Experts disagree about the optimal classification of upper limb disorders (ULDs). To explore whether differential response to treatments offers a basis for choosing between case definitions, we analysed previously published research.
We screened 183 randomised controlled trials (RCTs) of treatments for ULDs, identified from the bibliographies of 10 Cochrane reviews, four other systematic reviews, and a search in Medline, Embase, and Google Scholar to June 2010. From these, we selected RCTs which allowed estimates of benefit (expressed as relative risks (RRs)) for >1 case definition to be compared when other variables (treatment, comparison group, follow-up time, outcome measure) were effectively held constant. Comparisons of RRs for paired case definitions were summarised by their ratios, with the RR for the simpler and broader definition as the denominator.
Two RCT reports allowed within-trial comparison of RRs and thirteen others allowed between-trial comparisons. Together these provided 17 ratios of RRs (five for shoulder treatments, 12 for elbow treatments, none for wrist/hand treatments). The median ratio of RRs was 1.0 (range 0.3 to 1.7; interquartile range 0.6 to 1.3).
Although the evidence base is limited, our findings suggest that for musculoskeletal disorders of the shoulder and elbow, clinicians in primary care will often do best to apply simpler and broader case definitions. Researchers should routinely publish secondary analyses for subgroups of patients by different diagnostic features at trial entry, to expand the evidence base on optimal case definitions for patient management.
OBJECTIVES: To establish consensus case definitions for several common work related upper limb pain syndromes for use in surveillance or studies of the aetiology of these conditions. METHODS: A group of healthcare professionals from the disciplines interested in the prevention and management of upper limb disorders were recruited for a Delphi exercise. A questionnaire was used to establish case definitions from the participants, followed by a consensus conference involving the core group of 29 people. The draft conclusions were recirculated for review. RESULTS: Consensus case definitions were agreed for carpal tunnel syndrome, tenosynovitis of the wrist, de Quervain's disease of the wrist, epicondylitis, shoulder capsulitis (frozen shoulder), and shoulder tendonitis. The consensus group also identified a condition defined as "non-specific diffuse forearm pain" although this is essentially a diagnosis made by exclusion. The group did not have enough experience of the thoracic outlet syndrome to make recommendations. CONCLUSIONS: There was enough consensus between several health professionals from different disciplines to establish case definitions suitable for use in the studies of several work related upper limb pain syndromes. The use of these criteria should allow comparability between studies and centres and facilitate research in this field. The criteria may also be useful in surveillance programmes and as aids to case management.
Scientific evidence supports an association between environmental exposures and cancer. However, a reliable estimate for the proportion of cancers attributable to environmental factors is currently unavailable. This may be related to the varying definitions of the term “environment.” The current review aims to determine how the reporting of the definition of the environment and of the estimates of environmentally attributable risks have changed over the past 50 years.
A systematic literature search was performed to retrieve all relevant publications relating to the environment and cancer from January 1960 to December 2010 using PubMed, EMBASE, Scopus, and Web of Science. Definitions of the environment and environmentally attributable risks for cancer were extracted from each relevant publication.
The search resulted in 261 relevant publications. We found vast discrepancies in the definition of the environment, ranging from broad (including lifestyle factors, occupational exposures, pollutants, and other non-genetic factors) to narrow (including air, water, and soil pollutants). Reported environmentally attributable risk estimates ranged from 1–100%.
Our findings emphasize the discrepancies in reporting environmental causation of cancer and the limits of inference in interpreting environmentally attributable risk estimates. Rather than achieving consensus on a single definition for the environment, we suggest the focus be on achieving transparency for any environmentally attributable risks.
