Philip Harber

Diagnosis and Management of Work-Related Asthma: American College of Chest Physicians Consensus Statement

BACKGROUND A previous American College of Chest Physicians Consensus Statement on asthma in the workplace was published in 1995. The current Consensus Statement updates the previous one based on additional research that has been published since then, including findings relevant to preventive measures and work-exacerbated asthma (WEA). METHODS A panel of experts, including allergists, pulmonologists, and occupational medicine physicians, was convened to develop this Consensus Document on the diagnosis and management of work-related asthma (WRA), based in part on a systematic review, that was performed by the University of Alberta/Capital Health Evidence-Based Practice and was supplemented by additional published studies to 2007. RESULTS The Consensus Document defined WRA to include occupational asthma (ie, asthma induced by sensitizer or irritant work exposures) and WEA (ie, preexisting or concurrent asthma worsened by work factors). The Consensus Document focuses on the diagnosis and management of WRA (including diagnostic tests, and work and compensation issues), as well as preventive measures. WRA should be considered in all individuals with new-onset or worsening asthma, and a careful occupational history should be obtained. Diagnostic tests such as serial peak flow recordings, methacholine challenge tests, immunologic tests, and specific inhalation challenge tests (if available), can increase diagnostic certainty. Since the prognosis is better with early diagnosis and appropriate intervention, effective preventive measures for other workers with exposure should be addressed. CONCLUSIONS The substantial prevalence of WRA supports consideration of the diagnosis in all who present with new-onset or worsening asthma, followed by appropriate investigations and intervention including consideration of other exposed workers.

A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients With Neck Pain: Clinical Outcomes From the UCLA Neck-Pain Study

OBJECTIVES This study compared the relative effectiveness of cervical spine manipulation and mobilization for neck pain. METHODS Neck-pain patients were randomized to the following conditions: manipulation with or without heat, manipulation with or without electrical muscle stimulation, mobilization with or without heat, and mobilization with or without electrical muscle stimulation. RESULTS Of 960 eligible patients, 336 enrolled in the study. Mean reductions in pain and disability were similar in the manipulation and mobilization groups through 6 months. CONCLUSIONS Cervical spine manipulation and mobilization yield comparable clinical outcomes.

A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6-Month follow-up outcomes from the UCLA low back pain study

Study Design. A randomized clinical trial. Objectives. To compare the effectiveness of medical and chiropractic care for low back pain patients in managed care; to assess the effectiveness of physical therapy among medical patients; and to assess the effectiveness of physical modalities among chiropractic patients. Summary of Background Data. Despite the burden that low back pain places on patients, providers, and society, the relative effectiveness of common treatment strategies offered in managed care is unknown. Methods. Low back pain patients presenting to a large managed care facility from October 30, 1995, through November 9, 1998, were randomly assigned in a balanced design to medical care with and without physical therapy and to chiropractic care with and without physical modalities. The primary outcome variables are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, and low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire. Results. Of 1,469 eligible patients, 681 were enrolled; 95.7% were followed through 6 months. The mean changes in low back pain intensity and disability of participants in the medical and chiropractic care-only groups were similar at each follow-up assessment (adjusted mean differences at 6 months for most severe pain, 0.27, 95% confidence interval, -0.32–0.86; average pain, 0.22, -0.25–0.69; and disability, 0.75, -0.29–1.79). Physical therapy yielded somewhat better 6-month disability outcomes than did medical care alone (1.26, 0.20–2.32). Conclusions. After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but the possible benefit is small.

An Official American Thoracic Society Statement: Work-Exacerbated Asthma

RATIONALE Occupational exposures can contribute to the exacerbation as well as the onset of asthma. However, work-exacerbated asthma (WEA) has received less attention than occupational asthma (OA) that is caused by work. OBJECTIVES The purpose of this Statement is to summarize current knowledge about the descriptive epidemiology, clinical characteristics, and management and treatment of WEA; propose a case definition for WEA; and discuss needs for prevention and research. METHODS Information about WEA was identified primarily by systematic searches of the medical literature. Statements about prevention and research needs were reached by consensus. MEASUREMENTS AND MAIN RESULTS WEA is defined as the worsening of asthma due to conditions at work. WEA is common, with a median prevalence of 21.5% among adults with asthma. Different types of agents or conditions at work may exacerbate asthma. WEA cases with persistent work-related symptoms can have clinical characteristics (level of severity, medication needs) and adverse socioeconomic outcomes (unemployment, reduction in income) similar to those of OA cases. Compared with adults with asthma unrelated to work, WEA cases report more days with symptoms, seek more medical care, and have a lower quality of life. WEA should be considered in any patient with asthma that is getting worse or who has work-related symptoms. Management of WEA should focus on reducing work exposures and optimizing standard medical management, with a change in jobs only if these measures are not successful. CONCLUSIONS WEA is a common and underrecognized adverse outcome resulting from conditions at work. Additional research is needed to improve the understanding of the risk factors for, and mechanisms and outcomes of, WEA, and to inform and evaluate preventive interventions.

