[Guidelines for the use of the International Classification of Radiographs of Pneumoconioses of the International Labour Office (ILO): Substantial changes in the currrent edition]

The International Classification of Radiographs of Pneumoconioses is the scheme worked out by the International Labour Office in Geneva (ILO), to register radiographic chest abnormalities in a well-ordered, reproducible and comparable way. It is used for diagnosing abnormalities caused by dust exposure. Guidelines for the use of the ILO International Classification of Radiographs of Pneumoconioses contain detailed information and recommendations on how to use the classification, as well as how the chest X-ray examination should be performed and recorded. To facilitate the diagnosis of observed abnormalities the classification is completed by the set of standard radiograms illustrating typical irregularities referring to lungs and pleura, included in the classification. The article presents the key information on classification and the most important amendments adopted in the 2000 and 2011 ILO guidelines revisions. These changes refer to radiographs quality assessment, the way of presenting abnormalities registered in standard radiographs (QUAD set, digital images) and registration of failures not related to dust exposure. Particularly important complements result from the development of radiological imaging techniques. They are concerned about the classification of radiographic images of the chest recorded digitally. Med Pr 2016;67(6):833-837.

International perspective on common core competencies for occupational physicians: a modified Delphi study

OBJECTIVES

The competencies required of occupational physicians (OPs) have been the subject of peer-reviewed research in Europe and individual countries around the world. In the European Union (EU), there has been development of guidance on training and common competencies, but little research has extended beyond this. The aim of this study was to obtain consensus on and identify the common core competencies required of OPs around the world.

METHODS

A modified Delphi study was carried out among representative organisations and networks of OPs in a range of countries around the world. It was conducted in 2 rounds using a questionnaire based on the specialist training syllabus of a number of countries, expert panel reviews and conference discussions.

RESULTS

Responses were received from 51 countries around the world, with the majority from Europe (60%; 59%) and North and South America (24%; 32%) in rounds 1 and 2, respectively. General principles of assessment and management of occupational hazards to health and good clinical care were jointly considered most important in ranking when compared with the other topic areas. Assessment of disability and fitness for work, communication skills and legal and ethical issues completed the top five. In both rounds, research methods and teaching and educational supervision were considered least important.

CONCLUSIONS

This study has established the current priorities among OPs across 51 countries of the common competencies required for occupational health (OH) practice. These findings can serve as a platform for the development of common core competencies/qualifications within specific geographical regions or internationally. This is particularly pertinent with globalisation of commerce and free movement within the EU.

Shoulder Conditions: Diagnosis and Treatment Guideline

The following guideline covers a wide array of shoulder conditions seen in the workers' compensation, as well as the nonworkers' compensation, population. The guideline is intended to help establish work relatedness and aid in making the diagnosis of shoulder injuries and degenerative conditions. It also provides a nonoperative and operative guideline for the treatment of several shoulder conditions, not limited to rotator cuff tears, subacromial impingement syndrome, acromioclavicular arthritis and dislocations, as well as glenohumeral arthritis.

Improving occupational physicians' adherence to a practice guideline: feasibility and impact of a tailored implementation strategy

BACKGROUND

Although practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived by occupational physicians (OPs). Feasibility and impact on OPs' barriers were evaluated.

METHODS

OPs received 8 training-sessions in small peer-learning groups, aimed at discussing the content of the guideline and their perceived barriers to adhere to guideline recommendations; finding solutions to overcome these barriers; and implementing solutions in practice. The training had a plan-do-check-act (PDCA) structure and was guided by a trainer. Protocol compliance and OPs' experiences were qualitatively and quantitatively assessed. Using a questionnaire, impact on knowledge, attitude, and external barriers to guideline adherence was investigated before and after the training.

RESULTS

The training protocol was successfully conducted; guideline recommendations and related barriers were discussed with peers, (innovative) solutions were found and implemented in practice. The participating 32 OPs were divided into 6 groups and all OPs attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and the meetings spread over one year were highly effective training components. Significant improvements (p < .05) were found in knowledge, self-efficacy, motivation to use the guideline and its applicability to individual patients. After the training, OPs did not perceive any barriers related to knowledge and self-efficacy. Perceived adherence increased from 48.8% to 96.8% (p < .01).

CONCLUSIONS

The results imply that an implementation strategy focusing on perceived barriers and tailor-made implementation interventions is a feasible method to enhance guideline adherence. Moreover, the strategy contributed to OPs' knowledge, attitudes, and skills in using the guideline. As a generic approach to overcome barriers perceived in specific situations, this strategy provides a useful method to guideline implementation for other health care professionals too.

[Quality management in occupational dermatology]

BACKGROUND

Health care of patients with occupational dermatitis (OD) in the sense of suspected "BK 5101" is carried out in Germany within the optimized dermatologist's procedure and the "dermal intervention" (formerly: hierarchical multistep intervention approach) of the statutory accident insurance (UVT), respectively.

