Occupational medicine specialist referral triggers: Mixed-methods analysis of teleconsult cases.

Background: Qualitative analyses can yield critical lessons for learning organizations in healthcare. Few studies have applied these techniques in the field of occupational and environmental medicine (OEM). Aims: To describe the characteristics of complex cases referred for OEM subspecialty evaluation and variation by referring provider's training. Methods: Using a mixed methods approach, we conducted a content analysis of clinical cases submitted to a national OEM teleconsult service. Consecutive cases entered between April 2014 and July 2015 were screened, coded and analysed. Results: 108 cases were available for analysis. Local Veterans Health Administration (VHA) non-specialist providers entered a primary medical diagnosis in 96% of cases at the time of intake. OEM speciality physicians coded significant medical conditions based on free text comments. Coder inter-rater reliability was 84%. The most frequent medical diagnosis types associated with tertiary OEM referral by non-specialists were endocrine (19%), cardiovascular (18%) and mental health (16%). Concern for usage of controlled and/or sedating medications was cited in 1% of cases. Compared to referring non-specialists, OEM physicians were more likely to attribute case complexity to musculoskeletal (OR: 2.3, 1.68-3.14) or neurological (OR: 1.69, 1.28-2.24) conditions. Medication usage (OR: 2.2, 1.49-2.26) was more likely to be a source of clinical concern among referring providers. Conclusions: The findings highlight the range of triggers for OEM physician subspecialty referral in clinical practice with employee patients. The results of this study can be used to inform development of provider education, standardized clinical practice pathways, and quality review activities for occupational medicine practitioners.

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.

From worker health to citizen health: moving upstream.

New rapid growth economies, urbanization, health systems crises, and "big data" are causing fundamental changes in social structures and systems, including health. These forces for change have significant consequences for occupational and environmental medicine and will challenge the specialty to think beyond workers and workplaces as the principal locus of innovation for health and performance. These trends are placing great emphasis on upstream strategies for addressing the complex systems dynamics of the social determinants of health. The need to engage systems in communities for healthier workforces is a shift in orientation from worker and workplace centric to citizen and community centric. This change for occupational and environmental medicine requires extending systems approaches in the workplace to communities that are systems of systems and that require different skills, data, tools, and partnerships.

[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.

[Pathomorphosis and contemporary evolution of occupational and occupationally mediated diseases].

The authors present results of studies concerning pathomorphosis mechanisms underlying contemporary forms of occupational and occupationally mediated diseases. Systemic general pathologic approach enabled to specify importance of universal homeostatic mechanisms disorders at various structural and functional levels in pathogenesis of major disease types.

[EBC: a new matrix for assessment of airway and lung inflammation. Current aspects of environmental and occupational medicine]. / Atemkondensat: Eine neue Matrix zur Erfassung entzündlicher Veränderungen der Atemwege/Lunge. Aktuelle Aspekte aus der Umwelt- und Arbeitsmedizin.

For many environmental and occupational pollutants the respiratory system represents the route of entry. Inflammation is a fundamental process in the pathophysiological cascade leading to respiratory diseases such as asthma or chronic obstructive pulmonary disease. Non-invasive inflammatory monitoring may assist in the diagnosis as well as assessments of severity and response to treatment. Of these, exhaled nitric oxide is the best validated constituent and is used for assessing airway inflammation in clinical practice, particularly in patients with asthma. Exhaled breath condensate (EBC) is the liquid phase of the exhaled breath sampled by cooling. EBC, like blood or urine, is not a marker itself but a matrix in which a wide variety of substances have already been detected. EBC biomarkers reflect acid stress, oxidative stress, or inflammation. There are still many methodological limitations and the interpretation of findings is hampered by the fact that the most widely used devices differ significantly in their collection efficiency for markers of interest and the analytical technology employed is often near the limit of detection. In spite of promising data, standardisation of the already existing procedures is required for the implementation of EBC in clinical practice. EBC might be of particular interest in preventive medicine since adverse inflammatory processes often precede changes in lung function. Concerning the adverse effects of air pollution, there is a special focus on markers reflecting oxidative stress since air pollutants have the ability to drive free radical reactions. This overview focuses on recent data on EBC obtained from articles concerning applications of exhaled breath analysis in environmental and occupational medical research.

