[Patient Care in German Outpatient Clinics for Environmental Medicine Illustrated by the Examples of Hamburg and Munich University Hospitals]. / Versorgung von Patient*innen an umweltmedizinischen Ambulanzen in Deutschland am Beispiel der Universitätskliniken in Hamburg und München.

People can be affected by various environmental factors (e. g., odor, noise) which can lead to medical complaints or illnesses. Few adequate contact points are available for patients with suspected environmental complaints in Germany. Illustrated by the outpatient clinics for environmental medicine in Hamburg and Munich, this report shows how patients with suspected environmental medical diseases are cared for in Germany. For the exemplary presentation, the data of the environmental medicine outpatient clinics of both the university hospitals from 01.01.2019 to 31.03.2021 are presented and compared. Overall, more female than male patients were treated at both facilities. Suspected exposure to "heavy metals" was most frequently mentioned by patients as the assumed reason for their complaints. Nonetheless, the suspected exposure or "intoxication" could be ruled out in the majority of cases by appropriate examination methods in accordance to current medical guidelines. The data provided by the environmental medicine outpatient clinics show that there is a continuous demand for environmental medical care. A close cooperation between the private practice sector and the outpatient clinics for environmental medicine providing medical care to patients should therefore be sought.

Physical workload and cardiopulmonary parameters in relation to individual capacity of bulk waste workers - a cross-sectional field-study.

PURPOSE: Waste collection is considered particularly heavy work, although no previous study has yet investigated the strain of bulk waste collection. The aim of this study is to determine the workload of bulk waste workers in practice. METHOD: We conducted a cross-sectional field-study. Fourteen male volunteers from the bulk waste collection of the municipal sanitation department in Hamburg, Germany, were included. Performance was determined by cardiopulmonary exercise testing under laboratory conditions. During the shift, each worker was accompanied by a researcher, and heart rate (HR) was recorded under field conditions using an HR watch with a belt system. We examined mean HR, relative heart rate (RHR), relative aerobic strain (RAS), calculated oxygen uptake ([Formula: see text])  and individual ventilatory threshold 1 (VT1) as parameters of workload during their daily work. RESULTS: During the shift, HR was scaled: 102 bpm (SD 10.2), RHR: 36.9%, [Formula: see text]: 1267 ml/min (SD 161), RAS: 49.4% (SD 9.3), and [Formula: see text] in relation to VT1: 75% (SD 18.5). There was no significant difference between oxygen consumption during the main task of lifting and carrying bulky waste and the individual [Formula: see text] at VT1. CONCLUSION: Although the burden of the main task of lifting and carrying bulky waste is very high (at VT1 for more than 3 h), interruptions from other tasks or formal breaks spread the burden over the entire shift. The total workload exceeded most recommendations in the literature across the different work periods. However, the total burden remains below VT1, the only parameter that takes individual endurance performance into account. We recommend again VT1 as an individual upper limit for prolonged occupational work.

[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.] / S2k-Leitlinie zur fachärztlichen Diagnostik und Therapie von Asthma 2023.

The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.

Does working in an extremely cold environment affects lung function?: 10 years follow-up.

OBJECTIVE: The aim of this study is to investigate whether there is an association between brief but repeated exposures to extremely cold temperatures over many years and pulmonary function. METHODS: We performed a retrospective analysis of the data collected over 10 years in the context of the extended medical examinations of storeworkers exposed to extremely cold temperatures. We considered forced vital capacity (FVC), forced expiratory volume in one second (FEV1), Tiffeneau-Pinelli index (FEV1/FVC), CO diffusion capacity (DL,CO) and Krogh-factor (CO diffusion capacity relative to recorded alveolar volume, DL,CO/VA) reported as %-predicted. We analysed trends in outcome parameters with linear mixed models. RESULTS: 46 male workers participated in at least two extended medical examinations between 2007 and 2017. Overall 398 measure points were available. All lung function parameters had values above the lower limit of normality at the first examination. In the multivariate model including smoking status and monthly intensity of cold exposure (≤ 16 h/month vs. > 16 h/month) FEV1%-predicted and FVC %-predicted had a statistically significant positive slope (FEV1, 0.32% 95% CI 0.16% to 0.49% p < 0.001; FVC 0.43% 95% CI 0.28% to 0.57% p < 0.001). The other lung function parameters (FEV1/FVC %-predicted, DL,CO %-predicted, DL,CO/VA %-predicted) showed no statistically significant change over time. CONCLUSIONS: Long term intermittent occupational exposure to extreme cold temperatures (-55 °C) does not appear to cause irreversible deleterious changes in lung function in healthy workers, thus the development of obstructive or restrictive lung diseases is not expected.

