When the risk of a particular disease outcome is known to be increased in a particular industry, a strategy to determine the group experience with that outcome is called surveillance. When a particular outcome is not the focus of attention and the overall health experience of the individual or group is to be observed, the strategy is termed monitoring.
Monitoring may be applied to individual workers, as in the case of voluntary periodic health evaluations, or to groups, as in special research studies to determine the health risks of certain workplace exposures or certain jobs. The principal challenges facing physicians in individual voluntary monitoring programs are maintaining a high level of attention while examining many individuals, most of whom are healthy. Such programs are often performed by physicians in private practice who are the workers' family physician. When the experience of a group of workers is followed over time, however, patterns of illness may appear which suggest either unusual characteristics of that working population or exposures requiring control.
An increasing number of employers in high-risk industries provide surveillance programs at company expense. Monitoring programs, however, are usually limited to key employees or executives as a means of protecting the employee and the company from unexpected losses due to illness. As such, they are primarily intended for individual health care and not for population monitoring, and seldom cover high-risk groups unless they are arranged as part of a research study.
Surveillance is applied when the diseases in question are associated with a particular industry, such as the asbestos-associated lung disorders which will be used as an example in this chapter. Monitoring lends itself more readily to an effort to discover previously unrecognized health problems in an individual to control absenteeism from nonoccupational illnesses or to identify previously unsuspected health effects. In general, monitoring programs are more extensive and more costly to establish than surveillance programs. Surveillance is usually restricted to certain high-risk groups and is required by law to be provided at the employer's expense to workers exposed to specific hazards covered by OSHA or other regulations, such as asbestos, noise or lead.
The design of monitoring and surveillance programs is advancing rapidly. Surveillance is a strategy to determine a group experience with a particular disease outcome, while monitoring focuses on the overall health experience of the individual or group. Screening tests for early detection of abnormalities related to exposure are selected on the basis of sensitivity, specificity and the prevalence of the abnormality in a complicated relationship. Physicians involved in these programs must understand their rationale and legal framework to make sense of the results. Because the field of study is advancing so rapidly, certain terms have not yet become standardized. In reading other sources, one should determine exactly how an author is using such words as monitoring, surveillance and screening.
The selection of a screening test is based on three variables: the sensitivity and specificity of the test and the prevalence of the disease in the community. These terms describe essential concepts that apply to the use of tests in detecting any disease.
Sensitivity refers to the proportion of diseases persons in the population who are identified by the test. The higher the sensitivity of the test, the more effectively it will identify the diseased individuals.
The specificity of a test refers to the proportion of nondiseased individuals in the population who will have a negative result. The higher the specificity of a test, the more reliably it will exclude nondiseased individuals. The ideal is a combination of high sensitivity and high specificity. Most tests in clinical use fall well short of the ideal.
A test with low sensitivity but high specificity will detect only a small fraction of diseased individuals, but a positive result will be a more reliable indication that disease is present in an individual. However, a negative test result will not reliably rule out the disease. A test with high sensitivity and low specificity will correctly identify most true cases but will also yield positive results for many individuals who do not, in fact, have the disease. In other words, an insensitive but specific test may yield many flase-negative results, whereas a sensitive but nonspecific test may give many false-positives. If a disease is rare in the population, the false-positive results of a sensitive but nonspecific test may outnumber the true positives, requiring additional diagnostic tests to confirm the result. The diagnostic efficiency of a test is called its predictive value. Chapter 23 presents an example of the calculation of the predictive value of a test using these three factors to evaluate the efficacy of a drug screening program.
Studying the specificity and sensitivity of diagnostic tests, and calculating their diagnostic yield in a population with a given prevalence of a disease, constitute one aspect of clinical epidemiology. When physicians order diagnostic tests for their patients, they are applying the same concepts but the diagnostic yield is higher because the predictive value of the test is much higher. The tests are used in a small population of persons who have a high prevalence of the disease because they were selected for testing because they have suggestive symptoms. When tests are used for surveillance or monitoring, however, the predictive value is low because most of those tested are normal.
