Search

Purpose: To identify and quantify the risk of developing sarcoidosis associated with specific rural exposures previously recognized as potential risk factors for this disease., Methods: A matched case-control design was carried out with a 2-to-1 ratio of controls to cases. Case exposure histories were determine from a detailed questionnaire collecting self-reported information covering the period from birth through disease development and comparing that to exposure histories for the corresponding period in age-, race-, and gender-matched controls identified using Random Digit Dial survey methodology. Conditional logistic regression was used to analyze the matched data while controlling for several baseline variables., Results: A number of exposures were found to be univariately associated with the development of sarcoidosis including: the use of wood stoves, the use of fireplaces, the use of nonpublic water supplies, and living or working on a farm. A dose-response gradient was detected from exposure to wood stoves and fireplaces continued to be significantly associated with sarcoidosis in multivariable models., Conclusions: The results of this study provide further support for the hypothesis that behaviors associated with rural living play some role in the development of sarcoidosis. This study further suggests that exposures involving the handling or burning of wood such as using wood stoves or fireplaces for home heating may, in part, explain this rural association.

In 1991, an increased rate of childhood leukaemia was reported from the small northern German community of Elbmarsch, which is located on the banks of the River Elbe opposite the Kruemmel nuclear power plant. Owing to the fact that the increase occurred six years after the start-up of the plant, radioactive discharges were suspected as being implicated in the development of the cases. Previous investigations have failed to identify any exposure which might be associated with the cluster. Nonetheless, concern regarding the increased tritium burden in the environment remains. To further assess the impact of tritium releases to the environment upon population cancer rates, the releases and leukaemia rates at the Savannah River site, USA, were compared with the Kruemmel site. Based on the data from 1991 to 1995, the incidence of childhood leukaemia in the vicinity of the Savannah River site was non-significantly less than expected compared with the significantly higher than expected rates close to the German plant. In contrast, tritium releases from the Savannah River site exceed those from the Kruemmel site by several orders of magnitude. The results of this observational study suggest that factors other than environmental tritium releases are associated with the increased number of leukaemia cases near the Kruemmel site.

Geographic patterns of sarcoidosis have been detected and studied on a global scale. However, the associations between these disease patterns and population characteristics have not been determined. The authors studied the geographic pattern of sarcoidosis in South Carolina and its relation to socioeconomic status (SES) and health status indicators. Hospitalization rates for the period 1985-1995 were used as geographic indicators of sarcoidosis. Rates were assessed for the 46 counties in South Carolina, adjusting for differences in SES, availability/accessibility of health care, diagnostic practices, and hospital utilization. Patterns in geographic variation were assessed based on physiographic characteristics and proximity to the Atlantic coastline. Significant variation was identified with an increase in sarcoidosis rates proximal to the Atlantic coastline. Population characteristics were identified that appeared to explain regional variation in sarcoidosis in Caucasians; however, regression analysis was unable to explain the regional differences in disease distribution by variation in SES, diagnostic practices, accessibility/availability, or hospital utilization in African Americans. These results suggest that the development of sarcoidosis is associated with a geographically linked risk factor in African Americans. This work supports the need for additional studies that will identify this risk factor(s).

The occupational and environmental medicine (OEM) gap in US medical education is widely recognized. In 1992, a federal initiative stimulated a primary care approach to improve residency training in South Carolina. This three-part report documents progress in designing and implementing an OEM curriculum, which is family medicine-centered. Each of the state's residency training programs participate in an ongoing Environmental Medicine Curriculum Committee effort. Part 1, discusses the needs assessment; Part 2, the five key elements of curriculum; and Part 3 details a clinical guide to the OEM patient.

Part II of our three-part report examines five of the key elements for occupational and environmental medicine (OEM) training in family medicine residency. These were introduced by the Environmental Medicine Curriculum Committee (EMCC) faculty in South Carolina under a Department of Energy (DOE) grant to the Environmental Hazards Assessment Program (EHAP) of the Medical University of South Carolina, 1992-1997. Each element is being designed, tested, and updated by clinicians in the residency network. A pilot study of 100 third-year medical students conducted in 1996 suggests the difficulty in implementing OEM skills in current family medicine training.

A four-prototype approach to the occupational and environmental medicine (OEM) patient in a busy primary care setting is described. A 2 x 2 table illustrates the two diagnostic, interrelated tasks during the outpatient, non-urgent visit: (a) sick? yes/no, and (b) exposed? yes/no. One may have the basic skills for task (a) but feel insecure for task (b). With OEM experience, creative use of resources (databases and consultants), and patient cooperation, a better balance between task (a) and task (b) can be achieved. The Environmental Medicine Curriculum Committee (EMCC) initiative described in Part I and Part II of this study has developed this patient-centered model to help the resident in training cope as he or she tries to deal with emerging patient concerns from the workplace and beyond. In November 1996, an expert panel of consultants representing OEM, public health, and family medicine endorsed the prototype OEM patient model for further development.