General Approach to Initial Assessment and Documentation.

Well-rounded instruction in occupational medicine as part of family medicine residency training is feasible through a program that balances a longitudinal curriculum of monthly occupational and environmental medicine (OEM) lectures, community-based OEM patient care, and worksite assessment. Such training would help equip family medicine residents to integrate occupational medicine into their practices, which, in light of a shortage of board-certified practitioners in OEM, would help fill community needs. The Intern-Resident Training Committee of Carson City Hospital in rural Michigan established both learner and institutional goals and objectives for such a program of instruction. A learner-needs assessment found appreciable interest among the residents for occupational medicine training. In addition, results of a survey of the occupational health community suggested there is inadequate coverage of OEM in medical schools and residencies. Furthermore, a focus group of occupational health managers revealed that clarity of communication and standardization of reporting were paramount concerns. Instruments for standardized OEM history and for OEM case management were developed for use within the residency continuity clinic. The curriculum was implemented with a variety of teaching strategies, including worksite assessment. Practice-based, case-oriented instruction was subsequently phased into the program as residents assumed responsibility for managing cases under the supervision of family medicine preceptors knowledgeable in OEM. An occupational medicine rotation was developed that included focused clinical exposure to OEM patients and studies that would lead to eligibility for a certificate of additional qualification in occupational medicine. Learner evaluations included chart reviews and patient satisfaction surveys. Program evaluations included interviews with occupational health managers. The residents were judged by their preceptors to have performed well. The responses of the health managers and the patients were positive. This program in occupational medicine was found to be educationally sound with demonstrated community benefit and patient satisfaction. Further, it is cost-effective, requiring no external funding.

A survey of workload, facilities and awareness of uncertainty of measurement among Italian laboratories performing analyses in occupational and environmental medicine

To the Editor: The series of articles by Drs Schuman et al1-3 address an important issue in the training of family medicine (FM) doctors in occupational and environmental medicine (OEM). The teaching of OEM is variable in medical education throughout the world.4,5 In many countries, and OEM gap is apparent at both the undergraduate level in medical school, as well as the postgraduate level in FM training. We would like to share our experience on how this gap is bridged in Singapore. In the medical school in Singapore, both disciplines are taught primarily by the Department of Community, Occupational and Family Medicine. OEM training of medical undergraduates consists of a series of lectures based on an organ-systems approach. This is supplemented by small group tutorials on patients likely to be encountered in primary care and hospital practice, eg, those with contact dermatitis, anemia detected during pre-employment examination,6 and a visit to a workplace. One objective is to ensure that students are able to identify occupational factors in the causation of disease and recognize the need to consider occupational factors in the management of all patients. Another aim is for students to be aware of the importance of preventive measures for work-related illness and the promotion of health at work. The undergraduate FM curriculum includes formal teaching as well as practical training. In the practical training, there is a one-week posting to a family practice and another week at a government primary health care center. Cases seen during the postings are logged and discussed with the clinical tutor. In the teaching sessions, the impact of the work environment on disease etiology and management is discussed whenever relevant. At the postgraduate level, FM training is conducted by the School of Postgraduate Medical Studies of the university. In the curriculum, care of special groups of patients, including the worker, is specifically listed in the training requirements booklet. A module on OEM is mandatory in the training program. The OEM teaching, which is jointly given by OEM and FM physicians, includes slide quizzes on clinical cases seen in primary care practice. Subsequent discussion of these case studies centers around the clinical and OEM aspects. In addition, over 500 FM practitioners in the country (about one quarter of all FM practitioners) have undergone formal postgraduate training in OEM. This is because of a national statutory requirement for medical examinations among workers exposed to prescribed hazards (eg, noise, some heavy metals and chemicals). These FM practitioners have to complete an examinable 72-hour course in OEM successfully before they can register as Designated Factory Doctors (DFDs). In 1998, this course will be replaced with a 100-hour course leading to a postgraduate diploma in occupational medicine. Statutory medical examinations and certification for fitness to work in some occupations can only be performed by DFDs. As such, many employers prefer to appoint a DFD as their company contract doctor. While an OEM gap in medical and FM training may exist in many situations throughout the world, the experiences in South Carolina and in Singapore demonstrate that the problem is not insurmountable. An integrated clinical case-study approach in the training appears to be an effective way to reduce the OEM gap in primary care doctors. David Koh, MBBS, MSc, PhD Sin-Eng Chia, MBBS, MSc, MD Department of Community, Occupational and Family Medicine; Faculty of Medicine; National University of Singapore