For reasons of cost and reliability, occupational health surveillance programs tend to be simple, to utilize a few well-established tests and to be rigid in their requirements. For example, the surveillance program mandated by the Occupational Safety and Health Administration (OSHA) for workers exposed to high noise levels relies on an annual audiogram covering prescribes frequencies and performed by certified personnel with specified training, using well-known equipment with prescribed specifications.
Strategies for periodic health evaluation are under intense scrutiny within medicine, reflecting a sketical reevalution of their scientific basis and cost-effectiveness. The application of various periodic health evaluation strategies such as "annual physicals", multiphasic screening, lifetime health monitoring programs, is controversial but dictated in practice by long tradition. Medical practice has been slow to change in response to new data and informed opinion regarding optimal screening schedules.
Most large and many small companies provide periodic evaluations for their key managers and their executives. Employers are concerned about the fitness of key personnel whose death or incapacity would deprive them of special skills of knowledge and would result in disruption of activities during the preparation of a replacement. These evaluations are usually in the form of an "annual physical," a screening strategy considered obsolete by most authorities but sanctioned by years of tradition in industry.
Many employers send their employees for screening in groups during the off-season in business. Others conduct screening programs throughout the year and have employees screened on the anniversary of their employment or reassignment. The annual physical examination has been a traditional function of occupational medicine practice and is deeply entrenched among the services customarily provided. The annual physical examination enjoys the force of law in certain Occupational Safety and Health Administration standards, the acceptance of industry, and the tradition of an executive perquisite in the form of the "executive physical." A consensus is emerging, however, that more individualized periodic evaluations are likely to yield more useful health information and are more likely to result in effective interventions. It appears likely that a trend will develop toward the substitution of the annual physical examination with another form of periodic health evaluation for the asymptomatic patient, as recommended by the American College of Physicians.
Alternatives to the annual physical examination include multiphasic health screening (the performance of a battery of standard tests at periodic intervals) and a lifetime health monitoring program (LHMP). Multiphasic health screening is often provided for nonexecutive personnel but its effectiveness is limited because in practice it is seldom integrated into the patient's personal health care by the family physician reviewing the information.
The most sophisticated strategy is the lifetime health monitoring program (LHMP) developed by Breslow and Somers. The LHMP has not been offered on a large scale in industry. This form of health monitoring involves certain tests, examinations and health education interventions on a variable schedule according to the patient's age and known risk factors. The LHMP offers a medically sound approach to periodic health evaluation that is unlikely to miss preventable diseases or conditions identifiable by the screening elements selected. Properly performed, the LHMP absolutely requires personal health and risk factor information with absolute guarantees of confidentiality. A personal health problem uncovered in a periodic evaluation must be communicated in confidence to the worker and where appropriate, the occupational physician should be prepared to advise the worker as a patient apart from the occupational context and to suggest follow-up by the worker's own physician or referral.
The strategy is designed to create opportunities to provide educational and preventive services, to encourage extension of the LHMP into retirement years, and to articulate with a suitable health promotion program implemented at a younger age. This program is therefore intended to be a segment of a true lifetime program rather than a self-limited periodic health evaluation program covering only the working years. For optimal effect the LHMP should be combined with a program of health promotion designed to enhance fitness and to encourage self-help measures.
All periodic health evaluation formats are to some degree arbitrary in derivation and subjective in formulation, based as they are on interpretations of data from many sources. The LHMP presented in Figure 19.1 represents a step toward the goal of basing the periodic health evaluation on a more rational basis with attention to the cost-effectiveness of its elements, the biology of the diseases and conditions to be ruled out, and the characteristics of the population to be evaluated.