cancer; environmental exposures; environmental health risks; epidemiology; public health
To estimate the current occupational cancer burden due to past exposures in Britain, estimates of the number of exposed workers at different levels are required, as well as risk estimates of cancer due to the exposures. This paper describes the methods and results for estimating the historical exposures. All occupational carcinogens or exposure circumstances classified by the International Agency for Research on Cancer as definite or probable human carcinogens and potentially to be found in British workplaces over the past 20–40 years were included in this study. Estimates of the number of people exposed by industrial sector were based predominantly on two sources of data, the CARcinogen EXposure (CAREX) database and the UK Labour Force Survey. Where possible, multiple and overlapping exposures were taken into account. Dose–response risk estimates were generally not available in the epidemiological literature for the cancer–exposure pairs in this study, and none of the sources available for obtaining the numbers exposed provided data by different levels of exposure. Industrial sectors were therefore assigned using expert judgement to ‘higher'- and ‘lower'-exposure groups based on the similarity of exposure to the population in the key epidemiological studies from which risk estimates had been selected. Estimates of historical exposure prevalence were obtained for 41 carcinogens or occupational circumstances. These include exposures to chemicals and metals, combustion products, other mixtures or groups of chemicals, mineral and biological dusts, physical agents and work patterns, as well as occupations and industries that have been associated with increased risk of cancer, but for which the causative agents are unknown. There were more than half a million workers exposed to each of six carcinogens (radon, solar radiation, crystalline silica, mineral oils, non-arsenical insecticides and 2,3,7,8-tetrachlorodibenzo-p-dioxin); other agents to which a large number of workers are exposed included benzene, diesel engine exhaust and environmental tobacco smoke. The study has highlighted several industrial sectors with large proportions of workers potentially exposed to multiple carcinogens. The relevant available data have been used to generate estimates of the prevalence of past exposure to occupational carcinogens to enable the occupational cancer burden in Britain to be estimated. These data are considered adequate for the present purpose, but new data on the prevalence and intensity of current occupational exposure to carcinogens should be collected to ensure that future policy decisions be based on reliable evidence.
occupation; carcinogens; exposure
A recent review concluded that the evidence from epidemiology studies was indeterminate and that additional studies were required to support the diesel exhaust-lung cancer hypothesis. This updated review includes seven recent studies. Two population-based studies concluded that significant exposure-response (E-R) trends between cumulative diesel exhaust and lung cancer were unlikely to be entirely explained by bias or confounding. Those studies have quality data on life-style risk factors, but do not allow definitive conclusions because of inconsistent E-R trends, qualitative exposure estimates and exposure misclassification (insufficient latency based on job title), and selection bias from low participation rates. Non-definitive results are consistent with the larger body of population studies. An NCI/NIOSH cohort mortality and nested case-control study of non-metal miners have some surrogate-based quantitative diesel exposure estimates (including highest exposure measured as respirable elemental carbon (REC) in the workplace) and smoking histories. The authors concluded that diesel exhaust may cause lung cancer. Nonetheless, the results are non-definitive because the conclusions are based on E-R patterns where high exposures were deleted to achieve significant results, where a posteriori adjustments were made to augment results, and where inappropriate adjustments were made for the “negative confounding” effects of smoking even though current smoking was not associated with diesel exposure and therefore could not be a confounder. Three cohort studies of bus drivers and truck drivers are in effect air pollution studies without estimates of diesel exhaust exposure and so are not sufficient for assessing the lung cancer-diesel exhaust hypothesis. Results from all occupational cohort studies with quantitative estimates of exposure have limitations, including weak and inconsistent E-R associations that could be explained by bias, confounding or chance, exposure misclassification, and often inadequate latency. In sum, the weight of evidence is considered inadequate to confirm the diesel-lung cancer hypothesis.
Cumulative exposure; diesel exhaust; elemental carbon; epidemiology; exposure-response; latency; lung cancer; odds ratio
Thirty-five necropsied cases of diffuse malignant mesothelioma of pleura and six cases of mesothelioma of peritoneum are reported. Occupational histories from 40 cases showed that 32 cases (80%) were definitely exposed to asbestos; six cases (15%) were probably exposed and two (5%) had no known exposure. The mean latent interval was 34 years. Occupational histories of 56 control patients matched in pairs for age and sex with 28 of the mesothelioma cases revealed definite exposure to asbestos in 12 controls (21%), probable exposure in 11 (20%), and no evidence of exposure in 33 (59%). The difference in incidence of exposure between mesotheliomas and controls is statistically highly significant. Six-micron histological sections of lung, available in 39 mesothelioma cases, contained coated asbestos fibres in 36 cases (92%). Sixteen cases of mesothelioma showing fibres were free of asbestosis; asbestosis was slight in 14 cases, moderately severe in five cases, and severe in one case. The incidence of asbestos bodies in sections from mesothelioma cases was significantly higher than in a previously reported series of routine necropsies examined by lung smear.
