety), but also that the benefits of psychodynamic psychotherapy may endure longer and increase with time.

Armed Forces occupational health--a review.

BACKGROUND: The Armed Forces operate in a particularly arduous physical and psychological environment. The occupational health (OH) of all personnel is of paramount importance to sustain the service's fighting ability. AIMS: Firstly, to bring readers up to date with the current organization and delivery of OH to uniformed personnel in the Armed Forces. Secondly, to review the research that has led to an improvement in OH services and the ways in which the Armed Forces are responding to the various challenges. METHODS: A description of the type and delivery of OH to the Armed Forces is followed by a review of the relevant contemporaneous literature from both open publications and research dissertations. RESULTS: Although there are some similarities with civilian OH, the principal requirement to prepare and sustain service personnel for operations on land, sea and air adds considerable complexity to the task. Research undertaken by Armed Forces OH professionals has added to the evidence base and enabled attrition in all aspects of the Armed Forces to be reduced. CONCLUSIONS: To meet the challenges of the 21st century, Armed Forces OH practitioners must continue to provide the best evidence-based advice to enhance force preparation and sustainment. All consultations in the Armed Forces involve an OH consideration from the simplest consultations through to the input from specialist OH practitioners. While the assessment of fitness to work in home bases and on deployed operations remains the primary output of OH, the provision of support to command policy, procurement and research are also key to the ability to operate worldwide.

[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.

[The organization of the comprehensive prevention of urolithiasis among ferrous metallurgy workers].

The purpose of study is to evaluate the effectiveness of the set of preventive measures as applied to 321 workers of basic ferrous metallurgy specialties (steel makers, mill men, hot metal shearers). During the clinical examination all the workers were divided on three groups: the workers without any pathology (11.83%, the first group), the workers with metabolic disorders only without urolitiasis (64.81%, the second group) and the workers with urolitiasis diagnosis approved by ultrasonography (23.36%, the third group). The effectiveness of rehabilitation measures was evaluated during half a year (diet therapy, drinking regimen, medicinal plants treatment). After the course of preventive measures was applied the overall health condition of most workers ameliorated and the number of workers with urolitiasis development risk factors reliably decreased up to 6-12%.