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The authors would like to acknowledge the participation of 4 additional authors to this article. They contributed to the processing of the Japanese dataset used in the study. The corrected authorship, the corrected Acknowledgements and the corrected Contributors and Declaration of interests sections are presented below. H.M.C. and W.L. performed data analysis. W.L., D.R., A.U., A.E., A.M.V., A.Z., A.G., A.Z., A.T., B.A., B.F., C.Í., C.Å., C.F.S.N., E.I., E.L., F.M., F.A., F.S., H.O. H.K., J.K., J.M., J.S., J.J., K.K., M.H.D., M.S.R., M.H., M.P., N.R., N.S., S.O., S.T., X.S., Y.H., Y.K., YL.G., Y.G., and M.L.B. provided essential data resources. H.M.C. drafted the first version. H.M.C. and M.L.B. performed writing and editing the manuscript. H.M.C., W.L., A.U., A.G., A.T., B.A., E.L., F.S., S.T., and M.L.B. conducted reviewing. H.M.C. and D.R. have developed the figures. All authors have read and acknowledged the final manuscript., This publication was developed under Assistance Agreement No. RD83587101 awarded by the U.S. Environmental Protection Agency to Yale University. It has not been formally reviewed by EPA. The views expressed in this document are solely those of the authors and do not necessarily reflect those of the Agency. EPA does not endorse any products or commercial services mentioned in this publication. Research reported in this publication was also supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number R01MD012769. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Also, this work has been supported by the National Research Foundation of Korea (2021R1A6A3A03038675), Medical Research Council-UK (MR/V034162/1 and MR/R013349/1), Natural Environment Research Council UK (Grant ID: NE/R009384/1), Academy of Finland (Grant ID: 310372), European Union’s Horizon 2020 Project Exhaustion (Grant ID: 820655 and 874990), Czech Science Foundation (22-24920S), Emory University’s NIEHS-funded HERCULES Center (Grant ID: P30ES019776), and Grant CEX2018-000794-S funded by MCIN/AEI/10.13039/501100011033. The funders had no role in the design, data collection, analysis, interpretation of results, manuscript writing, or decision to publication.

Because of climate change, heavy precipitation is likely to become frequent and intense, thereby increasing the risk of shigellosis occurrence. However, few studies examined the impact of heavy precipitation on shigellosis and its impact modifiers in developed countries. This study aims to analyze the association between heavy precipitation and shigellosis in Taiwan, and to identify the vulnerable population and impact modifiers. We adopted a case-crossover design, and used conditional logistic regression to estimate odds ratios (ORs) for shigellosis occurrence. Information were collected on the daily shigellosis cases, precipitation, temperature, and typhoons from 1994 to 2015, and yearly data of medical resources and environmental factors were obtained at the city level from 1998 to 2015. Stratification analyses were performed by age, sex, medical resource, and environmental factors. We discovered that heavy precipitation ≥80 mm/day considerably increased the risk of shigellosis occurrence. The ORs of heavy rain (80 to200 mm/day) were 2.08-2.26 at lags 0-1. The ORs of extremely heavy rain (≥200 mm/day) increased to 2.17-4.73 at lags 5-8. Moreover, the effect of heavy precipitation was greater under high temperature condition (≥23.6 °C). Adults were more susceptible to heavy-precipitation-associated shigellosis, especially the elderly. Males experienced marginally higher effects than females did. Moreover, cities with more medical resources and forest cover and higher percentage of completed storm sewers had lower effects; however, dense population and higher pig density were the risk factors. Although the high water-supply penetration rate did not decrease Shigella infection after heavy precipitation, it did lower the risk of typhoon-related shigellosis. In conclusion, hot temperature could enhance the impact of heavy precipitation on shigellosis. Public health interventions should be introduced according to the lag period after heavy precipitation, particularly in areas with high population density, proportion of elderly people, and pig density. The improvement of medical resources and tree cover as well as the construction of storm sewers and piped water systems might be mitigation measures that can be considered.

Background Shiftwork and long work hours have been reported as significant risk factors for nurses’ burnout. In addition, whether nurses have ability to control their own schedule , such as having options and decision over swapping shifts or taking unpaid leave, remain lacking. Objective To examine the associations between nurses’ work schedule control (WSC) and their effect on burnout. Method A total of 3431 fulltime registered nurses working in the hospital were systematically sampled in 2013. A structured self-administered questionnaire was performed to assess nurses’ WSC, work schedule demands (WSDs) and their effect on burnout. The WSC was assessed by asking nurses’ experiences of requesting leave. Personal and client burnout status were measured using the Chinese version of the Copenhagen Burnout Inventory. Multivariable logistic regression was used to analyse the associations between nurses’ WSC and their effect on burnout. The WSDs, including shiftwork patterns and average weekly working hours, were controlled. Results A total of 2631 questionnaires were eligible for final analysis. Only 5% of participants experienced unrestricted leave. After adjusting for demographic data, both average weekly working hours and unrestricted leave were significantly associated with nurses’ personal and client burnout. Nurses exposed to rotating shift work were more likely to experience client burnout. Conclusion This study identified that work schedule control (WSC) was related to personal and client burnout among hospital nurses. Hospitals wishing to proactively reduce nurses’ burnout may permit more unrestricted leaves when requested by the staff nurse.

