Qualitative Assessment of Perceived Organizational Support for Employed Breast Cancer Survivors

OBJECTIVE

A more detailed understanding of unmet organizational support needs and workplace-based best practices for supporting cancer survivors is needed.

METHODS

Ninety-four working breast cancer survivors responded to an open-ended survey question regarding the desired types of organizational support that were and were not received during early survivorship. We performed content-analysis of qualitative data.

RESULTS

Major themes included instrumental support, emotional support, and time-based support. The need for flexible arrangements and reduced workloads was mostly met. Unmet needs included navigation/coordination, understanding/empathy, and time off for treatment and recovery.

CONCLUSIONS

Organizational support can help cancer survivors manage their health and work roles, diminishing work-health conflict and turnover intent. Study findings can be used to design targeted interventions to fulfill cancer survivors' unmet organizational support needs, which may also apply to workers with other chronic health conditions.

Associations between observed time sitting at work and musculoskeletal symptoms: a repeated-measures study of manufacturing workers

Time sitting at work is known to affect health overall, but its specific effects on musculoskeletal symptoms are unclear. We evaluated the relationship between observed time sitting at work and self-reported musculoskeletal symptoms among 195 manufacturing workers. Longer time sitting at work was significantly associated with lower prevalence of neck/shoulder (prevalence ratio [PR] = 0.70, 95% confidence interval [CI] [0.68, 0.72]; p < 0.001) and arm/wrist/hand (PR = 0.46, 95% CI [0.31, 0.69]; p < 0.001) musculoskeletal symptoms. Associations remained largely unchanged after adjusting for job type or occupational postures and load. Time sitting at work was associated with musculoskeletal symptoms, and should be taken into consideration as part of interventions to prevent musculoskeletal disorders (MSDs) and promote health of manufacturing workers.

Relative Importance of Incivility and Loneliness in Occupational Health Outcomes

Researchers have studied loneliness as a modern health epidemic which is associated with myriad negative health effects, yet the literature lacks evidence of loneliness' correlates, including incivility, in the workplace. This paper not only replicates previous work on incivility, a pervasive interpersonal workplace stressor, it also contributes novel findings on the relative importance of loneliness in explaining variance in occupational health outcomes. We tested hypotheses using two cross-sectional datasets containing data from the general working population (Sample 1) and state corrections supervisors (Sample 2). Through relative importance analyses, including relative weights analysis, we found that both general and workplace loneliness explain substantial variance in several outcomes (e.g., emotional exhaustion, depression symptoms, and turnover intentions) relative to the variance explained by workplace incivility. When controlling for perceived work stress, general loneliness appears to be more important than incivility in explaining variance in emotional exhaustion, job satisfaction, and depression symptoms.

Participatory design of a sleep intervention with correctional supervisors using a root causes approach

BACKGROUND

After a Design Team (DT) conducted a workforce health assessment of correctional supervisors, they selected sleep as an intervention priority, given its numerous health and work consequences. Existing workplace sleep interventions are designed with little worker input, but participatory solutions that incorporate workers' lived experiences and root causes of poor sleep may be more relevant, appropriate, and acceptable to end-users, resulting in better uptake.

METHODS

The DT met bi-monthly to complete the Intervention Design and Analysis Scorecard (IDEAS) tool to brainstorm interventions that address root causes of poor sleep, and evaluate, rank, and select interventions for implementation. We conducted a qualitative review of meeting notes and worksheets from each IDEAS step, and present our findings on root causes and prioritized solutions.

RESULTS

The DT consisted of two university researchers and seven members of a correctional supervisors' union, with 5-9 participants attending each meeting. IDEAS Steps 1-5 were completed in eight meetings over six months. Root causes of poor sleep included mind/body and environmental disruptions, and insufficient time. Three solutions were proposed: training on sleep hygiene, meditation, and sleep debt management; a sleep-tracking smartphone app; and a shared overtime policy based on splitting one 8-hour shift between two supervisors.

CONCLUSIONS

This is the first known application of IDEAS to address sleep, and targeting root causes may result in more efficacious interventions for sleep improvement. Moreover, because IDEAS guides DTs in selecting solutions with the greatest perceived health benefits, reach, cost-effectiveness, and feasibility, it may result in more successful implementation.

Participatory Assessment and Selection of Workforce Health Intervention Priorities for Correctional Supervisors

OBJECTIVE

A team of academics and unionized correctional supervisors collaborated to assess workforce health and determine intervention priorities using participatory methods and tools.

METHODS

Correctional supervisors took a web-based survey. Univariate and bivariate tests examined attitudes/behaviors, exposures, and outcomes most strongly associated with health; risk based on rank within chain-of-command; and health behaviors amenable to change. We used a voting process tool to prioritize intervention topics.

RESULTS

Some health behaviors and outcomes were poor (89% overweight/ obese, 41% poor-quality sleep). We also found favorable health behaviors (annual check-ups) and psychosocial conditions (meaningful work). Some health risks (excessive overtime) were not amenable to change or resisted acknowledgment (poor mental health). The team voted to develop interventions on sleep, mental health, and obesity.

CONCLUSIONS

Comprehensive health assessment informed the prioritization process, enabling the team to quickly reach consensus on intervention priorities.