OBJECTIVES AND METHODS

Dermatologists and UVT administrators are obliged to improve OD patient care by continuous quality management measures. Essential quality management elements include the research projects EVA_Haut and VVH, the clearing procedure of the Task Force on Occupational and Environmental Dermatology (ABD), training of dermatologists to receive the CME certificate "Occupational Dermatology (ABD)", the establishment of processing standards for administrators and optimized dermatologist's report forms (based on the results of all the above steps taken).

RESULTS

It was shown that the optimized dermatologist's procedure and "dermal intervention" are established in Germany. Also, the available preventive and therapeutic measures for OD patients are effective. Despite the increase of cases with suspected OD, the number of cases in which a career change was required is almost constant (3 %); at the same time the percentage of notified cases which, as a result, are covered within the dermatologist's procedure by the UVT is rising (86 %). The measures recently taken have continuously increased quality of health care in occupational dermatology.

[Risk assessment comparison of biomechanical overloading of the musculoskeletal system: 10 years' applied experience]

Risk assessment for upper extremity work related muscoloskeletal disorders by applying six methods of ergonomic: a ten years experience. The objective of this research was to verify and validate the multiple step method suggested by SIMLII guidelines and to compare results obtained by use of these methods: Washington State Standard, OCRA, HAL, RULA, OREGE and STRAIN INDEX.

METHODS

598 workstations for a total of 1800 analysis by different methods were considered, by adopting the following multiple step procedure: prelinminary evaluation by Washington State method and OCRA checklist in all the working stations, RULA or HAL as first level evaluation, OREGE or SI as second level evaluation.

RESULTS

The preliminary evaluation resulted negative (risk absent) in the 75% of examined work stations and by using checklist OCRA optimal-acceptable condition was found in 58% by HAL in 92% of analysis, by RULA in 100%, by OREGE in 64%; by SI in 70% of examined working positions. We observed similar evaluation of strain among methods and main differences have been observed in posture and frequency assessment.

DISCUSSION AND CONCLUSION

The preliminary evaluation by State of Washington method appears to be an adequate instrument for identify the working condition at risk. All the adopted methods were in a good agreement in two estreme situations: high risk or absent risk, expecially in absent risk conditions. Level of accordance varied on the basis of their rationale and of the role of their different components so SIML indications about the critical use of biouzechanical methods and about the possible use of more than one of them (considering working chlaracteristics) have been confirmed.

[Quality assurance systems and occupational medicine system: an history twenty years along]

Along the last tventy years, in our country the quality assurance systems and the occupational medicine deeply interacted both in theoretical and practical fields of interest at three levels: (i) the need of preventive and therefore of occupational medicine in quality assurance systems; (ii) the need on reverse of quality in prevention and occupational mnedicine mainly in qualification and updating process; (iii) the evidence, proofs of efficacy or appropriateness of different preventive procedures and occupational physician activities; (iv) the connection with European and national legal directives and with technical or good practice norms. Finally we discuss about the role of occupational physician as the global consultant for enterprise, as a mandatory strategic technical figure in a typical multidisciplinary processes as the implementation of the quality systems.

Official American Thoracic Society technical standards: spirometry in the occupational setting

PURPOSE

This document addresses aspects of the performance and interpretation of spirometry that are particularly important in the workplace, where inhalation exposures can affect lung function and cause or exacerbate lung diseases, such as asthma, chronic obstructive pulmonary disease, or fibrosis.

METHODS

Issues that previous American Thoracic Society spirometry statements did not adequately address with respect to the workplace were identified for systematic review. Medline 1950-2012 and Embase 1980-2012 were searched for evidence related to the following: training for spirometry technicians; testing posture; appropriate reference values to use for Asians in North America; and interpretative strategies for analyzing longitudinal change in lung function. The evidence was reviewed and technical recommendations were developed.

RESULTS

Spirometry performed in the work setting should be part of a comprehensive workplace respiratory health program. Effective technician training and feedback can improve the quality of spirometry testing. Posture-related changes in FEV1 and FVC, although small, may impact interpretation, so testing posture should be kept consistent and documented on repeat testing. Until North American Asian-specific equations are developed, applying a correction factor of 0.88 to white reference values is considered reasonable when testing Asian American individuals in North America. Current spirometry should be compared with previous tests. Excessive loss in FEV1 over time should be evaluated using either a percentage decline (15% plus loss expected due to aging) or one of the other approaches discussed, taking into consideration testing variability, worker exposures, symptoms, and other clinical information.

CONCLUSIONS

Important aspects of workplace spirometry are discussed and recommendations are provided for the performance and interpretation of workplace spirometry.

Models of occupational medicine practice: an approach to understanding moral conflict in "dual obligation" doctors

In the United Kingdom (UK), ethical guidance for doctors assumes a therapeutic setting and a normal doctor-patient relationship. However, doctors with dual obligations may not always operate on the basis of these assumptions in all aspects of their role. In this paper, the situation of UK occupational physicians is described, and a set of models to characterise their different practices is proposed. The interaction between doctor and worker in each of these models is compared with the normal doctor-patient relationship, focusing on the different levels of trust required, the possible power imbalance and the fiduciary obligations that apply. This approach highlights discrepancies between what the UK General Medical Council guidance requires and what is required of a doctor in certain roles or functions. It is suggested that using this modelling approach could also help in clarifying the sources of moral conflict for other doctors with "dual obligations" in their various roles.