Objective To understand the psychosocial effects of needlestick injuries (NSIs) among nurses working in different healthcare settings. Method A total of 5535 fulltime registered nurses (RN) working among secondary referral hospitals (SRH) or primary clinics (PC) were recruited between 2009 and 2010. A structured self-administered questionnaire was used to assess nurses’ psychosocial working conditions and their experiences of NSIs. The psychosocial working conditions were assessed by the Chinese Job Content Questionnaire and a workplace justice scale. The NSIs were assessed by asking nurses’ experiences of NSIs in the past 12 months. Multivariable logistic regression was used to analyse the associations between psychosocial factors and NSIs. Results A total of 1032 and 1020 eligible questionnaires for SRH and PC nurses were included for final analysis. The incidence rate of NSIs was 15.2% for SRH nurses and 19.9% for PC nurses. Shift work (AOR: 1.8, 95% CI: 1.2, 3.0) and high psychological demands (AOR: 1.5, 95% CI: 1.0, 2.1) were identified as risk factors of the annual incidence of NSIs among SRH nurses, whilst the risk factors of the annual NSIs included low job control (AOR: 1.4, 95% CI: 1.0, 2.0) and low workplace justice (AOR: 1.6, 95% CI: 1.1, 2.4) among PC nurses. Conclusion This study identified that the psychosocial factors of nurses’ NSIs varied across different healthcare settings. Specific strategies for different healthcare settings to prevent nurses’ NSIs are warranted.

Background Long-term effects of work-related factors on risk of psychiatric disorders among professional drivers have not been conclusive. A follow-up study was conducted to evaluate the individual and combined effects of stress and fatigue on drivers’ risk of developing psychiatric disorders. Methods The Taiwan Bus Driver Cohort Study (TBDCS) recruited 1650 professional drivers from a large bus company in 2005. The subjects were interviewed in person and completed two scales of job stress- the Demand-Control-Support model (DC) and Effort-Reward Imbalance model (ERI), and one job fatigue model- Swedish Occupational Fatigue Inventory (SOFI). Psychiatric diseases were the outcomes of this study, including substance abuse, anxiety, mood, and sleep disorders. Cox proportional hazards model was used to estimate the hazard ratio (HR) for psychiatric disorders. Results Between 2006 and 2012, 108 bus drivers were diagnosed as having psychiatric disorders. Neither DC nor ERI score was associated with psychiatric disorders risk. Drivers with high SOFI (>3.5) had an elevated risk for psychiatric disorders, adjusting for age, BMI, marriage status, education, drinking, smoking, exercise, sleeping pills, bus driving experience and shift work (HR: 2.02, 95% CI: 1.37 to 2.99; p=0.025). Among psychiatric disorders, those having anxiety or mood disorders were related to high SOFI in 2005. Conclusion Among professional drivers, occupational fatigue as indicated by high SOFI might have predicted higher risk of psychiatric disorders, especially anxiety or mood disorders.

Although advancements in the treatment of atrial fibrillation have improved patient prognosis for this persistent condition, interest in atrial fibrillation development is growing. Of note is the fact that additional attention is being focused on the accompanying effect of insomnia. The aim of the study was to investigate the effects of insomnia on the risk of atrial fibrillation development.This was a nationwide population-based retrospective cohort study using data from the Taiwan National health Insurance Research Database. We analyzed 64,421 insomnia cases and 128,842 matched controls without insomnia from January 1, 2000, to December 31, 2010. A Cox regression model was used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CI) for atrial fibrillation development.During the follow-up period, the incidence of atrial fibrillation development was significantly higher in the insomnia cases than in the comparison cohort (2.6% vs. 2.3%, p0.001). Insomnia was associated with an increased risk of atrial fibrillation (HR = 1.08, 95% CI: 1.01-1.14). Males, those65 years of age, and patients with peripheral artery disease who have insomnia had a higher rate of atrial fibrillation development.The findings of this nationwide analysis support the hypothesis that insomnia is associated with a significant risk of atrial fibrillation development.

BackgroundLong-term effects of sleep-related factors on risk of psychiatric disorders among professional drivers have not been conclusive. A cohort study was used to evaluate the effectiveness of subjective and objective sleep assessment tools to assess for both the 7 year risk of psychiatric disorders events. Methods: Taiwan Bus Driver Cohort Study (TBDCS) recruited 1650 professional drivers from a large bus company in Taiwan in 2005. The subjects were interviewed in person, completed the sleep assessment questionnaires (Pittsburg sleeping quality score (PSQI), Epworth daytime sleepiness score (ESS), Snore Outcomes Survey score(SOS)), and had an overnight pulse oximeter survey. Psychiatric diseases as diagnosed in the National Health Research Database were the outcomes of this study, including substance abuse, anxiety, mood, and sleep disorders. Cox proportional hazards model was performed to estimate the hazard ratio for psychiatric disorders. Results: Between 2006 and 2012, 102 bus drivers were diagnosed as having psychiatric disorders. Psychiatric disorders were related to higher PSQI score, SOS score, ODI4 levels, and ODI3 levels. The relation between PSQI and psychiatric disorders remains robust after adjusting for age, education, drinking, smoking, refreshing drinks, exercise, bus driving experience, and shift modes. Conclusion: This study showed increased psychiatric disorders in the 7 year follow-up after self-reported poor sleeping quality. Further research is warranted to develop strategies for preventing sleep-related psychiatric disorders among professional drivers.

