Neck Pain Clinical Prediction Rule to Prescribe Combined Aerobic and Neck-Specific Exercises: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

A previous randomized controlled trial revealed that combined aerobic and neck-specific exercises yielded greater improvement than neck-specific exercises alone after a 6-month intervention in outpatients with nonspecific neck pain (NP). The aim of this secondary analysis was to identify subgroups of patients in the combined exercises group most likely to benefit from the intervention.

METHODS

Sixty-nine patients were included. The original trial was conducted in multiple physical therapy outpatient clinics twice a week for 6 weeks; follow-up was 6 months after assignment. The primary outcome was the therapeutic success rate (Global Rating of Change Score ≥ +5, "quite a bit better") after 6 weeks of training and at the 6-month follow-up. Candidate predictors from patients' medical history and physical examination were selected for univariable regression analysis to determine their association with treatment response status. Multivariable logistic regression analysis was used to derive preliminary clinical prediction rules.

RESULTS

The clinical prediction rule contained 3 predictor variables: (1) symptom duration ≤6 months, (2) neck flexor endurance ≥18 seconds, and (3) absence of referred pain (Nagelkerke R2 = .40 and -2 log likelihood = 60.30). The pre-test probability of success was 61.0% in the short term and 77.0% in the long term. The post-test probability of success for patients with at least 2 of the 3 predictor variables was 84.0% in the short term and 87.0% in the long term; such patients will likely benefit from this program.

CONCLUSION

A simple 3-item assessment, derived from easily obtainable baseline data, can identify patients with NP who may respond best to combined aerobic and neck-specific exercises. Validation is required before clinical recommendation.

IMPACT

Patients experiencing NP symptoms ≤6 months who have no referred pain and exhibit neck flexor endurance ≥18 seconds may benefit from a simple self-training program of combined aerobic and neck-specific exercises.

The effectiveness of an aerobic exercise training on patients with neck pain during a short- and long-term follow-up: a prospective double-blind randomized controlled trial

Objective:

To examine the effect of adding aerobic exercise (AE) to neck-specific exercise treatment for patients with neck pain (NP) to reduce pain and disability.

Design:

A prospective multicentre randomized controlled trial.

Setting:

Physiotherapy outpatient clinics.

Subjects:

Patients with nonspecific NP.

Intervention:

Patients with NP were randomly assigned to six weeks of neck-specific exercise with and without the addition of AE.

Measures:

Patients were classified as having a successful or non-successful outcome according to the Global Rating of Change (GROC). Outcome measures included Visual Analogue Scale (VAS), Neck Disability Index (NDI), Fear Avoidance Beliefs Questionnaire (FABQ) and cervicogenic headache. Assessments were performed at six-week, and three- and six-month follow-ups.

Results:

A total of 139 participants (mean age: 54.6 ± 10.5 years) were recruited ( n = 69 AE, n = 70 control). According to GROC, 77.4% of the AE group reported a successful outcome at six months vs. 40% in the control group ( P < 0.001). There was a significant reduction in VAS from baseline to six months in the AE vs. control group 6.73 (±1.69) to 1.89 (±1.37) vs. 6.65 (±1.67) to 3.32 (±1.82), respectively ( P  < 0.001). Significant improvements were also obtained for NDI and FABQ from baseline to six weeks in the AE group: NDI from 16.10 (±4.53) to 7.78 (±4.78) vs. 17.01 (±4.84) to 11.09 (±5.64) in the control group ( P = 0.003); FABQ from 33.53 (±9.31) to 20.94 (±841) in the AE vs. 33.45 (±10.20) to 26.83 (±10.79) in the control group ( P < 0.001). The AE group also demonstrated significant reduction in cervicogenic headache from baseline to six months ( P = 0.003).

Conclusion:

Adding AE to long-term neck-specific exercises is an effective treatment for reducing NP and headache in patients with NP.

Returning to work after a hand injury: Does ethnicity matter?

Background

Hand injuries (HI) are common and may limit participation in work. The objective of this study is to examine the effect of ethnicity and other prognostic variables on return-to-work (RTW) among male manual workers after acute HI.

Methods

A cohort of 178 subjects (90 Arabs, 88 Jews) aged 22 to 65 was studied. Trained bilingual occupational therapists evaluated and interviewed the subjects, using structured validated questionnaires for evaluating personal and environmental factors, body function and structure, and activity limitation and participation restrictions. Employment status 3 months post injury was assessed by a telephone interview. To establish a predictive model for RTW, ethnicity and certain variables of the four domains mentioned above were analyzed using logistic regression analysis.

Results

A significant difference in the rate of RTW between Jews and Arabs was found (45.5% for Jews, 28.9% for Arabs, p = 0.03) three months post HI. In the univariate regression analysis, ethnicity was associated with RTW (OR = 2.05; CI: 1.10–3.81) for Jews vs. Arabs. Using a multivariate analysis, only legal counseling, educational attainment, and the severity of disability were significantly associated with RTW.

Conclusion

RTW three months post HI among manual workers is directly related to variables such as education and legal counseling and only indirectly related to ethnicity. Patients with a lower level of education and those who were engaged in legal counseling need special attention and close guidance in the process of RTW.

Prevalence of Asthma among Young Men Residing in Urban Areas with Different Sources of Air Pollution

BACKGROUND

Asthma is a common respiratory disease, which is linked to air pollution. However, little is known about the effect of specific air pollution sources on asthma occurrence.

OBJECTIVES

To assess individual asthma risk in three urban areas in Israel characterized by different primary sources of air pollution: predominantly traffic-related air pollution (Tel Aviv) or predominantly industrial air pollution (Haifa bay area and Hadera).

METHODS

The medical records of 13,875, 16- 19-year-old males, who lived in the affected urban areas prior to their army recruitment and who underwent standard pre-military health examinations during 2012-2014, were examined. Nonparametric tests were applied to compare asthma prevalence, and binary logistic regressions were used to assess the asthma risk attributed to the residential locations of the subjects, controlling for confounders, such as socio-demographic status, body mass index, cognitive abilities, and education.