[Quality of work of occupational health physicians and of National Health Services physicians: are there common goals?]

Starting from different institutional tasks, occupational health physicians and National Health Services physicians have a common goal represented by workers' health protection. The comparison between these professionals should not be limited to the moment of surveillance but should seek opportunities for dialogue aimed at improving their quality of performance. The points of contact may be sought on issues such risk assessment, health protocol, occupational diseases, occupational epidemiology, information/training and health promotion.

Health protection of health care workers from the prospective of ethics, science and good medical practice. Opinions from stakeholders in health care settings

Fitness for work (FFW) in health care workers poses multidisciplinary challenges because of management problems scientific and ethical implications and the implementation of preventive interventions in health care settings. All the relevant stakeholders, including the General Manager, Medical Director, worker's representative, the person responsible for prevention and protection, forensic medicine expert, the person responsible for prevention and health safety at public administration level, commented on: danger to third parties; FFW formulation; human resource management; stress; professional independence; role of the person responsible for prevention and protection and of the person responsible for prevention at public administration level; professional responsibilities. Opinions are reported regarding the main problems related to the role of the Occupational Physician in FFW formulation, such as the difficult balance between autonomy and independence, limited turnover and aging of workforce, need of confidentiality and respect for professional status of the HCW prevalence of susceptibility conditions, rights and duties of stakeholders. The most significant result was the request by the Lombardy Region for more quality in risk assessment and health surveillance; to maintain uniform conduct over all the local health authorities, to allow the board in charge of examining appeals against FFW to fully cooperate with the occupational physician; due attention to the person/worker; the opportunity to convene referral boards for complex FFW management; the challenge of stress management and the need for an observatory for psychological discomforts; the importance of the ICOH Code of Ethics and avoidance of conflicts of interests; the need for individual risk assessment and risk management; the concept of sharing responsibilities and of a real multidisciplinary approach.

[Chikungunya epidemic in 2005-2006: questions from occupational health professionals]

The exceptionally large-scale chikungunya outbreak that struck Reunion Island in 2005-2006 raised numerous yet-unresolved issues for occupational medicine professionals such as massive use of insecticides and recognition of occupational diseases.

A comparison of the recognition of overwork-related cardiovascular disease in Japan, Korea, and Taiwan

In Japan, Korea, and Taiwan, cerebrovascular and cardiovascular diseases (CVDs) caused by overwork are recognized by government as work-related. These three countries are the only countries in the world that officially recognize CVDs caused by psychosocial factors (e.g., overwork) as work-related cerebrovascular and cardiovascular diseases (WR-CVDs), and compensate employees accordingly. The present study compared the similarities and differences among the recognition of overwork-related CVDs in Japan, Korea, and Taiwan. The criteria by which WR-CVDs are identified are very similar in the three countries. However, in the interval surveyed (1996-2009), Korea had a remarkably larger number of recognized WR-CVD patients than did Japan or Taiwan. Recognition of occupational diseases is influenced by various factors, including socio-cultural values, the nature of occupational health care schemes, the extent of the social security umbrella, national health insurance policy, and scientific evidence. Our results show that social factors may be very different among the three countries studied, although the recognition criteria for WR-CVDs are quite similar.

Do approved doctors and medical referees in the UK agree when assessing a seafarer's fitness?

INTRODUCTION

The seafaring industry remains a hazardous occupation that requires sophisticated systems of risk and fitness assessment. This study aims to investigate the extent of agreement between Approved Doctors (ADs) and Medical Referees (MRs) when they assess a seafarer's fitness.

MATERIAL AND METHODS

Between 2003 and 2009 a total of 232,878 seafarer medical examinations were carried out by ADs, of which 465 were considered by the MRs because the seafarer appealed against the AD's decision. The extent of agreement between ADs and MRs was studied.

RESULTS

Two hundred and sixty-eight (58%) cases seen by the ADs were classed as category 4 "permanently unfit"; the referees only placed 85 (18%) of them in this category. On the other hand, 252 (54%) cases seen by the MRs were classed as category 2 "fit with restrictions", while the ADs had only placed 111 (24%) in this category. The overall agreement between the assessors (AD vs. MR) was poor (Kappa K = 0.18).

DISCUSSION

For cardiovascular diseases and for mental ill-health, access to additional information by the MR was the commonest reason for changing the fitness category, but for all other conditions factors such as the experience and knowledge of the MRs or their different interpretation of the standards were the most frequent reasons for a change to fitness category or to restrictions.

CONCLUSIONS

This study found that there was poor agreement between the AD's decision and the subsequent MR's decision regarding the fitness of those seafarers who decided to appeal against the AD's initial assessment. The reasons for this are considered.