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* Figure 19.1 NOT READY YET *
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Figure 19.1. One suggested format for
the lifetime health
monitoring program as
applied to adults in
low-risk managerial
positions.
In constructing a LHMP for a specific population, the known risk profile of the individual should be used to modify screening recommendations adopted for the general population. Table 19.1. presents factors that should be taken into account in modifying the LHMP to individual needs.
Continuity of the program may be interruped when the worker changes employment. It would be to the advantage of the second employer to continue the LHMP on schedule rather than reverting to the traditional annual physical. Implementation of the LHMP in conjunction with an employer-sponsored or -supported health promotion program would also provide the opportunity to encourage periodic health examinations beyond retirement age.
When a specific health outcome is known or suspected, the task of observing a population's health experience is much simplified. Surveillance programs are targeted to specific high-risk groups as defined by workplace assignment, known exposure history and environmental monitoring data.
Several standards promulgated by OSHA require specific surveillance procedures for workers exposed to certain hazards. When a surveillance procedure is required by regulation, it is termed mandated surveillance. The National Institute for Occupational Safety and Health (NIOSH) has issued voluntary surveillance recommendations applying to a larger number of exposures.
Surveillance programs are applied in many ways. The primary function is to ensure adequate workplace protection by identifying cases of occupational disease that occur despite proper industrial hygiene measures. A surveillance program that identifies no disease outcome despite suitable screening procedures suggests adequate control of the exposure in question and should be judged a success. If previous cases have been observed and the control measures instituted have not been extensive, however, the suspicion should be raised that new cases are being missed because the surveillance program is inadequate.
___________________________________________________________________________
Procedure Factor Modification
___________________________________________________________________________
Complete history Family history of Increase frequency of history and
cancer in several physical examination to annually
members; possible if appropriate
genetic risk
Alcohol intake Family history of Increase frequency of alcohol
history alcoholism, pattern intake history; education of
of heavy use counseling
Tobacco use Heavy smoker Increase frequency of smoking
history history; use; spirometry as
opportunity to counsel
patient on cessation
Sexual history Multiple partners; (See Papanicolaou smear, VDRL,
homosexual rectal examinations
life-style
Occupational Exposure on job to Increase frequency of occupational
history hazardous substances, history, considering appropriate
continuing or surveillance strategy
antecedent
Complete Family history Modify frequency of screening
physical suggestive of elements accordingly
elevated risk
Blood Race - black/family Increase frequency to annually
pressure history of essential
hypertension
Breast Family history of Increase frequency to annually
examination breast cancer; before age 40; reinforce need
female for self-examination
Pelvic Family history of Increase frequency to annually
examination malignancy before age 40; see Papanicolaou
smear
Rectal Family history of Consider increase in frequency
examination malignancy; male
homosexual life-style
Stool occult Family history of Increase frequency to annually
blood malignancy before age 50
Serum glucose Family history of Increase frequency to annually
juvenile-onset
diabetes
Serum lipids Family history of Considering increasing frequency;
cardiovascular emphasize cardiovascular
disease examination
VDRL Homosexual or Consider increasing frequency
heterosexual life-
style with multiple
partners
Papanicolaou Multiple sexual Consider increasing frequency to
smear partners; proclivity annually or every visit
to noncompliance
Proctosig- Family history Increase frequency
moidoscopy of malignancy
Mammography Family history of Consider increasing frequency
breast cancer female before age 50
___________________________________________________________________________
* These recommendations apply only to asymptomatic individuals; positive
findings, known preexisting conditions, and unusual exposure
opportunities alter the subject risk profile and impose additional
requirements for surveillance or monitoring.
A secondary function of surveillance is to identify new cases as early as possible to prevent the progression of disease. Because surveillance programs are highly visible, they have sometimes been proposed as alternatives to workplace exposure controls. This is an unacceptable compromise because the mere detection of a disease is not a substitute for its prevention.