RESULTS

The asthma rate among young males residing in Tel Aviv was 8.76%, compared to 6.96% in the Haifa bay area and 6.09% in Hadera. However, no statistically significant differences in asthma risk among the three urban areas was found in controlled logistic regressions (P > 0.20). This finding indicates that exposure to both industrial- and traffic-related air pollution is associated with asthma prevalence.

CONCLUSIONS

Both industrial- and traffic-related air pollution have a negative effect on asthma risk in young males. Studies evaluating the association between asthma risk and specific air pollutants (e.g., sulfur dioxide, particulate matter, and nitrogen dioxide) are needed to ascertain the effects of individual air pollutants on asthma occurrence.

Prevalence of polyps ≥6 mm on follow-up CT colonography in a cohort with no significant colon polyps at baseline

AIM

Assess the prevalence of neoplasia ≥6 mm at repeat CT colonoscopy (CTC) in individuals with no significant lesions at baseline.

METHODS

Individuals aged ≥18 years, with/without CRC risk factors, with no polyps ≥6 mm on baseline CTC (negative baseline) who underwent repeat CTC in a large HMO from 2001 to 2011 were retrospectively identified. Studies were reviewed by board-certified radiologists with experience interpreting CTC. Demographic details, CRC risk factors, and the number, size, and location of incident lesions were noted. Findings were classified using the C-RADS scale. Lesion prevalence at CTC-2 was determined, and study interval and risk characteristics of patients with- and without findings were compared.

RESULTS

Our study included 636 individuals (369 men [58.0%]; mean age 59.9 years) with negative baseline CTC who underwent repeat CTC after a mean 4.6 year interval (SD 1.6 years). At baseline, 469/636 (73.7%) were at average risk for CRC; 418 remained at average risk for CTC-2 with 51 (8.0%) developing new risk factors in the interval between studies. At CTC-2, 47 participants (7.4%) presented 52 significant neoplasia: 35 polyps 6-9 mm, 14 polyps ≥10 mm, and 3 masses in 3/636 participants (0.47%). 2/3 masses, 6/14 polyps ≥10 mm (42.9%), and 12/25 polyps 6-9 mm (48.0%) were in individuals with risk factors for CRC. Histopathology was available for 12/52 lesions (23.1%): 8 tubular adenomas, 2 villous adenomas, 1 hamartomatous polyp, 1 case of normal tissue.

CONCLUSION

A mean 4.6 years after negative-baseline CTC, neoplasia ≥6 mm were seen in 7.4% of participants, including masses in 0.47%, supporting recommendations for a 5-year study interval.

Cancer epidemiology fieldwork in a resource-limited setting: Experience from the western Kenya ESCCAPE esophageal cancer case-control pilot study

BACKGROUND

Case-control studies remain an important study design for aetiologic research on cancer, particularly when cohorts are not available. In addition to the potential biases inherent in this design, conducting fieldwork in settings with weak health care and information systems for cancer, such as in sub Saharan Africa, confer additional challenges which we present here with the aim to share experience to guide future studies.

METHODS

We undertook a hospital-based case-control study of squamous cell esophageal cancer at the Moi Teaching and Referral Hospital in Eldoret, West Kenya. Cases were recruited at endoscopy and controls from hospital wards, age and gender frequency-matched to cases. Urine, toenails, blood and tumour biopsy were collected and a questionnaire administered.

RESULTS

During this pilot phase, 143 cases and 155 controls were successfully recruited. Complete questionnaire data was obtained through e-data collection. Biospecimen collection was possible with support of an already existing equipped laboratory. We introduce changes made in the main study phase, including on expansion of the control groups to allow to consideration of selection bias.

CONCLUSIONS

Extra attention and funding to train and monitor data quality and biospecimen collection and collaboration of a large group held together by strong leadership are essential. We recommend studies based on regional treatment centres with their more defined catchment areas rather than in the capital cities as referral routes in multi-level health care systems are severely attrition prone.

Modeling long-term effects attributed to nitrogen dioxide (NO2) and sulfur dioxide (SO2) exposure on asthma morbidity in a nationwide cohort in Israel

Studies have provided extensive documentation that acutely elevated environmental exposures contribute to chronic health problems. However, only attention has been paid to the effects of modificate of exposure assessment methods in environmental health investigations, leading to uncertainty and gaps in our understanding of exposure- and dose-response relationships. The goal of the present study was to evaluate whether average or peak concentration exerts a greater influence on asthma outcome, and which of the exposure models may better explain various physiological responses generated by nitrogen dioxide (NO₂) or sulfur dioxide (SO₂) air pollutants. The effects of annual NO₂ and SO₂ exposures on asthma prevalence were determined in 137,040 17-year-old males in Israel, who underwent standard health examinations before induction to military service during 1999-2008. Three alternative models of cumulative exposure were used: arithmetic mean level (AM), average peak concentration (APC), and total number of air pollution exposure episodes (NEP). Air pollution data for NO₂ and SO₂ levels were linked to the residence of each subject and asthma prevalence was predicted using bivariate logistic regression. There was significant increased risk for asthma occurrence attributed to NO₂ exposure in all models with the highest correlations demonstrated using the APC model. Data suggested that exposure-response is better correlated with NO₂ peak concentration than with average exposure concentration in subjects with asthma. For SO₂, there was a weaker but still significant exposure response association in all models. These differences may be related to differences in physiological responses including effects on different regions of the airways following exposure to these pollutants. NO₂, which is poorly soluble in water, penetrates deep into the bronchial tree, producing asthmatic manifestations such as inflammation and increased mucus production as a result of high gaseous concentrations in the lung parenchyma. In contrast, SO₂, which is highly water soluble, exerts its effects rapidly in the upper airways, leading to similar limited correlations at all levels of exposure with fewer asthmatic manifestations observed. These data indicate that differing exposure assessment methods may be needed to capture specific disease consequences associated with these air pollutants.

Cross-cultural adaptation of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for Hebrew-speaking subjects with and without hand injury

PURPOSE

The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire is used internationally to assess function and disability. The instrument has been translated into several languages, but no Hebrew version exists. The objective of this study was to evaluate the use of the 12-item WHODAS 2.0 questionnaire among Hebrew speakers with and without hand injuries (HI).