The European influence on workers' compensation reform in the United States

Workers' compensation law in the United States is derived from European models of social insurance introduced in Germany and in England. These two concepts of workers' compensation are found today in the federal and state workers' compensation programs in the United States. All reform proposals in the United States are influenced by the European experience with workers' compensation. In 2006, a reform proposal termed the Public Health Model was made that would abolish the workers' compensation system, and in its place adopt a national disability insurance system for all injuries and illnesses. In the public health model, health and safety professionals would work primarily in public health agencies. The public health model eliminates the physician from any role other than that of privately consulting with the patient and offering advice solely to the patient. The Public Health Model is strongly influenced by the European success with physician consultation with industry and labor.

[The contribution of surveillance systems of occupational diseases and mesothelioma in environmental health studies]

National surveillance systems of occupational diseases may contribute to evaluate the work-related component of diseases investigated in SENTIERI Project. For a description of SENTIERI, refer to the 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI Project. The National Workers Compensation Authority (INAIL) archives all occupational diseases claims (more than 230 000 in the period 2000-2007) and is in charge of their compensation. The Italian National Mesothelioma Register (ReNaM) and the Sinonasal Cancer Register (ReNaTuNS) record high occupational etiological fraction neoplasms (i.e. mesothelioma and sinonasal cancers). The former has identified more than 10 000 mesothelioma cases until now, and covers almost the whole country; the latter is active only in three Italian regions, Piemonte, Lombardia and Toscana. The monitoring of cancer sites at lower occupational etiological fraction is based on a record-linkage procedure between population-based cancer registries and employment history data, available at the Italian National Institute for Social Security (INPS). Finally, the informative system Mal.Prof collects and classifies all the diseases possibly related to the work environment reported by the Prevention Services of the Local Health Units.

[Collaboration of the occupational physician for risk assessment activities in work environment]

In Italy, the legislative Decree n. 81/2008 (and further modifications) foresee the obligation, with relative sanction, for the "competent physician" to collaborate with the employer and the person responsible of the service of prevention and protection to the evaluation of the risks in the places of job. Objective of the present job is to give indications that allow the physician to acquit with correctness the obligation, looking for an equilibrium among the dictated normative and the resources to his/her disposition. For small and medium-sized companies, some activities developed by the physician can determine the real collaboration to the evaluation of the risks: periodic inspections; recording of the evaluations of the workers; planning of the biological monitoring; execution of the sanitary overseeing; epidemiological elaboration of the data of the sanitary overseeing; you meet with the employer etc. In the great farms the collaboration of the competent physician to the evaluation of the risks should culminate in the predisposition of a specific document Such document could compose him some followings sections: indication of the working risks; evaluation of the risks for the pregnant workers; evaluation of the risk job-correlated stress; analysis on the problem list alcohol and job; collaboration to the organization of the service of first help; analysis of the accident coarse; collaboration to the realization of programs of information; collaboration to the realization of programs of promotion of the health; layout of the sanitary plan; measures of prevention and protection necessary.

[Permanent education, updating and accreditation in occupational medicine: the contribution of the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII) in the first decade of the 21st century]

BACKGROUND

Permanent education of health workers is obligatory under Italian legislation and is managed by the Ministry of Health through its Permanent Education Programme.

METHODS

In 2000 the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII), set up and implemented a programme of Permanent Education and Accreditation for specialists in occupational medicine, based on participation in "non-mandatory" and "mandatory" educational activities. "Non-mandatory" activities were chosen by the individual physician for education in topics related to occupational medicine. "Mandatory" educational activities, which were organised by the Society, included in-depth analysis of the Society's guidelines related to specific topics in occupational medicine.

RESULTS AND DISCUSSION

The Guidelines study course played a pre-eminent role in the Society's permanent education programme and was greatly appreciated by all participants. The Board of the Society has recently approved a new Plan of Permanent Education, identifying the means (Guidelines, Consensus Documents) whereby occupational physicians can improve their professional standards. The Plan's aims are to facilitate accreditation and also to identify and promote high-quality updating programmes which will lead to recognition of 'professional excellence". Crucial to its success will be a 3-year on-line learning programme (MeLA) that SIMLII has just implemented, which will enable occupational physicians to acquire credits in "Occupational Medicine and Workplace Safety", as required by current Italian legislation. This article summarizes SIMLII activities over the past ten years in the field of permanent medical education for occupational physicians.

[Immigration, work and health--social, cultural and best practices in occupational medicine: the views of union patronage]

Observations from the trade union patronages report that migrants more often that before seek for their assistance, for various reasons, including health and safety at work. We have noticed, besides the "healthy migrant effect" (now decreasing), a certain mobility within occupations, as well as autonomous enterprise developments. Occupational injuries that we see in migrant workers tend to be less serious, potentially because of the greater instability and fear at work (and quick return to work), with informal patterns of health care. Under notification, greater frequency of temporary compensations are also present, likely related to higher vulnerability of migrant worker and to different access and quality of health services. As for the occupational diseases, we have observed an increase in notifications for migrant workers, mainly related to a greater knowledge and exercise of health care and insurance rights and options. Our Patronage experience enables to state that migrants are prone to accept uncomfortable conditions, high rhythm and heavy workloads and that health and safety at work is perceived as a factor not immediately necessary as compared to other issues such as work itself, residence permit, housing. On one side, society at large has to take care of such issues; on the other side, the occupational health system should proceed to a new cultural approach, using also appropriate indicators of process and outcome today available, while integrating the well known motto from Ramazzini, considering questions proper for migrant workers.

