A case of welder's lung with end-stage pulmonary fibrosis

BACKGROUND

Welding, performed regularly by more than a million workers worldwide, is associated with exposures to irritative, fibrogenic and carcinogenic fumes and gases.

METHODS AND RESULTS

We present the case of a welder who had worked under extremely poor hygiene conditions for nearly 20 years and had developed end-stage lung fibrosis, finally requiring lung transplantation. Detailed histopathology and scanning electron microscopy/energy dispersive X-ray spectroscopy (SEM/EDS) analyses of his lungs showed advanced interstitial fibrosis and dust deposits in the lungs and in peribronchial lymph nodes containing welding type bodies, Fe, Si (silica), Ti (titanium), SiAl (aluminum silicates), Fe with Cr (Steel), and Zr (Zirkonium).

CONCLUSION

In the absence of a systemic disorder and the failure to meet the criteria for diagnosis of idiopathic pulmonary fibrosis (IPF), these findings suggest welder's lung fibrosis as the most likely diagnosis.

Health consequences of exposure to aircraft contaminated air and fume events: a narrative review and medical protocol for the investigation of exposed aircrew and passengers

Thermally degraded engine oil and hydraulic fluid fumes contaminating aircraft cabin air conditioning systems have been well documented since the 1950s. Whilst organophosphates have been the main subject of interest, oil and hydraulic fumes in the air supply also contain ultrafine particles, numerous volatile organic hydrocarbons and thermally degraded products. We review the literature on the effects of fume events on aircrew health. Inhalation of these potentially toxic fumes is increasingly recognised to cause acute and long-term neurological, respiratory, cardiological and other symptoms. Cumulative exposure to regular small doses of toxic fumes is potentially damaging to health and may be exacerbated by a single higher-level exposure. Assessment is complex because of the limitations of considering the toxicity of individual substances in complex heated mixtures.There is a need for a systematic and consistent approach to diagnosis and treatment of persons who have been exposed to toxic fumes in aircraft cabins. The medical protocol presented in this paper has been written by internationally recognised experts and presents a consensus approach to the recognition, investigation and management of persons suffering from the toxic effects of inhaling thermally degraded engine oil and other fluids contaminating the air conditioning systems in aircraft, and includes actions and investigations for in-flight, immediately post-flight and late subsequent follow up.

Diagnostic limitations of lung fiber counts in asbestos-related diseases

Background

Lung dust fibre analyses have been used by some pathologists to estimate past asbestos exposure in the workplace and its related health risks. Asbestos, however, especially the predominately applied chrysotile asbestos type, undergoes translocation, clearance and degradation in the lungs.

Objectives

We quantified the asbestos fibre and ferruginous (asbestos) body (FB) content in human tissue with respect to the German asbestos ban in 1993 and the interim period of more than 20 years in order to evaluate the diagnostic evidence of these analyses for asbestos-related diseases (ARD).

Methods

Lung dust analyses have been used in empirical assessments of ARD since 1982. Tissue samples of about 2 cm3 were used and processed in standardized manner. FB was analysed by light microscopy and asbestos fibres by scanning transmission electron microscopy (STEM).

Results

Chrysotile and amphibole fibre concentrations in the lung tissue depend roughly on the cumulative asbestos exposure levels in the workplace.

However, the concentration of lung asbestos fibre and FB depends on the year of examination and especially on the interim period. As the interim period increases, the asbestos fibre burden decreases. There is no relationship between FB and chrysotile asbestos fibre concentrations and only a weak correlation between FB and crocidolite fibre concentrations.

There was no significant difference in chrysotile and amphibole fibre concentrations as well as in FB counts between the different ARD.

Conclusions

Due to the length of interim periods, a past exposure to chrysotile or amphibole asbestos can no longer be detected with FB or asbestos fibre measurement in lung tissue. This means that negative results of such measurements cannot disprove a qualified occupational case history of asbestos exposures and the related health risks due to the fibrogenic and carcinogenic potential of asbestos.

The Relationship Between Potential Occupational Sensitizing Exposures and Asthma: An Overview of Systematic Reviews

OBJECTIVES

The aim was to identify, appraise, and synthesize the scientific evidence of the relationship between potential occupational sensitizing exposures and the development of asthma based on systematic reviews.

METHODS

The study was conducted as an overview of systematic reviews. A systematic literature search was conducted for systematic reviews published up to 9 February 2020. Eligibility study criteria included persons in or above the working age, potential occupational sensitizing exposures, and outcomes defined as asthma. Potential occupational sensitizing exposures were divided into 23 main groups comprising both subgroups and specific exposures. Two reviewers independently selected studies, extracted study data, assessed study quality, and evaluated confidence in study results and level of evidence of the relationship between potential occupational sensitizing exposures and asthma.