Critical incident exposure among custody and noncustody correctional workers: Prevalence and impact of violent exposure to work-related trauma

BACKGROUND

Correctional workers are at high risk for exposure to trauma, both as direct violence and as threats to their safety and well-being. The distress associated with these critical incidents (CIs) affects mental and physical health. Current tools are limited for detecting CIs in this workforce and are therefore insufficient for addressing correctional worker trauma.

METHODS

Community prison employees (N = 105) self-reported CIs using the adapted Correctional Worker Critical Incident Survey (CWCIS). We examined: (1) prevalence of CIs and occurrences, (2) differences in exposures to CIs by custody and noncustody staff, and (3) differences in job satisfaction, posttraumatic stress (PTSD), lower back disease, and health behaviors, such as missed work and sleep.

RESULTS

CIs occurred among most staff (59%) and more often for custody staff as compared to noncustody staff. CIs most often experienced were coworker injury, exposure to disease, and badly beaten adults (frequency 10-50). For the 1-9 frequency category, the most described events were: seeing someone dying, life threatened, and coworker injury. PTSD was identified in 44% of staff, and those who experienced CIs reported lower job satisfaction, greater feelings of PTSD, and more work absences than those not experiencing CIs (p < 0.05).

CONCLUSIONS

CIs and PTSD are prevalent among custody and noncustody correctional workers; and job dissatisfaction, PTSD, and work absence are significantly worse for those who experienced CIs. The CWCIS detected CIs; future study is needed to inform trauma prevention, reduction, and rehabilitation interventions specific to correctional work.

Comparison of the Wrist-Worn Fitbit Charge 2 and the Waist-Worn Actigraph GTX3 for Measuring Steps Taken in Occupational Settings

OBJECTIVES

If consumer-based monitors such as Fitbit can measure activity accurately, it could provide opportunities for improved assessment of physical activity in general and at work for research purposes. The accuracy of the Fitbit has hardly been investigated in an occupational setting.

METHODS

We compared measurements of steps taken at work, out-of-work, and in total of a wrist-worn Fitbit to a waist-worn Actigraph. Seventeen participants wore the Fitbit and Actigraph for 1 full workday.

RESULTS

Compared with the Actigraph, the Fitbit consistently recorded more steps [mean steps at work Fitbit = 7850 (6974), Actigraph = 4396 (1991); out-of-work Fitbit = 6414 (5691), Actigraph = 4116 (3502); total Fitbit = 13 478 (10 666), Actigraph = 8009 (5167)].

CONCLUSIONS

Compared with the Actigraph, the Fitbit consistently recorded more steps at work, out-of-work, and in total. The Fitbit and Actigraph recordings were more consistent for measuring steps taken out-of-work compared with at work. Steps counts recorded by the Fitbit, especially in occupational settings, may be inaccurate.

Leisure-Time Physical Activity and General Health Mitigate Effects of Job Demands on Nonrestorative Sleep: CDC National Healthy Worksite Project

OBJECTIVE

We sought to determine if leisure-time physical activity (LTPA) modified the adverse relationship between high job demands and nonrestorative sleep (NRS).

METHODS

We conducted a multivariate logistic regression analysis among workers from the cross-sectional National Healthy Worksite Project (n = 4683) using self-report Likert-Scale data on psychological and physical demands of jobs, LTPA and general health in relation to NRS.

RESULTS

Not engaging in LTPA was associated with NRS for workers with jobs at the lowest or highest levels of the physical demand scale (OR 1.64, 95% CI: 0.96-2.81, OR 2.06, 95% CI: 0.95-4.45; respectively) in comparison to those who met LTPA recommendations. When assessing psychological demands, poor general health was associated with NRS at all levels of the scale independent of LTPA.

CONCLUSIONS

LTPA may reduce NRS for workers with jobs at either extreme of physical demands.

Participatory survey design of a workforce health needs assessment for correctional supervisors

INTRODUCTION

The correctional workforce experiences persistent health problems, and interventions designed with worker participation show favorable outcomes. However, participatory intervention research often leaves workers out of the health needs assessment, the basis of interventions subsequently developed. This omission risks failure to detect factors contributing to the health and is less likely to result in primary prevention interventions.

METHODS

Partnering with a correctional supervisors' union, we followed Schulz and colleagues' community-based participatory research (CBPR) methods for participatory survey design and used Healthy Workplace Participatory Program (HWPP) tools to develop a tailored survey to assess workforce health and contributing factors. Utilizing the HWPP Focus Group Guide, we generated key themes to adapt the HWPP All Employee Survey, a generic workforce health assessment, to become thorough and contextually-relevant for correctional supervisors.

RESULTS

Content analysis of focus group data revealed 12 priority health concerns and contributors, including organizational culture, masculinity, work-family conflict, family support, trauma, positive job aspects, health literacy and efficacy, health/risk behaviors, sleep, obesity, and prioritizing work and income over health. Twenty-six measures were added to the generic survey, mainly health-related antecedents including knowledge, attitudes, norms, and motivation.

CONCLUSION

Findings yielded new insights about supervisors' lived experiences of work and health, and resulted in a customized workforce survey. CBPR methods and HWPP tools allowed us to identify health issues that we would not have detected with conventional methods, and provide opportunities for interventions that address root causes of poor health. We share challenges faced and lessons learned using CBPR with the correctional workforce.