[Scientific research and academic promotion in occupational medicine: what are the rules of the game?]

INTRODUCTION

Recently, the National University Council (CUN) recognized the importance of bibliometric indicators in assessing scientific output and the Ministry of Education, University and Research established that the selection committees' decision must be guided by internationally recognized metrics including the impact factor (IF).

AIM

To analyse methods and tools of metrics to assess scientific performance in Occupational Medicine by examining some critical aspects for entry-level positions and academic promotion in the Universities.

METHODS

By means of different databases (Web of Knowledge, Scopus, SCImago), the h-index was studied to assess the scientific output in the field of Occupational Medicine. The h-index was used as an index of both output and quality of overall output of researchers, disciplines, journals, and countries.

RESULTS

Italian scientific output in the Public, Environmental & Occupational Health subject category (h-index = 62) was lower than almost the total of other medical disciplines and, at an international level, is ranked at 12th place (other disciplines ranked 3rd to 9th). Output was 32% compared to that of the USA (other disciplines ranged from 42% and 61%). However, it should be noted that most scientific papers of Occupational Medicine researchers are published mainly in journals of different disciplines (with a higher IF) rather than in journals of Public, Environmental & Occupational Health (with a lower IF).

CONCLUSION

Assuming that selection committees' decisions will be guided by metrics and will respect the minimum standard proposed by CUN, Occupational Medicine researchers aiming at academic promotion will have good reason to ask themselves not only which journals are most useful but also which journals have the greatest impact. This fact could have profound implications for the future of the discipline.

Quality measures for the diagnosis and non-operative management of carpal tunnel syndrome in occupational settings

INTRODUCTION

Providing higher quality medical care to workers with occupationally associated carpal tunnel syndrome (CTS) may reduce disability, facilitate return to work, and lower the associated costs. Although many workers' compensation systems have adopted treatment guidelines to reduce the overuse of unnecessary care, limited attention has been paid to ensuring that the care workers do receive is high quality. Further, guidelines are not designed to enable objective assessments of quality of care. This study sought to develop quality measures for the diagnostic evaluation and non-operative management of CTS, including managing occupational activities and functional limitations.

METHODS

Using a variation of the well-established RAND/UCLA Appropriateness Method, we developed draft quality measures using guidelines and literature reviews. Next, in a two-round modified-Delphi process, a multidisciplinary panel of 11 U.S. experts in CTS rated the measures on validity and feasibility.

RESULTS

Of 40 draft measures, experts rated 31 (78%) valid and feasible. Nine measures pertained to diagnostic evaluation, such as assessing symptoms, signs, and risk factors. Eleven pertain to non-operative treatments, such as the use of splints, steroid injections, and medications. Eleven others address assessing the association between symptoms and work, managing occupational activities, and accommodating functional limitations.

CONCLUSIONS

These measures will complement existing treatment guidelines by enabling providers, payers, policymakers, and researchers to assess quality of care for CTS in an objective, structured manner. Given the characteristics of previous measures developed with these methods, greater adherence to these measures will probably lead to improved patient outcomes at a population level.

Nuclear medicine annual external occupational dose distribution: Rio de Janeiro, Brazil, year 2005

Brazil has about 300 nuclear medicine services (NMS), 44 of them located in the state of Rio de Janeiro (RJ). Most nuclear medicine staff are routinely monitored for external dose. This paper makes a statistical analysis of all the RJ NMS annual external occupational doses in year 2005. Around 100 professionals of RJ NMS received annual doses >4.0 mSv, considering only external doses, but no one receives doses higher than the mean annual dose limit of 20 mSv. Extremities dosemeters are used by about 10 % of the staff. In some cases, these doses are more than 10 times higher than the dose in thorax. The maximum ratio of extremity dose/thorax dose, in 2005, was 72. This study shows the importance to improve radiation protection procedures in nuclear medicine, mainly because the number of occupational individuals in nuclear medicine and their external doses are increasing.

[Recommended general principles of good practice relating to psychological examinations in occupational medicine service]

This paper presents general principles of good practice in prophylactic psychological examinations. The principles are based on the binding law and standards of psychological examinations recommended by the Polish Psychological Association. They also take account of a specific nature of such examinations, resulting from their goals and the subject of their concern. Formal guidelines and health indications concerning this kind examinations, their scope, diagnostic methods, tools and documentation are discussed as well.