Evolution of work ability, quality of life and self-rated health in a police department after remodelling shift schedule.

BACKGROUND: There exists a great diversity of schedules concerning the way shift work is organized and implemented with ample agreement regarding recommendable features of a shift system. In order to adapt the shift schedule of a metropolitan police department to current recommendations, a remodelled shift schedule was introduced in 2015. The aim of this study was to evaluate the potential associations between the remodelled shift schedule and work ability, quality of life and self-rated health after one and five years. METHODS: A controlled before-and- after study was conducted during the piloting phase (2015-2016) as well as a 5-year follow-up using paper questionnaires. Outcome parameters included work ability, quality of life and self-rated health. RESULTS: Work ability, quality of life and self-rated health improved after the first year of the newly implemented shift schedule among police officers working in the piloting police stations compared to those working according to the former schedule. In 5-year follow-up differences between indicators diminished. CONCLUSIONS: The implementation of a remodelled shift schedule including more 12-h shifts accompanied by more days off and a coherent weekend off duty was not associated with detrimental effects to work ability, quality of life or self-reported health among police officers.

Police officers' work-life balance, job satisfaction and quality of life: longitudinal effects after changing the shift schedule.

OBJECTIVES: To evaluate mental health-related outcomes of police officers 5.5 years after implementing a new alternating shift schedule which was supposed to improve their health and work-life balance. DESIGN: Pre-post study design with a baseline survey at the beginning of the piloting of the new shift schedule in 2015 and another survey 5.5 years later in 2020. SETTING: Police departments of a German metropolitan police force piloting the new shift schedule. PARTICIPANTS: 116 shift-working police officers out of a population of 1673 police officers at the follow-up date. INTERVENTIONS: New shift schedule based on occupational health recommendations. OUTCOMES MEASURES: Work-life balance, job satisfaction and quality of life. METHODS: Mixed analyses of variances were used to test the hypotheses of within-subject and between-subject differences regarding time and gender. RESULTS: We found partly significant differences between the baseline and follow-up survey for work-life balance (F(1, 114) = 6.168, p=0.014, ηp² = 0.051), job satisfaction (F(1, 114) = 9.921, p=0.002, ηp² = 0.080) and quality of life (F(1, 114) = 0.593, p=0.443, ηp² = 0.005). Neither significant differences between male and female police officers nor interaction effects of time and gender were found. CONCLUSION: An increase was found for each of the three outcomes 5.5 years after implementing the new shift schedule. The results contribute to the current state of research on mental health-related outcomes of working conditions in shift work. On this basis, recommendations for designing shift schedules can be deduced to promote mental health and job satisfaction for employees in shift work.

Restrictions of VC and DLCO in relation to asbestos-related computed tomographic findings quantified by ICOERD-based parameters.

