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Objective: To evaluate agreement of the updated European League Against Rheumatism and European Scleroderma Trials and Research group (EUSTAR) recommendations for treatment of systemic sclerosis (SSc) among international experts. In addition, to determine factors that might influence agreement., Methods: Level of agreement (10-point scale: 0 = not at all, 10 = completely agree) and local drug availability (yes/no) were assessed using an online survey. The Web link to the survey was shared with 481 unique e-mail addresses and SSc networks (Scleroderma Clinical Trials Consortium, Australian Scleroderma Interest Group, International Systemic Sclerosis Inception Cohort). Level of agreement was compared between subgroups stratified for participant characteristics., Results: In total, 263 experts participated, of whom n = 209 (79%) completed each single item. The majority were rheumatologists (n = 200, 76%) working in Europe (n = 185; 71%); 59% (n = 156) were EUSTAR members; and 57% (n = 151) had > 10 years of clinical experience. Overall level of agreement was high (mean 8.0, SD 2.5). The 3 highest mean agreements included (1) angiotensin-converting enzyme inhibitors for scleroderma renal crisis (9.2, SD 2.1); (2) blood pressure control in SSc-patients treated with corticosteroids (9.0, SD 2.2); (3) proton pump inhibitors to prevent reflux complications (9.0, SD 2.2). The 3 lowest mean agreements included (1) fluoxetine for Raynaud phenomenon (RP; 4.6, SD 2.8); (2) hematopoietic stem cell transplantation (HSCT) for severe SSc (7.1, SD 2.9); (3) phosphodiesterase inhibitors 5 for RP (7.3, SD 2.7). Agreement differed between Europe and non-Europe for the use of iloprost, bosentan, methotrexate, HSCT, and cyclophosphamide. Treatment availability could partially explain differential agreement for iloprost, bosentan, and HSCT., Conclusion: In general, worldwide expert agreement on updated recommendations for treatment of SSc is high, supporting their value. Differences in agreement are partially explained by geographical area and treatment availability.

Objectives: In this study, the daily exposure action values (EAV) and the daily exposure limit values (ELV) for hand-transmitted vibration (HTV) and whole-body vibration (WBV), established by the EU Directive 2002/44/EC and the Italian Decree 81/2008, and expressed in terms of 8-hr frequency weighted r.m.s. acceleration magnitude, are discussed upon consideration of the findings of experimental and epidemiological studies., Methods: There is some epidemiological support for the EAV A(8) of 2.5 ms-2 r.m.s. and the ELV A(8) of 5 ms-2 r.m.s. for HTV, at least for the vascular component (secondary Raynaud's phenomenon) of the hand-arm vibration syndrome., Results: There is some experimental evidence for the EAV A(8) of 0.5 ms-2 r.m.s. for WBV, while there is neither biodynamic nor epidemiological validation for the ELV A(8) of 1.15 ms-2 r.m.s. for WBV, this latter lowered to 1 ms-2 r.m.s. in the Italian legislation., Competing Interests: The authors of this article have no conflict of interests to disclose., (Copyright© by Aracne Editrice, Roma, Italy.)