Progress in Corrections Worker Health: The National Corrections Collaborative Utilizing a Total Worker Health® Strategy

OBJECTIVE

To examine National Corrections Collaborative (NCC) activities, as an outreach initiative, to advance corrections workplace health and safety research, practice, and policy through a series of applied Research to Practice (r2p) meetings informed by the Total Worker Health(Total Worker Health is a registered trademark of the U.S. Department of Health and Human Services) (TWH) strategy.

METHODS

We mapped the coalescence of correctional worker health concerns, federal and national professional organization initiatives, and research activities that formed the NCC in 2014.

RESULTS

During the NCC's 5-years of TWH activities, attendance increased, partner composition expanded, and themes of concern evolved. Partners were motivated to participate and work together towards building evidence for health and safety r2p.

CONCLUSIONS

A unified plea to the academic and federal research communities for assistance with better evaluation instruments, data linkages, and for adopting an integrated TWH approach to workforce health and wellbeing continue to drive NCC r2p activities.

Defining 'Integration' for Total Worker Health®: A New Proposal

The effects of work and the conditions of employment on health behaviors and intermediate health conditions have been demonstrated, to the extent that these relationships should be addressed in efforts to prevent chronic disease. However, conventional health promotion practice generally focuses on personal risk factors and individual behavior change. In an effort to find solutions to the myriad of health challenges faced by the American workforce, the U.S. National Institute for Occupational Safety and Health (NIOSH) established the Total Worker Health® (TWH) program. Originally organized around the paradigm of integrating traditional occupational safety and health protections with workplace health promotion, TWH has evolved to a broader emphasis on workplace programs for enhancing worker safety, health, and well-being. Among the research programs and approaches developed by investigators at NIOSH Centers of Excellence for TWH and elsewhere, definitions of 'integration' in workplace interventions vary widely. There is no consensus about which organizational or individual outcomes are the most salient, how much to emphasize organizational contexts of work, or which program elements are necessary in order to qualify as 'Total Worker Health'. Agreement about the dimensions of integration would facilitate comparison of programs and interventions which are self-defined as TWH, although diverse in content. The specific criteria needed to define integration should be unique to that concept-i.e. distinct from and additive to conventional criteria for predicting or evaluating the success of a workplace health program. We propose a set of four TWH-specific metrics for integrated interventions that address both program content and process: (i) coordination and interaction of workplace programs across domains; (ii) assessment of both work and non-work exposures; (iii) emphasis on interventions to make the workplace more health-promoting; and (iv) participatory engagement of workers in pivotal ways during intervention prioritization and planning to develop self-efficacy in addressing root causes, skill transfer, building program ownership, empowerment, and continuous improvement. Thus we find that integration requires organizational change, both to engage two managerial functions with different goals, legal responsibilities, and (often) internal incentives & resources, and also to orient the organization toward salutogenesis. Examples from research activity within the Center for the Promotion of Health in the New England Workplace illustrate how these criteria have been applied in practice.

Acquired and Persistent Eldercare Demands: Impact on Worker Well-Being

Eldercare demands (ECD) may result in stress when finite resources needed to fulfill life roles (i.e., family, work) become scarce. ECD may be acquired, continue over time, or be relinquished. They thus may represent acute stress (immediate, severe) or chronic stress (persistent, milder). Workers at six U.S. manufacturing companies completed surveys (N = 520). ECD were operationalized as providing assistance to an adult aged 65+ years due to disability or illness. Workers were categorized into four ECD groups (persistent, relinquished, acquired, and none), and we examined the ECD groups' association with person-centric and work-centric outcomes. Respondents with acquired ECD had worse mental health and greater depressive symptoms than those with none, and those with persistent ECD had greater work stress and family-work conflict than those with none. Findings suggesting that acute stress is more related to person-centric outcomes and chronic stress is more related to work-centric outcomes could inform development of tailored interventions.

Cardiovascular and stress responses to short-term noise exposures-A panel study in healthy males

BACKGROUND

While previous epidemiological studies report adverse effects of long-term noise exposure on cardiovascular health, the mechanisms responsible for these effects are unclear. We sought to elucidate the cardiovascular and stress response to short-term, low (31.5-125Hz) and high (500-2000Hz) frequency noise exposures.

METHODS

Healthy male (n=10) participants were monitored on multiple visits during no noise, low- or high-frequency noise exposure scenarios lasting 40min. Participants were fitted with an ambulatory electrocardiogram (ECG) and blood pressure measures and saliva samples were taken before, during and after noise exposures. ECGs were processed for measures of heart rate variability (HRV): high-frequency power (HF), low-frequency power (LF), the root of the mean squared difference between adjacent normal heart beats (N-N) intervals (RMSSD), and the standard deviation of N-N intervals (SDNN). Systolic blood pressure (SBP), diastolic blood pressure (DPB), and pulse were reported and saliva was analyzed for salivary cortisol and amylase. Multivariate mixed-effects linear regression models adjusted for age were used to identify statistically significant difference in outcomes by no noise, during noise or after noise exposure periods and whether this differed by noise frequency.