Counts of coated and uncoated asbestos fibres were performed on samples of lung tissue from 33 mesothelioma cases. No fibres were identified in one case and only occasional coated fibres in a second case. The remainder gave counts ranging from 154 thousand to 684 million fibres per gram dry weight. Uncoated fibres were invariably present and usually comprised 50 to 80% of the count. No relationship was found between total fibre count and the latent period of the mesothelioma. Fibre counts were also performed on lung samples from 18 smear-positive and 30 smear-negative routine necropsies. Cases with numerous coated fibres in the smear gave total fibre counts similar to those of mesothelioma cases without asbestosis. Routine cases with only one fibre in the smear usually yielded only occasional fibres on analysis. Coated and uncoated fibres were found in 13 out of 30 smear-negative cases, indicating a true incidence of 56% of exposure to asbestos in the whole necropsy series. When compared with the mesothelioma series the difference in incidence of fibres remains statistically significant.
The data suggest that, on Tyneside, exposure to asbestos sufficient to cause an appreciable risk of developing mesothelioma has usually occurred through occupational exposure rather than by general environmental pollution by asbestos.
A case control study on patients with soft tissue sarcoma and malignant lymphoma was undertaken to test whether there was any association between these diseases and past exposure to chlorinated phenoxy acid herbicides or chlorophenols. It was carried out over the period 1982-1988 in Victoria, Australia. Thirty males with soft tissue sarcoma and 52 males with malignant lymphoma were matched by age, place of residence and sex with one population control and one cancer control each. Exposure was assessed by personal interviews conducted by an occupational hygienist. Exposures within 5 years prior to diagnosis of each matched case were ignored, both for the cases and their matched controls. The estimated relative risks for definite or probable exposure to chlorinated phenoxy compounds or chlorophenols for at least 1 day were 1.0 (95% confidence interval (CI): 0.3-3.1) for soft tissue sarcoma and 1.5 (95% CI: 0.6-3.7) for malignant lymphoma. When the criterion for exposure was raised to more than 30 days, the estimated relative risks were 2.0 (95% CI: 0.5-8.0) for soft tissue sarcoma and 2.7 (95% CI: 0.7-9.6) for malignant lymphoma. Additional analyses were carried out for exposure of at least 1 day to phenoxy herbicides alone or chlorophenols alone. None of the estimated relative risks was significantly greater than unity.
To identify efficient PubMed search strategies to retrieve articles regarding putative occupational determinants of conditions not generally considered to be work related.
Based on MeSH definitions and expert knowledge, we selected as candidate search terms the four MeSH terms describing ‘occupational disease’, ‘occupational exposure’, ‘occupational health’ and ‘occupational medicine’ (DEHM) alongside 22 other promising terms. We first explored overlaps between the candidate terms in PubMed. Using random samples of abstracts retrieved by each term, we estimated the proportions of articles containing potentially pertinent information regarding occupational aetiology in order to formulate two search strategies (one more ‘specific’, one more ‘sensitive’). We applied these strategies to retrieve information on the possible occupational aetiology of meningioma, pancreatitis and atrial fibrillation.
Only 20.3% of abstracts were retrieved by more than one DEHM term. The more ‘specific’ search string was based on the combination of terms that yielded the highest proportion (40%) of potentially pertinent abstracts. The more ‘sensitive’ string was based on the use of broader search fields and additional coverage provided by other search terms under study. Using the specific string, the numbers of abstracts needed to read to find one potentially pertinent article were 1.2 for meningioma, 1.9 for pancreatitis and 1.8 for atrial fibrillation. Using the sensitive strategy, the numbers needed to read were 4.4 for meningioma, 8.9 for pancreatitis and 10.5 for atrial fibrillation.
The proposed strings could help health care professionals explore putative occupational aetiology for diseases that are not generally thought to be work related.
Bibliometrics; PubMed; utilisation; disease; aetiology; evidence-based practice; methods; occupational medicine; methods; occupational health practice; computers and information technology
A few studies have investigated a possible relationship between Alzheimer's disease (AD) and occupations with extremely low frequency magnetic field (MF) exposure. The purpose of this study was to further evaluate this possible association in a large patient population with expert diagnoses.
Subjects came from the 8 of the 9 California Alzheimer's Disease Diagnostic and Treatment Centers not previously used in an earlier study. Cases had probable or definite AD; controls primarily had a dementia-related problem other than vascular dementia (VaD) and some were not demented upon expert examination. Occupations were classified as having low, medium or high MF exposure, based upon previous research, replicating the exposure methodology used in our previous published studies.