American Journal of Industrial MedicineVolume 32, Issue 3 p. 317-318 Letter to the Editor Partition of circulating lead between plasma and red cells does not seem to be different for internal and external sources of lead Ingvar A. Bergdahl MSc, Corresponding Author Ingvar A. Bergdahl MSc Department of Occupational and Environmental Medicine, Lund University, S-221 85 Lund, SwedenDept. of Occupational and Environmental Medicine, F-block, University Hospital, S-221 85 Lund, SwedenSearch for more papers by this authorStaffan Skerfving MD, Staffan Skerfving MD Department of Occupational and Environmental Medicine, Lund University, S-221 85 Lund, SwedenSearch for more papers by this author Ingvar A. Bergdahl MSc, Corresponding Author Ingvar A. Bergdahl MSc Department of Occupational and Environmental Medicine, Lund University, S-221 85 Lund, SwedenDept. of Occupational and Environmental Medicine, F-block, University Hospital, S-221 85 Lund, SwedenSearch for more papers by this authorStaffan Skerfving MD, Staffan Skerfving MD Department of Occupational and Environmental Medicine, Lund University, S-221 85 Lund, SwedenSearch for more papers by this author First published: 06 December 1998 https://doi.org/10.1002/(SICI)1097-0274(199709)32:3<317::AID-AJIM22>3.0.CO;2-XCitations: 18AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume32, Issue3September 1997Pages 317-318 RelatedInformation

Truckers with OSA, Should They Be Driving?