METHODS

The translated questionnaire was conducted among 155 uninjured subjects (UI) and 77 male workers with HI. Internal consistency was assessed using Cronbach's alpha. Test-retest reliability was assessed in UI subjects and calculated using the intraclass correlation coefficient (ICC_agreement). Validity was evaluated by correlating the 12-item WHODAS 2.0 to the short-form of health survey (SF-12) in UI subjects and comparing the 12-item WHODAS 2.0 scores and the Quick Disability of Arm, Shoulder, and Hand (QDASH) Outcome Measure in the HI group.

RESULTS

The Cronbach's alpha of the WHODAS 2.0 for the entire sample was α = 0.83. The ICC_agreement for test-retest reliability was 0.88. A positive significant correlation was found between the 12-item WHODAS 2.0 and the QDASH (r_s = 0.53, p < .005).

CONCLUSIONS

The results support the reliability and validity of this Hebrew translation of the 12-item WHODAS 2.0. IMPLICATIONS FOR REHABILITATION Measurement tools that assess activities and participation after HI are an essential part of the rehabilitation process. The 12-item WHODAS 2.0 is a useful tool, since it addresses a broader range of activity and participation domains compared to the DASH and enables better implementation of the ICF model. Since the WHODAS 2.0 does not target a specific disease (as oppose to the DASH), it can be used to compare disabilities caused by different diseases or traumas. The WHODAS 2.0 measures both the function and disability in general populations as well as clinical situations; therefore, the instrument is useful for assessing both health and disability.

Different effects of long-term exposures to SO2 and NO2 air pollutants on asthma severity in young adults

Numerous studies demonstrated that exposure to ambient air pollutants contributes to severity and frequency of asthma exacerbations. However, whether common air pollutants, such as nitrogen dioxide (NO2) and sulfur dioxide (SO2), exert differential effects on asthma occurrence and severity is unclear. The aim of this investigation was to determine whether exposure to NO2 and/or SO2 may initiate different long-term effects on prevalence and severity of asthma in young adults. Medical records of 137,040 males, 17 years old, who underwent standard premilitary service health examinations during 1999-2008 were examined. Air-pollution data for NO2 and SO2 were linked to the place of residence of each subject. The influence of specific air pollutants on asthma prevalence and severity was evaluated using bivariate logistic regression, controlling for individuals' sociodemographic attributes. For both ambient air pollutants, there was a significant dose-response effect on severity of asthma at ambient concentrations below the current National Ambient Air Quality Standards. However, in residential areas with high levels of SO2 (13.3-592.7µg/m(3)) and high levels of NO2 (27.2-43.2µg/m(3)) the risk of asthma occurrence was significantly higher than that in residential areas with high levels of NO2 (27.2-43.2 µg/m(3)) and intermediate levels (6.7-13.3 µg/m(3)) of SO2 pollution. The effects of exposure to SO2 and NO2 air pollutants on the respiratory airways system appear to differ, with possible implications regarding medical management, even in cases of exposure to mixtures of these pollutants.

Obstructive Sleep Apnea: Comparison of Syndrome Severity and Risk Factors for Adult Jewish and Arab Males in Northern Israel

Background: Obstructive sleep apnea (OSA) is a common health problem with an estimated prevalence of 4% among men, many of whom are undiagnosed and untreated.

OBJECTIVES

To compare demographic characteristics, health profiles, risk factors, and disease severity in Arab and Jewish men with OSA syndrome.

METHODS

In this cross-sectional study we retrospectively analyzed clinical data from the medical files of men ≥ 22 years old who were referred to the Rambam Medical Center sleep clinic during the period 2001-2009 with a suspected diagnosis of OSA. OSA severity was measured using the apnea-hypopnea index (AHI). Categorical variables were compared using the chi-square test. Relations between OSA severity and a set of independent risk factors were assessed by linear regression analysis.

RESULTS

A total of 207 men were included (39 Arabs, 19%; 168 Jews, 81%). Arab participants were younger than their Jewish counterparts (45.5 ± 8.9 years vs. 49.8 ± 11.8, P = 0.04) and their body mass index (BMI) was higher (3.1 ± 5.1 vs. 30.0 ± 4.4, P = 0.001). OSA severity (AHI score) was higher among Arab men, with low, medium and high severity scores seen in 10%, 33% and 56% of Arab men vs. 35%, 29% and 37% of Jewish men, respectively [T(198) = 2.39, P = 0.02]. Mean blood oxygen saturation was comparable.

CONCLUSIONS

Arab men presenting for evaluation of sleep apnea harbored more severe OSA symptoms, were younger, and had higher BMI compared to Jewish men. Since OSA syndrome evolves for several years until it becomes severe, these findings suggest that Arab men seek medical assistance later than Jewish men with OSA.

Work Ability Index in Israeli hospital nurses: applicability of the adapted questionnaire

BACKGROUND/STUDY CONTEXT: The Work Ability Index (WAI) questionnaire is widely used for evaluation of the work ability of workers. This is the first application of the validated Hebrew version of this questionnaire to Israeli nurses in order to evaluate factors affecting their work ability.

METHODS

A cross-sectional study was conducted among 515 nurses from two general hospitals in Israel (87.3% female).

RESULTS

A significant negative correlation was found between the WAI score and age, years in current job, and number of reported diagnoses. The most frequently reported illnesses (as diagnosed by a physician) were musculoskeletal disorders, endocrine/metabolic diseases, and cardiovascular diseases. Agreement between illnesses as diagnosed by a physician and as self-reported by nurses was low, especially with respect to mental/emotional stress, (kappa statistics = 16.4%, p < .001).

CONCLUSIONS

Mean WAI score found in Israeli hospital nurses is relatively high as compared with that of European nurses. It gradually decreases with age. The WAI questionnaire enables the early identification of those nurses with compromised work ability and who are in need of assistance in order to prevent early retirement. As retirement age is currently advancing, keeping elderly workers in the workforce is of prime importance.