Introduction: Raynaud's phenomenon (RP) describes excessive peripheral vasospasm to cold exposure and/or emotional stress. RP episodes are associated with digital colour changes, pain and reduced quality of life. Pharmacological interventions are of low to moderate efficacy and often result in adverse effects such as facial flushing and headaches. Recommended lifestyle and behavioural interventions have not been evaluated. The objectives of the proposed systematic review are to assess the comparative safety and efficacy of behaviour change interventions for RP and identify what we can learn to inform future interventions., Methods and Analysis: Studies eligible for inclusion include randomised controlled trials testing behaviour change interventions with a control comparator. A comprehensive search strategy will include peer review and grey literature up until 30 April 2017. Search databases will include Medline, Embase, PsychINFO and Cochrane. Initial sifting, eligibility, data extraction, risk of bias and quality assessment will be subject to review by two independent reviewers with a third reviewer resolving discrepancies. Risk of bias assessment will be performed using Cochrane risk of a bias assessment tool with quality of evidence assessed using Grading of Recommendations Assessment, Development and Evaluation(GRADE). A meta-analysis will be performed if there are sufficient data. Two subgroup analyses are planned: primary versus secondary RP outcomes; comparison of theoretically informed interventions with pragmatic interventions., Ethics and Dissemination: This review does not require ethical approval as it will summarise published studies with non-identifiable data. This protocol complies with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. Findings will be disseminated in peer-reviewed articles and reported according to PRISMA. This review will make a significant contribution to the management of RP where no review of behaviour-change interventions currently exist. The synopsis and protocol for the proposed systematic review is registered in the International Prospective Register of Systematic Reviews (registration number CRD42017049643)., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: Our primary purpose was to evaluate the efficacy of the high-potency α2C-adrenoceptor antagonist ORM-12741 in the attenuation of a cold-induced reduction in finger blood flow and temperature in patients with RP secondary to SSc. Secondary objectives were to assess safety and tolerability., Methods: This was a phase IIa, randomized, double-blind, crossover, single-dose, placebo-controlled, single-centre study. Patients attended five times: initial screening, treatment visits 1-3 (each at least 1 week apart) and 1-2 weeks after the last treatment. At each treatment visit, each subject received a single oral dose of 30 mg or 100 mg of ORM-12741 or placebo. Thirty minutes later the subject underwent a cold challenge. Blood flow to the fingers was assessed by three methods [temperature by probe, laser Doppler imaging (LDI) and infrared thermography] performed before, during and after the cold challenge., Results: Twelve patients (10 female, mean age 58 years) were included. The area under the rewarming curve (LDI) of the right index finger (arbitrary flux units × time) was lower for both 30 mg (P = 0.043) and 100 mg (P = 0.025) of ORM-12741 compared with placebo, indicating delayed reperfusion. The time to 70% temperature recovery (middle finger probe) was longer with active than placebo treatment: mean (s.d.) values for placebo, 30 mg of ORM-12741 and 100 mg of ORM-12741 were 21.4 min (12.4), 25.7 min (12.2) and 26.9 min (13.9), respectively. Overall ORM-12741 was well tolerated., Conclusion: ORM-12741 did not expedite recovery from a cold challenge in the fingers of patients with SSc., Trial Registration: https://www.clinicaltrialsregister.eu/; no. 2010-024005-13.

Background: Acupuncture has been shown to influence skin perfusion and the subjective cold perception threshold. Therefore, we hypothesized that auricular electroacupuncture (EA) might reduce symptoms in primary Raynaud's phenomenon (PRP)., Methods: Twenty-six patients with PRP received 6 cycles of auricular EA. After 3, 6 and 24 weeks attack frequency and severity were reevaluated using standardized questionnaires and a visual analogue scale (VAS). Skin temperature was assessed by infrared thermography and laser Doppler perfusion imaging was used to determine skin perfusion., Results: Compared to baseline we found a significant reduction of attack frequency after 3 (p = 0.001) and 6 weeks (p < 0.001) of auricular EA. This improvement sustained following cessation of EA, after 24 weeks (p < 0.001). Furthermore, attack associated pain was reduced after 3 (p = 0.003), 6 (p = 0.003) and 24 weeks (p = 0.001) of treatment, while skin temperature and skin perfusion did not change significantly throughout the study period., Conclusions: Auricular EA reduces symptoms by means of frequency and severity of attacks in PRP but has no influence on skin perfusion and skin temperature.

Meeting mothers' personal breast-feeding goals depends on a number of factors, including the timely resolution of any problems she encounters. Nurses are often the first providers who interact with the mother during the perinatal period and are positioned to guide mothers through the prevention and solving of breast-feeding problems. Although many problems may be "common," failure to remedy conditions that cause pain, frustration, and anxiety can lead to premature weaning and avoidance of breast-feeding subsequent children. This article describes strategies and interventions to alleviate common problems that breast-feeding mothers frequently encounter.