BACKGROUND: Even almost 30 years after the ban on the use of asbestos in Germany, the effects of asbestos are still highly relevant in everyday clinical practice in occupational medicine. The aim of this study was to further investigate the significance of essential parameters of both pulmonary function diagnostics and imaging techniques (low-dose HR-TCT) for the prevention and early detection of asbestos-related morphological and functional lung changes. METHODS: Data from spirometry, body plethysmography and diffusion capacity, as well as CT images of the thorax, were retrospectively studied from 72 patients examined between 2017 and 2019 at the Institute for Occupational and Maritime Medicine (ZfAM), Hamburg, Germany. The subjects were divided into four subgroups according to the presence of comorbidities (concomitant cardiac diseases, obstructive ventilatory disorder, pulmonary function pattern consistent with emphysema, and no other pulmonary or cardiac diseases). These subgroups were analysed in addition to the overall collective. The CT images were evaluated according to the International Classification of Occupational and Environmental Respiratory Diseases (ICOERD) with radiological expertise. In addition, some asbestos-related parameters were newly quantified, and corresponding scores were defined based on ICOERD. Statistical analysis included the use of correlations and fourfold tables with calculation of Spearman's rho (ρ), Cohen's κ, and accuracy. RESULTS: Vital capacity (VC) is slightly reduced in the total collective compared to the normal population (mean 92% of predicted value), while diffusion capacity for CO (DLCO) shows predominantly pathological values, mean 70% of the respective predicted value. The CO transfer coefficient (DLCO/VA), which refers to alveolar volume (VA), also shows slightly decreased values (mean 87% pred.). Seventy-nine percent of patients (n = 57) had signs of pulmonary fibrosis on CT scans, and pleural plaques appeared in 58 of 72 patients (81%). Of the newly quantified additional parameters, particularly frequently described findings are subpleural curvilinear lines (SC, n = 39) and parenchymal bands (PB, n = 29). VC correlates well with the expression of pleural plaques (ρ = - 0.273, P < 0.05), and DLCO measures show a better correlation with fibrosis score (ρ = - 0.315, P < 0.01). A third, newly developed score, which includes the extent of pleural plaques and additional subpleural parameters instead of fibrosis parameters, shows significant correlations for both VC and DLCO (ρ = - 0.283, - 0.274, resp.; both P < 0.05). DISCUSSION: The importance of spirometry (VC) and diffusion capacity measurement (DLCO) as essential diagnostic procedures for the early detection of asbestos-related changes ‒ also including patients with relevant concomitant cardiac or pulmonary diseases ‒ was confirmed. Significant and better correlations between lung function changes (VC and DLCO) and abnormal CT findings are seen when parenchymal bands (PB), subpleural curvilinear lines (SC), and rounded atelectasis (RA) are quantitatively included into the evaluation, in addition to assessing the extent of pleural plaques alone. Therefore, when assessing CT images according to ICOERD, these parameters should also be quantified.

Workplace-related inhalation test - Specific inhalation challenge: S2k Guideline of the German Society for Occupational and Environmental Medicine e.V. (DGAUM), the German Society for Pneumology and Respiratory Medicine e.V. (DGP) and the German Society for Allergology and Clinical Immunology e.V. (DGAKI).

Not available.

[Adaptation of infection protection measures in public services due to the COVID-19 pandemic]. / Anpassung der Infektionsschutzmaßnahmen im öffentlichen Dienst aufgrund der COVID-19-Pandemie: Handlungsempfehlungen für technische, organisatorische und persönliche Schutzmaßnahmen zur Reduktion der Infektionsausbreitung von SARS-CoV-2.

The COVID-19 pandemic is changing the requirements for occupational health and safety in the workplace. The aim of the measures implemented nationwide is to reduce the spread of the virus. This applies to all areas of life, including the workplace. The "public service" includes many system-relevant occupational groups: police, fire brigade, judiciary, municipal cleaning, waterworks and administrative bodies at local and state levels. There is a broad diversity of activities in communal and federal state enterprises, especially with regard to internal organisation as well as personnel and spatial conditions. Direct interactions with people are often necessary. Maintaining the functionality of these structures is essential for public life. Education institutions and care facilities for children, people with handicaps and vulnerable groups, institutions for nursing and geriatric care as well as public transport are not covered in this statement due to their special work structures. These recommendations address the professionally accountable in the respective public service institutions. It deals with infection control measures at work in the public service, derived from the risk assessments of various settings. The measures presented can be implemented as part of an operational concept for temporary infection control measures. The aim is to provide general guidance on infection protection with respect to work situations in order to slow down the dissemination of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), to protect at-risk groups, and ensure the functioning of the aforementioned structures.

[Classroom teaching at universities and colleges under the conditions of the SARS-CoV-2 pandemic]. / Präsenzlehre an Universitäten und Hochschulen unter den Bedingungen der SARS-CoV-2-Pandemie: Empfehlungen zu technischen, organisatorischen und persönlichen Schutzmaßnahmen im Rahmen des Arbeitsschutzes.