[Occupational asthma--the case of bakers' asthma]

Occupational asthma (OA) is the most common of all occupational lung diseases in industrialized countries and its prevalence has been rising steadily. It is estimated that occupational factors account for one out of six cases of adult asthmatic patients causing significant morbidity, disability and costs. Due to its high prevalence and substantial health and socio-economic impacts OA represents a significant public health concern. OA can be divided into allergic and non allergic asthma. Allergic OA is further divided into IgE mediated and non IgE mediated. Baker's asthma (BA), is the leading cause of IgE mediated OA caused by high molecular weight antgens in industrialized countries. Innovations in the baking industry during the last few decades have led to the introduction of new allergens inducing OA. OA is potentially preventable, through early diagnosis and exposure cessation interventions. Thus, clinicians should consider the occupational history in every adult patient presenting with newly diagnosed asthma.

[Mediterranean diet in cancer patients and cancer free adult Arabs in Israel--a case-control study]

BACKGROUND

Although several studies have investigated the association of the Mediterranean diet (MD) with overall risk of specific cancers, data on overall cancer risk are sparse, especially in Arab populations.

OBJECTIVES

To compare between the score of MD in cancer patients and cancer-free adult Israeli Arabs in order to identify risk factors amenable to intervention.

METHODS

A case control study was conducted in northern Israel, involving 200 Arab subscribers of a regional Health Maintenance Organization (HMO).

RESULTS

An inverse association was found (p = 0.000) between Mediterranean diet score and cancer, with OR = 0.4, 95% CI = 0.260-0.612.

CONCLUSIONS

Greater adherence to Mediterranean diet is associated with lower prevalence of cancer. The adoption of this dietary pattern also seems to moderate the prevalence of obesity and risks of chronic diseases.

Incidence of cancer among diabetic and non-diabetic adult Israeli Arabs

BACKGROUND

A worldwide epidemic of type 2 diabetes mellitus (T2DM) is in progress. This disease carries a heavy socioeconomic burden.

OBJECTIVES

To compare the incidence rate of overall and site-specific cancers among Israeli Arabs with T2DM to that of Israeli Arabs without.

METHODS

A retrospective cohort study of all adult Arab members of Clalit Health Care Services in northern Israel was conducted over a 10 year period (1999-2008).

RESULTS

During the study period 752 and 2045 incident cases of cancer were diagnosed among 13,450 adults with diabetes and 74,484 without, respectively. The follow-up time involved 817,506 person-years. Diabetes was associated with a standard incidence ratio (SIR) of 3.27 (95% CI 1.49-5.05) and 2.87 (95% CI 1.25-4.50) for pancreatic cancer in men and women, respectively. A significantly reduced SIR (0.67, 95% CI 0.36-0.99) was observed for esophageal, stomach and intestinal cancers in men.

CONCLUSIONS

Our findings support an association between T2DM and increased risk of cancer of the pancreas in Arab men and women. A significantly reduced risk of all other cancers was observed only in Arab men. Our findings underscore the need for effective diabetes and cancer prevention and intervention programs.

Occupational exposures and symptoms among firefighters and police during the carmel forest fire: the Carmel cohort study

BACKGROUND

From 2 to 5 December 2010, Israel experienced the most severe forest fire In its history, resulting in the deaths of rescue workers. Little research exists on the health risks to emergency responders during forest fires, and there is no published research to date on occupational health among firefighters in Israel.

OBJECTIVES

To describe the exposures experienced by emer gency responders to smoke, fire retardants and stress; the utilization of protective equipment; and the frequency of corresponding symptoms during and following the Carmel Forest fire.

METHODS

A cohort of 204 firfighers and 68 police who took part in rescue and fire-abating activites during the Carmel Forest fire were recruited from a representative sample of participating stations throughout the country and interviewed regarding their activities during the fire and their coinciding symptoms. Unpaired two-sample t-test compared mean exposures and symptom frequency for firefighters and police. Chi-square estimates of OR and 95%CI are provided for odds of reporting symptoms, incurring injury or being hospitalied for various risk factors

RESULTS

Of the study participants, 87% reported having at least one symptom during rescue work at the Carmel Forest fire,with eye irritation (77%) and fatigue (71%) being the most comon. Occupational stress was extremely high during the fire; the average length of time working without rest was 18.4 hours among firefighters.

CONCLUSION

Firefighter and police were exposed to smoke and ocupational stress prolonged periods during the fire. Further research is needed on the residual health effects from exposure to forest fires among emergency responders, and to identify areas for improvement in health preparedness.

[Work ability index questionnaire--first utilization of the Hebrew translation in Israel]

The work ability questionnaire is widely used in many countries and for different groups of workers. We present the first use of the Hebrew translation of the questionnaire in a target group of community nurses. The calculated mean values of the index, using a standardized questionnaire, were compared with independent questions regarding various characteristics of work conditions and occupational stress. High correlations were found between mean work ability index (WAI) values and the independent questions attesting to the validity and usefulness of this simple tool for ascertaining the work ability of individual workers or as a research tool.

[Diabetes mellitus and cancer: the different expression of these diseases in Israeli Arabs and Jews]

BACKGROUND

The Arab population of Israel is a separate ethnic group from the Jewish population, embracing a different lifestyle and different nutritional habits and environmental exposures. These variations may lead to dissimilar expressions of certain diseases in the Arab Israeli as compared with the Jewish population. In recent years, the Arab population in Israel has experienced rapid and marked changes toward westernization in lifestyle, and significant increases in the incidence rate of both diabetes mellitus (DM) and cancer This is combined with an increase in known risk factors common to both illnesses.

METHODS

Review of recent publications and official health statistics provided the sources of information for this review.

RESULTS

Studies show that in recent decades the incidence rate of DM in the Israeli Arab population has increased by 9.1 per 1000 persons annually and of cancer by 1.3 per 1000 person annually among males and by 1.2 per 1000 person among females. In contrast, these rates have decreased in the Jewish population.