RESULTS

A total of 658, 205, and 122, HRV, saliva, and blood pressure measurements were performed over 41 person days. Reductions in HRV (LF and RMSSD) were observed during noise exposure (a reduction of 19% (-35,-3.5) and 9.1% (-17,-1.1), respectively). After adjusting for noise frequency, during low frequency noise exposure, HF, LF, and SDNN were reduced (a reduction of 32% (-57,-6.2), 34% (-52,-15), and 16% (-26,-6.1), respectively) and during high frequency noise exposure, a 21% (-39,-2.3) reduction in LF, as compared to during no noise exposure, was found. No significant (p<0.05) changes in blood pressure, salivary cortisol, or amylase were observed.

CONCLUSIONS

These results suggest that exposure to noise, and in particular, to low-frequency noise, negatively impacts HRV. The frequencies of noise should be considered when evaluating the cardiovascular health impacts of exposure.

Process evaluation of two participatory approaches: Implementing total worker health® interventions in a correctional workforce

BACKGROUND

Correctional Officers (COs) have among the highest injury rates and poorest health of all the public safety occupations. The HITEC-2 (Health Improvement Through Employee Control-2) study uses Participatory Action Research (PAR) to design and implement interventions to improve health and safety of COs.

METHOD

HITEC-2 compared two different types of participatory program, a CO-only "Design Team" (DT) and "Kaizen Event Teams" (KET) of COs and supervisors, to determine differences in implementation process and outcomes. The Program Evaluation Rating Sheet (PERS) was developed to document and evaluate program implementation.

RESULTS

Both programs yielded successful and unsuccessful interventions, dependent upon team-, facility-, organizational, state-, facilitator-, and intervention-level factors.

CONCLUSIONS

PAR in corrections, and possibly other sectors, depends upon factors including participation, leadership, continuity and timing, resilience, and financial circumstances. The new PERS instrument may be useful in other sectors to assist in assessing intervention success. Am. J. Ind. Med. 59:897-918, 2016. © 2016 Wiley Periodicals, Inc.

Demographic, health-related, and work-related factors associated with body mass index and body fat percentage among workers at six Connecticut manufacturing companies across different age groups: a cohort study

BACKGROUND

Effective workplace interventions that consider the multifactorial nature of obesity are needed to reduce and prevent obesity among adults. Furthermore, the factors associated with obesity may differ for workers across age groups. Therefore, the objective of this study was to identify demographic, health-related, and work-related factors associated with baseline and changes in body mass index (BMI) and body fat percentage (BFP) and among Connecticut manufacturing workers acrossage groups.

METHODS

BMI and BFPof 758 workers from six Connecticut manufacturing companies were objectively measuredat two time points approximately 36 months apart. Demographic, health-related, and work-related factors wereassessed via questionnaire. All variables were included in linear regression models to identify factors associated with baseline and changes in BMI and BFP for workers in 3 age groups: <45 years (35 %), 45-55 years (37 %), >55 years (28 %).

RESULTS

There were differences in baseline and changes in BMI and BFP among manufacturing workers across age groups. Being interested in changing weight was significantly (p < 0.01) associated with higher baseline BMI and BFP across all age categories. Other factors associated with higher baseline BMI and BFP differed by age group and included: male gender (BMI p = 0.04), female gender (BFP p < 0.01), not having a college education (BMI p = 0.01, BFP p = 0.04), having childcare responsibilities (BMI p = 0.04), and working less overtime (p = 0.02) among workers in the <45 year age category, male gender (BMI p = 0.02), female gender (BFP p < 0.01) and reporting higher stress in general (BMI p = 0.04) among workers in the 45-55 year age category, and female gender (BFP p < 0.01) and job tenure (BFP p = 0.03) among workers in the >55 year age category. Few factors were associated with change in BMI or BFP across any age category.

CONCLUSIONS

Among manufacturing workers, we identified associations between individual, health-related, and work-related factors and baseline BMIand BFP that differed by age. Such results support the use of strategies tailored to the challenges faced by workers in specific age groups rather than adopting a one size fits all approach. Effective interventions should consider a full range of individual, health-related, and work-related factors. More work must be done to identify factors or strategies associated with changes in obesity over time.

Musculoskeletal disorder symptoms in correction officers: why do they increase rapidly with job tenure?

OBJECTIVE

In this study, we sought to explain the rapid musculoskeletal symptomatology increase in correction officers (COs).

BACKGROUND

COs are exposed to levels of biomechanical and psychosocial stressors that have strong associations with musculoskeletal disorders (MSDs) in other occupations, possibly contributing to their rapid health deterioration.

METHOD

Baseline survey data from a longitudinal study of COs and manufacturing line workers were used to model musculoskeletal symptom prevalence and intensity in the upper (UE) and lower (LE) extremity. Outcomes were regressed on demographics and biomechanical and psychosocial exposures.

RESULTS

COs reported significantly higher prevalence and intensity of LE symptoms compared to the industrial workers. In regression models, job tenure was a primary driver of CO musculoskeletal outcomes. In CO models, a single biomechanical exposure, head and arms in awkward positions, explained variance in both UE and LE prevalence (β of 0.338 and 0.357, respectively), and low decision latitude was associated with increased LE prevalence and intensity (β of 0.229 and 0.233, respectively). Manufacturing models were less explanatory. Examining demographic associations with exposure intensity, we found none to be significant in manufacturing, but in CO models, important psychosocial exposure levels increased with job tenure.

CONCLUSION

Symptom prevalence and intensity increased more rapidly with job tenure in corrections, compared to manufacturing, and were related to both biomechanical and psychosocial exposures. Tenure-related increases in psychosocial exposure levels may help explain the CO symptom increase.