[Characteristics of ambient air quality in office chambers and its influence on workers' state]

Increasing health complaints of office workers are associated with exposure to indefinite risk factors. Many discussions involve ano-particles (size less than 100 nm) in air of non-industrial chambers containing contemporary office equipment. Complex study covered quality of air in offices (microclimate, organic and inorganic pollutants, dust particles). New approach to assessment of non- industrial working environment is evaluation of air pollution by ultrasmall (nano) particles through their quantity and surface square. Polling method helped to study the state of office workers.

[Prophylactic care of workers with disabilities--the problem of contemporary occupational health service?]

According to the 2002 data there are in Poland 14.3% of people with disabilities. On the other hand, an employment level of people with disabilities in Poland is one of the lowest in Europe with its percentage rate of 13% in the year 2004. Therefore, the improvement in certification system and its efficacy is needed. Occupational health service (OHS) plays an important role in the process of occupational elicitation of this group of people. Barriers at the level of OHS mainly result from the lack of guidelines in this field, so now it is essential to implement those that have been proposed. The improvement in occupational medicine physicians training is also essential. Difficulties in certification of ability to work is also the result of unavailable data on patient's health. Psychiatric problems, epilepsy and diabetes cause the major problems in the certification of capacity to work.

The effectiveness of a health-surveillance program for caisson saturation divers in a tunnel-boring machine: a microbiological survey

The purpose of this field study is to report and evaluate the implementation of a health surveillance program we developed to monitor the microbiological load for saturation divers, including preventive and therapeutic interventions. We extended the DMAC protocol for Saturation Diving Chamber Hygiene and added some components: ear inspections, swabs and environmental swabs every third day. The implementation was evaluated by analyzing the results of the activities. In a pre-saturation dive check we examined a total of 17 divers. Here we present the data from all seven saturation phases, collected over a period of 1.5 years. In every saturation phase we have found pathogenic bacteria or fungi in divers and in the environment, but more in some periods than in others. We did not observe any serious infection that required a diver to abort his stay in the living chamber. This health surveillance program has demonstrated the potential value of an early warning system to prevent problems. The bacterial load found in divers and in the environment was clearly visible. Prevention could be improved by more consistent implementation of the protocol. Fortunately, the infections had no serious consequences for the health of the workers or for the continuation of the work process.

[Occupational health practice among law, evidence and ethics: a field study]

BACKGROUND

Quality in health care is defined as the degree to which health services increase the likelihood of desired health outcomes and are consistent with the law, the evidence and the ethical values.

MATERIALS AND METHODS

The paper aims at providing a framework in which the concept of quality is applied in the field of occupational health by analysing real-life decisions.

RESULTS

The Italian law states that the practice must be evidence-based and respectful of the code of ethics, emphasizeing that the practice should be relevant, knowledge-based, sound and appropriate. Any dilemma should be dealt according to the ethical principles of beneficience, autonomy and justice. Both the law and the code require that the practice is based on the available evidence. Results show that decisions in selected cases can be made according the above mentioned criteria. CONCLUSION; Decisions made on the basis of a process founded on scientific evidence result in effective and high-quality outcomes respectful of both law and ethics.

[The occupational physicians' responsibilities]

Occupational physicians can commit two kind of crimes: they can violate rules of safety and health at work with no immediate consequences for the employees but anyway creating a potential danger for them, or they can cause, because of their blame, occupational diseases or accidents at work to the employees. In both cases they can be punished. If we want to understand in detail this kind of responsibility, we must read the Supreme Court's judgements (Supreme Court, 19099/2009; 26539/2008; 20220/2006; 17838/2005; 26439/2007; 24290/2005). The numberless innovations introduced in recent years in the body of occupational safety and health laws called for a different reading of the meaning and the content of occupational physicians' functions, requiring them to collaborate, more than in the past, in the assessment of workplace risks. The responsibility of occupational physicians should be seen also in relation to the responsibility of employers and managers (see the link between health surveillance and art. 18 paragraph 1 letter c) of Legislative Decree no. 81/08). In the occupational safety and health context, the employer and his managers must also require (and ensure) occupational physicians to fulfill their obligations and professional duties.

[Professional activity of "competent physician": actual troubles and future perspectives]

In recent years, Health has experienced a great transformation, due to the latest technological breakthroughs, the discovery of new drugs and changing social and economic conditions of our country. The professional activity of the "competent physician", even, from the definition of art. 33 of DPR 303/56, result in today's complex set of procedural formalities that make your role as a great professional and social responsibility. However, there are still areas of uncertainty in the law and different interpretations that make it difficult to work. The competent physicians faced with a series of problems that hinder the development of their work, instead, should be free from interference in order to always get the expected results in preserving the worker's health. After a brief discussion of the main weaknesses found, are made some concrete proposals to ensure that the physician in the foreseeable future is increasingly a qualified professional capable of responding adequately to the needs arising from modern scientific evidence and the expectations of workers and the whole society.

[The occupational physician as global consultant for implementing the quality systems]

From many years the quality systems and the occupational prevention have been compared and connected both on theoretical and practical fields. The opportunity to discuss again and to deepen these themes appears to be mandatory to be able to govern the new working processes which shall follow the worldwide financial and productive crisis of last period and in our country to try to adequately apply the preventive norms 81/08 and 106/09. In this contribution we will deal with quality systems more intertwined with prevention (ISO 14000, EMAS, SA8000 and OHSAS 18001 and discuss in particular the role of with occupational physician in his meaning of global consultant for enterprise, a crucial technical figure in a typical multidisciplinary process as the implementation of the quality systems.