Occupational information was available for 98.6% of the 1527 cases and 98.5% of the 404 controls with age-at-initial examination known to be at least 65. Among cases, 2.1% and 5.4% had high and medium occupational MF exposure, respectively, while among controls the percentages were 0.8% and 3.0%. In univariate analyses, the odds ratio (OR) for subjects with medium or high MF exposures combined was 2.1 (p < 0.01), while for high exposure alone the OR was 2.9 (p < 0.08). Two models were used in multivariate analyses, with gender, stroke, and either age-at-onset or age-at-initial examination as covariates. The ORs for MF exposure varied little between the two models: 2.2 (p < 0.02) and 1.9 (p < 0.03) for medium or high exposure; 2.7 (p < 0.11) and 3.2 (p < 0.12) for high exposure. OR estimates for females were higher than for males, but not significantly higher. There were no material differences between the ORs resulting from univariate and multivariate analyses.
Elevated occupational MF exposure was associated with an increased risk of AD. Based on previous published studies, the results likely pertain to the general population.
An epidemiological surveillance system for work-related musculoskeletal disorders (MSDs) was implemented in 2002 in France’s Pays de la Loire region to assess the incidence and prevalence of MSDs in the general and working populations, identify levels of exposure to occupational risk factors and investigate the proportion of cases attributable to work exposure.
The program combines (1) surveillance of sentinel health events in the general population (carpal tunnel syndrome (CTS) was the sentinel event for upper limb MSDs), (2) assessment of the prevalence of the main upper limb MSDs and their risk factors in the workplace based on a network of occupational physicians and (3) registration of the notification of work-related diseases (WRDs).
1168 incident cases of CTS were included over a 3 year period. The estimated incidence of CTS was 1.00 per 1000 person-years in those aged 20–59 years (0.60 in men and 1.40 in women). The incidence rate was higher in employed than unemployed persons in the year of diagnosis (0.6 per 1000 vs 0.3 in men and 1.7 vs 0.8 in women). The occupational physician network noted high prevalence rates: 11% of men and 15% of women had at least one of the six main upper limb clinically-diagnosed MSDs. The WRD survey showed that MSDs represented 65% of notified WRDs.
The Pays de la Loire program plays a significant role in informing the authorities and the public about the state of current MSDs. It is planned to extend it to a routine national surveillance program.
OBJECTIVES: To determine the association between maternal occupational exposure to anaesthetic gases and risk of spontaneous abortion. METHODS: A meta-analysis was performed of published epidemiological studies identified from literature reviews, unsystematic perusal of reference lists of relevant publications, and two Medline searches (1984-92, keywords: anaesthetic gases; anaesthetics; anaesthetics, local; operating rooms; operating room nursing; pregnancy; abortion; 1985-92, keywords: anaesthetics; adverse effects; occupational exposure; anaesthesia, inhalation; operating room nursing; pregnancy; abortion). All peer reviewed studies were retained. Student theses were excluded, as were conference abstracts, unpublished material, and two studies in which data on paternal and maternal occupational exposures were pooled. The relative risk of spontaneous abortion was estimated. RESULTS: One study found no increase in risk of abortion when gases were scavenged or when the exposure to unscavenged gases was low. None of the studies included ambient gas sampling. 24 comparisons between exposed and unexposed women, obtained from 19 reports, were included. The overall relative risk was 1.48 (95% confidence interval (95% CI), 1.4 to 1.58). To test whether this result was influenced by the quality of the studies, the validity of the reviewed papers was rated on the basis of three criteria: appropriateness of the unexposed comparison group, control for non-occupational confounding variables, and response rate. The estimate of risk increased to 1.9 (95% CI, 1.72 to 2.09) when analysis was restricted to the six comparisons which were rated the most rigorous. CONCLUSIONS: Epidemiological studies based on data obtained in the prescavenging era indicate an increased risk of spontaneous abortion. The estimated increased risk was not diminished but rather increased by exclusion of the more methodologically flawed studies.