High stability, the quality that made polychlorinated biphenyls (PCBs) so useful in hundreds of industrial and commercial applications during the mid-1900s, has ensured the compounds’ continuing presence in the environment despite decades of banned and restricted use.1 This class of more than 200 structurally related chemicals has been linked to both cancer and noncancer outcomes,1 and some studies suggest prenatal or early-life exposure to PCBs may adversely affect the auditory system.2,3 A new study reported in EHP specifically links postnatal—but not prenatal—PCB exposure with impaired cochlear function.2 Clusters of hair cells populate the cochlea and detect sounds transmitted to the inner ear. The cochlea, an extremely sensitive organ in the inner ear, converts soundwave vibrations to nerve impulses transmitted to the brain. Cochlear damage can impair hearing and is a well-known side effect of certain antibiotics and chemotherapeutic drugs.4 Rodent studies have shown that PCBs, too, can affect the cochlea, leading to hearing loss.5 Some human studies have reported associations between PCB exposure and hearing impairment, particularly in children,6,7 although others have found no such association.8 The current study focused on mother–infant pairs from an ongoing birth cohort study in eastern Slovakia. Study participants enrolled during hospital stays for childbirth in 2002–2004. Maternal and cord blood samples were collected for PCB and lipid measurements, and children underwent blood tests at 6, 16, and 45 months of age. At 45 months, the children also underwent otological and auditory testing, including an assessment of distortion product otoacoustic emissions (DPOAEs), a measure of cochlear function. Health records provided information on the children’s births and subsequent medical visits. Mothers completed questionnaires at study enrollment and at the 16- and 45-month followup visits, providing sociodemographic information and data on lifestyle, diet, medical history, and other factors that could affect their children’s health and hearing. A total of 351 children were included in the study. Blood tests measured 15 PCB congeners, but analyses focused on PCB-153, which was detected in nearly all samples and closely correlated with total PCB concentrations. An inverse relationship existed between decreased DPOAE amplitude (a marker of diminished cochlear function) and postnatal serum PCB concentrations, with the strongest association observed for cumulative levels of PCBs. The authors suggest this could indicate that duration of exposure, rather than timing, is most important for cochlear development. No association was observed between prenatal PCB exposure and decreased DPOAE amplitude.2 The PCB-associated decrease in DPOAE amplitude was not large.2 “Certainly, the hearing impairment would be subclinical,” says study coauthor Tomas Trnovec, a professor of environmental medicine at Slovak Medical University in Bratislava. However, the cochlea is vulnerable to any number of environmental insults, including noise, organochlorine pesticides, and drugs, among others, Trnovec says. “The combined effect of these factors is completely unknown,” he says, adding that “under different settings and other data treatment … a prenatal exposure effect cannot be excluded.” It’s also unknown whether effects persist and whether continued exposure (combined with other stressors) builds on early damage. “In my opinion, PCB ototoxicity may be involved in the pathogenesis of hearing impairment in the adult population,” says Kyoung-Bok Min, an assistant professor in occupational and environmental medicine at South Korea’s Ajou University School of Medicine, who was not involved in the study. Min and colleagues recently reported an association between PCB serum levels and increased prevalence of hearing impairment in adults who participated in the National Health and Nutrition Examination Survey.9 “Further epidemiologic studies are needed in terms of whether the impact of exposure to PCBs on cochlear function changes throughout the life span of the human,” he says. In addition, Susan Schantz, a professor of veterinary biosciences and psychology at the University of Illinois at Urbana–Champaign, raises the possibility of potential impacts beyond hearing. “One of the things that really interests me—and that I don’t know the answer to—is what does that kind of a decrease [in DPOAE amplitude] mean? Would it be enough to have subtle impacts on language acquisition in children?” asks Schantz, who was not involved in the study. Previous PCB cohort studies have shown an adverse impact on cognitive function, including verbal abilities.10 “I’ve always wondered whether subtle changes in hearing could be affecting language development, and then that could be affecting verbal abilities,” Schantz says. The new study features a particularly strong design based on multiple PCB measurements in a well-characterized population. However, it did not account for potential effects of co-contaminants, which may produce damage when combined with other exposures.11 “I think it’s very interesting that they’re seeing reductions to amplitudes related to postnatal exposure,” says Schantz. “That’s not what I would have predicted based on the animal research, but I think it’s very interesting and potentially important.”

History taking in clinical medicine — A forgotten art?