In order to maintain university teaching while observing the distance rules in accordance with the occupational health and safety standard of the German Federal Ministry of Labour and Social Affairs (BMAS), special regulations and measures must be observed under the conditions of the COVID-19 pandemic when students and teaching staff meet in large groups (lecture hall) and small teaching rooms (seminars, internships). The article gives detailed recommendations for the practical implementation of protective and preventive measures according to the STOP principle, which is customary in occupational health and safety: substitution, technical, organisational and personal protective measures. Responsibilities are named and also difficult situations where physical proximity is necessary (e.g. teaching medical examinations, joint laboratory work, sports and dance seminars) are analysed with regard to the necessary measures; recommendations are formulated.

Severe bronchial reaction to provocation with fish and crustaceans.

The specific inhalation challenge (SIC), a workplace-related inhalation exposure test, is used to identify allergic asthma when symptoms such as coughing, wheezing, or dyspnea occur at the workplace. Its use is risky. A cook (28 years old) has been complaining of rhinoconjunctivitis and contact urticaria while preparing seafood for 3 years. He continues to work, now wears gloves, no longer tastes fish dishes, and receives anti-obstructive therapy (ICS, LABA). Methacholine (MCH) testing for bronchial hyperreactivity (BHR) shows mild BHR (PD100;sRaw: 0.28 mg MCH), skin and blood tests show type I sensitization to fish and crustacean proteins. In SIC with fried shrimps, rhinoconjunctivitis, coughing and distance wheezing, FEV1 drop > 20%, sRaw increase to 9.6 kPa*s and angioedema occur. Since routine tests showed only a moderate BHR, the suspicion of an occupational disease was formulated very late in the medical examination process. Only the SIC showed the severity of the cook's bronchial asthma.

Relations between vital capacity, CO diffusion capacity and computed tomographic findings of former asbestos-exposed patients: a cross-sectional study.

BACKGROUND: Asbestos-related lung diseases are one of the leading diagnoses of the recognized occupational diseases in Germany, both in terms of their number and their socio-economic costs. The aim of this study was to determine whether pulmonary function testing (spirometry and CO diffusion measurement (DLCO)) and computed tomography of the thorax (TCT) are relevant for the early detection of asbestos-related pleural and pulmonary fibrosis and the assessment of the functional deficiency. METHODS: The records of 111 formerly asbestos-exposed workers who had been examined at the Institute for Occupational and Maritime Medicine, Hamburg, Germany, with data on spirometry, DLCO and TCT were reviewed. Workers with substantial comorbidities (cardiac, malignant, silicosis) and/or pulmonary emphysema (pulmonary hyperinflation and/or TCT findings), which, like asbestosis, can lead to a diffusion disorder were excluded. The remaining data of 41 male workers (mean 69.8 years ±6.9) were evaluated. The TCT changes were coded according to the International Classification of High-resolution Computed Tomography for Occupational and Environmental Respiratory Diseases (ICOERD) by radiologists and ICOERD-scores for pleural and pulmonary changes were determined. Correlations (ρ), Cohens κ and accuracy were calculated. RESULTS: In all 41 males the vital capacity (VC in % of the predicted value (% pred.)) showed only minor limitations (mean 96.5 ± 18.0%). The DLCO (in % pred.) was slightly reduced (mean 76.4 ± 16.6%; median 80.1%); the alveolar volume related value (DLCO/VA) was within reference value (mean 102 ± 22%). In the TCT of 27 workers pleural asbestos-related findings were diagnosed whereof 24 were classified as pulmonary fibrosis (only one case with honey-combing). Statistical analysis provided low correlations of VC (ρ = - 0.12) and moderate correlations of DLCO (- 0.25) with pleural plaque extension. The ICOERD-score for pulmonary fibrosis correlated low with VC (0.10) and moderate with DLCO (- 0.23); DLCO had the highest accuracy with 73.2% and Cohens κ with 0.45. DLCO/VA showed no correlations to the ICOERD-score. The newly developed score, which takes into account the diffuse pleural thickening, shows a moderate correlation with the DLCO (ρ = - 0.35, p < 0.05). CONCLUSIONS: In formerly asbestos-exposed workers, lung function alterations and TCT findings correlated moderate, but significant using DLCO and ICOERD-score considering parenchymal ligaments, subpleural curvilinear lines, round atelectases and pleural effusion in addition to pleural plaque extension. DLCO also showed highest accuracy in regard to pulmonary findings. However, VC showed only weaker correlations although being well established for early detection. Besides TCT the determination of both lung function parameters (VC and DLCO) is mandatory for the early detection and assessment of functional deficiencies in workers formerly exposed to asbestos.