Objective The effect of perfluoroalkyl substances (PFASs) on the development of neurotoxicity in children is still controversial. This study aimed to evaluate the association between in utero exposure to four PFASs and the development of neurobehavioral symptoms related to attention deficit hyperactivity disorder (ADHD) in early childhood. Methods Eligible study subjects were selected from the Taiwan Birth Panel Study and the Taiwan Early-Life Cohort, which enrolled a total of 1526 mother-infant pairs during 2004 and 2005. We collected umbilical cord blood and analyzed perfluorooctanoic acid (PFOA), perfluorooctanyl sulfonate (PFOS), perfluorononanoic acid (PFNA), and perfluoroundecanoic acid (PFUA) levels. When a child was 7 years old, to evaluate ADHD related neurobehavioral symptoms, their parents completed the Swanson, Nolan, and Pelham IV scale (SNAP-IV), the Child Behavior Checklist (CBCL), and the Strengths and Difficulties Questionnaire (SDQ) questionnaires. We used linear regression models with inverse probability weighting to explore the association between prenatal exposure to four PFASs and ADHD rating scores. Results A total of 282 subjects have completed the PFASs analysis and questionnaire survey. After adjusted for potential confounders, we observed that PFNA is inversely associated with inattention and oppositional defiant disorder of SNAP-IV, and hyperactivity/inattention of SDQ. No association between PFOA, PFOS, or PFUA and ADHD symptoms was found. Conclusions Prenatal exposure to PFNA was found to associate with neurobehavioral symptoms related to ADHD among Asian seven-year-old children. Further studies are needed to elucidate the causal relationship.

Background/Purpose Occupational dermatitis among cement workers is a major occupational health concern. The two most important occupational hazards for cement workers are irritant and allergic cement contact dermatitis. The objective of this study was to investigate the severity of occupational cement contact dermatitis and the common allergens among cement workers in Taiwan. Methods A total of 97 cement workers from the Cement Workers’ Association of Tainan City and County participated in this study. A structured questionnaire was used to evaluate the demographic data and work-related activities of these cement workers. A complete skin examination was conducted, and skin manifestations were assessed by a dermatologist. Allergens from European Standard Tray (Chemotechnique Diagnostic AB, Sweden) with a total of 25 substances were used for patch testing. Results Our results showed that 65 out of 97 cement workers were suffering from occupational cement hand contact dermatitis. The most affected skin area was the hand. Thickening of the dorsal surface of the hand, especially around the metacarpophalangeal joint area, and hyperkeratosis of the palm were the major skin manifestations. The results of the patch test showed that 24 out of 97 were allergic to potassium dichromate, nine were allergic to thiuram mix, nine were allergic to fragrance mix and seven were allergic to cobalt chloride. The final diagnosis, based on the results of the skin examination and the patch test, showed that 43 of 97 cement workers had irritant cement contact dermatitis and 22 had allergic cement contact dermatitis. Conclusion We conclude that occupational cement hand dermatitis among cement workers is an important and severe issue in Taiwan, and the most common allergens among cement workers are potassium dichromate, thiuram mix, fragrance mix and cobalt chloride. The high positive rate of chromium hypersensitivity among cement workers reflects the urgency to regulate the addition of ferrous sulfate to cement in Taiwan.

Please cite this paper as: N-acetylcysteine inhibits chromium hypersensitivity in coadjuvant chromium-sensitized albino guinea pigs by suppressing the effects of reactive oxygen species. Experimental Dermatology 2010; 19: e191–e200. Abstract Background: Chromium hypersensitivity is an important issue in occupational skin disease. When hexavalent chromium enters the cell, it can be reduced to trivalent chromium, resulting in the formation of reactive oxygen species (ROS). ROS are considered to play an important role in the progression of allergic contact dermatitis. N-acetylcysteine (NAC) could increase glutathione levels in the skin and act as an antioxidant. Aims: We attempted to demonstrate that NAC could inhibit chromium hypersensitivity in a coadjuvant chromium-sensitized albino guinea pig model by counteracting the formation of ROS. Methods: We utilized a coadjuvant chromium-sensitized albino guinea pig model to evaluate both the severity of the skin reaction by intradermal and epicutaneous elicitation tests and the sensitization rate of chromium hypersensitivity in NAC-treated and NAC-untreated albino guinea pigs (GP). Furthermore, three ROS parameters, including H2O2, malondialdehyde (MDA) levels in the skin and the oxygen radical absorbance capacity (ORAC) in plasma, were analyzed in NAC-treated and NAC-untreated coadjuvant chromium-sensitized albino GP. Results: The severity of the skin reaction in the intradermal and epicutaneous elicitation test significantly diminished when the albino GP were treated with a dose of 1200 mg/kg/day of NAC. This dose also significantly decreased the sensitization rate of chromium hypersensitivity. In addition, treatment with 1200 mg/kg/day of NAC significantly reduced the H2O2 and MDA levels in the skin and significantly increased the ORAC in the plasma of albino GP. Therefore, NAC could be a potential chemopreventative agent to prevent the progression of chromium hypersensitivity.