Surveillance programs may be conducted in-plant or by an outside medical facility or physician under agreement with the employer. The tests to be conducted and the frequency of screening must be clearly specified, and the referral process for individuals found to have a disorder, as well as the employer's response to these individuals must be spelled out in advance.
Even when mandated by law or contract, a new surveillance program should have the approval and understanding of all workers involved, through their union or through direct worker education programs in the case of a nonunionized work force. The education program should explicitly state the purpose of the surveillance, the measures being taken to control workplace exposure, the measures that employees can take to minimize personal exposure or to reduce the risk of the outcome in question and the right of an employee to withdraw from a voluntary program.
A surveillance program must be built around the best available testing procedure that is in established use at the time the program is started. A test that is very controversial or is difficult to interpret will lead to considerable confusion and may delay prompt action. Thus, the most widely applied OSHA-mandated surveillance procedures utilize relatively simple and straightforward tests: the lead standard is based on determination of the blood lead level, the noise standard on audiometric screening, and the asbestos standard primarily on the chest film and spirometric testing.
A surveillance program may incorporate an experimental test, but when a new screening test is validated and introduced as a replacement for an older test of less reliability, both tests should be performed for a period of several years so that the findings can be compared and trends will not be obscured by the transition.
The frequency of testing in a surveillance program depends on convenience and the biological characteristics of the disease. Most surveillance procedures are repeated annually, since one year is a convenient interval and the actual elapsed time is somewhat arbitrary. The noise standard, for example, requires annual audiometric screening for workers exposed to 85 dBA or more of noise. There is nothing inherent in noise-induced hearing loss that makes annual testing optimal, but testing less often may lead to undetected progression of hearing loss between tests and to inadvertent omission of tests. Testing more often than every year would be very expensive and unlikely to identify a significantly higher proportion of new cases.
To be useful in surveillance, a screening test must detect an exposure-related abnormality as early as possible. Ideally, such a test would detect an adaptation to the exposure well before subclinical impairment develops. Such tests fall into two categories: biological monitoring and toxicological screening.
Biological monitoring includes techniques to determine the magnitude of an effect the exposure is having on the body without direct measurement of the toxic substance. Measuring serum and red cell cholinesterase levels after low-level exposure to organophosphate insecticides and determining free erythrocytic protoporphyrin levels after exposure to lead are two examples.
Toxicological screening includes tests to determine, by direct measurement, the levels of a toxic substance or its residues in tissue body fluids or excreta. Testing for blood lead levels is a common example of this more traditional approach.
With both biological monitoring and toxicological screening, the intent is to detect potentially toxic exposures before their effects become manifest. Often, however, disease due to hazardous exposure cannot be detected during the subclinical phase. Some diseases, because of their natural history and biologic characteristics, are already in an advanced stage by the time detection is possible, and a targeted intervention to change the outcome is fruitless in all but a handful of cases. Unfortunately, that is the case in screening for lung cancer with sputum cytology and chest roentgenography. These tests should be considered screening techniques for case-finding and diagnosis. If the disease being sought is infectious, as in the case of tuberculosis, secondary infection can be prevented.
An important complement to a surveillance program is environmental monitoring which involves periodic or continuous measurements of the potential exposures in the workplace. In toxicologic terms, this provides information on the potential dose received by an individual or group of employees, while medical monitoring or surveillance indicates the potential response. If an association exists or is suspected between a given exposure and a disease outcome, the data from environmental monitoring and either medical monitoring or surveillance can be used to construct a dose-response relationship. The demonstration of a strong dose-response relationship is powerful evidence in support of a suspected association.
Environmental monitoring data from industrial hygiene surveys should be made available to the worker's physician, if possible, and must be disclosed to the worker. In practice, this information is usually available only to in-plant health services. Monitoring the environmental levels of hazards is one of the most important functions of an occupational health service. It can be completely preventive in the sense that, in circumstances where dangerous levels are found, it may be possible to take corrective action before harm comes to the employee.