RESULTS

Twenty-seven systematic reviews were included covering 1242 studies and 486 potential occupational sensitizing exposures. Overall confidence in study results was rated high in three systematic reviews, moderate in seven reviews, and low in 17 reviews. Strong evidence for the main group of wood dusts and moderate evidence for main groups of mites and fish was found. For subgroups/specific exposures, strong evidence was found for toluene diisocyanates, Aspergillus, Cladosporium, Penicillium, and work tasks involving exposure to laboratory animals, whereas moderate evidence was found for 52 subgroups/specific exposures.

CONCLUSIONS

This overview identified hundreds of potential occupational sensitizing exposures suspected to cause asthma and evaluated the level of evidence for each exposure. Strong evidence was found for wood dust in general and for toluene diisocyanates, Aspergillus, Cladosporium, Penicillium, and work tasks involving exposure to laboratory animals.

Malignant mesothelioma: Ongoing controversies about its etiology in females

Malignant mesothelioma (MM) is one of the most aggressive cancers with the poorest of outcomes. There is no doubt that mesothelioma in males is related to asbestos exposure, but some authors suggest that most of the cases diagnosed in females are "idiopathic." In our assessment of the science, the "low risk" of mesothelioma in females is because of the nonsystematic recording of exposure histories among females. Indeed, asbestos exposure is mentioned in only some of the studies that include females. We estimate the risk of MM among females to be close to that in males. The absence of detailed exposure histories should be rectified in future studies involving ​women. As a matter of social justice, the ongoing failure to recognize asbestos as the cause of a majority of cases of MM in females does them, and their kin, a profound disservice.

[Guideline for the Diagnosis and Treatment of Asthma - Addendum 2020 - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]

The present addendum of the guideline for the diagnosis and treatment of asthma (2017) complements new insights into the diagnosis and management of asthma as well as for the newly approved drugs for the treatment of asthma. Current, evidence-based recommendations on diagnostic and therapeutic approaches are presented for children and adolescents as well as for adults with asthma.

Ongoing downplaying of the carcinogenicity of chrysotile asbestos by vested interests

Industries that mine, manufacture and sell asbestos or asbestos-containing products have a long tradition of promoting the use of asbestos, while placing the burden of economic and health costs on workers and society. This has been successfully done in recent years and decades in spite of the overwhelming evidence that all asbestos types are carcinogenic and cause asbestosis. In doing so, the asbestos industry has undermined the WHO campaign to reach a worldwide ban of asbestos and to eliminate asbestos-related diseases. Even worse, in recent years they succeeded in continuing asbestos mining and consuming in the range of about 1.3 million tons annually. Nowadays, production takes place predominantly in Russia, Kazakhstan and China. Chrysotile is the only asbestos type still sold and represents 95% of asbestos traded over the last century.The asbestos industry, especially its PR agency, the International Chrysotile Association, ICA, financed by asbestos mining companies in Russia, Kazakhstan and Zimbabwe and asbestos industrialists in India and Mexico, continues to be extremely active by using slogans such as chrysotile can be used safely.Another approach of the asbestos industry and of some of its insurance agencies is to broadly defeat liability claims of asbestos victims.In doing so they systematically use inappropriate science produced by their own and/or by industry-affiliated researchers. Some of the latter were also engaged in producing defense material for other industries including the tobacco industry. Frequent examples of distributing such disinformation include questioning or denying established scientific knowledge about adverse health effects of asbestos. False evidence continues to be published in scientific journals and books.The persisting strong influence of vested asbestos-related interests in workers and public health issues including regulations and compensation necessitate ongoing alertness, corrections and appropriate reactions in scientific as well as public media and policy advisory bodies.

Outdoor air pollution from industrial chemicals causing new onset of asthma or COPD: a systematic review protocol

Background

Until today, industrial sources contribute to the multifaceted contamination of environmental air. Exposure to air pollutants has the potential to initiate and promote asthma and chronic obstructive pulmonary disease (COPD). At global scale, both entities cause the majority of about 4 million annual deaths by respiratory disease. However, we identified industrial contamination as a subgroup of air pollution that may be associated with this burden and is underinvestigated in research. Therefore, the aim of this study is to investigate associations between substances industrially released into environmental air and the occurrence of asthma and COPD in the human population. Here we present the protocol for our systematic review of the current evidence.

Methods

The following determinations will be applied during the systematic review process and are specified in the protocol that complies with the PRISMA-P statement. Populations of children and adults, as well as outdoor workers, exposed to industrially released air pollutants are of interest. Eligible studies may include subjects as controls who are non- or less exposed to the investigated air pollutants. The outcomes new-onset asthma and/or COPD investigated with risk ratio, odds ratio, hazard ratio, incidence rate ratio, cumulative incidence, and incidence rate are eligible. We will search the electronic literature databases EMBASE, MEDLINE, and Web of Science for peer-reviewed reports of incidence studies and incidence case-control studies. After systematic sorting of initial records, included studies will be subjected to quality assessment. Data will be synthesized qualitatively and, if appropriate, quantitatively for risk ratio and odds ratio. We will maintain and provide a PRISMA report.