The Collegium Ramazzini is an international scientific society that examines critical issues in occupational and environmental medicine with a view towards action to prevent disease and promote health. The Collegium derives its name from Bernardino Ramazzini, the father of occupational medicine, a professor of medicine of the Universities of Modena and Padua in the late 1600s and the early 1700s. The Collegium is comprised of 180 physicians and scientists from 35 countries, each of whom is elected to membership. The Collegium is independent of commercial interests. The Collegium Ramazzini recognizes the work of the 2014 expert committee convened by the Finnish Institute of Occupational Health (FIOH) to update the 1997 and 2000 Helsinki criteria on Asbestos, Asbestosis, and Cancer in light of new advances in research. The published consensus report of the Helsinki Committee [Wolff et al., 2015] and its more extensive on-line version (Helsinki Criteria Update 2014 Asbestos, Asbestosis, and Cancer) provide a valuable synthesis of many aspects of current knowledge of the hazards of asbestos. The Collegium Ramazzini is, however, very concerned about the sections of the 2014 Helsinki consensus report that discuss criteria for pathological diagnosis of the diseases caused by asbestos. The sections of the Helsinki report dealing with pathology diagnosis are based on a selective reading of the medical literature. They rely overly much on certain published articles [Srebro et al., 1995; Butnor et al., 2003; Roggli et al., 2010] while omitting reference to other important and highly relevant information. They are heavily influenced by the outdated and incorrect concept that analysis of lung tissue for asbestos fibers and asbestos bodies can provide data to contradict exposures that are documented in a reliable occupational history. Further, without any explanation the most accepted College of American Pathologists (CAP)-NIOSH 1982 asbestos definition which underwent extensive review and endorsement by NIOSH is now replaced in the 2014 Helsinki criteria by the more restrictive CAP/Pulmonary Pathology Society (PPS) modification which differs especially in the early histological stages of asbestosis and in the higher numbers of asbestos bodies needed to make the pathological diagnosis of asbestosis [Hammar and Abraham, 2015]. For these reasons, relying on lung tissue analysis for the diagnosis and compensation of asbestos-related disease—while ignoring the history of occupational exposure—is unacceptable. Application of these recommendations will cause harm to the health of workers and their families in countries around the world. Over-reliance on the detection of "asbestos bodies" as indicators of past exposure to asbestos. Chrysotile asbestos, the predominant form of asbestos in use today, is now recognized to rarely form asbestos bodies. Therefore, failure to detect asbestos bodies cannot be used as a criterion for excluding exposure to chrysotile asbestos. Reliance on the detection of asbestos bodies as an index of past exposure to asbestos may lead to false negative diagnoses [Dodson, 2011; Hammar and Abraham, 2015]. The Collegium Ramazzini is particularly critical of the suggestion in the 2014 Helsinki consensus report that a finding of "over 1000 asbestos bodies per gram of dry tissue (100 asbestos bodies per gram of wet tissue) or over 1 asbestos body per milliliter of bronchoalveolar lavage fluid as measured by light microscopy in a qualified laboratory" can be used as a guideline "to identify persons with a high probability of exposure to asbestos dust." This suggestion is not consistent with the current recognition that chrysotile asbestos rarely forms asbestos bodies. It omits any mention of what defines a "qualified laboratory." It fails to address the well-documented variability across laboratories in both counting procedures and standards [Dodson et al., 1985, 2008]. And, it may lead to unethical, unnecessary, and risky surgical procedures (see below). The Collegium Ramazzini has no concern about using a finding of asbestos bodies as an indicator of past exposure to asbestos. However, there is no reliable basis for the proposed thresholds that must be met before such a conclusion is allowed; and the failure to find asbestos bodies cannot be used to contradict a reliable occupational history of exposure, particularly to chrysotile. Over-reliance on asbestos fiber counts in lung tissue as an indicator of past exposure to asbestos. Asbestos fiber counts obtained from human lung tissue are now recognized to be a highly insensitive measure of past exposure to chrysotile asbestos. Chrysotile asbestos fibers are now well documented to have only a short residence time in lung tissue and therefore, their measurement in the lung cannot be used as a measure of cumulative past exposure [Wagner et al., 1982; Baker, 1991; Kohyama and Suzuki, 1991; Churg and Wright, 1994; Finkelstein and Dufresne, 1999; Roggli et al., 2002; Suzuki and Yuen, 2002; Dodson et al., 2008; Egilman, 2009]. As with asbestos bodies, the Collegium Ramazzini has no concern about using a finding of asbestos fibers in lung tissue as an indicator of past exposure to asbestos. However, there is no reliable basis for the failure to find asbestos fibers in lung tissue to be used to contradict a reliable occupational history of exposure, particularly to chrysotile. Short asbestos fibers, less than 5 microns in length, are a further issue here and are not discussed in the Helsinki consensus report. These fibers were originally not counted by most laboratories because they were below the visibility limits of the phase contrast microscope. Today, they are readily visible under the electron microscope and are counted by some laboratories and not by others. The Helsinki report considers neither short asbestos fibers nor their possible contribution to the pathogenesis of asbestos-related diseases [Dodson et al., 2003, 2008; Suzuki et al., 2005; Abraham 2006]. Nor does it consider the well-documented wide intra- and inter-laboratory variability in procedures for the counting of short fibers [Dodson et al., 1985, 2008; Baker 1991]. Use of the Scanning Electron Microscope (SEM) at low magnification as a tool for evaluation of asbestos-related disease. The Scanning Electron Microscope (SEM) at low magnification should not be used for causal attribution in diagnosis of the diseases potentially caused by asbestos because it is incapable of detecting most chrysotile fibers [Roggli et al., 1986, 2002; Roggli, 1989; Baker, 1991]. An additional problem with microscopic screening of lung tissue for asbestos bodies and asbestos fibers by SEM at low magnification is that there is wide intra- and inter-laboratory variability in these procedures with no standardization of diagnostic procedures across laboratories [Dodson et al., 1985, 2008]. For all of these reasons, use of low-magnification SEM as a diagnostic instrument will lead to false-negative diagnoses, particularly in the case of individuals with a history of exposure to chrysotile. The Collegium Ramazzini recommends instead that the analytical transmission electron microscopy (ATEM) should be the diagnostic instrument of choice for fiber analysis in cases of suspected exposure to asbestos [Upton et al., 1991]. There is no recognition that chrysotile is the predominant type of asbestos fiber found in pleural mesothelioma tissue. Multiple studies have demonstrated that chrysotile fibers are the predominant type of asbestos fiber found in pleural mesothelioma tissue. The relative abundance of chrysotile fibers in mesothelioma tissue contrasts with their relative scarcity in lung tissue [Wagner et al., 1982; Kohyama and Suzuki, 1991; Churg and Wright, 1994; Finkelstein and Dufresne, 1999; Suzuki and Yuen, 2002; Dodson et al., 2008; Egilman, 2009]. These concerns are not new or novel. Rather, they have been recognized for at least the past 25 years [Baker, 1991; Roggli et al., 2002]. As chrysotile has always been the vast majority of the asbestos used globally, and for at least the past 20 years has essentially been the only form of asbestos used, these concerns are all the more significant going forward. In conclusion, the Collegium Ramazzini emphasizes that a carefully obtained history of occupational exposure to asbestos is the cornerstone of an accurate diagnosis of the diseases caused by asbestos [Baur et al., 2015]. An occupational history taken by an experienced clinician and supplemented as necessary by an exposure assessment conducted by an experienced industrial hygienist is a far more sensitive and specific indicator of lung cancer risk from chrysotile asbestos than asbestos body counting or lung fiber burden analysis [Begin and Christman, 2001; WHO, 2009]. The Collegium Ramazzini recommends against any requirement for lung biopsy or for the use of lung tissue histopathology or fiber-counts from lung tissue as procedures for the diagnosis of pulmonary fibrosis, including asbestosis, in medico-legal or compensation cases, because of the invasive and potentially risky nature of the lung biopsy [Raghu et al., 2011] and because the procedure is medically unnecessary. It is the opinion of the Collegium Ramazzini that such invasive diagnostic procedures are "never" ethically justified solely for medico-legal or compensation purposes, given that asbestos exposure can reliably be ascertained through a properly obtained occupational history. The Collegium Ramazzini notes that a diagnosis of idiopathic pulmonary fibrosis is a diagnosis of exclusion. This diagnosis should never be made until exposures to asbestos and to other known exogenous causes of lung fibrosis have been carefully excluded which says cannot make diagnosis of IPF in setting of exposure to fibrosing agent [Raghu et al., 2011]. Professor Irving Selikoff, the Founder of the Collegium Ramazzini, stated 35 years ago that "Patients should be compensated if there is documented history of occupational exposure to asbestos" [Selikoff 1980]. This principle applies also to environmental exposures to asbestos. It still holds true today. Drs. Baur, Budnik, Soskolne and Woitowitz, and Dr. Landrigan as President of the Collegium Ramazzini, declare no conflict of interest. Dr. Oliver does medicolegal work on behalf of plaintiffs in asbestos litigation. Dr. Frank does asbestos medical legal work, primarily for plaintiffs. Dr. Welch occasionally serves as expert witness for individuals with asbestos disease. Dr. Lemen testifies in asbestos litigation, mainly on behalf of plaintiffs. Paul Landsbergis declares that he has no competing or conflicts of interest in the review and publication decision regarding this article. Rodney Ehrlich is a member of the Collegium Ramazzini.