Small molecule tyrosine kinase (TK) inhibitor, such as imatinib, is well established in the treatment of malignancy. Oral administration, high efficacy, and an excellent safety profile have made imatinib a drug of choice for several malignancies and benign conditions. Recent progress in the understanding of several benign conditions has led to the use of TK inhibitors in the treatment of hypereosinophilic syndrome and mastocytosis. Systemic sclerosis (SS) is a recalcitrant disease featuring multiorgan fibrosis and dysfunction. Molecular and biological evidence point to a central role for platelet-derived growth factor receptor, a TK-associated entity, in the pathogenesis of SS. The ability of several TK inhibitors, namely imatinib, to abrogate the activation of platelet-derived growth factor receptor-TK may entail their use in the treatment of SS and possibly more limited forms of sclerosis. Several human studies aiming to examine the use of imatinib in the treatment of SS are currently underway.

Objective: To evaluate the efficacy and tolerability of prolonged administration of quinapril, a long-acting angiotensin-converting enzyme inhibitor, in the management of the peripheral vascular manifestations of limited cutaneous systemic sclerosis (lcSSc) and in the prevention of the progression of visceral organ involvement in the disease., Methods: This was a multicenter, randomized, double-blind, placebo-controlled study evaluating quinapril 80 mg/day, or the maximum tolerated dosage, in 210 patients with lcSSc or with Raynaud's phenomenon (RP) and the presence of SSc-specific antinuclear antibodies. Treatment was for 2-3 years. The primary outcome measure was the number of new ischemic ulcers appearing on the hands; secondary measures were the frequency and severity of RP attacks, skin score, treatments for ischemia, health status (measured by the Short Form 36 instrument), measures of kidney and lung function, and echocardiographic estimates of pulmonary artery pressure. An intent-to-treat analysis was used., Results: Quinapril did not affect the occurrence of digital ulcers or the frequency or severity of RP episodes. It did not alter the treatments that were prescribed for either infected ulcers or severe RP symptoms. There was no apparent effect on the estimated tricuspid gradient. Health status was not affected by quinapril, and one-half of the patients who believed they had benefited from the trial treatment were in the placebo arm. Quinapril was not tolerated by one-fifth of the patients, with dry cough being the most frequent side effect., Conclusion: Administration of quinapril for up to 3 years had no demonstrable effects on the occurrence of upper limb digital ulcers or on other vascular manifestations of lcSSc in this patient population.

Objective: Familial cold autoinflammatory syndrome (FCAS) is a rare, hereditary disorder characterized by cold-induced inflammation. We describe the successful longterm treatment of a patient with FCAS with anakinra, an interleukin 1 receptor antagonist (IL-1Ra). The remarkable response of FCAS and associated Raynaud's disease in this patient suggests that IL-1 is an important mediator of these inflammatory diseases. Our report supports increasing evidence that anakinra plays an important role in the treatment of select chronic inflammatory diseases.

The operators of the single-axle tractors are especially exposed to hand-arm transmitted vibrations. These vibrations can cause the complex of vascular, neurological and musculoskeletal disorders, collectively named hand-arm vibration syndrome. Among these, the most common disorder is vibration-induced white finger (Raynaud's phenomenon). The vibration levels were measured in three tractor's working conditions, namely idling, transportation and soil tillage. The vibration level on the handles was measured and analysed and the frequency spectra for the chosen working conditions were obtained. The frequency-weighted acceleration, given in m/s2, was calculated and the obtained values are graphically presented. The measured vibration levels are then discussed with regard to the operator's daily exposure limits recommended by the ISO 5349. The vibration levels were much higher in the x and y directions than the z-direction in all working conditions. The vibration total values in idling, transportation and soil tillage were 3.37, 8.37 and 9.62 m/s2, respectively. Results showed that the 10% of workers are exposed to a risk of vibration-induced white finger disorder of the hands after relatively short periods (3-4 years), if the tractor is used 8 hour per day in soil tillage and transportation at full load. Considering the criteria of the ISO 5349, the daily working time with the single-axle tractor should be limited in order to protect the operator and work schedules should be arranged to include vibration-free periods.

