Description: Objectives Occupational exposure to disinfectants is associated with work-related asthma, especially in healthcare workers. However, little is known about the specific products involved. To evaluate disinfectant exposures, we designed job-exposure (JEM) and job-task-exposure (JTEM) matrices, which are thought to be less prone to differential misclassification bias than self-reported exposure. We then compared the three assessment methods: self-reported exposure, JEM and JTEM. Methods Disinfectant use was assessed by an occupational questionnaire in 9073 US female registered nurses without asthma, aged 49–68 years, drawn from the Nurses' Health Study II. A JEM was created based on self-reported frequency of use (1–3, 4–7 days/week) of 7 disinfectants and sprays in 8 nursing jobs. We then created a JTEM combining jobs and disinfection tasks to further reduce misclassification. Exposure was evaluated in 3 classes (low, medium, high) using product-specific cut-offs (eg, 〈30%, 30–49.9%, ≥50%, respectively, for alcohol); the cut-offs were defined from the distribution of self-reported exposure per job/task. Results The most frequently reported disinfectants were alcohol (weekly use: 39%), bleach (22%) and sprays (20%). More nurses were classified as highly exposed by JTEM (alcohol 41%, sprays 41%, bleach 34%) than by JEM (21%, 30%, 26%, respectively). Agreement between JEM and JTEM was fair-to-moderate ( 0.3–0.5) for most disinfectants. JEM and JTEM exposure estimates were heterogeneous in most nursing jobs, except in emergency room and education/administration. Conclusions The JTEM may provide more accurate estimates than the JEM, especially for nursing jobs with heterogeneous tasks. Use of the JTEM is likely to reduce exposure misclassification.

Description: Background To date, the association of the neurotoxic agent cadmium (Cd) with depression in elderly people has been poorly evaluated. By investigating the relationship between blood cadmium levels and scores on a depression screening test, we aimed to investigate the impact of cadmium exposure on elderly depression. Methods From 2008 to 2010, a total of 395 elderly participants residing in Seoul, Korea, were evaluated 3 times. Demographic data and lifestyle information were obtained via a systemised questionnaire, and blood samples were collected for analysis. Participants underwent the Korean Version of the Short Form Generic Depression Scale test (SGDS-K) for screening depression and associations were estimated using logistic regression models adjusted for potential confounders. Results Blood cadmium levels were associated with depressive symptoms in the first visit data analysis. By analysing the first visit data, the highest quartile blood cadmium group (Q4) showed increased risk for depressive symptoms compared to the lowest quartile group (Q1) (OR 3.50, 95% CI 1.22 to 10.00). However, the data of the second and third visits suggested that blood cadmium may be protective against depressive symptoms (second visit data, Q4 vs Q1, OR 0.78, 95% CI 0.19 to 3.14; third visit data, Q4 vs Q1, OR 0.58, 95% CI 0.04 to 8.77). Conclusions Owing to inconsistent results in analyses between blood cadmium levels and depressive symptoms, we cannot conclude any solid association between blood cadmium levels and depressive symptoms in the elderly population. To clarify the relationship, other prospective studies are needed in the future.

Description: Objectives To conduct a systematic review of changes in lung function in relation to presence of pleural plaques in asbestos-exposed populations. Methods Database searches of PubMed and Web of Science were supplemented by review of papers’ reference lists and journals’ tables of contents. Methodological features (eg, consideration of potential confounding by smoking) of identified articles were reviewed by ≥two reviewers. Meta-analyses of 20 studies estimated a summary effect of the decrements in per cent predicted (%pred) forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV 1 ) associated with presence of pleural plaques. Results Among asbestos-exposed workers, the presence of pleural plaques was associated with statistically significant decrements in FVC (4.09%pred, 95% CI 2.31 to 5.86) and FEV 1 (1.99%pred, 95% CI 0.22 to 3.77). Effects of similar magnitude were seen when stratifying by imaging type (X-ray or high-resolution CT) and when excluding studies with potential methodological limitations. Undetected asbestosis was considered as an unlikely explanation of the observed decrements. Several studies provided evidence of an association between size of pleural plaques and degree of pulmonary decrease, and presence of pleural plaques and increased rate or degree of pulmonary impairment. Conclusions The presence of pleural plaques is associated with a small, but statistically significant mean difference in FVC and FEV 1 in comparison to asbestos-exposed individuals without plaques or other abnormalities. From a public health perspective, small group mean decrements in lung function coupled with an increased rate of decline in lung function of the exposed population may be consequential.