American Journal of Industrial MedicineVolume 16, Issue 3 p. 341-341 Book Review Cancer incidence and mortality in the vicinity of nuclear installations; england and wales, 1959–1980. studies on medical and population subjects, No. 51. Edited by P. J. Cook-Mosaffari, F.L. Ashwood, T. Vincent, D. Forman, and M. Alderson. Her Majesty Stationery Office, London. 1987, 275 pages, $48.00 (paper with microfiche. (Available in North America from Bernan-Unipub, 461 I-F Assembly Drive, Lanham MD 20706–4391 O-lI-691068–2/.) P. J. Cook-Mosaffari, P. J. Cook-Mosaffari Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorF. L. Ashwood, F. L. Ashwood Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorT. Vincent, T. Vincent Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorD. Forman, D. Forman Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorM. Alderson, M. Alderson Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorDr. David E. Lilienfeld MD, MScE, Corresponding Author Dr. David E. Lilienfeld MD, MScE Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Division of Environmental and Occupational Medicine, Box 1057, Mount Sinai School of Medicine, 1 Gustave Levy Place, New York, NY 10029–6574Search for more papers by this author P. J. Cook-Mosaffari, P. J. Cook-Mosaffari Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorF. L. Ashwood, F. L. Ashwood Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorT. Vincent, T. Vincent Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorD. Forman, D. Forman Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorM. Alderson, M. Alderson Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Search for more papers by this authorDr. David E. Lilienfeld MD, MScE, Corresponding Author Dr. David E. Lilienfeld MD, MScE Division of Environmental and Occupational Medicine Mount Sinai School of Medicine New York, NY 10029–6574Division of Environmental and Occupational Medicine, Box 1057, Mount Sinai School of Medicine, 1 Gustave Levy Place, New York, NY 10029–6574Search for more papers by this author First published: 1989 https://doi.org/10.1002/ajim.4700160316AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume16, Issue31989Pages 341-341 RelatedInformation