Patients with Raynaud's phenomenon have abnormal digital vasoconstriction in response to cold. The pathogenesis remains unknown but may involve a local neurovascular defect leading to vasoconstriction. Diagnosis of primary Raynaud's phenomenon is based on typical symptomatology coupled with normal physical examination, normal laboratory studies and lack of observable pathology by nail fold capillaroscopy. Secondary Raynaud's phenomenon is known to occur associated with several connective tissue diseases, vascular injury due to repeated vibrational trauma, and other causes which produce demonstrable vascular and microcirculatory damage. Treatment of Raynaud's symptoms is conservative and aimed at prevention of attacks. Patients are advised to remain warm and, if possible, to live in warm climates. We suggest that an ergogenic (thermogenic) steroid, 7-oxo-DHEA (3-acetoxyandrost-5-ene-7,17-dione), which is available without prescription as the trademarked 7-keto DHEA, may be very helpful in prevention of primary Raynaud's attacks by increasing the basal metabolic rate and inhibiting vasospasm.

Sistemic sclerosis is a connective tissue disease characterized by excessive deposit of collagen in the skin and in different viscera such as the lung, the heart, the kidney, the gastrointestinal tract and muscoloskeletal system. Fibrosis is a natural and not reversible consequence of this extracellular matrix accumulation. Past management strategies have not been successful, usually. New physiopathologic knowledges establish the bases to obtain a more successful control of the disease evolution. Literature data underline the importance of a timely and personalized therapy based on kind, seriousness and stage of internal organs involvement to allow the patient to continue normal public relations, a good quality of life and the improvement of its global prognosis of this disease, often cause of disability and death. Actually, drug therapeutic management is based on combined use of vascular drugs: topical (Nitroglycerin patches), oral (Ace inhibitors and Calcium channel blockers) or, in severe cases, parenteral vasodilators (Prostaglandins and Prostacyclins), immunosuppressive therapies (Cyclophosphamide, Cyclosporin A, Methotrexate) and antifibrotic drugs (Penicil-lamine, Interferons).

We evaluated the effect of 12 months of 300-mg oral sarpogrelate hydrochloride (SH) once daily on the symptoms of Raynaud's phenomenon, respiratory failure and cardiac function in seven patients with systemic sclerosis. Arterial blood gases, pulmonary function, mean pulmonary arterial pressure, left ventricular ejection fraction (LVEF), right ventricular ejection fraction (RVEF), white blood cell count, C-reactive protein and the plasma concentrations of fibrinopeptide A, beta-thromboglobulin, platelet factor 4 and thrombomodulin were evaluated before and 2 and 12 months after SH administration. After 2 and 12 months of SH administration, a significant decrease was found in the frequency and duration of Raynaud's phenomenon, as well as the coldness, numbness and pain of Raynaud's phenomenon. Respiratory failure, as estimated by Hugh-Jones classification, was significantly decreased, whereas the percentage carbon monoxide diffusion capacity was significantly increased. The mean pulmonary arterial pressure decreased significantly, as did plasma fibrinopeptide A, beta-thromboglobulin and platelet factor 4. There was no significant change in LVEF after 2 or 12 months, but after 12 months of SH administration, RVEF increased significantly. In conclusion, use of SH may prevent Raynaud's phenomenon, respiratory failure and right ventricular failure in patients with systemic sclerosis.

This article reviews the health effects, treatment, prevention strategies, and international standards for hand-arm vibration syndrome (HAVS). It draws attention to the proposed International Standards Organization (ISO) 1998 revision requirement to base the assessment of vibration on the root-sum-of-squares for all directions rather than the dominant direction; the European Economic Commission (EEC) directives with their threshold, action, and ceiling levels; and the intent of the EEC, United Kingdom, and Japanese jurisdictions to propose action levels to prevent the incidence of vibration-induced Raynaud's phenomenon (VWF) from exceeding the background level in their countries. Proposals for the revision of the American Conference of Governmental Industrial Hygienists (ACGIH) Threshold Limit Values (TLVs) are presented.