BACKGROUND: Maternal hypothyroidism during pregnancy can cause adverse effects in the fetus. Scientific evidence has shown that probable thyroid-like function of some phthalates in vitro and in vivo, and phthalates exposure, can begin in utero. This study investigated the association between phthalate exposure and thyroid hormones in pregnant women. METHODS: Serum and spot urine samples were collected from 76 Taiwanese pregnant women at second trimester. Thyroid hormones, including thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4) and free T4 (FT4) were analysed in serum samples, and five urinary phthalate monoesters, including mono butyl phthalate (MBP), monoethyl phthalate (MEP) and mono ethylhexyl phthalate (MEHP), were measured. RESULTS: Urinary MBP, MEP and MEHP, the median levels of which were 81.8, 27.7 and 20.6 ng/ml, respectively, were the predominant substances in the urinary phthalate monoesters. Significant mild negative correlations were found between T4 and urinary MBP (R 52 0.248, P< 0.05), and between FT4 and urinary MBP (R 52 0.368, P< 0.05). After adjusting for age, BMI and gestation, urinary MBP levels showed negative associations with FT4 and T4 (FT4: b 52 0.110, P< 0.001; T4: b520.112, P 5 0.003). CONCLUSIONS: Exposure to di-n-butyl phthalate (DBP) may affect thyroid activity in pregnant women, but how DBP affects thyroid function is unclear. Further studies are needed to elucidate the mechanism of action and to investigate whether any other factors related to DBP exposure alter the thyroid function.

Background:This study investigated the prevalence, incidence, and hospitalization for chronic airway obstruction (CAO) in a population cohort. Methods:Medical reimbursement claims from 1996 to 2002 based on a 1996 insured cohort of 167,372 persons from National Health Insurance, Taiwan, were used. We presented the chronological trends of CAO (International Classification of Diseases, Ninth Revision code 496) and the relationships between the CAO severity and age, sex, urbanization, and hospitalization and comorbidity for the population ≥ 40 years old. Results:The overall average annual prevalence and incidence rates were 2.48/100 and 0.66/100, respectively, for the population, among 4,568 patients with CAO cared during the study period. For the population aged ≥ 70 years, the prevalence rates had a peak of 8.83/100 in 1998 and afterward remained a plateau until 2002. The corresponding incidence decreased from 2.48/100 to 1.62/100, and the hospitalization rate for them had a peak of 2.22/100 in 1999. The multivariate logistic regression analysis showed that the risk of hospitalization for CAO was higher for patients with the comorbidity of renal failure, coronary artery disease, and pneumonia and influenza, but lower with skin and joint disorders. Conclusions:The national insurance program promotes patient care and provides a proper pathway for surveillance and identification of CAO.

UNLABELLED The objective of the present study was to develop a simple clinical model for predicting pulmonary embolism (PE) in patients with acute dyspnea in the emergency room. PATIENTS AND MEASUREMENTS We enrolled 56 patients diagnosed with PE, and 92 consecutive patients without PE, all of whom presented with acute dyspnea in the emergency room. Primary emergency-room physicians assessed the initial evaluation and interpretation of various laboratory findings. Some significantly independent predictors of PE were identified and integrated into a clinical model of pretest probability: low ( or= 30%, 70%). After setting up the model, another 40 patients (16 with PE, 24 without PE) were tested using the pretest model. Clinical variables associated with an increased likelihood of PE were being female and having unilateral low-leg edema, a high alveolar-arterial oxygen gradient, a clear chest x-ray, and electrocardiographic findings of right ventricular strain. Variables associated with a decreased likelihood of PE were cough, chest tightness, and unclear breath sounds. Our clinical model predicted that 95% of patients with PE had a high or low probability of PE. The positive predictive value for high probability was 94.1% and the negative predictive value for low probability was 94.4%. In the tested group, the positive predictive value for high probability was 92.9%. The negative predictive value for low probability was 91.3%. This simple and easily available prediction model was useful for estimating the pretest probability of PE in patients with acute dyspnea.

Background: Over 2000 Taiwanese ingested cooking rice oil contaminated with polychlorinated biphenyls (PCBs) and polychlorinated dibenzofurans (PCDFs) in 1979. A Yucheng (‘oil-disease’ in Chinese) ...

Objectives: In 1979, approximately 2,000 people who were exposed to polychlorinated biphenyls (PCBs) and dibenzofurans (PCDFs) due to ingestion of contaminated rice oil in central Taiwan, and were ...