Discussion

Results of this systematic review may indicate alterations of incidence and risk of asthma and/or COPD in populations within industrial exposure radiuses including outdoor workplaces. Specific causal substances and compositions will be identified, but results will depend on the exposure assessment of the eligible studies. Our approach covers effects of industrial contributions to overall air pollution if studies reportedly attribute investigated emissions to industry. Results of this study may raise the question wether the available higher-level evidence sufficiently covers the current scale of industrial exposure scenarios and their potential harm to respiratory health.

Trial registration

This protocol was registered in PROSPERO, registration number CRD42020151573.

[Assessment of Asbestos-related Occupational Diseases: Socio-medical and Legal Aspects]

Occupational diseases are certain diseases designated as such by law. Whereas the medical conditions are described in guidelines, their recognition is based on judicial administrative procedures. Establishing causality is based on requirements of social law. The basic socio-legal concepts are mentioned and the principles of causality in asbestos-related occupational diseases are listed. Exemplary social court judgments are cited. Judgements may not infrequently differ from the medical point of view. The aim of this article is to describe the correct use of social medical understanding in order to carry out adequate assessment of occupational diseases, which implements the legal requirements.

Exposure to fumigants in containers: a questionnaire assessment on 125 French dockers

BACKGROUND

Cases of intoxications to gas from container's atmosphere have been described. For diagnosis, Fum Ex 2 questionnaire has been developed by the European Society for Environmental and Occupational Medicine. The aim of this study was to enhance knowledge on health effects of toxic substances in containers and to validate this questionnaire in medical follow-up and diagnosis.

MATERIALS AND METHODS

In 2014, 125 French dockers answered the questionnaire in a face-to-face interview.

RESULTS

83.5% declared no exposure to fumigants or pesticides. Most frequently declared symptoms were fatigue and neurological disorders for dockers and respiratory irritation for refrigeration technicians. Only 28 workers wore regularly individual protection equipment.

CONCLUSIONS

A "healthy worker" effect could explain low level of symptoms. Fum Ex 2 questionnaire is relevant for diagnosis. Workers in all steps of the logistic transport chain and consumers are exposed to containers' atmosphere.

[Diagnostic Challenges of Mixed Dust Silicosis (Mixed Dust Pneumoconiosis) - 5 Case Reports]

Exposure to granular or fibrous inorganic dusts of the alveolar dust fraction initiates inflammatory and fibrotic lung processes. Furthermore, such exposures are associated with an increased risk for lung cancer. By taking a detailed occupational history into consideration the diagnosis of relatively frequent pneumoconioses such as silicosis or asbestosis with dominating pictures, i. e. with its predominant rounded or irregular opacities located especially in the upper and lower lung fields, respectively, is mostly not difficult. However, rarely exposure to a single agent exists. Rather, mixed dust exposures occurring at the same time or in the follow-up have to be taken into consideration, e. g. quartz and carbon in hard coal mines, quartz, asbestos, various other components of cement and concrete dusts in the construction industry. It is also important that during the working life, changes of working processes and used raw materials as well as changes of jobs are associated with variations of type and intensity of exposures. This heterogenicity of exposures and of the associated intrapulmonary depositions result in variations of the pulmonary structural changes, i. e. more or less modifications of the pictures of pneumoconioses as described being typical in textbooks. This is associated with diagnostic difficulties, especially with regard to the differential diagnosis of idiopathic interstitial lung diseases. There is also evidence for genetic influence on disease susceptibility and on the degree of pathohistological changes.This publication includes 5 case reports; all of them were initially diagnosed as idiopathic pulmonary fibrosis, but a detailed workup of the author, mostly during social court litigations, showed that mixed dust pneumoconioses were the most likely diagnoses.

How can the integrity of occupational and environmental health research be maintained in the presence of conflicting interests?

BACKGROUND

The sciences, and especially the research subspecialties of occupational and environmental health, are being misused. The misuse serves to interfere with the advancement of policies that depend on rational evidence needed for policies to protect public health.

METHODS

We selectively surveyed the independent scientific literature. In addition, the efforts of respected international professional organizations of scientists whose focus is on maintaining and improving public health have been considered. This commentary is unique in assembling not only the factual basis for sounding alarms about significant bias in occupational and environmental health research, but also about the manipulative mechanisms used, and, in turn, the methods needed to keep science honest.