Objective: In seven patients with systemic sclerosis (SS), we evaluated the clinical effectiveness of oral administration of saprogrelate hydrochloride (SH: 300 mg/day) for 2 months on Raynaud's phenomenon (RP) and respiratory failure estimated by Hugh-Jones classification., Methodology: We evaluated laboratory data (arterial blood gas (pH, PaO2 and PaCO2), pulmonary function tests (%VC, FEV1/FVC and %DL(CO)), mean pulmonary arterial pressure (mPAP), white blood cell count, C-reactive protein and the plasma levels of fibrinopeptide A (FPA), beta-thrombogloblin (beta-TG), platelet factor 4 (PF4) and thrombomodulin (TM)) before and after SH administration., Results: The frequency and duration of RP, as well as the coldness, numbness and pain of RP were significantly decreased after SH administration (P < 0.05, P < 0.01 and P < 0.001). Respiratory failure estimated by Hugh-Jones classification was also significantly decreased after SH administration (P < 0.05), and the %DL(CO) was significantly increased (P < 0.01). The mPAP decreased significantly after SH administration (P < 0.05). Plasma FPA, beta-TG and PF4 significantly decreased after administration (P < 0.05 and P < 0.01)., Conclusions: SH therapy could prevent RP and respiratory failure in patients with SS.

Advances in the management of metastatic testicular cancer are attributed mainly to the introduction of cisplatin into combination chemotherapy. In parallel with the development of effective chemotherapy resulting in long-term survival for the majority of patients, possible adverse effects of treatment have been systematically investigated. Besides acute side effects of cisplatin, such as gastro-intestinal toxic effects and moderate myelosuppression, reduction in glomerular filtration rate occurs in 20% to 30% of patients despite prophylactic intensive hydration and forced diuresis. Such changes in glomerular function are essentially irreversible. Persistent effects on tubular renal function occur less commonly, but hypomagnesemia due to hypermagnesiuria is often seen. Neurotoxicity, mainly sensory peripheral neuropathy, is common during treatment but disappears in the majority of patients after its completion. However, persistent paresthesias are found in 20% to 60% of patients. A typical audiometric abnormality affecting up to 50% of patients is bilateral loss of hearing at 4 to 8 kHz. A correlation between the cumulative cisplatin dose applied and the frequency of neuro- and nephrotoxicity has been demonstrated in some studies. The administration schedule additionally appears to influence the extent of toxicity, whereby single-day infusion schedules are associated with pronounced neural and renal toxicity, possibly due to higher peak plasma levels of cisplatin. Other long-term abnormalities after treatment with cisplatin-based combination regimens are a weak predisposition to secondary malignancies, infertility and chronic vascular toxicity. Several strategies have been developed to reduce such side effects. Ongoing trials are investigating the role of the aminothiol amifostine as a nephro- and neuroprotectant.

The magnitudes of the hand-transmitted vibration, 297 hand-held tools and workpieces were measured at workplaces. The tools were used mainly in construction and manufacturing industries. The current standard for the measurement of hand-transmitted vibration has been based on the frequency-weighted acceleration of dominant axis method. According to the proposal of ISO/CD5349-1, the results of measurements (462 points) were recalculated by the method of the frequency-weighted acceleration sum. There is 32% of difference in average value between the acceleration sum and the dominant axis method.

Temporary Threshold Shift (TTS) is often used as an indicator of the effect of hand-transmitted vibration on the human body. An experiment for the prediction of TTS in exposure to intermittent vibration was conducted in the present study to examine the exposure equivalent rule, as well as the equations for growth and recovery TTS. It was found that the prediction of TTS obtained here was in good agreement with measured TTS. This estimation procedure for predicting TTS was compared with the notification of the Labor Ministry in Japan, in which control of the operation time and the rest time for hand-vibrating tools was described. The results suggest that the rest time of five minutes for a continuous exposure time of 30 minutes with low-level of vibration tools should be extended to 10 minutes of rest time.