[Ideas, reflections and tools for a modern role of the occupational physician]

Over the last few years, following new legislations, events of media impact, transitions in workplaces, Occupational Medicine is at stake. Often, debate is strong about technical-scientific issues in Occupational Physician (OP) activities, ethics and deontology, professional independence, dignity, training and education. The present work develops through personal thoughts, literature data, reporting of concrete personal experience across various occupational settings and risks, with the aim of promoting a "new" role for the OP, enhance his autonomy, professional skills, uniqueness, quality, credibility, while being convinced that it is certainly necessary and possible to conjugate ethics and scientific approach within daily professional activity of the OP, who in turn should be prone to change pace, evaluate effectiveness of his actions, abandon obsolete and useless practices, focussing on a new, proactive, clinical-diagnostic and managerial role, through good medical practices.

[Identification of the most common problems and mistakes in the medical certification of inability to work for disability pension provision based on the expertise carried out by the Out-Patient Clinic of Occupational Diseases, Nofer Institute of Occupational Medicine, Łódź, 2005-2007]

BACKGROUND

The definition of "inability to work" and principles of medical certification of disabilities, determining the entitlement to an ill-health pension provision are regulated by law. However, the term ,,"inability to work" is not precisely defined and the standards of its assessment are not accurately formulated. This refers not only to the term "loosing ability to work to considerable degree", but also to the criteria of occupational qualifications.

OBJECTIVES

The aim of this study was to identify the most common problems and mistakes in the medical certification that entitles to disability pension provision.

MATERIALS AND METHODS

The study, based on medical consultations provided for the president of the Social Insurance Company (ZUS) in the years 2005-2007, was carried out in the Out-Patient Clinic of Occupational Diseases, Nofer Institute of Occupational Medicine, Lódź. In total, 293 medical cases were analyzed, of which 61 concerned consequences of occupational diseases, 44--accidents at work and 188--idiopathic diseases.

RESULTS

Men formed the majorityof the study group (66%) and the mean age of the examined individuals was 49. The predominant causes of medical certification of patient's inability to work, both in men and female, were musculoskeletal disorders, cardio-vascular diseases, diabetes and mental health problems. Significant discrepancies in the medical statements on inability to work were observed between ZUS and the Nofer Institute of Occupational Medicine. They concerned the evaluation of people's inability to work in general, as well as the degree (partial or complete) of lost capability for work. A consensus of medical statements was found in 153 cases, and differences in other 140 (47.8%) cases. Most differences were found in the evaluation of inability to work caused by consequences of occupational diseases.

CONCLUSIONS

Lack of certification guidelines, excessive preference of medical criteria used for defining body fitness disturbances and insufficient consideration of occupational and economic aspects of certified inability to work in terms of assuming work in future) are the main reasons for difficulties in inability to work certification. The scheme of certification procedure was also suggested.

[Age management in enteprises as a part of occupational safety and health in elderly workers]

An aging society is one of the most important demographic, social and economic challenges facing the contemporary world. Human capacity to perform work changes with age, which is mostly caused by the decrease in physical capacity, physical fitness and in some elements of psychophysical fitness (e.g., perceptibility, reaction time, efficiency of sense organs). Moreover, the incidence of disorders of the circulatory, respiratory, and musculoskeletal systems as well as of hormonal and metabolism disorders is higher in older persons. On the other hand, the requirements posed by professional work, as long as no change of post takes place, most often remain the same irrespective of age. As a result, the actual workload may increase with age. Although work ability decreases with age, the demographic and economic contexts point to the necessity to prolong occupational activity. It is justifiable to encourage an increasing number of elderly workers to remain in employment but only if the measures are being taken to maintain their work ability during the entire occupational activity period and to advance their qualifications. These measures must be accompanied by activities targeted at the modification of tasks, work stands, time and rhythm of work, so as to adapt them to the changing worker's capacities. Numerous activities are being systematically implemented in enterprises and the process is called "age management". The article describes the main assumptions of this new approach and the role of occupational physicians in the whole process.

[Ageing and work: technical standards]

Over the last few years, studies on the relationship between ageing and work have attracted growing interest due to the increased probability among workers of developing major health problems as a consequence of ageing of the working population. Negative outcomes for health are possible when an age-related imbalance appears between physical workload and physical work capacity. Interventions based on workload reductions should help to keep workers on the job for as long as allowed by law. Reference masses by age and sex are suggested by the technical standards of the ISO 11228 series, which are also quoted by Italian law D.Lgs. 81/2008, and EN 1005 series, which recommend limits valid also for manual material handling, and pushing and pulling. Decreasing low back pain prevalence or recurrence, in an ageing population with high prevalence of back disorders, could be more effective than many other approaches to enhance workers' quality of life and consequently maintain and improve workers' performance.