RESULTS

Scientific integrity is based on the principle that research is conducted as objectively as possible; it cannot be compromised by special interests whose primary goals are neither to seek truth nor to protect human health. Evidence demonstrates a significant risk of bias in research reports sponsored by financial interests. Practices of corporate malfeasance include the orchestrated contamination of editorial boards of peer-reviewed scientific journals with industry apologists; interference with activities of national regulatory bodies and international review panels engaged in safeguarding occupational and public health; constructing roadblocks by capitalizing on uncertainty to undermine scientific consensus for much-needed government regulation of carcinogenic, endocrine-disrupting and/or immunotoxic agents; promoting "causation" criteria that lack foundation and effectively block workers' access to legal remedies for harms from occupational exposures resulting in morbidity and premature mortality; and, violating standards of professional conduct by seducing reputable scientists with financial incentives that make them beholden to corporate agendas.

CONCLUSIONS

Well-orchestrated assaults on science continue unabated and must now be met head-on. Success could be achieved by promoting and protecting the integrity of research. Furthermore, avoiding influence by conflicted corporate affiliates in occupational and public health regulations is needed. Identifying, managing and, ideally, eliminating corporate influence on science and science policy are needed to protect research integrity. Protecting the public's health, preventing disease, and promoting well-being must be the unambiguous goals of research in occupational and environmental health.

Immunological methods for diagnosis and monitoring of IgE-mediated allergy caused by industrial sensitizing agents (IMExAllergy)

Industrial sensitizing agents (allergens) in living and working environments play an important role in eliciting type 1 allergic disorders including asthma and allergic rhinitis. Successful management of allergic diseases necessitates identifying their specific causes (ie, identify the causative agent(s) and the route of contact to allergen: airborne, or skin contact) to avoid further exposure. Identification of sensitization by a sensitive and validated measurement of specific IgE is an important step in the diagnosis. However, only a limited number of environmental and occupational allergens are available on the market for use in sIgE testing. Accordingly, specific in‐house testing by individual diagnostic and laboratory centers is often required. Currently, different immunological tests are in use at various diagnostic centers that often produce considerably divergent results, mostly due to lack of standardized allergen preparation and standardized procedures as well as inadequate quality control. Our review and meta‐analysis exhibited satisfactory performance of sIgE detection test for most high molecular weight (HMW) allergens with a pooled sensitivity of 0.74 and specificity of 0.71. However, for low molecular weight (LMW) allergens, pooled sensitivity is generally lower (0.28) and specificity higher (0.89) than for HMW tests. Major recommendations based on the presented data include diagnostic use of sIgE to HMW allergens. A negative sIgE result for LMW agents does not exclude sensitization. In addition, the requirements for full transparency of the content of allergen preparations with details on standardization and quality control are underlined. Development of standard operating procedures for in‐house sIgE assays, and clinical validation, centralized quality control and audits are emphasized. There is also a need for specialized laboratories to provide a custom service for the development of tests for the measurement of putative novel occupational allergens that are not commercially available.

Performance of specific immunoglobulin E tests for diagnosing occupational asthma: a systematic review and meta-analysis

OBJECTIVES

To determine the test performance parameters for the retrievable range of high-molecular-weight (HMW) and low-molecular-weight (LMW) occupational allergens and to evaluate the impact of allergenic components and the implementation of measures for test validation.

METHODS

A protocol with predefined objectives and inclusion criteria was the basis of an electronic literature search of MEDLINE and EMBASE (time period 1967-2016). The specific inhalation challenge and serial peak flow measurements were the reference standards for the specific IgE (sIgE) test parameters. All of the review procedures were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Seventy-one studies were selected, and 62 entered meta-analysis. Pooled pairs analysis indicated a sensitivity of 0.74(95% CI 0.66 to 0.80) and specificity of 0.71(95% CI 0.63 to 0.77) for HMW allergens and a sensitivity of 0.28(95% CI 0.18 to 0.40) and specificity of 0.89(95% CI 0.77 to 0.95) for LMW allergens. Component-specific analysis improved the test parameters for some allergens. Test validation was handled heterogeneously among studies.

CONCLUSION

sIgE test performance is rather satisfactory for a wide range of HMW allergens with the potential for component-specific approaches, whereas sensitivity for LMW allergens is considerably lower, indicating methodological complications and/or divergent pathomechanisms. A common standard for test validation is needed.