In this study, both personal sampling and biological monitoring were conducted on 27 and 30 workers selected from decorative plating and hard-surface plating operation, respectively. For personal sampling, the inhalable aerosol sampling technique was adopted in order to measure worker’s soluble Cr+6 exposure level (CINH) on the last day of the workweek. For biological monitoring, a urine specimen was collected at the end of the shift on the last day of the work week in order to determine a worker’s urinary chromium concentration (CURINE). Results show that hard-surface plating workers had higher CINH (arithmetic mean ≈ 25.2 μg/m3) than decorative plating workers (arithmetic mean ≈ 1.91 μg/m3). The above results could be due to the longer plating time involved in the former plating operation than in the latter. The relationship between CINH and CURINE was found as CURINE=1.86 CINH-0.21(R2=0.87, n=57), which suggests that the inhalable aerosol sampling results were able to explain the variation in workers’ urinary chromium concentrations up to 87%. Assuming the level of CINH was equivalent to the current TLV-TWA of 50 μg/m3, the above regression model yielded a level of CURINE as approximately 93 μg/g·creatinine. The above value is clearly different from the current present biological exposure index BEI of 30 μg/g·creatinine which is known to be applicable only to welding workers. The above discrepancy could be due to the intrinsic difference in particle size distribution between the Cr+6 droplets generated during the plating process and Cr+6 fumes generated during the welding process. Considering that no BEI has been suggested for chromium plating industries, the result obtained in this study will be helpful in introducing a new BEI in the future.

Objectives: The prevalence of job stress, distributions of major job stressors, and the associations of job stress with multiple self-reported health complaints were examined in a national survey conducted in 1994 in Taiwan. Methods: A total of 9,746 men and 5,599 women who were employed at the time of the survey and aged between 25 and 65-years were studied. Information on employment status, perceived level of job stress, major job stressors, and health complaints were obtained by a self-administered questionnaire. Results: Overall, 7.6% of men and 6.5% of women reported often or always feeling very stressed at work. Higher levels of perceived job stress were found among subjects who were younger, with higher education level, working in a larger firm, working for longer hours per week, and who were administrators or managers. Problems with individual job content were ranked as the most important job stressor in men across all employment categories and in most women. Other major job stressors included problems with monetary rewards and lack of career prospects. The patterns of major job stressors appear to vary by employment grade and by gender. After adjustment for age and education, employees who perceived higher levels of job stress had significantly increased risks of multiple health problems, including strained eyes, ringing ears, chronic cough with phlegm, chest tightness, stomach problems, headache, and musculoskeletal discomfort. Conclusions: These results suggest that psychosocial stress in the workplace has profound impacts on health. This study identified high-risk groups and major types of job stressors for further investigation.

Prevalence of Self-Reported Work-Related Skin Conditions in Taiwanese Working Population: Yu-Hsuan SHAO, et al. Environmental and Occupational Health, National Cheng Kung University—Work-related skin conditions are among the most prevalent occupational diseases, but population-based studies of occupational skin diseases are few. This study was conducted by a nationwide representative sampling of employed workers in Taiwan to estimate the prevalence of work-related skin conditions. A total of 18942 non-self-employed workers participated in this survey. Data were collected by selfadministered questionnaires. Those workers who reported having upper extremity skin conditions and considered their skin conditions caused by work exposure were defined as having work-related skin conditions. More than a half of the skin conditions were considered work-related. Overall, 4.4% of male employees and 4.2% of female employees reported having work-related skin conditions in the past year. Work-related skin conditions were more prevalent among male workers than female workers (adjusted OR=0.8, p

An Integrated Approach to Initiate Preventive Strategies for Workers Exposed to Teflon Pyrolytic Gases in a Plastic Industry: PerngJy TsAl, et al. Department of Environmental and Occupational Health, Medical College, National Chen Kun UniversitThis study illustrates an integrated approach for industries to find possible hazardous factors, to identify the causes of an accident, and eventually to start preventive measures after a fatal accident occurred in a Teflon heating process. A team consisting of experts from several disciplinary areas was formed for the purpose. Through literature review and the examination of clinical reports, possible hazardous factors were proposed, and then examined and confirmed through a field study. The technique of fault tree analysis (FTA) was adopted to investigate the causes of the accident logistically. Investigation of the causes of the accident was not limited to those which were directly relevant to it, but all potential causes were included. A preventive strategy was proposed with prioritized measures which were determined based on their importance from the practical standpoint. This study demonstrates the benefits of integrating expertise from a number of disciplines for accident investigation, especially for those accidents in which the scenario cannot be reconstructed.

Background.The occurrence of occupational illness and injury has been seriously underestimated in Taiwan, which subsequently contributes to difficulties in performing effective control of occupational hazards and implementing intervention programs for protecting workers. Methods.Based on the successful experience of the nationwide blood lead level surveillance program, the Department of Health, the Executive Yuan, Taiwan, Republic of China, has established a work-related diseases surveillance system. This government-administered system requests practicing physicians to report the suspected cases suffering from six categories of work-related disorders. Results.An occupational illness and injury surveillance program in Taiwan has been in operation since June of 1995. Conclusion.Background information of work-related diseases obtained from this surveillance system will be useful for providing better management of available resources for occupational medicine, for preventing hazards, and for enforcing occupational diseases prevention programs. Our experience in establishing this surveillance system will be used in other countries and settings.