To clarify the trends in the number and the severity of vibration syndrome in Wakayama for these 23 years, the records of the medical examinations for vibration syndrome were analyzed with 4,652 (a total of 9,920) private forestry workers exposed to hand-arm vibration. The number of the subjects who took the medical examinations reached a maximum of 1,242 in 1978. After that, it decreased year by year, but remained at about 300 or less from 1988. There was a corresponding increase in age and the number of years of operating chain saws among the subjects examined. The compensated cases reached a maximum number of 393 cases in 1977, and then a drastic decrease was noted. Year by year there was an increase in the number of cases whose medical examinations revealed no abnormality. The regional occupational health care system including the surveillance card, which has been active since 1975, has probably contributed to the decrease or prevention of occurrence of vibration syndrome in Wakayama.

Medical examinations were carried out in a group of 297 men exposed to hand-arm vibration in the metallurgical industry. The group consisted of 93 rammers, 77 grinders and 127 chippers. The level of vibration at workposts was also measured. The average occupational exposures exposed in years and total hours were as follows: in the group of rammers - 14.5 yrs and 19,954 h; grinders - 15.2 yrs and 10,131 h; and chippers - 8.8 yrs and 5,444 h. The vibration-dose limit was exceeded by 5.0, 0.96 and 1.1 times, respectively. Raynaud's phenomenon was found significantly more frequent in chippers than in rammers or grinders. Medical examinations showed the highest health risk among chippers and the lowest among rammers. No correlation was found between intensity of mechanical vibration at the workplace and the biological response in groups examined. The results of the examinations provided evidence that different groups of workers require different preventive programmes.

Objectives: To study whether vibrotactile sense combined with questionnaires (subjective complaints) and a clinical examination (including scoring of the Stockholm workshop scale (sensorineural staging)) could serve as a screening procedure, in the health care service, for sensorineural symptoms. A group of blue collar workers exposed to vibration in a manufacturing industry (rock crushing plants) was used as the study group. Another group of workers not exposed to vibration but subjected to heavy manual work served as the control group., Methods: Vibrotactile sense was determined. The index and the little fingers of both hands were investigated. A clinical examination was performed. Questionnaires were used for exposure data and for assessment of symptoms., Results: Important findings were that impairment in vibrotactile sense correlated with impairment in grip force, cold sensitivity, and other sensorineural symptoms--such as numbness and tendency to drop items. Clinical findings such as Phalen's test and two point discrimination were related only in those workers with the poorest vibrotactile sense. There was a relation between vibrotactile sense and the Stockholm workshop scale (sensorineural staging) for the sensorineural symptoms. Muscle and joint problems were more often seen in workers with decreased vibrotactile sense., Conclusions: Tactilometry for assessment of vibrotactile sense is a useful tool in assessing and evaluating the severity of vibration induced neuromuscular symptoms and verifying the patients' clinical complaints. Heavy manual work without exposure to vibration may contribute to impairment of vibrotactile sense. The relation between impairment in vibrotactile sense and grip strength indicates that impaired sensory feedback may contribute to muscle weakness.

Successful orthotopic liver transplantation may reverse extrahepatic manifestations of the primary chronic liver disease. A well documented improvement of Raynaud's phenomenon, following successful liver transplantation realized for end-stage primary biliary cirrhosis, using repetitive angiological examination and capillary microscopy is presented.

Raynaud's phenomenon (RP) which is the episodic and reversible vascular spasm of the extremities can be elicited by cold or emotional changes. RP has been classified into two groups. One is primary Raynaud's phenomenon (PRP) with no identifiable underlying disease and/or cause, and the other is the secondary form of RP (Raynaud's syndrome) with underlying disease and/or cause, e.g., collagen disease, trauma, vibration from vibrating tools, etc. In the present study using this definition of RP the prevalences of RP were studied in general populations in a mountain village "T" and in a town "K" located in a plain area in Gifu prefecture, Japan. The prevalences of RP in T Village were 8.0% (25/314) in males and 3.5% (16/454) in females, and in K Town 2.7% (7/259) in males and 3.2% (21/657) in females. In 52% of the male cases in T Village it was estimated that the exposure to vibration from vibrating tools was the cause of RP. In K Town no male cases of RP were induced by vibration. Exposure to vibration may be one of the important factors when prevalences of RP are investigated in various areas. There were no significant differences between the two areas in the prevalences of PRP (T Village: male 2.9%, female 3.1%; K Town: male 2.7%, female 2.9%). The annual mean air temperature was usually 5-6 degrees C lower in T Village than that in K Town. From the results of this study the differences in the mean air temperature did not appear to have a significant influence on the prevalence of PRP in each area.