Working youths face many safety and health risks. Among these risks are those posed by disinfectant exposures. In this study we describe acute occupational disinfectant-related illness among youth. Data on U.S. children younger than 18 years with acute occupational disinfectant-related illnesses between 1993 and 1998 were collected from the Toxic Exposure Surveillance System and from the California Department of Pesticide Regulation. We analyzed data from persons with exposures who met the case definition for acute occupational disinfectant-related illness. The case definition required onset of new adverse health effects that were both temporally related to a disinfectant exposure and consistent with the known toxicology of the disinfectant. We calculated incidence rates of acute occupational disinfectant-related illness among youths 15-17 years old and incidence rate ratios to compare these rates with those of adults 25-44 years old. We found 307 children with disinfectant-related illnesses. The average annual incidence rate was 16.8/billion hours worked with a relative risk compared with adults of 4.14 (95% confidence interval, 3.66-4.68). Most illnesses were of mild severity (78%). There were no fatalities. Hypochlorites (e.g., bleach) were responsible for 45% of the illnesses. Among the 206 cases where the responsible disinfectant's U.S. Environmental Protection Agency toxicity category was known, 80% were in category I (highest toxicity level). These findings suggest the need for greater efforts to prevent adolescent acute occupational disinfectant-related illness. This may require strengthening regulations and enforcement as well as increased educational efforts directed at employers, youths, parents, school officials, and physicians. Better mechanisms for reporting and tracking chemical illnesses among working adolescents are also needed.
Prospective epidemiologic studies have characterized major risk factors for incident diabetes by a variety of diabetes case definitions. Whether different definitions alter the association of diabetes with risk factors is largely unknown. Using 1987–1998 data from the ongoing Atherosclerosis Risk in Communities (ARIC) Study, the authors assessed the relation of traditional risk factors with 3 different diabetes case definitions and 4 fasting glucose categories. They compared the study protocol case definition with 2 nested case definitions, self-reported diabetes and a multiple-evidence definition. Significant differences in risk factor associations by case definition and by screening cutpoints were observed. Specifically, the magnitude of the association between the risk factors (baseline metabolic syndrome, fasting glucose, blood pressure, body mass index, and serum insulin) and incident diabetes differed by case definition. Associations with these risk factors were weaker with a case definition based on self-report compared with other definitions. These results illustrate the potential limitations of case definitions that rely solely on self-report or those that incorporate measured glucose values to ascertain undiagnosed cases. Although the ability to identify risk factors of diabetes was consistent for the case definitions studied, tests of novel risk factors may result in different estimates of effect sizes depending on the definition used.
diabetes mellitus, type 2; epidemiologic methods
OBJECTIVE—Our objective was to perform a quantitative review of prospective studies examining the association between the metabolic syndrome and incident diabetes.
RESEARCH DESIGN AND METHODS—Using the title terms “diabetes” and “metabolic syndrome” in PubMed, we searched for articles published since 1998.
RESULTS—Based on the results from 16 cohorts, we performed a meta-analysis of estimates of relative risk (RR) and incident diabetes. The random-effects summary RRs were 5.17 (95% CI 3.99–6.69) for the 1999 World Health Organization definition (ten cohorts); 4.45 (2.41–8.22) for the 1999 European Group for the Study of Insulin Resistance definition (four cohorts); 3.53 (2.84–4.39) for the 2001 National Cholesterol Education Program definition (thirteen cohorts); 5.12 (3.26–8.05) for the 2005 American Heart Association/National Heart, Lung, and Blood Institute definition (five cohorts); and 4.42 (3.30–5.92) for the 2005 International Diabetes Federation definition (nine cohorts). The fixed-effects summary RR for the 2004 National Heart, Lung, and Blood Institute/American Heart Association definition was 5.16 (4.43–6.00) (six cohorts). Higher number of abnormal components was strongly related to incident diabetes. Compared with participants without an abnormality, estimates of RR for those with four or more abnormal components ranged from 10.88 to 24.4. Limited evidence suggests fasting glucose alone may be as good as metabolic syndrome for diabetes prediction.
CONCLUSIONS—The metabolic syndrome, however defined, has a stronger association with incident diabetes than that previously demonstrated for coronary heart disease. Its clinical value for diabetes prediction remains uncertain.
Adherence to urate-lowering drugs (ULDs) has not been well evaluated among those with gout. Our aim was to assess the level and determinants of non-adherence with ULDs prescribed for gout.
We identified persons using two integrated delivery systems aged 18 years or older with a diagnosis of gout who initiated use of allopurinol, probenecid or sulfinpyrazone from 1 January 2000 to 30 June 2006. Non-adherence was measured using the medication possession ratio (MPR) over the first year of therapy and defined as an MPR < 0.8. Descriptive statistics were calculated and logistic regression was used to estimate the strength of the association between patient characteristics and non-adherence.