The purpose of this study was to investigate environmental lead exposure in the general Taiwanese population. A total of 8828 Taiwanese adults selected by a multistage sampling method were investigated. Characteristics of the participants were ascertained by questionnaire and 10 ml venous blood was drawn by public health nurses. The blood specimens were distributed to six laboratories for blood lead level (BLL) measurement. A quality control program was applied during the analysis of the BLLs in order to improve precision and accuracy. The arithmetic mean BLL of the 8828 Taiwanese adults was 7.70 +/- 5.23 micrograms/dl, with a maximal level of 69.1 micrograms/dl. The median was 6.5 micrograms/dl and the 90th percentile was 14.0 micrograms/dl. After logarithmic transformation, the geometric mean was 1.84 +/- 0.67 microgram/dl. This study also found that elevated BLLs were associated with certain personal characteristics, i.e., gender, ethnic group, and education level; life-style factors, such as smoking, alcohol consumption, Chinese herbal drug consumption, milk consumption, and sources of drinking water; residential location, i.e., level of urbanization; and occupational history of lead exposure. However, age, floor level of residence, distance from house to road, and betel nut consumption were not associated with elevated BLLs. These results showed that BLLs in the Taiwanese population were not higher than those in developed and developing countries. Most of the influencing factors were also found in other studies; however, local factors such as ethnic group, Chinese herbal drug consumption, and sources of drinking water are important considerations in Taiwan when examining ways to prevent overexposure to lead in the general population.

Phosgene, a toxic gas widely used as an industrial chemical intermediate, is known to cause life-threatening latent noncardiogenic pulmonary edema. Mechanisms related to its toxicity appear to involve lipoxygenase mediators of arachidonic acid (AA) and can be inhibited by pretreatment with drugs that increase adenosine 3′,5′-cyclic monophosphate (cAMP). In the present study, we used the isolated buffer-perfused rabbit lung model to investigate the mechanisms by which cAMP protects against phosgene-induced lung injury. Posttreatment with dibutyryl cAMP (DBcAMP) was given 60-85 min after exposure by an intravascular or intratracheal route. Lung weight gain (LWG) was measured continuously. AA metabolites leukotriene (LT) C4, LTD4, and LTE4 and 6-ketoprostaglandin F1 alpha were measured in the perfusate at 70, 90, 110, 130, and 150 min after exposure. Tissue malondialdehyde and reduced and oxidized glutathione were analyzed 150 min postexposure. Compared with measurements in the lungs of rabbits exposed to phosgene alone, posttreatment with DBcAMP significantly reduced LWG, pulmonary arterial pressure, and inhibited the release of LTC4, LTD4, and LTE4. Intratracheal administration of DBcAMP was more effective than intravascular administration in reducing LWG. Posttreatment also decreased MDA and protected against glutathione oxidation observed with phosgene exposure. We conclude that phosgene causes marked glutathione oxidation, lipid peroxidation, release of AA mediators, and increases LWG. Posttreatment with DBcAMP attenuates these effects, not only by previously described inhibition of pulmonary endothelial or epithelial cell contraction but also by inhibition of AA-mediator production and a novel antioxidant effect.

Purpose To compare the accuracy of ultrasonography and magnetic resonance imaging (MRI) in diagnosing carpal tunnel syndrome (CTS) in both the rest and grasp positions. We postulated that the diagnostic accuracy could be improved by imaging hands in the grasp position rather than in the rest position. Methods Fifty patients with CTS and 45 healthy volunteers received a package of questionnaires and had a physical examination and a nerve conduction study. Ultrasonography and MRI images were recorded in both the rest and grasp positions for each participant. Results There were significant differences between the patients and the healthy volunteers regarding patient-reported outcomes, the results of physical examinations, the nerve conduction studies, and the ultrasonography and MRI imaging. The area under the receiver operating characteristic curve of ultrasonography was significantly improved by measuring the bowing of the flexor retinaculum in the grasp position than by measuring that in the rest position. The diagnostic accuracy of ultrasonography was similar to that of MRI when we used a combination of the measurements of the cross-sectional area of the median nerve in the rest position and the bowing of the flexor retinaculum in the grasp position. Conclusions The accuracies of MRI and ultrasonography for diagnosing CTS were improved by measuring the bowing of the flexor retinaculum in the grasp position. Ultrasonography can be an adequate screening method for CTS if clinicians combine the cross-sectional area of the median nerve in the rest position and the bowing of the flexor retinaculum in the grasp position. Type of study/level of evidence Diagnostic I.