Modern Korean society is experiencing fundamental transformations in industrial structures and working environments driven by complex factors, including demographic shifts, the Fourth Industrial Revolution, the coronavirus disease 2019 pandemic, and digital transformation. The evolving dynamics between the manufacturing and service industries, the emergence of technology-driven sectors, and the proliferation of new occupational categories are reshaping traditional employment models. This has directed the labor market toward nonstandard employment forms, including temporary, contract-based, and platform labor. Consequently, issues such as employment instability and reduced accessibility to workplace health programs, including occupational safety training, health examinations, and workplace health management, have become increasingly prominent. Although occupational and environmental medicine has subsequently gained significance, the current occupational health and safety framework inadequately addresses the nuances of emerging labor forms. Legal gaps persist, leaving vulnerable groups such as nonregular workers, platform laborers, and older workers insufficiently protected under existing systems. Furthermore, systemic issues are evident in the inadequate follow-up care during occupational health examinations, lacking continued adherence to hazard-centric approaches, and insufficient attention to chronic diseases and mental health challenges. This study proposes strategies that occupational and environmental medicine can address these issues. First, legal and institutional reforms must encompass new labor forms, accompanied by modernized safety and health guidelines. Second, state-of-the-art technologies should be leveraged to enhance predictive disease management and personalized healthcare for workers. Third, a preventive approach integrating chronic disease management, mental healthcare, and psychosocial risk factors must be established. Fourth, fostering interdisciplinary research collaboration across medicine, engineering, and psychology is essential for developing practical solutions to emerging challenges. In conclusion, occupational and environmental medicine in Korea must adapt to effectively address the evolving labor landscape. Through systematic innovation, integrated health-management approaches, technological advancements, and interdisciplinary cooperation, the health and safety of all workers in the rapidly changing world can be ensured.