[Cooperation among clinics and practices. Integrated medical care in occupational dermatology]. / Neue Formen der Zusammenarbeit zwischen Praxis und Klinik. Integrierte Versorgung in der Berufsdermatologie.

Preventive measures in occupational dermatology have proven to be very effective in recent years, especially measures of primary and secondary prevention as components of a complex hierarchical prevention concept. For those cases of occupational dermatoses in which these outpatient prevention measures are not successful, interdisciplinary inpatient rehabilitation measures have been developed ("tertiary individual prevention" [TIP]). TIP comprises 3 weeks inpatient treatment including intensive disease-oriented teaching and psychological counseling, followed by outpatient treatment by the local dermatologist. In 2005, a German prospective cohort multicenter study ("Medizinisch-Berufliches Rehabilitationsverfahren Haut--Optimierung und Qualitätssicherung des Heilverfahrens" [ROQ]) started which will further standardize TIP and evaluate long-term success and scientific sustainability in depth. This integrated concept of an inpatient/outpatient disease management reveals remarkable pertinent options for patients with severe occupational dermatoses in all high-risk professions.

Presente y futuro de la Medicina de Trabajo / Present and future of occupational health

La medicina del trabajo tiene por finalidad considerar cómo afecta el trabajo a la salud del trabajador, y también la influencia del estado de salud del trabajador sobre su habilidad para desempeñar las tareas de su puesto de trabajo. La población trabajadora está tendiendo a envejecer, lo que va unido a una repercusión económica importante. Por este motivo, la posibilidad de prevenir, retrasar o disminuir la patología en los trabajadores está adquiriendo una relevancia cada vez mayor. La prevención que el médico del trabajo debe realizar se sitúa en los tres planos clásicos de la prevención: primaria, en cuanto a promoción de la salud, educación sanitaria, hábitos de vida, vacunas, nutrición, seguridad, higiene, ergonomía...; secundaría, especialmente con programas de diagnóstico precoz, de seguimiento médico, controles biológicos, prevención de discapacidades laborales; y terciaria, con tratamientos de las enfermedades, programas de retorno al trabajo tras incapacidad, rehabilitación... De todo ello existe evidencia científica basada en trabajos que se están publicando en los últimos años. El Americam College of Occupational and Environmental Medicine establece para los próximos años unos objetivos para la actividad profesional del médico del trabajo que se resumen en: el aumento de la influencia e impacto en la empresa, la innovación, el valorar la información de salud mediante métricas, la evaluación programada y la investigación sistemática (AU)

The main concern of Occupational Medicine is to consider how work and the work environment affect the worker´s health status, and also how the worker´s health status impinges on his/her ability to carry out his/her tasks at the workplace. The workforce shows a trend towards ageing, which is associated to a significant economic impact. Therefore, the posibility to prevent, retard or diminish disease among workers is achieving an ever-increasing relevance. At the Occupational Physician level, prevention may be understood in the three classical levels: Primary, as for health promotion, health education, lifestyle habits, vaccinations, nutrition, safety, ergonomy, etc.; Secondary, particularly with early diagnosis and medical follow-up programmes, biologic controls and prevention of lavour dyscapacitations, and Tertiary, with therapeutic measures for disease, labour reinsertion after dyscapacitation, rehabilitation, etc. papers published over the last years provide scientific evidence for all the above (AU)

A clinical perspective on workplace depression: current and future directions.

OBJECTIVE: To identify and propose potential solutions to challenges encountered by clinical and consulting occupational and environmental medicine practitioners in the management of workplace depression. METHOD: A review of English-language medical literature from 1960 to the present. RESULTS: Numerous consequences and challenges to clinical management of workplace depression are recognized. Several potential present and future roles of the practitioner--in prevention, initial recognition and management, appropriate referral, care integration, stakeholder advocacy and education, and administration--are identified, and specific interventions are proposed and explored. CONCLUSION: Numerous opportunities exist for clinical and consulting practitioners to intervene to improve the current management of workplace depression.

Chronologic history of occupational medicine.