A total of 4,166 gout patients initiated ULDs; 97% received allopurinol. Median MPR for any ULD use was 0.68 (interquartile range (IQR) 0.64). Over half of the patients (56%) were non-adherent (MPR < 0.8). In adjusted analyses, predictors of poor adherence included younger age (odds ratio (OR) 2.43, 95% confidence interval (CI) 1.86 to 3.18 for ages <45 and OR 1.44, 95% CI 1.08 to 1.93 for ages 45 to 49), fewer comorbid conditions (OR 1.46, 95% CI 1.20 to 1.77), no provider visits for gout prior to urate-lowering drug initiation (OR 1.28, 95% CI 1.05 to 1.55), and use of non-steroidal anti-inflammatory drugs in the year prior to urate-lowering drug initiation (OR 1.15, 95% CI 1.00 to 1.31).
Non-adherence amongst gout patients initiating ULDs is exceedingly common, particularly in younger patients with less comorbidity and no provider visits for gout prior to ULD initiation. Providers should be aware of the magnitude of non-adherence with ULDs.
OBJECTIVES—To test associations between non-specific low back pain and several risk factors when definitions of low back pain vary.
DESIGN/SETTING/PARTICIPANTS—A cross sectional study was set up in 1991, 725 workers from four occupational sectors answered a self administrated questionnaire including the Nordic questionnaire and questions about intensity of pain and individual and occupational factors.
MAIN RESULTS—Prevalence of low back pain varied from 8% to 45% according to the definition used. Psychosomatic problems, bending or carrying loads were often associated to low back pain, whereas other risk factors were related to some specific dimensions of the disorder.
CONCLUSIONS—Risk factors of low back pain vary with the definition. This could explain inconsistencies found in literature reviews. To be able to compare data, it seems important to be precise what definition is used and to use comparable questionnaires.
Keywords: epidemiology; low back pain; definition; risk factors
In a case referent study of about 600 cases of male lung cancer in northern Sweden the risk in professional drivers was specifically studied. Data concerning occupations, time and type of employment, and smoking habits were collected by questionnaires directed to close relatives. On average, professional drivers were heavier smokers and this was the chief cause of a slightly increased crude risk ratio in the study as a whole. Smoking drivers in an upper age group (70 and over) had a high relative risk of lung cancer, whereas in a lower age group (under 70) no significant increase was found. The relative risk in non-smoking drivers in the upper age group was moderately raised with borderline statistical significance. The high relative risk estimated for smoking drivers in the upper age group suggests a synergistic effect between smoking and occupational exposure.
To evaluate the possible association between pesticides and the risk of childhood cancers, epidemiologic studies published between 1970 and 1996 were critically reviewed. Thirty-one studies investigated whether occupational or residential exposure to pesticides by either parents or children was related to increased risk of childhood cancer. In general, the reported relative risk estimates were modest. Risk estimates appeared to be stronger when pesticide exposure was measured in more detail. Frequent occupational exposure to pesticides or home pesticide use was more strongly associated with both childhood leukemia and brain cancer than either professional exterminations or the use of garden pesticides. Occupational pesticide exposure was also associated with increased risk of Wilms' tumor, Ewing's sarcoma, and germ cell tumors. Residence on a farm, a proxy for pesticide exposure, was associated with increased risk of a number of childhood cancers. Although increased risk of some childhood cancers in association with pesticide exposure is suggested by multiple studies, methodological limitations common to many studies restrict conclusions; these include indirect exposure classification, small sample size, and potential biases in control selection. Opportunities for methodologic improvement in future studies of pesticides and childhood cancers are described.
Torture has been defined most precisely in legal contexts. Practitioners who work with torture survivors and researchers who study torture have frequently cited legal definitions, particularly those in the United States’ Torture Victims Relief Act, the United Nations Convention against Torture, or the World Medical Association’s Declaration of Tokyo. Few practitioners have operationalized these definitions and applied them in their practice. We describe how a New York City torture treatment clinic used a coding checklist that operationalizes the definitions, and present results. We found that in practice these definitions were nested; that using guidelines for applying the definitions in practice altered the number of cases meeting criteria for these definitions; and that the severity of psychological symptoms did not differ between those who were tortured and those who were not under any definition. We propose theoretical and practical implications of these findings.