Description: Objectives Nurses are at increased risk of occupational asthma, an observation that may be related to disinfectants exposure. Whether asthma history influences job type or job changes among nurses is unknown. We investigated this issue in a large cohort of nurses. Methods The Nurses’ Health Study II is a prospective study of US female nurses enrolled in 1989 (ages 24–44 years). Job status and asthma were assessed in biennial (1989–2011) and asthma-specific questionnaires (1998, 2003). Associations between asthma history at baseline (diagnosis before 1989, n=5311) and job type at baseline were evaluated by multinomial logistic regression. The relations of asthma history and severity during follow-up to subsequent job changes were evaluated by Cox models. Results The analytic cohort included 98 048 nurses. Compared with nurses in education/administration (likely low disinfectant exposure jobs), women with asthma history at baseline were less often employed in jobs with likely high disinfectant exposure, such as operating rooms (odds ratio 0.73 (95% CI 0.63 to 0.86)) and emergency room/inpatient units (0.89 (0.82 to 0.97)). During a 22-year follow-up, nurses with a baseline history of asthma were more likely to move to jobs with lower exposure to disinfectants (HR 1.13 (1.07 to 1.18)), especially among those with more severe asthma (HR for mild persistent: 1.13; moderate persistent 1.26; severe persistent: 1.50, compared with intermittent asthma, p trend: 0.004). Conclusions Asthma history was associated with baseline job type and subsequent job changes among nurses. This may partly reflect avoidance of tasks involving disinfectant use, and may introduce bias in cross-sectional studies on disinfectant exposure and asthma in nurses.

Description: Introduction Since 2000 a decline in the incidence of occupational asthma (OA) has been reported in the UK and Europe. We aimed to describe and account for trends in the incidence of OA in the West Midlands, UK using annual notification data from the SHIELD voluntary surveillance scheme over the period 1991–2011. Methods All notifications to the SHIELD database between January 1991 and December 2011 were identified, along with patients’ demographic data, occupations, causative agents and confirmatory tests. Annual notifications were scaled to give an annual count per million workers, giving a measure of incidence, and also standardised against those of bakers’ asthma. Non-parametric analyses were undertaken between annual incidence and time (years) for common causative agents using (1) a negative binomial regression univariate model and (2) a logistic regression model calculating annual reporting ORs. A step-change analysis was used to examine time points at which there were marked reductions in incidence. Results A decrease in annual incidence of OA was observed over the study period (incident rate ratio=0.945; 95% CI 0.933 to 0.957; p〈0.0001), an effect that was lost after standardising for bakers’ asthma. Decreases in incidence were seen for most common causative agents, with only cleaning product-related OA increasing over 21 years. Marked fall in incidence was seen in 2004 for isocyanates, and in 1995 for latex. Most notifications came from a regional specialist occupational lung disease unit, with notifications from other sites falling from 16 cases/million workers/annum in 1995 to 0 in 2004. Conclusions Reporter fatigue and increasing under-recognition of OA are both factors which contribute to the apparent fall in incidence of OA in the West Midlands. There is a future need for interventions that enable health professionals to identify potential cases of OA in the workplace and in healthcare settings.

Description: Background A few studies have investigated exposure–response relationships for sensitisation to wheat, work-related symptoms and wheat allergen exposure. IgG4 is suggested to protect against the development of allergic sensitisation. The main aim of this current study was to explore the nature of exposure–response relationships for a range of clinically relevant endpoints among bakery workers, and to investigate the role of IgG4 in these relationships. Methods A cross-sectional study of 517 supermarket bakery workers in 31 bakeries used a questionnaire, serum-specific IgE and IgG4 to wheat, and methacholine challenge testing. Exposure models were developed previously using job, bakery size, tasks and specific ingredients used. These models were used to predict average personal exposure to wheat allergens. Results The exposure–response relationships for average exposure followed a linear relationship for sensitisation, but a bell-shaped curve for allergic symptoms and probable occupational asthma, increasing up to 10–15 µg/m 3 wheat allergen concentration after which they plateau off and decrease at higher exposure concentrations. This relationship was modified by atopic status. IgG4 levels were strongly exposure related: a clear increase in prevalence of higher IgG4 with increase in wheat allergen exposure was observed among those sensitised and non-sensitised to wheat, with IgG4 even more strongly associated with exposure than IgE to wheat. Conclusions The bell-shaped exposure–response relationship in the current study is consistent with the findings of previous studies. IgG4 showed no protective effect for sensitisation, confirming the findings of previous studies, suggesting that the pattern is probably related to a healthy worker effect.

Description: Objective The study was designed to investigate whether beryllium exposure was related to illness diagnosed as sarcoidosis. Chronic beryllium disease (CBD) and sarcoidosis are clinically and pathologically indistinguishable, with only the presence of beryllium-specific T-lymphocytes identifying CBD. Testing for such cells is not feasible in community studies of sarcoidosis but a second characteristic of CBD, its much greater incidence in those with a glutamic acid residue at position 69 of the HLA-DPB1 gene (Glu69), provides an alternative approach to answering this question. Methods Cases of sarcoidosis aged 18–60 years diagnosed in Alberta, Canada, from 1999 to 2005 were approached through their specialist physician, together with age-matched and sex-matched referents with other chronic lung disease. Referents were grouped into chronic obstructive pulmonary disease (COPD), asthma and other lung disease. Participants completed a telephone questionnaire, including industry-specific questionnaires. DNA was extracted from mailed-in mouthwash samples and genotyped for Glu69. Duration of employment in types of work with independently documented beryllium exposure was calculated. Results DNA was extracted for 655 cases (270 Glu69 positive) and 1382 referents (561 positive). No increase in sarcoidosis was seen with either Glu69 or beryllium exposure (none, 〈10, ≥10 years) as main effects: longer duration in possible beryllium jobs was related to COPD. In Glu69 positive men with exposure ≥10 years, the trend towards increasing rate of COPD was reversed, and a significant interaction of duration of exposure and Glu69 was detected (OR=4.51 95% CI 1.17 to 17.48). Conclusions The gene–environment interaction supports the hypothesis that some cases diagnosed as sarcoidosis result from occupational beryllium exposure.