CONCLUSIONS

Lifestyle change in recent decades (westernization) in the Israeli Arab population has led to a marked increase in the incidence rate of DM and cancer in this group. The most influential risk factors are unhealthy diet, physical inactivity and tobacco smoking. By understanding these processes, effective intervention efforts can be initiated in order to reverse these trends.

Carpal tunnel syndrome: under-recognition of occupational risk factors by clinicians

This study was performed in order to demonstrate that non-occupational physicians are often unaware of the possible role of occupational risk factors in the multifactorial etiology of carpal tunnel syndrome (CTS). Study participants consisted of 229 individuals, 127 cases of CTS matched with 102 controls. In only 41% of the cases did family or attending physicians in the hospital asked the concerned patients about their occupation or specific job tasks, and less than 10% of the cases were referred for further evaluation to an occupational physician. Occupational risk factors that were identified were: work with repeated movements of the wrist (OR=2.15, 95% CI=1.14-4.07) and work in a cold environment (OR=3.52, 95% CI=1.08-11.47). By improving the awareness of clinicians (and patients) to the possible role of work-related factors in the etiology of CTS, appropriate preventive measures can be introduced in order to reduce the burden of this syndrome.

[The role of occupational exposures in the etiology of bladder cancer]

In a case-control study in southern Israel, 150 male subjects with histologically proven transitional cell cancer (TCC) of the bladder were matched with 150 controls. Both groups were interviewed regarding past occupational exposures, lifestyle habits, and co-morbidities. Significant associations were demonstrated between certain occupational exposures and the risk to develop TCC. These exposures were (a) organic solvents (OR 3.5, 95% CI = 1.4-8.4), (b) aromatic amines and\or paints (OR = 2.7, 95% CI = 1.1-6.3) and (c) PAHs (OR = 1.9, 95% CI = 1.2-4.3). Similarly, significant associations were found between certain occupations (jobs) and the risk of future TCC, such as metal workers and welders. In conclusion, certain types of occupational exposures and industrial jobs bear extra risk for the future development of TCC (in addition to the well established risk of smoking). Thus, better identification and control of these occupational risk factors (chemicals and work processes) is required in order to reduce the risk for this relatively common cancer and improve protection for the relevant groups of workers.

Neighbors and enemies: lessons to be learned from the Palestinian-Israeli conflict regarding cooperation in public health

We aim to demonstrate on the example of recent Palestinian-Israeli collaborative projects how sustainable cooperation can be achieved despite unfavorable political atmosphere and continuing violent disputes. Palestinian and Israeli participants of the collaborative projects declared that their attitude and belief in coexistence was positively changed as a result of their experience in cooperative work. Their main motivations were a desire to contribute to the resolution of the conflict and to improve professional skills. The experience in Israeli-Palestinian conflict showed that the collaborative projects of higher chance of success and sustainability should address issues of high priority to the concerned parties, lead to demonstrable benefits in the immediate future, and preferably be organized by non-governmental organizations. Also, to secure long-term success of collaborative projects, parity and symmetry should be maintained, as well as equal division of work and responsibility between the partners. Collaboration in public health field is first to be (re)established in conflict areas to alleviate suffering, minimize future health risks, and prevent further health deterioration. Thereby, public health can serve as a bridge to peace in areas of unrest or war.

Regional occupational health service - an assessment

AIM

To present, partially in quantitative terms, the basic characteristics of a regional occupational health service in southern Israel.

METHOD

Records of the annual activities of the regional occupational health service were analyzed over a period of about 10 years.

RESULTS

Overall there were about 25,000 contacts per year, such that about 15,000-16,000 different individuals were examined each year (out of a population of about 150,000 workers). About 45% of the examinations performed were surveillance (statutory), 38% fitness-to-work, and 15% pre-employment examinations. These proportions were quite stable over the whole study period, even though services are provided to hundreds of work-sites of markedly different sizes, exposures, and technological development. As expected, the type and rate of abnormal findings differ significantly among the 3 categories: 7% for pre-employment examinations, 18% for surveillance, and 53% for fitness-to- work examinations.

CONCLUSION

In order to provide adequate occupational health services to a large, non-uniform population of workers, a clear understanding of the "occupational map" of the region is needed. A good insight into the characteristics, aims, and scope of the 3 main categories of examinations used in occupational health could assist in forecasting, planning, and providing adequate regional occupational health service.

Assessment of work-related risks factors for carpal tunnel syndrome

BACKGROUND

The association of carpal tunnel syndrome with occupational risk factors is well established. However, in clinical practice these factors are only rarely considered and evaluated. Managing these risk factors could prevent the occurrence of future cases and alleviate treatment of the afflicted individuals.

OBJECTIVES

To estimate the role of occupational risk factors in a large group of patients diagnosed by electrophysiological studies as suffering from CTS.

METHODS

A group of 396 subjects (204 women, 165 men) who were tested in one laboratory by electrophysiological studies were further evaluated (by questionnaire) to determine the possible role of occupational and other risk factors in the etiology of their syndrome.

RESULTS

Persons employed in high force--low repetitive or low force--high repetitive jobs, harbor an extra risk for developing CTS as compared with controls, OR = 3.21 (95% C1 = 1.5-6.9) and OR = 4.72 (95% C1 = 1.8-12.5), respectively. These jobs include typists/secretaries, nursing personnel, production workers and housewives.

CONCLUSION

Evaluation of a general group of examinees referred for electrophysiological studies on sympathology compatible with CTS may show that occupational risk factors play a substantial role in the development of symptoms. By increasing the awareness of clinicians and the public to these risk factors, appropriate preventive measures can be introduced and the burden of the disease reduced.

Herbicide (Roundup) pneumonitis

A case of acute intoxication presented as toxic pneumonitis after exposure to Roundup (glyphosate) (Solaris Group, Monsanto; San Ramon, CA) herbicide in an agriculture worker. The correct etiologic factor causing this specific clinical picture was identified only 2 weeks later, after a thorough occupational history was taken and meticulous delineation of the working conditions and exposures of the involved worker were made. As a rule, occupational related diseases are not readily elucidated by nonoccupational physicians. However, most acute intoxication events are first encountered by such physicians. In these situations, rapid and comprehensive evaluation is necessary in order to clearly identify the causative agent(s) and to initiate the appropriate treatment. Consulting occupational physicians at this early stage may facilitate early and accurate diagnosis.