The aim of the study is to assess the incidence of Lyme disease, established diagnosis based on medical history and clinical symptoms, serology, duration of exposure in the workplace and occupational disease certification among forestry workers in selected districts of the Warmia and Mazury region. The study consisted of annual screening of 332 employees in 6 forest districts under the supervision of the Health Center Medica in Ostróda. Serological tests were performed in all serum samples and IgG and IgM antibodies were determined by ELISA test. Positive results were confirmed by Western-blot test. Diagnosis was made based on medical history and clinical symptoms. Results were presented by the division of selected forest districts, gender, duration of exposure in the workplace and genospecies of spirochete Borrelia responsible for the disease development. Lyme disease incidence was found in all selected forest districts. Positive results in Western-blot test were determined in 120 people (63.1% of all the surveyed). However, after taking a detailed medical history of the patients Lyme disease was diagnosed in 91 people which makes 27.4% of all the examined. Among patients with diagnosed disease, IgG antibodies were found in 76 people, IgM in 25 people, while both IgM and IgG in 10 people. There was also variation in the involvement of genospecies generating the disease; spirochete B. afzeli--46% for IgG antibodies, whereas spirochete B. burgdorferi--50% of all cases for IgM antibodies. At the same time the relationship between the extended duration of occupational exposure to tick bites and the increased incidence of Lyme disease was confirmed, indicating the group of workers employed for at least 25 years. Forestry districts of the Warmia and Mazury region, creates extremely dangerous occupational conditions because of exposure to tick bites. At the same time the duration of employment significantly increases the risk of Lyme. The analysis of serological tests results indicated differences in the reactivity of IgG and IgM classes and confirmed the correlation between clinical symptoms of Lyme disease and the variation of genospecies inducing the disease.

Occupational and environmental medicine (OEM) clinicians require specialized electronic health records (EHRs) to address the privacy, data governance, interoperability, and medical surveillance concerns that are specific to occupational health. The American College of Occupational and Environmental Medicine (ACOEM) Section of Health Informatics evaluated clinical workflow concerns, assessed health information requirements, and developed informatics recommendations through iterative consultation with ACOEM members. The ACOEM presents 10 recommendations that specialized occupational EHR systems (OEHRs) should meet to serve the information needs and practice requirements of OEM clinicians. Common challenges in OEM practice and potential informatics solutions are used to illustrate each recommendation. The recommendations serve as a framework for occupational health clinicians to consider in their adoption of OEHRs and provide software engineers a set of requirements to facilitate the development and improvement of OEHRs.

Digital applications in occupational medicine – new regulations in development The world of work is changing – and with it occupational medicine. Digital solutions are increasingly finding their way into occupational health practices, whether in risk assessment, preventive care, or company integration management (BEM). In order to accompany this change in a technically sound and legally secure manner, the Committee for Occupational Medicine (AfAMed) is working in a newly founded project group on occupational health rules (AMR) and occupational health recommendations (AME) for digital applications. In an interview with Lukas Brethfeld (VDBW), Prof. Dr. Thomas Kraus, President of the DGAUM and Director of the Institute for Occupational, Social, and Environmental Medicine at RWTH Aachen University, explains how the project group is structured, which opportunities and risks are associated with digital tools – and what is needed to successfully integrate them into operational practice.

Work-Relatedness.

Accuracy of diagnosis of malignant mesothelioma (pleural and peritoneal) was studied in a cohort of asbestos insulation workers in the United States and Canada. Initial clinical diagnosis, clinical diagnosis at death and death certificate diagnosis were compared with the diagnosis of malignant mesothelioma ascertained by full data review at the Division of Environmental and Occupational Medicine, Mount Sinai Medical Center, New York ('best evidence'). In both groups the death certificate diagnosis was somewhat less frequently accurate than clinical diagnosis at death. Knowledge of the patients' occupational history by the attending physician and its relation to accuracy of diagnosis of malignant mesothelioma is considered.