Description: Objectives To investigate inter-reader agreement for the detection of pleural and parenchymal abnormalities using CT in a large cross-sectional study comprising information on individual cumulative exposure to asbestos. Methods The project was approved by the hospital ethics committee, and all patients received information on the study and gave their written informed consent. In 5511 CT scans performed in a cohort of retired workers previously exposed to asbestos and volunteering to participate in a multiregional survey programme (Asbestos Related Diseases Cohort, ARDCO), double randomised standardised readings, triple in case of disagreement, were performed by seven trained expert radiologists specialised in thoracic imaging and blind to the initial interpretation. Inter-reader agreement was evaluated by calculating the -weighted coefficient between pairs of expert readers and results of routine practice and final diagnosis after expert reading. Results -Weighted coefficients between trained experts ranged from 0.28 to 0.52 (fair to good), 0.59 to 0.86 (good to excellent) and 0.11 to 0.66 (poor to good) for the diagnosis of asbestosis, pleural plaques and fibrosis of the visceral pleura, respectively. -Weighted coefficients between results of routine practice and final diagnosis after expert reading were 0.13 (poor), 0.53 (moderate) and 0.11 (poor) for the diagnosis of asbestosis, pleural plaques and fibrosis of the visceral pleura, respectively. Conclusions Interpretation of benign asbestos-related thoracic abnormalities requires standardisation of the reading and trained readers, particularly for participants asking for compensation, and with a view to the longitudinal survey of asbestos-exposed workers.

Description: Objectives To examine vascular endothelial growth factor (VEGF) and PGE2 levels in urine from the copper smelting workers exposed to arsenic and analyse the relationships between urinary VEGF or PGE2 level and arsenical metabolites. Methods The study was conducted in a group of 106 copper-smelting male workers. Information about each subject was obtained by questionnaire, inorganic As (iAs), monomethylarsonic acid (MMA), dimethylarsinic acid (DMA), VEGF and prostaglandin E2 (PGE2) in urine were determined. Standing height, body weight, and blood pressure were measured. Results According to the urine arsenic levels, participants were separated into three groups: Group 1: urine total arsenic 〈35 mg/L, Group 2: 35–100 mg/L, and Group 3: 〉100 mg/L. The median levels of urinary VEGF and PGE2 in Groups 1, 2 and 3 were 10.57 and 1032.0 pg/mL, 24.39 and 1060.9 pg/mL, and 49.0 and 1330.4 pg/mL, respectively. Urinary VEGF levels were positive associated with arsenical metabolites (iAs, MMA, DMA and TAs). Additionally, urinary VEGF and PGE2 levels were all correlated positively with the urinary MMA% (r=0.221, p=0.026 and r=0.206, p=0.037). While urinary VEGF was negatively with DMA% and secondary methylation index (r=–0.242, p=0.014 and r=–0.214, p=0.030, respectively). Conclusions Urinary VEGF and PGE2 levels increased in arsenic exposure copper smelting workers, and urinary VEGF levels are well associated with the urinary arsenicals. This finding may provide useful information for developing measurement, prevention and treatment of damage induced by arsenic in the future.

Description: The quality of guidelines is often modest and highly variable. We searched the Medline database for occupational asthma (OA) guidelines meeting our inclusion criteria and undertook a systematic appraisal of them. Six appraisers independently evaluated these guidelines using the AGREE II (Appraisal of Guidelines, Research and Evaluation II) instrument. Standardised scores for each domain and for overall quality were calculated, as well as intraclass correlation coefficients to assess agreement among appraisers. Seven relevant guidelines were identified. Three were based on a systematic review of the evidence. Most guidelines scored high on the domains ‘Scope and purpose’ and ‘Clarity and presentation’, but scores on the other domains were variable. The lowest scores were for ‘Applicability’, suggesting that guideline developers did not pay sufficient attention to practical problems affecting the implementation of their recommendations. We also observed a trend toward improved scores in guidelines published after 2000. Inter-rater agreement was good for most domains, and particularly for ‘Rigour of development’. This domain was most strongly correlated with the overall assessment scores, together with ‘Scope and purpose’ and ‘Editorial independence’. The quality of OA guidelines is variable, both within and across guidelines. There is significant room for improvement, and greater efforts to produce high-quality guidelines are warranted, in order to assist clinical decision-making.