Mixed-dust pneumoconiosis: Review of diagnostic and classification problems with presentation of a work-related case

Environmental aerosolized particulates pose a potential risk to human health worldwide. Among others, high amounts of contaminants are generated especially in newly industrializing countries in the vicinity of industrial manufacturing, mining operations, but also during agricultural and natural processes. As an example of the needed multi-disciplinary diagnostic and differential diagnostic approach, we report a case of a 59-year old industrial worker who has suffered from chronic bronchitis and progressive dyspnea on exertion for 8years. He showed severe lung function impairment, a cavity in his right upper lung lobe, nodular and irregular opacities, fibrotic pleural changes and emphysema. According to the occupational history and the industrial hygiene report, he had been engaged in the production of various refractory materials and been exposed to very high levels of inorganic dust, especially to silica, silicon carbide and aluminum compounds, but also to carbon and other dusty materials for 28years. Histopathology of the two resected lung segments showed focally infarcted granulomas and chronic inflammation. Stains for organisms were negative. The lung tissue away from the granulomas showed significant dust deposition including dust macules. In spite of the inorganic dust deposits, with adjacent tissue lesions evident from the radiological findings (which were interpreted as atypical for pneumoconiosis) and the presence of granulomas in lung tissue, a diagnosis of necrotizing sarcoid granulomatosis was made, which was later changed to mixed-dust pneumoconiosis on further detailed examination. Scanning Electron Microscopy/Energy-Dispersive X-ray Spectroscopy (SEM/EDS) analysis of individual particles showed predominantly Si (silica or silicon carbide [SiC]) and Al particles (consistent with aluminum metal and/or oxide), as well as numerous Al silicates, Ti, and occasional Zr, Nb, V, steel, including Si fibers (consistent with SiC). We present the controversy about the pathogenesis of the lung disorder and whether it represents an occupational disease - which is more or less representative for many such cases.

[COPD due to Occupational Noxae]

The chronic obstructive pulmonary disease (COPD) is characterised by mainly non-reversible bronchial obstruction with airflow limitation. Typically, it exhibits a progressive course. It is one of the leading causes of morbidity and mortality worldwide. In addition to dominating causative smoking and environmental exposures (especially biomass smoke from cooking with open fire stoves), about 15 % are due to occupational exposure. Relatively rare cases (ca. 6 %) do not show an external noxious influence. Occupational causes are frequently not recognised because a detailed occupational history has not been taken. This is especially evident by the discrepancy in the identified COPD prevalences and incidences shown in many studies on the one hand and relatively low numbers in the official statistics on reports, acknowledgements and compensations of the disorder on the other hand. Whether occupational exposures to inhalative noxae are - in addition to non-occupational factors (e. g. smoking) - causative according to legal definitions is frequently a challenging question. Respective decisions of social courts in litigations are presented.

Review on the adverse health effects of asbestiform antigorite, a non-regulated asbestiform serpentine mineral

BACKGROUND

Although antigorite is generally described as platy, its fibrous (asbestiform) variant is present widespread in serpentinite rocks. In addition to its primarily fibrous occurrence, asbestiform antigorite may also be formed from serpentinite with massive appearance during tunneling and mining. It is not of commercial interest, but exposure may occur in the certain environments.

METHODS AND RESULTS

Detailed studies of the structural features of this antigorite type revealed characteristics closely related to those of chrysotile. Therefore, it is plausible that this serpentine mineral may present a similar health risk for exposed subjects. This is in agreement with results from clinical and animal studies, as well as in vitro experiments showing the cytotoxic, fibrogenic, and carcinogenic potential of antigorite, similar to that of chrysotile and amphibole asbestos.

CONCLUSIONS

Current evidence supports a need for an update to existing regulations to include unregulated asbestiform antigorite, similar to regulatory measures taken for asbestos.

Misleading “New Insights into the Chrysotile Debate”

Although there is no dispute among independent scientists about the carcinogenic and fibrogenic effects of chrysotile, the asbestos industry has been continuously and successfully acting to cast doubts on its harm. Another approach including asbestos insurance entities is to refuse compensation by raising the bar and fight criminal prosecution for asbestos-related diseases by the help of paid scientists. A recent publication on asbestos fibre burden in human lungs fits well in this context. The claim that chrysotile fibres are biopersistent in human lung is not based on the data provided by these authors, and, additionally, exhibits serious inconsistencies and obvious mismeasurements and significant methodological problems. The conclusion of the authors that fibre analysis of workersʼ lungs “is of high significance for differential diagnosis, risk assessment and occupational compensation” is unfounded and reprehensible. Also the available literature, the statements of the WHO, IARC, other decisive independent international organizations, and all our experience provide abundant evidence to the contrary. Note, the method is generally restricted to research only and is not recognized for diagnostic purpose and compensation in any other country. In conclusion, fibre counting in lung tissues should not be used to estimate former exposure to chrysotile comprising c. 94 % of applied asbestos in Germany. The authors claim that the analyses can improve the compensation rates in Germany. However, the opposite has been the case; it significantly worsens the non-justified denial of well-substantiated compensation claims.