torture definition; torture criteria; treatment; clinical practice; screening instruments
The purpose of this article was to provide a literature review of occupational neurological disorders and related research in Korea, focusing on chemical hazards. We reviewed occupational neurological disorders investigated by the Occupational Safety and Health Research Institute of Korean Occupational Safety and Health Agency between 1992 and 2009, categorizing them as neurological disorders of the central nervous system (CNS), of the peripheral nervous system (PNS) or as neurodegenerative disorders. We also examined peer-reviewed journal articles related to neurotoxicology, published from 1984 to 2009. Outbreaks of occupational neurological disorder of the CNS due to inorganic mercury and carbon disulfide poisoning had helped prompt the development of the occupational safety and health system of Korea. Other major neurological disorders of the CNS included methyl bromide intoxication and chronic toxic encephalopathy. Most of the PNS disorders were n-hexane-induced peripheral neuritis, reported from the electronics industry. Reports of manganese-induced Parkinsonism resulted in the introduction of neuroimaging techniques to occupational medicine. Since the late 1990s, the direction of research has been moving toward degenerative disorder and early effect of neurotoxicity. To understand the early effects of neurotoxic chemicals in the preclinical stage, more follow-up studies of a longer duration are necessary.
Neurotoxic Chemicals; Korea; Carbon Disulfide; Manganese; n-Hexane; CNS; PNS; Neurodegenerative Disorders
Cutaneous melanoma (CM) is a cancer usually associated with high socio-economic level in the literature. Few studies have, however, assessed this relationship by gender and site or the association between CM and rurality.
A major-sized historical occupational Swedish cohort comprising 2,992,166 workers was used to estimate relative risk of cutaneous melanoma, broken down by gender and anatomical site, for occupational sectors (as a proxy of socio-economic class) and rurality. To this end, Poisson models were fitted for each site in men and women, including occupational sector and town size, with adjustment for age, period of diagnosis and geographical area as possible confounding factors.
White collar workers presented a marked increased of risk in men in all melanoma cases, as well as in trunk, upper and lower limbs. This pattern was less clear for women, in which some heterogeneity appeared, as low risks in lower socioeconomic sectors in trunk, or risk excesses in white collar workers in lower limbs did not achieve statistical significance. Males also showed significant differences in risk by rural/urban distribution, but in women this association was limited to CM of lower limb. Risk of CM of head/neck did not vary by occupational sector or town size, thus depicting a specific epidemiological profile, which proved common to both sexes.
While differences in risk between men and women could suggest greater homogeneity in UV-exposure behaviour among women, the uniform risk pattern in head and neck melanoma, present in both sexes, might support the coexistence of different aetiological pathways, related to anatomical site.
Hypospadias is one of the most common urogenital congenital anomalies affecting baby boys. Prevalence estimates in Europe range from 4 to 24 per 10,000 births, depending on definition, with higher rates reported from the United States. Relatively little is known about potential risk factors, but a role for endocrine-disrupting chemicals (EDCs) has been proposed.
Our goal was to elucidate the risk of hypospadias associated with occupational exposure of the mother to endocrine-disruptor chemicals, use of folate supplementation during pregnancy, and vegetarianism.
We designed a case–control study of 471 hypospadias cases referred to surgeons and 490 randomly selected birth controls, born 1 January 1997–30 September 1998 in southeast England. Telephone interviews of mothers elicited information on folate supplementation during pregnancy and vegetarianism. We used a job exposure matrix to classify occupational exposure.
In multiple logistic regression analysis, there were increased risks for self-reported occupational exposure to hair spray [exposed vs. nonexposed, odds ratio (OR) = 2.39; 95% confidence interval (CI), 1.40–4.17] and phthalate exposure obtained by a job exposure matrix (OR = 3.12; 95% CI, 1.04–11.46). There was a significantly reduced risk of hypospadias associated with of folate use during the first 3 months of pregnancy (OR = 0.64; 95% CI, 0.44–0.93). Vegetarianism was not associated with hypospadias risk.
Excess risks of hypospadias associated with occupational exposures to phthalates and hair spray suggest that antiandrogenic EDCs may play a role in hypospadias. Folate supplementation in early pregnancy may be protective.
endocrine disruptors; hair spray; folate supplementation; hypospadias; occupation
We examined the association between extremely low-frequency magnetic fields (EMF) and the risk of dementia and Alzheimer’s disease using all 9,508 individuals from the Study of Dementia in Swedish Twins (HARMONY) with valid occupational and diagnostic data.