Periodical multiphasic screening and lung cancer prevention

The purpose of this work is to evaluate the utilization of information gathered by multiphasic screening with respect to lung cancer detection and smoking cessation techniques. A cohort (follow-up) study is reported in which cancer incidence and factors affecting its occurrence are evaluated in a group of about 20,000 presumably healthy adults along a period of approximately 10 years following comprehensive multiphasic health examinations. Lung cancer occurrence is primarily related to smoking. The risk is higher in smokers and is dose-dependent; OR = 0.21, (CI = 0.08, .53) in never smokers, OR = 1.53 (CI = 0.8, 3.2) in past and current moderate smokers, OR = 4.92 (CI = 2.18, 11.11) in current heavy smokers. Moreover, smokers with compromised pulmonary function (FEVI/FVC < 75%) are at an even higher risk of developing lung cancer OR = 4.22 (CI = 2.2, 8.2) for past and current moderate smokers; and OR = 10.7 (CI-2.5, 38.6) in current heavy smokers. Information gathered in periodical multiphasic health examinations could be utilized by health professionals to encourage smoking cessation and smoking prevention in the appropriate screenees. Various elements of the multiphasic test results could contribute to such prevention efforts. While every smoker should receive appropriate evaluation and consultation regarding nicotine dependence, smokers with reduced pulmonary function represent an extra high risk group to which special attention should be given.

Effects of work overload and burnout on cholesterol and triglycerides levels: the moderating effects of emotional reactivity among male and female employees

The effects of objective and subjective overload, and of physical and emotional burnout, on cholesterol and triglycerides levels were studied in a quasiprospective design. The possible moderating effects of emotional reactivity on these relationships were also investigated. The study's hypotheses were tested separately for male and female employees. Time 1 (T1) data were collected from 665 healthy employees (30% women) while they were undergoing periodic health examinations in a health-screening center. Time 2 (T2) measures of cholesterol and triglycerides were collected 2 to 3 years after T1. The hypotheses were tested by regressing each T2 criterion on its T1 level; the control variables of age, obesity, diet, alcohol consumption, and smoking; and the other predictors. For female employees, the T2-T1 changes in the serum lipids were positively predicted by emotional burnout, as expected, but negatively predicted by physical fatigue. For male employees, both types of T1 burnout were positive predictors of the T2-T1 change in total cholesterol.

Effects of work overload and burnout on cholesterol and triglycerides levels: the moderating effects of emotional reactivity among male and female employees

The effects of objective and subjective overload, and of physical and emotional burnout, on cholesterol and triglycerides levels were studied in a quasiprospective design. The possible moderating effects of emotional reactivity on these relationships were also investigated. The study's hypotheses were tested separately for male and female employees. Time 1 (T1) data were collected from 665 healthy employees (30% women) while they were undergoing periodic health examinations in a health-screening center. Time 2 (T2) measures of cholesterol and triglycerides were collected 2 to 3 years after T1. The hypotheses were tested by regressing each T2 criterion on its T1 level; the control variables of age, obesity, diet, alcohol consumption, and smoking; and the other predictors. For female employees, the T2-T1 changes in the serum lipids were positively predicted by emotional burnout, as expected, but negatively predicted by physical fatigue. For male employees, both types of T1 burnout were positive predictors of the T2-T1 change in total cholesterol.

Biological monitoring of workers' exposure to bromine

The use of serum bromine concentration (SeBr) as a measure of exposure was examined in an occupational cohort. Associations with work site, department type, chemical handling, and occupation, as proxy measures of exposure, were studied. SeBr was associated with all of these measures. SeBr was also associated with various demographic characteristics (age, country of origin, and education) in men. In women, there was no association between SeBr and age, country of origin, or education. The use of SeBr as a measure of exposure is discussed. The conclusion is that the exposure to bromine can be assessed by regular monitoring of SeBr.

A Regional Occupational Medicine Service: Qualitative and Quantitative Assessment

A quantitative description of a regional occupational medicine system, serving some 200,000 workers in a broad spectrum of occupations, is given. The main activities of the service-pre-employment, medical surveillance, and fitness-to-work examinations-are presented in quantitative terms. Approximately 27,000 examinations are performed annually, of which about 50% require biological monitoring for a specific occupational exposure, 35% are fitness-for-work examinations, and 15% are pre-employment examinations. The main abnormal findings identified by fitness examinations involved the musculoskeletal (25%), cardiovascular (13%), or upper respiratory, pulmonary, and neurologic systems (3% each). Among surveillance examinations, the most frequently identified pathology is phonal trauma (11%). The three types of examinations are looked at with respect to rates of abnormal findings over a one-year period, compared with the mean rate of abnormal findings over the preceding five-year period, and future trends are extrapolated. The implications regarding assessment of resource allocation, appropriate budgeting, and personnel recruitment and training, as well as planning of worker safety and health maintenance programs, are noted. The authors conclude that ongoing quantitative analysis of the activities of a regional occupational medicine service is mandatory for quality assurance and future planning responsive to the dynamic needs of the target workforce.

[Annual activities of a regional occupational health service]

The scope and content of the services provided by a regional, occupational health service are described in quantitative terms. Many of its activities are in compliance with state regulations. In this respect this service differs greatly from other, regular, clinical services. About 22,000 examinations are performed annually, and there are about 140,000 employed persons in the region, so that about 1 in 5 workers is examined by the service annually. The 3 main activities of the clinic are pre-employment examinations, periodic surveillance of certain groups of workers and evaluating work capacity. Most of the abnormal findings identified in such examinations relate to musculo-skeletal disorders, noise-induced hearing loss and, to a much lesser degree, lung and skin problems. Some of the ways in which service is provided in remote and small work sites are described, and issues of availability and accessibility presented. Based on the data collected, suggestions are made with respect to future changes, including computerization and quality assurance methods.