Musculoskeletal pain among offshore wind industry workers: a cross-sectional study.

OBJECTIVE: To assess whether there are differences in musculoskeletal pain among different types of occupations offshore and their relationship to ergonomic demands. METHODS: We conducted a web-based cross-sectional survey among workers from offshore wind energy companies operating within the German exclusive economic zone. We selected workers with regular offshore commitments and at least 28 days spent offshore in the past year (n = 268). Musculoskeletal pain was assessed using the Subjective Health Complaints inventory (SHC), which considers the past month. RESULTS: Of the 268 male participants eligible for analysis, 54% reported back pain 50.4% neck pain, 40.3% lower back pain, 35.5% shoulder, 23.3% arm and 22.1% leg pain, all of them during the past month. Compared to other offshore occupations, technicians reported more frequently arm (OR 3.13; 95% CI 1.58-6.19), back (OR 1.97; 95% CI 1.15-3.39), shoulder (OR 1.94; 95% CI 1.11-3.40) and neck pain (OR 1.89; 95% CI 1.11-3.22). After adjusting for age and nationality, lifting and carrying heavy loads were associated with all types of pain except leg pain. Overhead work, work in awkward postures, and the use of personal protection equipment and heavy tools was associated with shoulder, back and arm pain. CONCLUSIONS: Our findings suggest that occupational health counselling, health promotion and preventive interventions of offshore wind energy workers needs to consider the specific tasks of the employee and be particularly tailored to the ergonomic needs of technicians.

Development of the Metabolic Syndrome: Study Design and Baseline Data of the Lufthansa Prevention Study (LUPS), A Prospective Observational Cohort Survey.

The Lufthansa Prevention Study (LUPS) study is a prospective observation of a healthy worker cohort to identify early changes in metabolism leading to the Metabolic Syndrome (MetS) and to analyze their relation to behavioral factors like nutrition, physical activity, psychological status, and to underlying genetic conditions. The LUPS study recruited a sample of 1.962 non-diabetic healthy adults between 25-60 years, employed at a flight base of Lufthansa Technik GmbH in Hamburg, Germany. Baseline assessments included anthropometric measures, blood and urine samples and medical history. Psychosocial variables, dietary habits and life-style risk factors were assessed via self-reported questionnaires.In this report we describe the study design and present baseline parameters including the prevalence of the MetS using different classification criteria. The MetS was present in 20% of male and 12% of female subjects according to the 'Harmonizing the metabolic syndrome' definition. The prevalence varies between 2.6% in male and 2.3% in female subjects up to 48% in male and 41% in female subjects according to different classification criteria of MetS.In conclusion, this first cross-sectional view on the LUPS data confirms the expectation that this cohort is rather healthy and thus provides the opportunity to analyze early changes associated with the development of the MetS. The LUPS study is registered as a clinical trial NCT01313156.

Phenotyping Occupational Asthma Caused by Acrylates in a Multicenter Cohort Study.

BACKGROUND: While acrylates are well-known skin sensitizers, they are not classified as respiratory sensitizers although several cases of acrylate-induced occupational asthma (OA) have been reported. OBJECTIVE: To evaluate the characteristics of acrylate-induced OA in a large series of cases and compare those with OA induced by other low-molecular-weight (LMW) agents. METHODS: Jobs and exposures, clinical and functional characteristics, and markers of airway inflammation were analyzed in an international, multicenter, retrospective cohort of subjects with OA ascertained by a positive inhalation challenge to acrylates (n = 55) or other LMW agents (n = 418) including isocyanates (n = 125). RESULTS: Acrylate-containing glues were the most prevalent products, and industrial manufacturing, dental work, and beauty care were typical occupations causing OA. Work-related rhinitis was more common in acrylate-than in isocyanate-induced asthma (P < .001). The increase in postchallenge fractional exhaled nitric oxide was significantly greater in acrylate-induced OA (26.0; 8.2 to 38.0 parts per billion [ppb]) than in OA induced by other LMW agents (3.0; -1.0 to 10.0 ppb; P < .001) or isocyanates (5.0; 2.0 to 16.0 ppb; P = .010). Multivariable models confirmed that OA induced by acrylates was significantly and independently associated with a postchallenge increase in fractional exhaled nitric oxide (≥17.5 ppb). CONCLUSIONS: Acrylate-induced OA shows specific characteristics, concomitant work-related rhinitis, and exposure-related increases in fractional exhaled nitric oxide, suggesting that acrylates may induce asthma through different immunologic mechanisms compared with mechanisms through which other LMW agents may induce asthma. Our findings reinforce the need for a reevaluation of the hazard classification of acrylates, and further investigation of the pathophysiological mechanisms underlying their respiratory sensitizing potential.