Unfortunately, certain hazards, mental stress is an example, do not lend themselves to the monitoring methods used by the industrial hygienist. What is more, the fact that workplace hazard levels may be found to be within "safe" or acceptable limits does not necessarily mean that workers will be unaffected. This is due to the fact that employee populations are not homogeneous and certain members will be particularly vulnerable or at greater risk than others. These employees, collectively described as the high risk population, include:
In order to provide workers at high risk with the highest degree of protection feasible, they must be identified as early in the employment as possible. Ideally, this would occur at the time of pre-placement examination (see Chapter 18), but in circumstances where illness supervenes during employment, identification should be made no later than when the employee returns after sickness absence. By identifying an employee as at special risk, it becomes possible to provide appropriately timed periodic medical examinations, biological monitoring, and additional preventive measures as needed.
Ideally, surveillance of the high risk employee should continue until the abnormal level of risk has ended. Unfortunately, this can be a problem because some occupational diseases do not produce signs until years of exposure have passed. Employees may the company, change their line of work or retire. How long should surveillance continue in these circumstances and how should it be paid for? The occupational health service can provide input into the employer's policy on continued medical surveillance, but the decision is one that ultimately must be made by employers, employee associations, worker's representatives, and governments.
The final section in this chapter illustrates a surveillance program for high-risk workers using the common example of asbestos exposure.
Biological monitoring involves taking samples of fluids from exposed employees and analyzing them to determine the uptake or the health effect of a hazard. The particular test used must directly reflect the hazardous substance, its passage in the body, the chemical change it may undergo, its effect on body tissue, its route of excretion or its place of storage in the body. "Shotgun" screening or testing for multiple unrelated variables is wasteful and the results usually present more questions than answers.
Whether biological monitoring should be mandatory or voluntary is controversial, as discussed further below. This fact alone is justification for using a high degree of discrimination in selecting tests to be performed. The requirements for employees to undergo testing may be a condition of employment, but must be accompanied by adequate worksite hazard monitoring and control and by employee health hazard information and education.
Mandatory monitoring has the advantage of insuring that all the workers at risk are gularly screened. Whenever abnormal results occur, appropriate action can be taken at the earliest possible time. It also means that the occupational health service is collecting sufficient health data with respect to the hazard that it will have a complete and unbiased record of the effectiveness of their preventive program. With a voluntary monitoring system, a significant number of exposed workers may never be monitored. It may then become impossible to draw valid conclusions about the condition of the population of workers who are at risk. Do acceptable levels found in voluntaeered samples indicate that all workers at risk are remaining healthy? Did the workers who agreed to be monitored do so because they are the conscientious and safe workers, whereas those who declined are more slipshod in their approach to personal health? Are the latter group afraid to reveal what possibly could be significant absorption of the hazardous substance? Are they possibly just taking a stand on a personal belief that their health is their own business? Without carrying out a valid opinion survey, it is impossible to know for certain.
On the other hand, voluntary monitoring may avoid labor unrest caused by worker perception of the employer as unilaterally imposing his will on his employees. Of course, in situations where the hazard is such that regulatory authorities require regular monitoring of all exposed workers, the problem is resolved for all concerned- the employer, the occupational health service and the workers.
Deciding whether or not to start a monitoring program is one problemp; closing down an existing program is another. Occasionally, biological monitoring that has been carried on for some time -possibly for many years- may be found not cost effective. Analysis of the results obtained over the time the program has been in operation may reveal that so few positive results have been obtained relative to the number of samples analyzed, that the cost in time and dollars to detect those few cases is astronomical. There may be a better way to monitor the workers or, possibly, a new work process or equipment has significantly decreased the hazard. The workers, now well accustomed to being monitored, feel reassured by the program and appreciate that the positive results that were obtained resulted in timely action. "How can you justify on the basis of a few dollars in expense", they may ask, "cutting off this program which has prevented some of use from becoming ill from your unhealthy workplace conditions?"