Detection of Protein Changes in Serum of Workers following Inhalation Exposure to Toluene Diisocyanate Vapors

Serum samples of 10 workers undergoing occupational type inhalative challenge tests by toluene diisocyanate (TDI) were investigated by anion-exchange fast-protein-liquid-chromatography (FPLC) and polyacrylamide-gel electrophoresis (PAGE-SDS). Their serum chromatography profiles were compared to those of 20 unexposed individuals. The peak height of the first prealbumin peak in sera of workers after inhalative challenge tests was significantly different (p > 0, 01 Chi-square test) compared to that obtained before exposure and to that of unexposed subjects. In addition, qualitative changes of these peaks were also noted in sera of workers exposed to TDI. In the cases of exposed individuals, that peak was more diffuse with some shoulders and less symmetric in appearance. Similarly, PAGE-SDS of the serum proteins, followed by silver nitrate staining, revealed a different banding pattern after in vivo TDI exposure. One of the serum components at approximately 15 kD showed an increase of staining intensity after exposure (n = 10), compared to unexposed subjects or to patients before exposure. This serum fraction has not yet been identified. The results here demonstrate that it is possible to detect changes of serum proteins in TDI-exposed individuals within a relatively short analysis time. This could be useful for biological monitoring of exposure, since no method for such is yet available.

Diagnosis, monitoring and prevention of exposure-related non-communicable diseases in the living and working environment: DiMoPEx-project is designed to determine the impacts of environmental exposure on human health

The WHO has ranked environmental hazardous exposures in the living and working environment among the top risk factors for chronic disease mortality. Worldwide, about 40 million people die each year from noncommunicable diseases (NCDs) including cancer, diabetes, and chronic cardiovascular, neurological and lung diseases. The exposure to ambient pollution in the living and working environment is exacerbated by individual susceptibilities and lifestyle-driven factors to produce complex and complicated NCD etiologies. Research addressing the links between environmental exposure and disease prevalence is key for prevention of the pandemic increase in NCD morbidity and mortality. However, the long latency, the chronic course of some diseases and the necessity to address cumulative exposures over very long periods does mean that it is often difficult to identify causal environmental exposures. EU-funded COST Action DiMoPEx is developing new concepts for a better understanding of health-environment (including gene-environment) interactions in the etiology of NCDs. The overarching idea is to teach and train scientists and physicians to learn how to include efficient and valid exposure assessments in their research and in their clinical practice in current and future cooperative projects. DiMoPEx partners have identified some of the emerging research needs, which include the lack of evidence-based exposure data and the need for human-equivalent animal models mirroring human lifespan and low-dose cumulative exposures. Utilizing an interdisciplinary approach incorporating seven working groups, DiMoPEx will focus on aspects of air pollution with particulate matter including dust and fibers and on exposure to low doses of solvents and sensitizing agents. Biomarkers of early exposure and their associated effects as indicators of disease-derived information will be tested and standardized within individual projects. Risks arising from some NCDs, like pneumoconioses, cancers and allergies, are predictable and preventable. Consequently, preventative action could lead to decreasing disease morbidity and mortality for many of the NCDs that are of major public concern. DiMoPEx plans to catalyze and stimulate interaction of scientists with policy-makers in attacking these exposure-related diseases.

Asbestos-Related Disorders in Germany: Background, Politics, Incidence, Diagnostics and Compensation

There was some limited use of asbestos at end of the 19th century in industrialized countries including Germany, but its consumption dramatically increased after World War II. The increase in use and exposure was followed by the discovery of high numbers of asbestos-related diseases with a mean latency period of about 38 years in Germany. The strong socio-political pressure from the asbestos industry, its affiliated scientists and physicians has successfully hindered regulatory measures and an asbestos ban for many years; a restrictive stance that is still being unravelled in compensation litigation. This national experience is compared with the situation in other industrialized countries and against the backdrop of the constant efforts of the WHO to eliminate asbestos-related diseases worldwide.

[Guideline for the Diagnosis and Treatment of Asthma - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]

The present guideline is a new version and an update of the guideline for the diagnosis and treatment of asthma, which replaces the previous version for german speaking countries from the year 2006. The wealth of new data on the pathophysiology and the phenotypes of asthma, and the expanded spectrum of diagnostic and therapeutic options necessitated a new version and an update. This guideline presents the current, evidence-based recommendations for the diagnosis and treatment of asthma, for children and adolescents as well as for adults with asthma.

[Differential Diagnosis of Mediastinal and Hilar Lymphadenopathy with Focus on Occupational Diseases]

Hilar and mediastinal lymphadenopathy may represent a diagnostic challenge in clinical practice. This article is intended to facilitate differential diagnosis by a systematic description of relevant pathologies, notably with occupational etiology. Clinical findings of relevant diseases, i. e. of tuberculosis, chronic beryllium disease, sarcoidosis, lung cancer, malignant lymphoma, Epstein-Barr virus infection, and histoplasmosis are compared.Case history, imaging and laboratory tests have important diagnostic impact. But also invasive methods can be necessary in order to exclude and prove malignancy, infection or autoimmune disease.