APPLICATION

Although exposure assessment improvements are proposed, findings suggest focusing on improving the psychosocial work environment to reduce MSD prevalence and intensity in corrections.

Understanding speech when wearing communication headsets and hearing protectors with subband processing

An adaptive, delayless, subband feed-forward control structure is employed to improve the speech signal-to-noise ratio (SNR) in the communication channel of a circumaural headset/hearing protector (HPD) from 90 Hz to 11.3 kHz, and to provide active noise control (ANC) from 50 to 800 Hz to complement the passive attenuation of the HPD. The task involves optimizing the speech SNR for each communication channel subband, subject to limiting the maximum sound level at the ear, maintaining a speech SNR preferred by users, and reducing large inter-band gain differences to improve speech quality. The performance of a proof-of-concept device has been evaluated in a pseudo-diffuse sound field when worn by human subjects under conditions of environmental noise and speech that do not pose a risk to hearing, and by simulation for other conditions. For the environmental noises employed in this study, subband speech SNR control combined with subband ANC produced greater improvement in word scores than subband ANC alone, and improved the consistency of word scores across subjects. The simulation employed a subject-specific linear model, and predicted that word scores are maintained in excess of 90% for sound levels outside the HPD of up to ∼115 dBA.

Antisocial personality disorder is associated with receipt of physical disability benefits in substance abuse treatment patients

BACKGROUND

Opioid dependence is growing at an alarming rate in the United States, and opioid dependent patients have substantial medical, as well as psychiatric, conditions that impact their ability to work. This study evaluated the association between antisocial personality disorder (ASPD) and receipt of physical disability payments in methadone maintenance patients.

METHODS

Using data from 115 drug and alcohol abusing methadone maintained patients participating in two clinical trials, baseline characteristics of individuals receiving (n=22) and those not receiving (n=93) physical disability benefits were compared, and a logistic regression evaluated unique predictors of disability status.

RESULTS

Both an ASPD diagnosis and severity of medical problems were significant predictors of disability receipt, ps<.05. After controlling for other variables that differed between groups, patients with ASPD were more than five times likelier to receive physical disability benefits than patients without ASPD (odds ratio=5.66; 95% confidence interval=1.58-20.28).

CONCLUSIONS

These results demonstrate a role of ASPD in the receipt of disability benefits in substance abusers and suggest the need for greater understanding of the reasons for high rates of physical disability benefits in this population.

Engaging in job-related activities is associated with reductions in employment problems and improvements in quality of life in substance abusing patients

Reinforcement-based interventions are highly efficacious in the treatment of substance use disorders, and their benefits can extend to other areas of functioning as well. In particular, reinforcing participation in job-related activities may be useful for improving employment outcomes, which in turn may enhance quality of life and decrease substance use. These secondary analyses compared substance abusing patients randomized with reinforcement interventions (N = 185) who selected and completed two or more job-related activities during treatment versus those who did not. Patients who completed two or more job-related activities during treatment had significantly greater reductions in employment-related problems and improvements in quality of life than those who completed only one or no job-related activities, even after controlling for baseline differences that may impact employment outcomes. Further, patients who completed employment activities remained in treatment significantly longer and achieved greater durations of abstinence than those who did not. These data suggest that reinforcing job-attainment activities may have broad beneficial effects. Reinforcement interventions should be considered for enhancing employment skills training acquisition more generally.

Musculoskeletal disease and disability in dentists

There is conflicting evidence on the extent that medical conditions, particularly musculoskeletal conditions related to work, cause disability and premature retirement in dentists. Reports based on data from disability insurance in the United States suggest dentists are not susceptible to work related musculoskeletal disability. Surveys of symptom rated debility suggest higher rates of dysfunction, however, as do compulsory employment injury reports from European countries. These data, including information on Swedish dentists, analyzed for this study, tend to put dentists at the higher end of health care professionals in terms of musculoskeletal injury and lost work time. Because compensation patterns and proprietorship vary between national systems, the relationship between exposure and injury and retirement from the active work force may include differing national characteristics.

Risk factors for lung cancer and for intervention effects in CARET, the Beta-Carotene and Retinol Efficacy Trial

BACKGROUND

Evidence has accumulated from observational studies that people eating more fruits and vegetables, which are rich in beta-carotene (a violet to yellow plant pigment that acts as an antioxidant and can be converted to vitamin A by enzymes in the intestinal wall and liver) and retinol (an alcohol chemical form of vitamin A), and people having higher serum beta-carotene concentrations had lower rates of lung cancer. The Beta-Carotene and Retinol Efficacy Trial (CARET) tested the combination of 30 mg beta-carotene and 25,000 IU retinyl palmitate (vitamin A) taken daily against placebo in 18314 men and women at high risk of developing lung cancer. The CARET intervention was stopped 21 months early because of clear evidence of no benefit and substantial evidence of possible harm; there were 28% more lung cancers and 17% more deaths in the active intervention group (active = the daily combination of 30 mg beta-carotene and 25,000 IU retinyl palmitate). Promptly after the January 18, 1996, announcement that the CARET active intervention had been stopped, we published preliminary findings from CARET regarding cancer, heart disease, and total mortality.

PURPOSE

We present for the first time results based on the pre-specified analytic method, details about risk factors for lung cancer, and analyses of subgroups and of factors that possibly influence response to the intervention.