An answer to the question whether or not to monitor (in the absence of a regulatory requirement to do so), may be difficult to find, particularly one which will be acceptable to both the employer and his workforce. Naturally, local circumstances come into play, but there are definite criteria that should always be considered when deciding whether or not a particular biological monitoring program should be implemented. The following are suggested criteria for deciding whether to start or to discontinue a biological monitoring procedure:
This section presents an important example of an occupational health surveillance program for high-risk workers, that for workers exposed to asbestos. Such programs are required by law in about every jurisdiction in North America for workers exposed to asbestos and other hazardous exposures. The asbestos exposure surveillance program is intended to satisfy requirements for the ongoing surveillance of workers exposed to asbestos in their present occupation or in their past work. The concept is to detect adverse health effects occurring as a result of exposure as early as possible so that future exposure can be controlled and disability limited. The program will be described as it is mandated by regulation in California as an illustration.
Asbestos is thought to be the most common occupational carcinogen and the most common and widespread occupational hazard conferring a substantial risk for the development of cancer. Although the health effects of asbestos were well described in Europe in the early part of this century, it was not until the 1960s that the health risks of exposure to this substance were recognized widely in the United States. At present, there are approximately 3,500,000 workers in the United States thought to have sustained significant exposure to asbestos. Very few of these are involved in the mining and milling process. Most are involved in the use of asbestos-containing products and the processing of asbestos materials into these products. The single largest group, numbering approximately 2,000,000 workers, are engaged in automobile service and repair. A large group of workers which is now declining in number due to the decline of the industry is shipbuilding. During the second World War, many hundreds of thousands of workers sustained an exposure to asbestos and this group is responsible for a large fraction of the current epidemic of asbestos-related lung cancer. Plumbers and pipefitters, insulation workers, construction workers, cement pipe manufacturing operatives, and workers handling hot metal objects, such as welders and foundry workers, all have had significant asbestos exposure particularly in the past. A number of other occupations have relatively low levels of exposure, which may not be immediately apparent without close examination of the work processes.
The management of surveillance programs for asbestos-exposed workers in California, to use a clearly defined example, is covered in the General Industry Safety Orders of Title Eight of the California Administrative Code, Section 5208. This regulation, at the time of writing, specified a permissible exposure level of two fibers (longer than five microns) per cubic centimeter as an eight-hour time waited average and a peak exposure level of ten fibers per cubic centimeter. This standard is clearly going to be reduced to one-half fiber in the near future however. The method of determination is specified to be the phase contrast illuminated microscope examining a membrane filter at 400-450 times magnification. The regulation further specifies work processes, emphasizing wetting and prompt cleanup of spills, and prohibits spraying of asbestos-containing material with certain exceptions. Asbestos is to be disposed of in sealed bags and treated as a hazardous waste.
Personal protective equipment is specified in the absence of feasible engineering controls, but engineering controls are preferred. Provision of special clothing not to be worn home and the separation of this clothing from street clothes by the use of separate lockers and separate laundering facilities is specified in the regulation. This semingly picky provision is amply justified by the demonstration that spouses and children of asbestos-exposed workers have contracted asbestos-related diseases, and at times have died, as a result of passive exposure to asbestos brought home on work clothes. Evaluations at least of semi-annually and following any major change in the industrial process is required of all employers using asbestos. Employers are also required to maintain complete and accurate records of the monitoring for at least 30 years and to label asbestos-containing materials and post warning signs.
The medical surveillance part of the standard is Subsection J. This protocol is designed to satisfy these requirements. The remainder of the regulation covers training of employees for safe handling of asbestos and notification of employees that exposure has occurred.