Alternative drugs go global: possible lead and/ or mercury intoxication from imported natural health products and a need for scientifically evaluated poisoning monitoring from environmental exposures

Background

With increases in globalization, cultural remedies from Chinese, Ayurvedic, Arab and other traditions have become more available to international consumers, offering unfamiliar “Natural Health Products” (NHP), used as alternative medicine or supplementary medicine.

Contamination with toxic ingredients including lead, mercury, arsenic, and other toxic elements has been documented in several of these products from various parts of the globe, particularly from some parts of Asia and the Orient.

Findings

We have been following this development in the last 6 years and have analyzed n = 20 such products (60 analyses) from patients with intoxication symptoms in a pilot study, showing alarming high concentrations of mercury and/or lead (the first one in “therapeutic” doses). 82 % of the studied NHP contained lead concentrations above the EU limit for dietary supplements. 62 % of the samples exceeded the limit values for mercury. Elevated blood lead and mercury levels in patients along with clinical intoxication symptoms corroborate the causal assumption of intoxication (s). We present one detailed clinical case report of severe lead and mercury intoxications and give an overview about blood concentration related symptoms and signs of n = 41 case reports of mercury intoxications of the German monitoring BfR-DocCenter.

Conclusions

For NHP there is evidence on a distinct toxicological risk with alarming low awareness for a possible intoxication which prevents potentially life-saving diagnostic steps in affected cases. In many cases patients do not communicate the events to their physicians or the local health authority so that case reports (e.g. the BfR-DocCentre) are missing. Thus, there is an urgent need to raise awareness and to initiate more suitable monitory systems (e.g. National Monitoring of Poisonings) and control practice protecting the public.

[Lung Cancer as an Occupational Disease]

Lung cancer is one of the most frequently encountered cancer types. According to the latest WHO data, about 10 % of this disease are due to occupational exposure to cancerogens. Asbestos is still the number one carcinogen. Further frequent causes include quarz and ionizing radiation (uranium mining). Probable causes of the disease can be identified only with the help of detailed occupational history taken by a medical specialist and qualified exposure assessment. Without clarifying the cause of the disease, there is neither a correct insurance procedure nor compensation for the victim, and furthermore, required preventive measures cannot be initiated.

Determination of albumin adducts of 4,4'-methylenediphenyl diisocyanate after specific inhalative challenge tests in workers

4,4'-Methylenediphenyl diisocyanate (MDI) is the most important isocyanate used in the industry. Lung sensitization with bronchial asthma is the main disorder in exposed workers. Albumin adducts of MDI might be involved in specific immunological reactions. MDI adducts with lysine (MDI-Lys) of albumin have been found in MDI-workers and construction workers. MDI-Lys is an isocyanate-specific adduct of MDI with albumin. In the present study, we report MDI-adducts in workers undergoing diagnostic MDI challenge tests. The workers were exposed for 2h to 5ppb of MDI. The adduct levels increase significantly after the exposure to MDI in the challenge chamber. About 0.6% of the dose was bound to albumin. So far, only urinary metabolites of MDI were measured to monitor isocyanate workers. However, such urinary metabolites are not isocyanate specific. Therefore, we propose to measure albumin adducts for monitoring MDI exposed subjects.

Asbestos: Socio-legal and Scientific Controversies and Unsound Science in the Context of the Worldwide Asbestos Tragedy - Lessons to be Learned

Eight to fifteen per cent of lung cancer cases and nearly all mesothelioma cases are caused by asbestos. Problems in compensation issues ensue from strict legal requirements for eligibility and regulations of the statutory accident insurance institution pertaining to eligibility for occupational disease benefits. The latter include the unscientific requirement for set numbers of asbestos bodies or fibers to be found in lung tissue in order to "prove" disease causation if lung specimen are available. Although the validity of such evidence has been discredited by independent scientists, it is still used as evidence by an influential US pathology department. Frequently, epidemiological evidence regarding causal relationships and exposure histories is also often being ignored by insurance-affiliated medical experts.Similar misleading arguments are currently being used in newly industrialized countries where white asbestos - which is carcinogenic and fibrogenic like other asbestos types - is efficiently promoted as being less harmful. As a result, asbestos use is increasing in some of these countries. Behind the worldwide asbestos tragedy, a well-designed strategy orchestrated by certain transnational or multinational industrial interest groups can be perceived.Beyond the asbestos tragedy their covert plan is motivated by economic interests and discounts the ensuing damage to health and the impact of the diseases they create on public health systems.