Laboratory-acquired Rocky Mountain spotted fever. The hazard of aerosol transmission.

Nine patients with laboratory-acquired Rocky Mountain spotted fever were seen during the period 1971 to 1976. Investigation of each case revealed either definite or probable exposure to an aerosol containing infectious rickettsiae; in no case was there evidence of parenteral exposure either by accidental self-inoculation or by tick bite. These illnesses are believed to represent infection acquired via the respiratory route. This report emphasizes the aerosol hazard of Rickettsia rickettsii in the laboratory and discusses the possibility of respiratory transmission of Rocky Mountain spotted fever in nature. The illness occurred only in personnel who had received either no vaccination or the primary series of the commercial (Lederie) vaccine against this infection. Other personnel who had received the primary series with multiple booster vaccinations demonstrated increased immunity as measured by humoral antibody titers and rickettsial antigen-induced lymphocyte transformation; no cases of clinical disease developed in these multiply-vaccinated personnel.

Work environment and occupational health of dental hygienists: a qualitative assessment.

Objective: We sought to characterize the work environment and identify factors that influence the occupational health of dental hygienists. Methods: We conducted a qualitative analysis of dental hygiene work based on five national focus groups. Results: We found that musculoskeletal symptoms are common, particularly after 10 years; common ergonomic problems included instruments and chairs. Important nonphysical workplace problems include role ambiguity (eg, employee vs. independent practitioner), inadequate recognition, role identity (eg, distinction from dental assistants), role conflict (eg, with dentists and spousal office managers), and social isolation. Conclusions: Work organizational factors (eg, frequent part-time work, inadequate breaks, perception as a “second team” distinct from the dentist and dental-assistant team) impede the remediation of ergonomics and other problems. Job flexibility encourages hygienists to change work hours or location rather than deal with work conditions. Occupational health interventions should address social environment and work organization.

Spirometry in the Occupational Setting

: This position statement reviews several aspects of spirometric testing in the workplace, where spirometry is employed in the primary, secondary, and tertiary prevention of occupational lung disease. Primary prevention includes pre-placement and fitness-for-duty examinations as well as research and monitoring of health status in groups of exposed workers; secondary prevention includes periodic medical screening of individual workers for early effects of exposure to known occupational hazards; and tertiary prevention includes clinical evaluation and impairment/disability assessment. For all of these purposes, valid spirometry measurements are critical, requiring: documented spirometer accuracy and precision, a rigorous and standardized testing technique, standardized measurement of pulmonary function values from the spirogram, adequate initial and refresher training of spirometry technicians, and, ideally, quality assessment of samples of spirograms. Interpretation of spirometric results usually includes comparison with predicted values and should also evaluate changes in lung function over time. Response to inhaled bronchodilators and changes in relation to workplace exposure may also be assessed. Each of these interpretations should begin with an assessment of test quality and, based on the most recent ATS recommendations, should rely on a few reproducible indices of pulmonary function (FEV1, FVC, and FEV1/FVC.) The use of FEF rates (e.g., the FEF25-75%) in interpreting results for individuals is strongly discouraged except when confirming borderline airways obstruction. Finally, the use of serial PEF measurements is emerging as a method for confirming associations between reduced or variable pulmonary function and workplace exposures in the diagnosis of occupational asthma. Throughout this position statement, ACOEM makes detailed recommendations to ensure that each of these areas of test performance and interpretation follow current recommendations/standards in the pulmonary and regulatory fields. Submitted by the Occupational and Environmental Lung Disorder Committee on November 16,1999. Approved by the ACOEM Board of Directors on January 4,2000.

Economic Evaluation of Four Treatments for Low-back Pain: Results From a Randomized Controlled Trial

Objective:We sought to compare total outpatient costs of 4 common treatments for low-back pain (LBP) at 18-months follow-up. Methods:Our work reports on findings from a randomized controlled trial within a large medical group practice treating HMO patients. Patients (n = 681) were assigned to 1 of 4 treatment groups, ie, medical care only (MD), medical care with physical therapy (MDPt), chiropractic care only (DC), or chiropractic care with physical modalities (DCPm). Total outpatient costs, excluding pharmaceuticals, were measured at 18 months. We did not perform a cost-effectiveness analysis because previously published findings showed no clinically meaningful difference in outcomes among the 4 treatment groups. Thirty-seven participants were lost to follow-up at 18 months, leaving a final sample size of n = 654. Results:Adjusting for covariates, DC was 51.9% more expensive than MD (P < 0.001), DCPm 3.2% more expensive than DC (P = 0.76), and MDPt 105.8% more expensive than MD (P < 0.001). The adjusted mean outpatient costs per treatment group were

Rigorous Development does not Ensure that Guidelines are Acceptable to a Panel of Knowledgeable Providers

369 for MD,

Diacetyl-Induced Lung Disease

560 for DC,