Asbestos is known to be associated with a number of serious illnesses. Asbestosis is a disease of pulmonary parenchymal fibrosis leading to a profound restrictive defect, ultimately resulting in respiratory failure, susceptibility to infection, and a high risk for lung cancer. Asbestos exposure is known to be associated with three forms of thoracic cancer, bronchogenic carcinoma of the epithelial type, adenocarcinoma of the lung, and mesothelioma. Mesotheliomas may be pleural or, on occasion, peritoneal or pericardial and are exceedingly rare in the absence of a history of asbestos exposure. Of these major outcomes, the two forms of lung cancer, particularly bronchogenic carcinoma, are known to be synergistic with cigarette smoking, but neither mesothelioma nor asbestosis are known to have a relationship to cigarette smoke exposure. Other health outcomes known to be associated with asbestos exposure include pleural fibrosis (frequently difficult to distinguish from mesothelioma), benign pleural effusion (also frequently resembling mesothelioma), Blesovsky's syndrome (invaginated or in-folded lung parenchyma creating an atelectatic mass resembling a tumor), and asbestomas (which appear in the lung as solitary nodules and on the skin as asbestos corns). A variety of conditions have been tentatively associated with asbestos exposure, including gastrointestinal malignancies, laryngeal carcinoma, lymphomas, and ovarian carcinomas. The relationship of these conditions to asbestos is still uncertain.
Protocol
To be administered to employees who are younger than 40 years of age and who have a duration of potential exposure to asbestosis of less than ten years. This evaluation is to be repeated every three years.
To be administered to employees 40 years of age or older or any employee of any age who has been exposed to asbestos for more than ten years. The initial exposure does not necessarily have to be with the current employer. This examination is to be repeated annually except as noted.
To facilitate the recording of the results of this screening program and the interpretation of trends and identification of key signs, an asbestos surveillance flow sheet has been prepared. This flow sheet is structured in such a way that the physician is forced to consider the significance of the various signs rather than providing a simple record of test results over time. The intent of this format is to prompt the physician to think in terms of health outcomes and their early identification rather than treating each test result piecemeal.
The concepts and rationale behind this asbestos surveillance program and the California standard used to illustrate the legal requirements are common to all surveillance programs. For details on the specific requirements of mandated surveillance for particular exposures covered by regulatory standards, contact state or federal OSHA or, in Canada, provincial occupational health agencies. For recommended surveillance programs, many standard reference works detail reasonable protocols and the National Institute for Occupational Safety and Health has outlined suitable programs for a number of exposures not now covered by mandated surveillance standards.
NAME: MED. REC. #
ADDRESS:
EMPLOYER:
+ = Present - = Absent
Conditions now known or strongly suspected to be associated with asbestos exposure: asbestosis*, benign pleural effusion, asbestoma, pleural plaques*, Blesovsky's syndrome, mesothelioma*, bronchogenic carcinoma*, laryngeal carcinoma*, lymphomas.
* Probably most common
Year of Assessment
___________________________________________________________
FINDINGS 19 19 19 19 19 19 19 19
___________________________________________________________
Indices of History of continued exposure _____________________________
Exposure CXR: pleural plaques _____________________________________
Rule out Dyspnea, dry cough, tachypnea _____________________________
benign Clubbing, with/without cyanosis ___________________________
asbestos- Rales on auscultation _____________________________________
associated CXR: interstitial fibrosis _______________________________
disease CXR: asbestosis criteria _________________________________
CXR: pleural effusion ____________________________________
PFT: restrictive defect __________________________________
Rule out History of exposure years previously ______________________
malignant Clinical symptoms compatible ______________________________
asbestos- Stool guaiac positive _____________________________________
associated CXR: solitary nodule _____________________________________
disease CXR: pleural effusion ____________________________________
CXR: infiltrating mass ___________________________________
Follow-up investigations:
1. ________________________________________________________
2. ________________________________________________________
3. ________________________________________________________
4. ________________________________________________________
5. ________________________________________________________
6. ________________________________________________________
7. ________________________________________________________
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