Increasing recognition by workers that blanching of their fingers may be due to hand-arm vibration exposure from the tools they use at work and their consequent claims for compensation emphasize a need for better clinical evaluation and prevention. We describe the symptoms and signs, and enumerate the diagnostic procedures (both screening and laboratory) necessary to establish the diagnosis and severity grading of subjects with hand-arm vibration syndrome. Although effective treatment of the condition other than avoidance of further vibration exposure is still being researched, prevention is all important. The necessary steps are identified.

Clinical studies of vibration disease cases among workers dealing hand-operated equipment: cut-hammers, pneumorammers, pneumopolishers,--revealed diversified physiological influences of different equipment on human organism. The vibrational analysis performed proved that the VD clinical peculiarities were partially due to the percussive impulses' characteristics.

A prevalence estimate for Raynaud phenomenon among adult residents of South Carolina was based on data obtained from respondents in a statewide health survey, followed by face-to-face interviews and clinical screening for Raynaud phenomenon, using a screening procedure developed by the authors. The survey obtained 5246 personal interviews from a probability sample of over 3000 households, and 494 survey subjects participated in the clinical screening. The prevalence estimates and their standard errors were computed using survey case weights, design-based estimation, and logistic modelling techniques. The prevalence of Raynaud phenomenon among adult residents of South Carolina was determined to be 3.5%, with a standard error of 0.6%. Prevalence was higher for females (4.3%, SE = 0.7%) than for males (2.7%, SE = 0.6%). These figures are much lower than most estimates in the existing literature on Raynaud phenomenon.

We previously reported that the working and health conditions of vibrating tool operators in an iron foundry were investigated in 1975 and vibration hazards were observed to occur frequently in workers operating chipping-hammers powered by compressed air. After that, we instituted medical treatment for the afflicted workers and improvement of working conditions in the foundry, and have performed annual medical examinations for four years. In this paper, the course of hygienic control and the change in the medical findings of twenty-four chipping-hammer operators are reported. 1. The following measures were taken to improve the working conditions of chipping-hammer operators and therapy for patients (Table 1): (1) The operating time of vibrating tools, including chipping-hammer, was limited to two hours per day. The casting process was improved to diminish the flashes that are the objects of chipping-hammer operation. For the purpose of reducing the vibration transmitted to the operator, a servo-arm that has a servomechanism for the chipping-hammer was developed and introduced. (2) Infrared lamps in the foundry and air curtains at the doorway were installed for keeping the chipping-hammer operating area warm. A warm room was set up in the foundry for providing warmth during rest periods and protective clothing against the cold was provided. (3) Workers who displayed health disturbances by medical examinations were treated during the cold season from November to April by periodic visits to the clinic or extended hospitalization, or transferred to job without vibration exposure, according to their stage of disease. Preventive treatment with vasodilator and bubble bath was performed in winter for the chipping-hammer operators. 2. In order to estimate the effect of these countermeasures, annual medical examinations were conducted in March 1975, March 1976, April 1977 and March 1978. Such subjective symptoms as Raynaud's phenomenon, finger numbness, finger listlessness, heavy-headedness, forgetfulness, irritability and hearing disorder showed a tendency for improvement, but other complaints did not (Tables 2-4). The improvement of Raynaud's phenomenon is considered to be due not merely to the countermeasures but also to reducing the chance of provocation and therefore the countermeasures should not be overestimated as a factor of recovery of vibration hazards. Of the functional tests, a tendency for improvement was recognized in sensory functions and peripheral circulatory functions, but not in motor functions (Tables 5, 6). However, the course of recovery was not fast and some advanced cases, especially those using chipping-hammers for more than ten years, showed less improvement after hospital treatment (Table 7, Fig. 1). This indicates the importance of hygienic control which enables vibration hazards patients to have early diagnosis and treatment. Furthermore, in order to eradicate the vibration hazards in the cast metal industry, a drastic reform of the finishing process is considered to be necessary.