[Case Report with Differential Diagnostic Aspects of Sarcoidosis]

A 73-year-old non-atopic patient had developed at the age of 29 shortness of breath on exertion, general malaise, enlarged axillary lymph nodes and nodular cutaneous eruptions. Based on the presence of bihilar lymphadenopathy, the diagnosis of sarcoidosis was made at that time without any histological investigations and without taking detailed case history. Administration of systemic steroids resulted in remission. However, 12 years later, there was a relapse with alterations of lung parenchyma, followed by a more chronic course of the disorder. Since this relapse, an obstructive-restrictive ventilation defect requiring treatment has persisted till today. About five years ago and at the insistence of the patient, clarifying diagnostics were performed. The case shows the important role of a detailed case history including occupational history. Its failure not only led to disadvantages to the patient but also to incorrect social insurance handling and missing appropriate preventive measures with regard to co-workers.

[Asbestos: Social Legal and Scientific Controversies and Unsound Science in the Context with the Worldwide Asbestos Tragedy - Lessions to be Learned]

8 to 15% of lung cancer cases and nearly all mesothelioma cases are caused by asbestos. Problems in compensation issues refer to high legal as well as insurance barriers in attesting the occupational diseases. Claiming of certain numbers of asbestos bodies or fibers in lung tissue is of special relevance in substantiating legal medical cases. Such evidence, which is disproved by a sound science, is also used by an influential US pathology department. Frequently, also epidemiological evidence with its causal relationships and exposure histories are ignored. Similar misleading arguments are currently found in industrializing countries where white asbestos which is carcinogenic and fibrogenic like other asbestos types, is efficiently promoted as less harm. As a result, the asbestos consumption is increasing in some of these countries. Beyond the worldwide asbestos tragedy a well-designed strategy of certain transnational or global acting industrial interest groups can be recognized. Their plan, hidden from the public eyes, follows rigorously sole economic interests, while leaving the resulting health harm to the public health systems.

Spotlight on the diagnosis of extrinsic allergic alveolitis (hypersensitivity pneumonitis)

Repeated inhalative exposures to antigenic material from a variety of sources, mainly from moulds, thermophilic Actinomycetes, and avians, respectively, can induce immune responses with the clinical picture of extrinsic allergic alveolitis (EAA) or hypersensitivity pneumonitis. Delays of years or even decades till the diagnosis is made are not uncommon; frequent misdiagnoses include allergic asthma, COPD, recurrent flue and other infections. We provide here the state of the art references, a detailed case description and recommend a current diagnostics schema.

[Standardization of spirometry: 2015 update. Published by German Atemwegsliga, German Respiratory Society and German Society of Occupational and Environmental Medicine]

Spirometry is a simple test and considered the gold standard in lung function. An obstructive ventilatory defect is a disproportionate reduction of maximal airflow from the lung in relation to the maximal volume that can be displaced from the lung. It implies airway narrowing and is defined by a reduced FEV1/FVC ratio below the 5th percentile of the predicted value (lower limit of normal, LLN). A restrictive disorder may be suspected when vital capacity (FVC) is reduced and FEV1/FVC is normal. It is definitely proven, however, only by a decrease in TLC below the 5th percentile of predicted value (LLN). The measurement of TLC by body plethysmography is necessary to confirm or exclude a restrictive defect or hyperinflation of the lung when FVC is below the LLN. 2012 a task force of the ERS published new reference values based on 74,187 records from healthy non-smoking males and females from 26 countries. The new reference equations for the 3-95 age range are now available that include appropriate age-dependent mean values and lower limits of normal (LLN). This presentation aims at providing the reader with recommendations dealing with standardization and interpretation of spirometry.

How conflicted authors undermine the World Health Organization (WHO) campaign to stop all use of asbestos: spotlight on studies showing that chrysotile is carcinogenic and facilitates other non-cancer asbestos-related diseases

The silicate mineral asbestos is categorized into two main groups based on fiber structure: serpentine asbestos (chrysotile) and amphibole asbestos (crocidolite, amosite, anthophyllite, tremolite, and actinolite). Chrysotile is used in more than 2 000 applications and is especially prevalent in the construction industry. Although its use is banned or restricted in more than 52 countries, an estimated 107 000 workers die from asbestos exposure each year, and approximately 125 million workers continue to be exposed. Furthermore, ambient exposures persist to which the public is exposed, globally. Today, the primary controversies regarding the use of asbestos are the potencies of different types of asbestos, as opposed whether or not asbestos causes morbidity and mortality. The asbestos industry has promoted and funded research based on selected literature, ignoring both clinical and scientific knowledge. In this piece, we highlight a prominent example of a conflicted publication that sought to undermine the World Health Organization (WHO) campaign to stop the use of all forms of asbestos, including chrysotile asbestos. Independent and rigorous scientific data provide sufficient evidence that chrysotile asbestos, like other forms of asbestos, is a cause of asbestos-related morbidity and premature mortality.