Introduction Hand impairment is a common and serious occupational injury among workers because it can affect the outcome to return to work (RTW) and even cause permanent dysfunction. The hand measures can directly describe the primary hand function and limitation. This study investigated the correlation of RTW and the overall hand impairment measures in the workers with traumatic hand injury. Methods Ninety-six subjects with occupational hand injury were recruited in this study to answer the RTW questionnaire and received the hand evaluation and motion analysis for their affected hands. RTW outcomes assessed whether the subjects successfully returned to work, either from a job change or salary reduction, and the length of the time it took for them to return to work (TRTW). The hand impairment measures included the hand impairment ratio, total active motion loss, motion area loss, grasp power loss, lateral-pinch power loss, and palmar-pinch power loss. Results A stepwise regression indicated that grasp power loss was a significant predictor for the length of TRTW. The motion area loss was firstly adopted to show statistically significance with RTW outcomes. Besides, the hand impairment ratio was also found to have mild positive correlation with TRTW significantly. Conclusions This study presented the subtle correlation of RTW outcomes and hand impairment measures. Both the strength loss and the motion area loss of the hand showed the significant correlation with RTW outcomes. The findings can point to some practical focuses in occupational rehabilitation for the workers with hand trauma.

In certain cell types, it has been found that, hexavalent chromium could increase ROS formation, activate cell signaling and stimulate the release of cytokines. But, in keratinocytes, these effects have not yet fully been demonstrated. Our aim is to observe the above effects of hexavalent chromium on keratinocytes. By utilizing HaCaT cells and the skin of albino guinea pigs, we showed that hexavalent chromium could increase ROS formation, activate the Akt, NF-kB, and MAPK pathways as well as increase the production of cytokines, including TNF-alpha and IL-1alpha. The release of these cytokines from keratinocytes is considered to be a key participant in the pathogenesis of contact hypersensitivity. Among cement workers, chromium hypersensitivity is an important occupational skin disease issue. Therefore, the observations of our study help us better understand the role of hexavalent chromium on the development of chromium hypersensitivity, which might provide clues for clinicians in the development of chemopreventative agents for the prevention of chromium hypersensitivity among cement workers.

To examine the relationship between initial anatomic severity evaluated by the Hand Injury Severity Scoring (HISS) system and recovered hand function evaluated by the Purdue Pegboard after occupational hand injury.In the retrospective cohort study, 95 patients hospitalized between 1 January 2000 and 31 December 2003 for surgery due to occupational hand injury were recruited. The HISS scores were obtained by chart review by a surgeon. The Purdue Pegboard was performed at least 6 months after the injury by well-trained occupational therapists. The Purdue Pegboard scores were compared with the initial HISS scores by simple regression, multiple regression and logistic regression analysis.The total HISS score was negatively correlated with scores of the Purdue Pegboard subtests, including injured-hand, both-hands, and assembly. The risk of having low injured-hand score (13) was significantly increased in workers with initial major severity (HISSor= 101), with OR 9.57 (95% CI 1.4-94.8). The risk of having low both-hands score (10) was significantly increased in workers with initial severe and major severity (HISS of 51-100 andor=101), with OR 4.5 (95% CI 1.1-21.8) and OR 25 (95% CI 3.5-263). The risk of having low assembly score (25) was significantly increased in workers with initial major severity (HISSor= 101), with OR 9.0 (95% CI 1.3-72.5).The study showed that after occupational hand injury, initial anatomic severity evaluated by the HISS system could predict hand function after recovery.

This study investigated the prevalence, incidence, and hospitalization for chronic airway obstruction (CAO) in a population cohort.Medical reimbursement claims from 1996 to 2002 based on a 1996 insured cohort of 167,372 persons from National Health Insurance, Taiwan, were used. We presented the chronological trends of CAO (International Classification of Diseases, Ninth Revision code 496) and the relationships between the CAO severity and age, sex, urbanization, and hospitalization and comorbidity for the population/= 40 years old.The overall average annual prevalence and incidence rates were 2.48/100 and 0.66/100, respectively, for the population, among 4,568 patients with CAO cared during the study period. For the population aged/= 70 years, the prevalence rates had a peak of 8.83/100 in 1998 and afterward remained a plateau until 2002. The corresponding incidence decreased from 2.48/100 to 1.62/100, and the hospitalization rate for them had a peak of 2.22/100 in 1999. The multivariate logistic regression analysis showed that the risk of hospitalization for CAO was higher for patients with the comorbidity of renal failure, coronary artery disease, and pneumonia and influenza, but lower with skin and joint disorders.The national insurance program promotes patient care and provides a proper pathway for surveillance and identification of CAO.

The objective of the present study was to develop a simple clinical model for predicting pulmonary embolism (PE) in patients with acute dyspnea in the emergency room.We enrolled 56 patients diagnosed with PE, and 92 consecutive patients without PE, all of whom presented with acute dyspnea in the emergency room. Primary emergency-room physicians assessed the initial evaluation and interpretation of various laboratory findings. Some significantly independent predictors of PE were identified and integrated into a clinical model of pretest probability: low (30%), intermediate (or= 30%,or= 70%), and high (70%). After setting up the model, another 40 patients (16 with PE, 24 without PE) were tested using the pretest model. Clinical variables associated with an increased likelihood of PE were being female and having unilateral low-leg edema, a high alveolar-arterial oxygen gradient, a clear chest x-ray, and electrocardiographic findings of right ventricular strain. Variables associated with a decreased likelihood of PE were cough, chest tightness, and unclear breath sounds. Our clinical model predicted that 95% of patients with PE had a high or low probability of PE. The positive predictive value for high probability was 94.1% and the negative predictive value for low probability was 94.4%. In the tested group, the positive predictive value for high probability was 92.9%. The negative predictive value for low probability was 91.3%. This simple and easily available prediction model was useful for estimating the pretest probability of PE in patients with acute dyspnea.