Severe Occupational Asthma: Insights From a Multicenter European Cohort.

BACKGROUND: Although sensitizer-induced occupational asthma (OA) accounts for an appreciable fraction of adult asthma, the severity of OA has received little attention. OBJECTIVE: The aim of this study was to characterize the burden and determinants of severe OA in a large multicenter cohort of subjects with OA. METHODS: This retrospective study included 997 subjects with OA ascertained by a positive specific inhalation challenge completed in 20 tertiary centers in 11 European countries during the period 2006 to 2015. Severe asthma was defined by a high level of treatment and any 1 of the following criteria: (1) daily need for a reliever medication, (2) 2 or more severe exacerbations in the previous year, or (3) airflow obstruction. RESULTS: Overall, 162 (16.2%; 95% CI, 14.0%-18.7%) subjects were classified as having severe OA. Multivariable logistic regression analysis revealed that severe OA was associated with persistent (vs reduced) exposure to the causal agent at work (odds ratio [OR], 2.78; 95% CI, 1.50-5.60); a longer duration of the disease (OR, 1.04; 95% CI, 1.00-1.07); a low level of education (OR, 2.69; 95% CI, 1.73-4.18); childhood asthma (OR, 2.92; 95% CI, 1.13-7.36); and sputum production (OR, 2.86; 95% CI, 1.87-4.38). In subjects removed from exposure, severe OA was associated only with sputum production (OR, 3.68; 95% CI, 1.87-7.40); a low education level (OR, 3.41; 95% CI, 1.72-6.80); and obesity (OR, 1.98; 95% CI, 0.97-3.97). CONCLUSIONS: This study indicates that a substantial proportion of subjects with OA experience severe asthma and identifies potentially modifiable risk factors for severe OA that should be targeted to reduce the adverse impacts of the disease.

Are high- and low-molecular-weight sensitizing agents associated with different clinical phenotypes of occupational asthma?

BACKGROUND: High-molecular-weight (HMW) proteins and low-molecular-weight (LMW) chemicals can cause occupational asthma (OA) although few studies have thoroughly compared the clinical, physiological, and inflammatory patterns associated with these different types of agents. The aim of this study was to determine whether OA induced by HMW and LMW agents shows distinct phenotypic profiles. METHODS: Clinical and functional characteristics, and markers of airway inflammation were analyzed in an international, multicenter, retrospective cohort of subjects with OA ascertained by a positive inhalation challenge response to HMW (n = 544) and LMW (n = 635) agents. RESULTS: Multivariate logistic regression analysis showed significant associations between OA caused by HMW agents and work-related rhinitis (OR [95% CI]: 4.79 [3.28-7.12]), conjunctivitis (2.13 [1.52-2.98]), atopy (1.49 [1.09-2.05]), and early asthmatic reactions (2.86 [1.98-4.16]). By contrast, OA due to LMW agents was associated with chest tightness at work (2.22 [1.59-3.03]), daily sputum (1.69 [1.19-2.38]), and late asthmatic reactions (1.52 [1.09-2.08]). Furthermore, OA caused by HMW agents showed a higher risk of airflow limitation (1.76 [1.07-2.91]), whereas OA due to LMW agents exhibited a higher risk of severe exacerbations (1.32 [1.01-1.69]). There were no differences between the two types of agents in the baseline sputum inflammatory profiles, but OA caused by HMW agents showed higher baseline blood eosinophilia and a greater postchallenge increase in fractional nitric oxide. CONCLUSION: This large cohort study describes distinct phenotypic profiles in OA caused by HMW and LMW agents. There is a need to further explore differences in underlying pathophysiological pathways and outcome after environmental interventions.