OBJECTIVES: To provide a chronologic review of growing knowledge in occupational medicine relating work and work hazards to health, and to provide a perspective on the lessons learned from the frequent inattention or misrepresentation of hazards. METHODS: Many books on the social and medical history of work including epidemiology and toxicology were reviewed, as well as published papers and interviews. RESULTS: Throughout history workplace hazards and occupational medicine have been shaped by the forces that shape work itself, social evolution, changing modes of production, shifting economic powers, and demographic changes in the workforce. Lest we think these changes are unique to the present time, this paper emphasizes the long-term and inevitable relationship between social structure and worker health. Hippocrates emphasized the relation between environment (air and water) and health, although he has less to say about the non-military work environment, perhaps because of the denigration of manual labor in Greece. The impact of work on health can be traced to the Edwin Smith Surgical Papyrus, written approximately 1700 BC. The earliest occupational physicians served military forces, and Galen was physician to Roman gladiators. Finger and wrist guards worn by Bronze Age archers represent early personal protective equipment. Writers of the classic period mention diseases and hazards of miners, and Pliny (1st century AD) mentions veils to cover the face. In the Middle East Rhazes included occupation in his case studies (9th century). Paracelsus, and Agricola were prominent, figures in the 15th century, with an emphasis on mining and health. Ramazzini's (c1700) work was widely translated in ensuing decades and is now well-known to all, but its influence between about 1800 and 1940 is inapparent. The emergence of a public health movement in the mid-1800s focused attention on the abominable conditions of many factories and on the living conditions, poor nutrition, high stress, poverty and ill health of the new factory working class, while paying scant attention to specific workplace hazards. CONCLUSIONS: The recognition of occupational diseases in the United States has often lagged by a generation behind the recognition of the same diseases in Europe. We are now into a second industrial revolution led by multinational corporations and information technology, shifting production facilities, and jobs moving around the world in search of cheap labor in the countries with the fastest growing population and the greatest poverty. Occupational medicine must be alert to the new challenges imposed by this revolution.

Negative and non-positive epidemiological studies.

The aim of this study was to identify and discuss validity aspects on so called negative and non-positive studies. Arguments and examples are drawn from experiences in occupational health epidemiology regarding the interpretation of more or less equivocal study results. A negative study may be defined as showing a result that goes against the investigated hypothesis of an increased (or prevented) risk. Traditionally, studies with a risk estimate (relative risk or odds ratio) above, but close to unity are also referred to as negative, given a narrow confidence interval (CI) that includes unity. A risk estimate above unity with the CI including unity is non-positive, however, but an estimate below unity with upper CI bond exceeding unity might be seen as possibly negative or non-negative. A weaker "significance" than usually required should perhaps be accepted when evaluating serious hazards. In contrast to positive studies, the negative and non-positive studies tend to escape criticism in spite of questionable validity that may have obscured existing risks (or preventive effects). Even stronger arguments can be made in criticising negative and non-positive studies than positive studies, for example, regarding selection phenomena, and observational problems regarding exposure and outcome. Negative confounding should be considered although usually weak. In case-control studies, so called over-matching may obscure an existing risk as could the "healthy worker effect" in cohort studies. Small scale non-positive studies should be made available for meta-analyses and when considering studies that do not convincingly show a risk; those who are exposed should be given the "benefit of the doubt".

[From industrial hygiene and toxicology to environmental hygiene and toxicology: problems and prospects]. / Dall'igiene e tossicologia industriale all'igiene e tossicologia ambientale: problemi e prospettive.

BACKGROUND: Low-dose exposures to mixtures of substances have received increasing interest and they involve many different occupational and environmental situations. The presence in the population (working and general) of groups of susceptible individuals is an important public health issue that poses new challenges to science and society. OBJECTIVES: To discuss the evolution from traditional occupational hygiene and toxicology to the new environmental (general and occupational) hygiene and toxicology. RESULTS: Environmental hygiene and toxicology have remarkably improved analytical tools available to solve most of the analytical issues posed by the present exposure scenario. Biomarkers of low-dose exposure, early effects and individual susceptibility are being intensively investigated. CONCLUSIONS: The challenge in this field for the coming years appears to be not the analytical but the medical and ethical implications.