Objectives Early stress markers are useful in detecting workers with occupational stress. The aim of this study was to determine whether heart rate variability was associated with physicians’ duty loading, and also a good predictor for stress markers. Method An observational study on physicians with variable duty loading was conducted in a secondary referral medical centre in northern Taiwan in 2012. For every participant, 24-hr electrocardiography (EKG) and hourly blood pressure were obtained during three test days, i.e., regular-duty (only day shift), moderate-duty (day and night-shift with moderate number of patients cared), and high-duty days (day and night-shift with higher number of patients cared). Blood samples for stress markers were obtained at 8 am on the test day, and 8 am on the second morning. Results A total of 12 staff physicians satisfactorily completed the study. The number of patients covered at night shift was 0, 92 ± 8, and 187 ± 9, for regular-, moderate-, and high-duty nights, respectively. Total phone calls, urgent procedures, new patients admitted, critical patients cared and times of awakenings were significantly higher as the duty loads increased. The parasympathetic indicator derived from continuous EKG, high frequency normalised unit (HFnu), was negatively related to loading of total patient cared (P Conclusions HFnu derived from heart rate variability measurement may predict several important stress markers during nightshift duties.

We have been following up the biological and mental development of children exposed prenatally to polychlorinated biphenyls and their contaminants(Yucheng children). When we started this 12-year follow-up study in August 1985, 118 Yucheng children we assigned a non-exposed child matched by sex, age, locality of residence, mother's age, socio-economic status of the family. This article reports the cognitive aspect of the development of Yucheng children as compared to their matched controls. A consistent tendency which indicates that Yucheng children score lower in each kind of measurement tool at each age level has been observed. This seems to imply that congenitally exposure to PCBs and their contaminants has long-term adverse effects on the cognitive development of human being.

The purpose of this study was to investigate the environmental lead exposure of the general population in Taiwan. A total of 2919 residents of Taiwan were selected by multistage sampling methods. The participants were characterized by questionnaires and 10 ml venous blood was collected for blood lead measurement. A quality assurance/quality control program was designed during the analysis of blood lead levels. The mean blood lead level of 2719 residents without occupational lead exposure was 8.29 +/- 5.92 micrograms/dl. After adjustment for age and sex distribution to the Taiwan general population, the mean blood lead level was 8.10 micrograms/dl. Adjusted for an 11% underestimation of blood lead levels among the six laboratories, the mean blood lead level was estimated to be 8.99 micrograms/dl. This study also found that blood lead levels were associated with personal characteristics, i.e., gender, ethnic group, education level; lifestyle factors, i.e., smoking, alcohol consumption, sources of drinking water; and residential location, i.e., levels of urbanization, distance of house from the road. However, age, floor of residence, milk consumption, betel nut consumption, and Chinese herbal drug consumption were not found to be associated with blood lead levels. These results show that blood lead levels in Taiwan residents were not higher than in most developed and developing countries. Environmental lead pollution does not seem to be a serious problem in Taiwan.

ISEE 22nd Annual Conference, Seoul, Korea, 28 August-1 September 2010: Heavy Metals and Metalloids

Objective. —To compare the cognitive development in Taiwanese children who had been exposed prenatally to high levels of heat-degraded polychlorinated biphenyls (PCBs) with control children who were exposed to background levels. The disorder was called Yu-Cheng, "oil disease," in Taiwan. Design. —Matched-pair cohort study. Setting. —Communities in central Taiwan in which there had been a cooking-oil contamination and mass poisoning by heat-degraded PCBs in 1978 through 1979. Participants. —One hundred eighteen children born between June 1978 and March 1985 during or after their mothers' consumption of contaminated rice oil; 118 children matched for age, sex, neighborhood, maternal age, and parental education and occupational class; and 15 older siblings of exposed children, born before the poisoning. Main Outcome Measures. —Cognitive development measured from 1985 through 1990 using the Chinese versions of the Stanford-Binet test and the Wechsler Intelligence Scale for Children, Revised. Results. —The exposed children scored approximately 5 points lower on the Stanford-Binet test at the ages of 4 and 5 years and approximately 5 points lower on the Wechsler Intelligence Scale for Children, Revised, at the ages of 6 and 7 years. Children born up to 6 years after their mothers' exposure were as affected as children born within a year or two after exposure when examined at 6 and 7 years of age. Older siblings resembled the control children. Conclusion. —Children prenatally exposed to heat-degraded PCBs had poorer cognitive development than their matched controls. The effect persisted in the children up to the age of 7 years, and children born long after the exposure were still affected. ( JAMA . 1992;268:3213-3218)