Factors affecting long-term sick leave in an industrial population

Factors affecting long-term absenteeism for non-accident-related sickness leave in a large, remotely located factory (Dead Sea Industry, Israel) were evaluated. About 10% (89 persons) of the workers were found to be on sick leave for more than 20 days/year. This group was designated as high absence workers (HAW). Most of the sickness absence were for repeated short-term leaves due to intercurrent diseases, rather than for continuous periods related to a major or single illness. Average cumulative duration of sick leave in this group was 54 days/year. The average number of spells was 11 per year (4.9 days/spell). There were significantly more HAW among skilled (relative risk, R.R. = 1.6) workers or shift workers (R.R. = 1.3), compared to white collar workers. There were significantly fewer HAW among workers 35-49 years of age (7.6%) than among younger (12.5%) or older workers (13.8%). Except for possible hearing loss in one worker, no occupationally related illness was identified. Sixty-six percent of the HAW took many sick leaves, over 20 days during the year following the study year, and 52% of this group took over 20 days in the preceding year (usually for minor diseases or complaints). This pattern of long-term sickness absence indicates that various socio-economic factors determine HAW to a greater extent than immediate occupational risks or health problems.

"Souvenir" casting silicosis

A case of silicosis in a 47-year-old worker who was employed for many years in a small souvenir casting shop is described. This work site demonstrates many unfavorable characteristics of small industries, such as lack of awareness of the need for safety measures, exposure control, protection of workers, and lack of compliance with environmental and medical-legal standards.

Repeated multiphasic screening examinations: evaluating the process

There are sound clinical and epidemiological reasons to promote and emphasize early detection efforts and disease prevention services. A large body of scientific literature supports the notion that detection and intervention early in the course of many diseases is beneficial both to the afflicted individual and to society at large. Several publications deal with the evaluation of multiphasic screening examinations (MSE) as a tool for simultaneous early detection and prevention of multiple risk factors and various diseases. Usually, this technology is evaluated based on data from a single (cross-sectional) comprehensive screening study. However, frequently MSE are performed periodically, resulting in repeated test results of the same individuals. The health impact of such repeated (longitudinal) MSE has not been studied extensively. Similarly, many of the unique theoretical, technical, and epidemiological features characteristic of consecutive (periodical) comprehensive screening examinations are not well-documented. The purpose of this study was to compare the test results of two MSE, performed 3.5 years apart, in order to demonstrate certain characteristics of multiphasic health testing (MHT) technology related to repeated (longitudinal) multiphasic examination of the same individuals.

Findings in pre-employment examinations

Results of comprehensive pre-employment examinations of about 8,600 persons were analyzed. The most frequent findings are those related to the more prevalent risk factors and morbidity (of adults) in industrialized countries. Of special interest were the associations found between low level of education (or socioeconomic status), exposure to various occupational hazards, and poor life-style habits. These findings attest to the need for providing preventive follow-up (intervention) services to complement any large-scale screening program. Such services could be developed, relatively simply, based on existing occupational medicine units. The advantages and pitfalls of utilizing multiphasic screening technology in general and in occupational health settings are discussed.

Delayed health sequelae of accidental exposure to bromine gas

The delayed health effects from accidental exposure to bromine vapors in a group of six people were evaluated. During the acute exposure, they had only some respiratory symptoms and skin burns of first to second degree involving small areas. All were treated in one hospital and released within 1-4 d. Six to 8 wk later, some still had health complaints such as cough, shortness of breath, chest tightness, eye irritation, headache, dizziness, fatigue, and memory, sleep, and sexual disturbances, but no objective laboratory or clinical evidence of effects. Mechanisms that might have led to manifestations of such complaints 1-2 mo after the accident are discussed and possible ways to alleviate similar situations are suggested.

Changes in smoking patterns in young military recruits in relationship to psychosocial characteristics

We followed 295 young infantry recruits during their first 14 weeks of basic training. The prevalence of smoking increased by 50%. About half of this increase was accounted for by ex-smokers, 57% of whom had resumed the habit. Average education and military psychometric measures of both the baseline smokers and the new smokers were significantly lower than those of the abstaining never-smokers. Asian and North African origin and a lower peer group evaluation score were also risk factors. These relationships were not demonstrated among resuming ex-smokers. The rise in the smoking rate accounts for most of the known rise during full military service. We suggest early preventive measures, especially for the two groups at risk.

Comparison of two pre-admission testing methods for elective surgery patients

Patients admitted for elective surgery (inguinal hernia, varicose veins and hemorrhoids) were studied in order to evaluate the impact of performing pre-admission testing (PAT) by utilizing an automated multiphasic health testing (AMHT) technology on the rate of repeating the pre-operative routine laboratory tests during hospitalization. A slightly lower but statistically significant rate of repeated tests was found among patients who performed PAT by AMHTS compared with those who performed the tests via the conventional ambulatory system. This result suggests that performing routine tests before hospitalization in a single authorized AMHTS facility is preferred since it saves the patient time and reduces the need for repeated tests.

Occupational stress and well-being: do seafarers harbor more health problems than people on the shore?

The popular image of life at sea is one of stress: often difficult physical conditions, dislocation, isolation and less than ideal personal habits. In order to determine whether this stressful way of life is manifested when seamen's health status is assessed by standard measurements, we studied 144 sea captains and marine chief engineers as compared with a group of ordinarily employed men. The referent men were matched for age, ethnic origin, and level of education with the seamen. Outcome measures included a wide spectrum of physiological, psychological and behavioral indices. The comparisons revealed only mild differences between the two groups. Captains and chief engineers tend to harbor slightly higher levels of certain biochemical or physiological parameters (risk factors), such as serum cholesterol and uric acid, hemoglobin level and leukocyte count. Certain behavioral risk factors were more dominant among the seamen than among the control group (smoking level, alcohol consumption and lack of leisure-time physical activity). The study group did not exhibit a greater prevalence of overt disease or a higher degree of psychological symptoms. It is suggested that the group under study represents a self-selected group of persons well adjusted to their job and their special way of life.