[Work: disease and health. The role of occupational medicine]

To assess the role of Occupational Medicine in the promotion of workers'health over the last forty years, the author studied the evolution of this discipline from a clinical-diagnostic approach to the current emphasis on prevention. However, it is stressed that in Occupational Medicine even preventive measures are based on clinical methodology, as for example in health surveillance, where the main tasks are the identification of individual hyper-susceptibility and the assessment of early and reversible health effects due to occupational risks. Moreover, the traditional clinical-diagnostic approach is still of utmost importance. In fact, the classical occupational diseases do not present with the specific clinical features of the recent past. Instead, today it is necessary to evaluate whether occupational risk factors play a concomitant role in the origin of diseases that affect the general population. Moreover, new occupational diseases are emerging, due to the continuous changes in manufacturing processes and work organization. To assess the role that Occupational Medicine has played in the binomial expression "disease-health", topics which particularly suit the Author's cultural background are considered and are used as "indicators" of the various scientific, cultural, social, economic, and legislative aspects that contribute to the professional development of Occupational Physicians. Important results have been achieved over the last 40 years, however Occupational Physicians face new problems that impose a continuous updating process, not only on medical topics but also on the development of technological processes. The laws and the recommendations of the most prestigious national and international organizations and the principles of the ICOH Code of Ethics should guide Occupational Physicians in their profession and their actions must imply full professional independence. They must acquire and maintain the necessary competence for their duties and adequate conditions to carry out their tasks according to good practice and professional ethics.

Evaluation of the practice guidelines of Finnish Institute of Occupational Health with AGREE instrument

Guidelines for occupational physicians are increasing in number. Their quality and content is varied and they may even provide conflicting recommendations. Earlier studies show that guidelines directed at professionals in occupational health use scientific evidence unsystematically or inadequately. This article assesses the guidelines of the Finnish Institute of Occupational Health (FIOH). We selected a random sample of 29 guidelines from all those published by FIOH, which were assessed by four people individually using the AGREE instrument. The items were scored in six domains: scope and purpose of the guideline, stakeholder involvement, rigour of guideline development, clarity and presentation, application, and editorial independence. Mean domain scores were calculated according to AGREE instructions. The guidelines presented their scope and purpose well; the mean domain score was 62%. Their clarity and presentation was fairly good, mean domain score 47%. The stakeholder involvement's mean domain score was 33%. The other domains scored low: applicability domain, 15%, rigour of guideline development, 9%, and editorial independence, 7% only. The rigour and reporting of guideline development seems to be the main challenge for future guideline production in FIOH. A common structure for guideline preparation is needed.

The Canadian National Calibration Reference Center for Bioassay and in Vivo Monitoring: an update

The Canadian National Calibration Reference Center (NCRC) for Bioassay and In Vivo Monitoring is part of the Radiation Protection Bureau, Health Canada. The NCRC operates three performance testing programs that are designed to confirm that workplace monitoring results are accurate and provide the necessary external verification that is part of a comprehensive quality assurance program. The NCRC performance testing programs cover the in vitro, in vivo, and internal dosimetry parts of Canadian facilities' radiation protection programs. The internal dosimetry performance testing is a new addition to the performance testing suite. This summary also describes the recent reorganization of the NCRC.

[The new methodology to produce instruments for updating occupational physician proposed by Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII)]

Starting from the experience of last five years, during which 24 guide liens about the most important aspects of Occupational Physician activity have been produced, the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII) delegated a specific working group for updating the methodology to be adopted for guide lines and other instruments for improving and standardizing the current activity in our professional field. SIMLII produced in the context of the specific Education and Accreditation Programme for occupational physicians prepared from 2002 25 guide lines or other informative instruments on the most important and controversial themes in which our discipline is involved. They were considered and treated to meet the need to improve and standardise activities and to modify the current approach of occupational physicians and aimed not only at improving the effectiveness of preventive actions but also at constantly adopting rigorous methodologies based where possible on evidence based or on consensus procedures. The Directive of SIMLII was firmly convinced about the opportunity-necessity to critically evaluate the experience carried out during the last years, at the light of the National Program for Guide Lines edited By Italian National Health Institute since 2002 and which concerns preparation, dissemination, updating, implementation of guide lines in Medicine. The guide lines were defined as rational critical effective aid addressed to professionals and patients for health services organization. Relevant was the new Framework Act for the occupational safety and health (Decreto legislativo 81/08) too signed by the President of the Italian Republic on April 9, 2008, which for the first time includes and defines in a legislative act the different possible instruments (technical normative, good practices, guide lines). In this paper we present the new methodology defined by our Society for producing the different kind of instruments such as guide lines, consensus conference reports, technology assessments, good practices statements guide lines focusing as the main aspects those related to definitions, argument choice, working group and coordinator identification, producing methods, evidence evaluation, grading, quality evaluation using AGREE method, dissemination procedure, the conflict of interest and the possible use for distance formation procedure focusing the recommendations that take a practical-applicative approach.