METHODS

CARET was a randomized, double-blinded, placebo-controlled chemoprevention trial, initiated with a pilot phase and then expanded 10-fold at six study centers. Cigarette smoking history and status and alcohol intake were assessed through participant self-report. Serum was collected from the participants at base line and periodically after randomization and was analyzed for beta-carotene concentration. An Endpoints Review Committee evaluated endpoint reports, including pathologic review of tissue specimens. The primary analysis is a stratified logrank test for intervention arm differences in lung cancer incidence, with weighting linearly to hypothesized full effect at 24 months after randomization. Relative risks (RRs) were estimated by use of Cox regression models; tests were performed for quantitative and qualitative interactions between the intervention and smoking status or alcohol intake. O'Brien-Fleming boundaries were used for stopping criteria at interim analyses. Statistical significance was set at the .05 alpha value, and all P values were derived from two-sided statistical tests.

RESULTS

According to CARET's pre-specified analysis, there was an RR of 1.36 (95% confidence interval [CI] = 1.07-1.73; P = .01) for weighted lung cancer incidence for the active intervention group compared with the placebo group, and RR = 1.59 (95% CI = 1.13-2.23; P = .01) for weighted lung cancer mortality. All subgroups, except former smokers, had a point estimate of RR of 1.10 or greater for lung cancer. There are suggestions of associations of the excess lung cancer incidence with the highest quartile of alcohol intake (RR = 1.99; 95% CI = 1.28-3.09; test for heterogeneity of RR among quartiles of alcohol intake has P = .01, unadjusted for multiple comparisons) and with large-cell histology (RR = 1.89; 95% CI = 1.09-3.26; test for heterogeneity among histologic categories has P = .35), but not with base-line serum beta-carotene concentrations.

CONCLUSIONS

CARET participants receiving the combination of beta-carotene and vitamin A had no chemopreventive benefit and had excess lung cancer incidence and mortality. The results are highly consistent with those found for beta-carotene in the Alpha-Tocopherol Beta-Carotene Cancer Prevention Study in 29133 male smokers in Finland.

Epidemiology of occupational disorders of the upper extremity

The rise in reports of occupational disorders of the upper extremity has been meteoric. This chapter examines the frequency and prevalence of upper extremity disorders, reviews the active surveys of upper extremity disorders in selected occupations, examines current surveillance systems, and discusses the problem of effective case definition.

A comparison of traditional electrodiagnostic studies, electroneurometry, and vibrometry in the diagnosis of carpal tunnel syndrome

In 49 patients (98 hands), referred to an electrodiagnostic laboratory, assessments were made by conventional nerve conduction studies on the upper extremity and by two more portable modalities, namely electroneurometry (skin surface electrical stimulation of the motor nerve) and single-frequency (120 Hz) vibrometry. Tests were performed on median and ulnar nerves. Correlations with motor nerve conduction studies for each screening test on the median nerve were r = .81 for the electroneurometer and r = .48 for the vibrometer. When carpal tunnel syndrome was diagnosed either by clinical criteria only or by nerve conduction abnormality, the association with electroneurometry was characterized by high sensitivity and low specificity, while the opposite relationship prevailed with vibrometry. These associations were highly dependent on the methods used to select normal values from a reference population. While the manufacturer's recommended normal values offered good predictability, with thresholds that corresponded to nerve conduction studies, normal values generated in a more standard way produced much weaker and less useful associations. The selection of an appropriate electrical screening test for peripheral nerve injury, such as entrapment neuropathy, depends on the prevalence and seriousness of the target disease and the relative consequences of over- and underdiagnosis.

Raynaud's phenomenon associated with the use of pneumatically powered surgical instruments

Five patients developed symptoms of Raynaud's phenomenon and upper extremity paresthesias after 7-32 months of exposure to air-powered surgical instruments used for the harvest of bone for bone banks. Results of cold challenge plethysmography, nerve conduction studies, vibrotactile thresholds, and quantitative sensory testing were as follows: all patients had significant reproducible vasospasm with nondetectable finger systolic blood pressure (FSBP = 0) after local digital cooling; nerve conduction abnormalities included delayed median nerve sensory conduction (< 48 m/s) across 5 of 10 wrists; and no ulnar nerve abnormalities were detected. Vibrotactile thresholds were only modestly elevated, an unexpected outcome given the frequently recognized association between vibrotactile tests and nerve conduction studies. These abnormalities occurred with exposures to frequencies previously thought to be too high to be harmful to medical personnel.

The beta-carotene and retinol efficacy trial (CARET) for chemoprevention of lung cancer in high risk populations: smokers and asbestos-exposed workers

CARET is a multicenter, two-armed, double-masked randomized chemoprevention trial in Seattle, Portland, San Francisco, Baltimore, Connecticut, and Irvine, to test whether oral administration of beta-carotene (30 mg/day) plus retinyl palmitate (25,000 IU/day) can decrease the incidence of lung cancer in high risk populations, namely, heavy smokers and asbestos-exposed workers. The intervention combines the antioxidant action of beta-carotene and the tumor suppressor mechanism of vitamin A. As of April 30, 1993, CARET had randomized 1,845 participants in the 1985-1988 pilot phase plus 13,260 "efficacy" participants since 1989; of these, 4,000 are asbestos-exposed males and 11,105 are smokers and former smokers (44% female). Accrual is complete everywhere except Irvine, which was the last center added (1991), and the safety profile of the regimen to date has been excellent. With 14,420 smokers, 4,010 asbestos-exposed participants, and 114,100 person-years through February 1998, we expect CARET to be capable of detecting a 23% reduction in lung cancer incidence in the two populations combined and 27, 49, 32, and 35% reductions in the smokers, female smokers, male smokers, and asbestos-exposed subgroups, respectively. CARET is highly complementary to the alpha-tocopherol-beta-carotene study in Finland and the Harvard Physicians Health Study (beta-carotene alone) in the National Cancer Institute portfolio of major cancer chemoprevention trials.