Dementia diagnoses were based on telephone screening followed by in-person clinical workup. Main lifetime occupation was coded according to an established EMF exposure matrix. Covariates were age, gender, education, vascular risk factors, and complexity of work. Based on previous research, data were also analyzed separately for cases with disease onset by age 75 years versus later, men versus women, and those with manual versus nonmanual main occupation. We used generalized estimating equations with the entire sample (to adjust for the inclusion of complete twin pairs) and conditional logistic regression with complete twin pairs only.
Level of EMF exposure was not significantly associated with dementia or Alzheimer’s disease. However, in stratified analyses, medium and high levels of EMF exposure were associated with increased dementia risk compared with low level in cases with onset by age 75 years (odds ratio: 1.94, 95% confidence interval: 1.07–3.65 for medium, odds ratio: 2.01, 95% confidence interval: 1.10–3.65 for high) and in participants with manual occupations (odds ratio: 1.81, 95% confidence interval: 1.06–3.09 for medium, odds ratio: 1.75, 95% confidence interval: 1.00–3.05 for high). Results with 42 twin pairs discordant for dementia did not reach statistical significance.
Occupational EMF exposure appears relevant primarily to dementia with an earlier onset and among former manual workers.
Dementia; Magnetic fields; Occupation; Alzheimer’s disease
The National Urban Air Toxics Research Center (NUATRC) hosted its first scientific workshop in 1994 that focused on possible relationships between air toxics and asthma. From that meeting came recommendations for future research including a need for more complete individual personal exposure assessments so that determinations of personal exposures to pollutants could be made. In the spring of 2001, NUATRC held a second such workshop to review progress made in this area during the intervening 7 years. Peer-reviewed articles from the workshop are published in this issue of (italic)Environmental Health Perspectives Supplements(/italic). As in 1994, academic, government, and industry scientists participated. Dave Guinnup of the Environmental Protection Agency discussed the nature of air toxics, their definition, and the basis for federal regulation. George Leikauf from the University of Cincinnati reviewed the 1994 workshop and subsequent research in this field. Current research funded by NUATRC that is addressing individual personal exposure was presented by Clifford Weisel (Environmental and Occupational Health Sciences Institute, University of Medicine and Dentistry of New Jersey), Patrick Kinney (Columbia University) and Candis Claiborn (Washington State University). David Corry from Baylor College of Medicine highlighted new insights into asthma pathogenesis while Stephen Redd from the Centers for Disease Control presented an overview of asthma epidemiology as well as the societal costs of the disease. Mary White (Agency for Toxic Substances and Disease Registry) discussed recent epidemiologic investigations by public health agencies into community concerns about asthma and hazardous air pollutants. David Peden (University of North Carolina) reviewed scientific studies into the links between asthma and air toxics as well as criteria air pollutants. In a session on occupational asthma, Lee Petsonk (National Institute for Occupational Safety and Health) discussed risk factors for work-related asthma, whereas Ralph Delfino (University of California, Irvine) addressed limitations of extrapolating from occupational asthma to asthma in the general population. These presentations were followed by panel discussions focusing on future research programs, both for NUATRC and similar research institutions. Recommendations for future research included improved assessments of personal exposure to air toxics as well as research focused on specific hazardous air pollutants. The latter recommendation was based on medical literature that suggests certain pollutants from the list of 188 air toxics are most likely to adversely affect respiratory health.
STUDY OBJECTIVE--The aim was to estimate the quantitative impact of working conditions on cardiovascular diseases in Denmark. DESIGN--The study was based on a review of recent epidemiological research publications in which relative risks were estimated and risk factor prevalences were determined. The impact of working conditions was quantified by means of aetiological fractions. SETTING--The aetiological fractions were estimated on the Danish population. MAIN RESULTS--16% of the premature cardiovascular mortality in men and 22% in occupationally active women is avoidable through interventions in the work environment. If "sedentary" work is included in the occupational risk factors, the aetiological fractions reach 51% for men and 55% for women. Taken separately, the major aetiological fractions for cardiovascular risk factors at work are respectively (women in parentheses) 6% (14%) for monotonous high paced work, 7% (7%) for shift work, and 2% (2%) for passive smoking. CONCLUSIONS--The aetiological fractions show that working conditions play a considerable role in cardiovascular diseases. Furthermore they might widen the focus of preventive cardiology from interventions directed only at individual and lifestyle risk factors to interventions directed also at working conditions.