In Japan daily motorcycle mail deliverers have been exposed to vibration from the handlebars of their motorcycles. Handlebar vibration was measured during the operation of a motorcycle in order to evaluate the hazardous effects of vibration and to identify preventive measures against the vibration hazards. Tests were made on asphalted, unpaved, and packed-snow road surfaces. The tested motorcycles were selected from the many motorcycles in daily use. The test motorcycle was a 1-cylindered, 89-cm3, 4-cycle machine. The direction showing the maximum value of vibration acceleration was not always in the directions of X, Y, and Z proposed by the International Organization for Standardization (ISO). The maximum vibration acceleration level exceeded the exposure guideline of ISO, while its frequency corresponded to that of the engine speed during operation. Vibration of greater than 20 Hz was transmitted through the front forks from the road surface and tires.

The Association Française de Normalisation (AFNOR) is preparing a standard on the exposure assessment of vibration from percussive tools. Therefore, a test code was developed for the measurement of vibration from percussive tools under laboratory conditions. The handle vibration from six different breakers, among which three tools were of "antivibration design," was measured with the following energy absorption methods: hydraulic base, steel shot, actual breaking of concrete, AFNOR concrete block, pointed chisel embedded in concrete. The last four methods were applied with breakers held by three successive operators. In addition, the first two were used with tools mounted in a rig which held them vertically and loaded them with a vertical downforce. The results indicated that the steel shot method was preferable although it gave 20% lower vibration results than those recorded for the actual breaking of concrete. It has the advantages of yielding consistent results with low scatter and being simple and cheap. Since difficulties have been experienced during the use of a pneumatic rig with breakers of antivibration design conception, the shot method should be applied with human operators.

The mode of vibration of hand-held tools cannot be considered without knowledge of the influence of the operator's hand-arm system. Therefore some technical applications of hand-arm models were realized for drill hammers by the University of Dortmund. These applications are a software program to simulate the motion of machine components, a horizontal drilling jig, and a chucking device in a drilling rig.

In an assessment of the accuracy with which impedance can be determined in the hand-arm system, two subjects were each tested six times at 28 frequencies between 10 and 800 Hz. In addition the effect of wearing an air cushion glove was investigated, and an attempt was made to develop a simple model of the glove. The results showed agreement with other recently published data for impedance in the hand-arm system at frequencies above about 25 Hz but not below. The mean values of the impedance for a single subject had standard errors of about 10%. When the subjects wore an air cushion glove, there was only a small change in impedance, and consequently in the total amount of energy dissipated in the hand-arm system. A simple mass-spring damper model of the glove predicted that the attenuation provided by the glove was minimal, except at the highest frequencies.

The hand-held roadbreaker plays a vital role in enabling the British gas distribution workforce to install gas supply pipework. Hence, any potential problem which could lead to a restriction of the use of this equipment would present pipework installation departments with serious operational problems. A test program was therefore set up to enable risks to operators to be quantified. The vibration levels measured exceeded proposed limits laid down in current guidelines for vibration exposure. If these limits were realistic, a high prevalence of vibration-induced white finger (VWF) would have been expected. However, a survey of the workforce using the roadbreakers indicated a VWF prevalence of 20 times less than that predicted by the guidelines. It was concluded that a possible explanation could be that the current frequency-weighting factors used in the guidelines are inappropriate for application to this type of equipment with dominant frequencies below 25 Hz. The application of the current weighting factors to the test data produced during the program led to high weighted acceleration values and unrealistic dose-response relationships. It is proposed that the application of the various guidelines to the use of this equipment be reconsidered.