Diseases of unusual occupations: an historical perspective

A compilation of conditions deemed unusual from previous eras serves to highlight now obsolete jobs and remind that even relatively prevalent occupational disorders of today will be viewed retrospectively as strange in the proximate future. Discussed are coal miners' nystagmus, scrotal cancer in chimney sweeps, phossy jaw, hatters' shakes, painters' colic, potters' rot, chauffeurs' knee, glanders, caisson disease, and others.

A cross sectional epidemiological survey of shipyard workers exposed to hand-arm vibration

The hand-arm vibration syndrome, widely known as vibration white finger, is a disorder of nerves and blood vessels that occurs in workers exposed to segmental vibration. A cross sectional symptom survey was performed on a sample of workers employed by a large shipyard in the north eastern United States. Random samples were drawn from departments composed of full time dedicated pneumatic grinders, workers with part time exposure to vibration, and other workers not exposed to vibratory tools. Of the 375 workers sampled, 79% responded. The prevalence of white finger symptoms was 71%, 33%, and 6% among the three exposure groups respectively. Similarly, the prevalence of numbness and tingling in the hands and fingers in the three exposure groups was 84%, 50%, and 17%. Workers were classified according to the Stockholm Workshop staging systems for vascular and sensorineural symptom severity. Exposure-response analyses of both vascular and sensorineural stage showed monotonically increasing prevalence of higher disease stages with increasing duration of exposure. Logistic regression analysis, performed to control for potential confounding factors including age and current smoking state, produced highly significant (p less than 0.001) associations between cumulative duration of exposure and prevalence of symptoms. In these analyses smoking state was significantly related to vascular and sensorineural symptoms and age was not. Average latency to onset of symptoms was less than five years of full time equivalent work with vibratory tools. Logistic regression analyses were performed to assess the effect of use of particular work practices on reported symptoms. Further study of this workforce with objective, quantitative measures of peripheral neurological and vascular function is required to characterise the clinical and subclinical effects of vibration exposure.

Detailed clinical assessment of neurological function in symptomatic shipyard workers

Forty eight patients with extensive occupational exposure to pneumatic grinding tools were evaluated at a university sponsored occupational health clinic. All patients were interviewed and examined by a physician and assessed neurologically with standard clinical, functional motor, quantitative vibrotactile, and electrodiagnostic tests. Sensorineural symptoms were nearly universal; 47 patients (98%) reported numbness and tingling of the hands and fingers. Among clinical tests, two point discrimination and 30 Hz vibration perception were most frequently abnormal. In order to evaluate associations between quantitative test results and sensorineural symptoms, patients were stratified into two groups of symptom severity according to a consensus sensorineural staging system. The tests that discriminated best between the groups of more and less symptomatic patients were hand strength dynamometry, and vibrotactile thresholds. Age standardised 120 Hz vibrotactile thresholds were significantly raised in digit II in 41% of hand measurements. Nerve conduction studies were neither significantly different between more and less symptomatic groups nor correlated with clinical and quantitative sensory tests. Twenty five per cent of the patients had slowing of sensory conduction velocities in the median nerve at the wrist (less than 48 m/s). Of this subset of patients only two showed abnormal slowing of the median nerve distal to the wrist, but half also showed ulnar nerve slowing (less than 47 m/s). This observation highlights the difficulty of differentiating median nerve entrapment from diffuse distal neuropathy in workers exposed to vibration and points to the need for concomitant quantitative sensory and functional motor assessment.

Raynaud's phenomenon of occupational origin

Vibration delivered to the hand and arm by industrial pneumatic tools is a common cause of vascular and neurovascular problems, including cold-induced vascular spasm (vibration white finger) and peripheral neuropathies with paresthesias, dysesthesias, and sensory abnormalities. A decade ago, the US Public Health Service estimated that 1.2 million American workers were at risk. Differentiation of primary and secondary Raynaud's phenomenon from the thoracic outlet syndrome and from the carpal tunnel syndrome pose potential diagnostic difficulties. Despite growing public recognition of upper extremity problems caused by repetitive trauma, there have been few investigations of vibration-induced disorders in the United States. This is not true worldwide, particularly in Northern Europe, where there has been significant intervention in medical surveillance and tool design. There does appear to be, however, frequent misdiagnosis and misdirected surgery. This has particular significance for the clinician, since in the 1990s, cumulative trauma injuries are expected to exceed all other work-related injuries.