[Late health sequelae of accidental bromine exposure]

Health and environmental assessment of the consequences of accidental contamination of an area in the Negev desert is described and the effects of exposure to bromine vapor in 6 persons evaluated. They were only mildly affected during the acute spillage of the bromine, with some respiratory symptoms and first and second degree skin burns of small exposed areas on the legs. All were treated in hospital and were released within 1-4 days. 6-8 weeks later they demonstrated a complex array of complaints, including cough, shortness of breath, chest tightness, eye irritation, headache, dizziness, fatigue, memory disturbances, sleep and sexual disturbances. These complaints could not be substantiated by objective clinical or laboratory examination. There was thus obvious magnification of the complaints 1-2 months after the accident.

Smoking, leukocyte count, and ventilatory lung function in working men

Results of a cross-sectional study of ventilatory lung function (VLF) in a group of 307 working men showed that the leukocyte count in peripheral blood is more closely associated with the relative position (percentile) of a person in the frequency distribution of VLF than is smoking intensity. Leukocyte count is significantly (and inversely) correlated with VLF in nonsmokers as well as in smokers. A multiple regression analysis indicated that, after accounting for the effect of height and age, white blood cell (WBC) count explains more of the VLF variance than many other health determinants. Moreover, WBC count is the only variable, apart from height and age, that contributes significantly to the regression. Current smokers with elevated leukocyte count in peripheral blood may constitute a defined high-risk group because they demonstrate more negative regression age coefficients when compared with smokers without elevated WBC or with nonsmokers. Mechanisms that may explain these findings are discussed.

Routine urinalysis (dipstick) findings in mass screening of healthy adults

We present results of simple urinalysis examinations (dipstick) in a large (approximately 21,000 people) working population. In about 10% of the screened individuals at least one abnormality was found. In men the most common finding was proteinuria (4.9%). Hematuria was found in 2.6% and glycosuria in 0.6%. The most prevalent finding in women was hematuria (8.1%), followed by proteinuria (3.9%) and glycosuria (0.6%). Only about 1% of the examinees had two or more abnormalities in their urine examinations. These findings attest to the utility and practicability of incorporating urine testing into various screening and clinical examinations.

Routine urinalysis (dipstick) findings in mass screening of healthy adults

We present results of simple urinalysis examinations (dipstick) in a large (approximately 21,000 people) working population. In about 10% of the screened individuals at least one abnormality was found. In men the most common finding was proteinuria (4.9%). Hematuria was found in 2.6% and glycosuria in 0.6%. The most prevalent finding in women was hematuria (8.1%), followed by proteinuria (3.9%) and glycosuria (0.6%). Only about 1% of the examinees had two or more abnormalities in their urine examinations. These findings attest to the utility and practicability of incorporating urine testing into various screening and clinical examinations.

Hypertension in European immigrants to Israel--the possible effect of the holocaust

To examine the effect of stressful life events and chronic emotional distress in the development of hypertension, we compared the blood pressure of 1,150 Israelis (aged 50 to 80) who immigrated from Europe before 1939 with that of 2,159 European-born Israelis who immigrated to Israel after World War II. Most of the subjects were examined as part of a periodical health examination offered by their employers. There were only minor differences in age, height, country of origin and level of education between the two groups. There was no difference in the prevalence of hypertension between the two immigration groups, and a similar percentage of both groups were receiving treatment. Hypertension was defined as any one or more of the following: supine systolic greater than or equal to 160 mm Hg, diastolic greater than or equal to 95 mm Hg, or treatment with antihypertensive medications. Analysis of variance showed that age, sex and degree of obesity were the main factors contributing to the blood pressure. Although the degree of emotional stress was greater in the Holocaust survivors, there was no correlation between level of emotional distress, satisfaction with life or number of psychosomatic complaints and level of blood pressure or prevalence of hypertension.

Evaluation of the annual activity of a continuing medical and home care unit

This report presents the annual activity of a home care unit which operates as an extension of a regional hospital into the community. This 'intermediate-care' (between hospitalization and ambulatory care) was developed because of the demographic and health characteristics of the urban population served and in response to their specific health care needs (immediate availability and accessibility of care). During this period, 471 patients were under care, 85% of whom were 65 years old and over. Forty percent were referred with a diagnosis of a malignant disease, about 20% with a diagnosis of a cerebral event and 15% with cardiac and vascular problems. The average period of stay in the program was three months, with less than 10% remaining under supervision for more than a year. In about 50% of the patients involved the care goals were attained and in an additional 25% (terminal cases) the patients were cared for at home until death. The service was found to be an important factor in the interim phase between acute hospitalization and the continuation of care provided by the family physician. The multidisciplinary team care approach was found to be effective in providing services to that group of patients characterized by old age, multiple medical problems and being homebound. The concerned service is continuously developing in compliance with the changing and growing needs of particular groups of patients such as advanced malignant disease, complex cardiovascular problems and multiple (simultaneous) diseases.

Preadmission testing in elective surgery--improving the process

Patients admitted for elective surgery (inguinal hernia, varicose veins and hemorrhoids) were evaluated in order to determine the differential impact between two methods of performing preadmission testing (PAT) on the length of stay and on the completeness of the requested data. The two methods compared were: conventional, whereby patients performed the PAT in the regular clinics and laboratories of a health care organization (health maintenance organization-like) and an automated multiphasic health testing system (AMHTS). For these particular operations no significant difference in length of stay between the two methods was found. Based on the accumulated experience with these modalities, a model for performing preadmission procedures (in a preanesthetic clinic for elective surgery) was designed in order to identify high-risk patients. Use of this model can reduce cost, increase patient satisfaction and prevent hospitalization when immediate surgery is contra-indicated.

Emotional distress and satisfaction in life among Holocaust survivors--a community study of survivors and controls

Results are reported from a large population study (of working people) comparing Holocaust survivors and a control group in regard to emotional distress, satisfaction in life and psychosomatic symptoms. It was found that, even 40 years after the traumatic experience, this group of survivors exhibited a slightly higher degree of emotional disorders than controls who were not under Nazi occupation during WWII. These long-term effects were usually more prominent in women than in men, and the relationship to age was minimal.