Historical perspectives in occupational medicine. Pancoast and the image of silicosis

In the two decades following the First World War, American occupational medicine was consumed in cataloguing the pneumoconioses, and no physician was more prominent than Henry K. Pancoast of the University of Pennsylvania. In a landmark trial following the worst silicosis outbreak in the United States at Gauley Bridge, West Virginia, Pancoast testified for the defense, attributing the disease to tuberculosis. Pancoast was not an isolated commentator, as the prominence of the cases attracted some of the country's leading authorities on occupational medicine. Pancoast's error, as well as the accuracy of some of his colleagues, clarifies an important occupational disease in its epidemic period. There is also a less historically specific exposition of the impact of professional involvement in social policy, liability, and compensation.

Spectrum of occupational disease in an academic hospital-based referral center in Connecticut from 1979 to 1987

The inability to characterize the extent of occupational disease in the United States limits clinical diagnosis and public health interventions. We present an 8-year (1979 to 1987) experience with clinic-based reporting in Connecticut. Altogether, 3566 cases were sequentially coded for demographics, diagnoses, workplace identification, and exposures at two academic occupational medicine clinics. The lungs were the principal organs of diagnosed effect, with asbestos-related disorders predominating, whereas the urinary tract, endocrine organs, and cardiovascular systems were rarely involved. Of all diseases, 64.8% were diagnosed as chronic and irreversible. Three common disorders, lead intoxication (acute and chronic), asbestosis, and occupational asthma were selected for illustration. Patients with lead poisoning and asbestosis, although collectively numerous (40 and 504, respectively), came from a small number of worksites and industries. Occupational asthma was more variable: 141 diagnosed cases came from 56 different trades and industries and were caused by 28 recognized agents. While we recognize that clinic-based reporting suffers from obvious problems with referral bias and misclassification, our experience shows that it provides an important index of disease burden. Our data document the effects of legislation and litigation on lead poisoning and asbestosis, and correspondingly helps characterize diseases that will respond to broad intervention. On the other hand, occupational asthma is more pervasive and would require a more specialized, partially clinical approach.

Chronic beryllium disease in a precious metal refinery. Clinical epidemiologic and immunologic evidence for continuing risk from exposure to low level beryllium fume

Five workers at a precious metal refinery developed granulomatous lung disease between 1972 and 1985. The original diagnosis was sarcoidosis, but 4 of the workers were subsequently proved to have hypersensitivity to beryllium by in vitro proliferative responses of lymphocytes obtained by bronchoalveolar lavage. Review of medical records of coworkers and extensive industrial hygiene surveillance of the plant demonstrated that 4 cases occurred in the furnace area where air concentrations of beryllium fume were consistently below the permissible exposure limit of 2 micrograms/M3. A single case has been recognized from parts of the refinery where exposures to cold beryllium dust often exceeded the standard by as much as 20-fold. These data demonstrate that chronic beryllium disease still occurs and confirm the importance of specific immunologic testing in patients suspected of having sarcoidosis but with potential exposure to beryllium. The data raise concern about the adequacy of modern industrial controls, especially in the setting of exposure to highly respirable beryllium fume.

Silicosis in a grey iron foundry. The persistence of an ancient disease

An industrial hygiene and medical survey was conducted in an iron foundry to study the occurrence of silicosis. Breathing zone exposures to respirable crystalline silica had been very high in 1977 [1 045 micrograms/m3 (geometric mean) for coremakers and 198 micrograms/m3 for fettlers]; exposures in 1980 and 1982 were substantially lower. A radiographic evaluation of 188 workers revealed silicosis in 18 (9.6%). Eight had category 1 profusion of small rounded pulmonary lesions (by the 1980 classification of the International Labour Office); two had category 2; and eight had category 3. Two had progressive massive fibrosis. Four workers without silicosis in 1977 had developed lesions by 1980. The prevalence increased from 1.5% among workers employed less than 20 years to 53% among longer term workers. No association was found between the prevalence of silicosis and cigarette smoking. Chronic cough was more common in workers with heavy current dust exposure than in those with light exposure, more common in smokers than in nonsmokers, and more common in silicotics than in nonsilicotics. A multiplicative interaction existed between dust exposure and smoking in the etiology of cough. Silicosis continues to exist in American foundries. Cigarette smoking does not contribute to the causation of silicosis, but it aggravates the attendant respiratory symptoms.

Review of the biodistribution and toxicity of the insect repellent N,N-diethyl-m-toluamide (DEET)

A review of the biodistribution and toxicity of the insect repellent N,N-diethyl-m-toluamide (DEET) is presented. Workers using repellent containing this compound may be exposed to greater than 442 g in 6 mo. In human studies, variable penetration into the skin of from 9 to 56% of a topically applied dose and absorption into the circulatory system of approximately 17% have been reported. Excretion of DEET by humans was initially rapid but not as complete as in animal models. Only about one-half of the absorbed DEET was excreted by humans over 5 d. Depot storage of DEET in the skin was also documented. Skin irritant effects, including scarring bullous dermatitis in humans, were reported. One animal study that reported embryotoxicity could not be confirmed by other investigators. The limited testing for mutagenicity and carcinogenicity provided negative results. Neurotoxic effects were observed in workers exposed to 4 g or more per week. Six young girls developed encephalopathies after exposure to unspecified amounts of DEET ranging from small to massive doses. Three of these girls later died. The cause of their death has not been resolved. Because of the lack of information, further research into the absorption, carcinogenicity, and neurotoxic effects is needed.