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6MORBIDITY WITH ALLERGIC RHINITIS AND BRONCHIAL ASTHMA AS OCCUPATIONAL DISEASES IN LATVIA
Kristina Karganova
6th year student, Faculty of Medicine, Riga Stradins University, Latvia Jelena Reste M.D./Ph.D., researcher Institute of Occupational Safety and Environmental Health, Riga Stradins University, Latvia
ABSTRACT
Introduction: Allergic rhinitis (AR) is an inflammation of nasal mucosa caused by inhaled allergens. Up to 40% of population worldwide are suffering from AR of different severity. AR is approximately three times more often caused by occupational factors then factors found out of work environment. The importance of occupational AR (OAR) lays in its negative impact on a person's physical, emotional and social well-being, as well as work performance and productivity. Moreover, OAR has the potential to provoke occupational bronchial asthma (OBA) that if left undiagnosed and untreated has afar worse effect on a person's health and well-being.
Aim: The purpose of the research is to describe and analyze incidence of registered cases of OAR in relation to OBA among employees in Latvia between 2005 and 2014.
Materials and methods: Data were obtained from the Latvian State Register of Patients with Occupational Diseases between 2005 and 2014 and analyzed with appropriate statistical tests using Excel and IBM SPSS programmes to compare epidemiological parameters between OAR and OBA and identify the link between both of these diseases when caused by occupational factors.
Results: In total data were acquired about 2489 patients with officially registered 2562 cases of occupational ear, nose and throat (ENT) diseases, of them 114 cases OAR, and 397 cases of OBA. The mean age at the moment of OAR diagnosis was 51.75 K 9.04 years and at the moment of OBA diagnosis - 53.88 K 7.83 years. OAR was statistically significantly more common in female patients (p<0.001, Cramer's V=0.18, OR=6.90) as well as OBA (p<0.001, Cramer's V=0.29, OR=5.26). Statistically significant association was found between OAR and OBA (OR=11.75).
Most frequently OAR and OBA were registered in employees of manufacturing and health and social work sectors. More than half of the registered cases of OAR and OBA in manufacturing sector came from production of: 1) food and beverages; 2) wood and products of wood and cork, except furniture; 3) textile and 4) wearing apparel; dressing and dyeing of fur industries. These data show workers of which economic activities sectors are at the highest risk for the development of OAR and OBA and demonstrates which industries employees occupational health should be closely monitored.
Incidence of OAR and OBA per 100 000 employees in Latvia in corresponding year considerably higher was in female employees throughout the study period. In both diseases starting from 2007 there was an increase in incidence until 2010. Afterwards incidence decreased.
Conclusions: In total OAR was the fourth most frequently registered occupational ENT disease after noise induced hearing loss, chronic laryngitis and chronic pharyngitis. Most of the employees with OAR and OBA were females aged 55-64. Significant statistical association was found between OAR and OBA, therefore further studies are necessary to evaluate the most frequent etiological factors of OAR and the length of exposure to the offending aeroallergen before the symptoms of OAR appear, as well as professions at the highest risk for the development of this condition.
Key words: occupational allergic rhinitis, allergy, occupational bronchial asthma.
Statement of the problem. Allergic rhinitis (AR) is one of to evaluate the effectiveness of preventive methods used in the the most common allergic diseases that has a significant effect workplace.
on a person's health, quality of life and work performance [1]. Analysis of recent research and publications. OAR is an IgE Over the last decades recognition about AR and bronchial mediated in-flammation of the nasal mucosa caused solely by asthma (BA) co-existence has increased. It has been postulated aeroallergens found at the workplace [9, 10]. OAR appears only that both of them are manifestation of the same airway disease in those persons who have been previously sensitized and have with symptoms from the upper or lower airways predominating a genetic predisposition to atopy [9]. A significant risk factor [2]. AR is caused three times more frequently by occupational for the development of OAR and OBA is high concentration factors than stimuli encountered out of workplace [3]. of agents and multiple irritants in the air of the workplace [10].
The prevalence of AR and BA continues to vary throughout Upon the contact with aeroallergen local symptoms the world, despite the increase noted in the last couple of in variable degree of severity and duration, such as nasal decades [4, 5]. In the U.S., up to 60 million people are thought congestion, rhinitis, sneezing and itching appear. Moreover, to be affected by AR, 10-30% of adults and approximately 40% patients use to complain about general symptoms as well: of children [4, 6, 7]. Whereas, BA affects around 24 million daytime sleepiness, fatigue, headaches, mood changes, people in the U.S., 7.4% of adults and 8.6% of children [8]. depression that together with nasal symptoms considerably Aeroallergens able to elicit symptoms of AR are widely found in affect person's work performance and productivity [11-13]. a work environment, therefore newest data about incidence of Clinically significant is the association of AR with BA OAR and the dynamics of OAR appearance are of importance due to similar epide-miological, immunological, clinical and
pathophysiological data and common ap-proach to the patient [14-16]. Based on this knowledge the "united airway disease hypothesis" has been imposed stating that upper and lower airway diseases are manifestation of a single inflammatory process in the respiratory system [17]. Furthermore, it has been reported that up to 78% of workers diagnosed with OAR sooner or later develop OBA [18]. In global population up to 20-50% of patients with AR have BA and 80% of patients with BA have AR as well [5].
Altogether up to 40% of global population suffer from AR of different severity. High prevalence has been recorded in the developed nations of Europe and in the U.S., 23-30% and 12-30%, respectively, whereas in the countries of South Hemisphere the prevalence of AR varies considerably within a region and between nations from 2.9% to 54.1% [13]. In several countries more than 50% of adolescents claim to have symptoms of AR [12, 19].
The European Community Respiratory Health Survey (ECRHS) was per-formed to assess prevalence of BA and atopy, including AR, in an adult population in 22 countries of Europe. The survey showed that overall prevalence of AR was 21% and BA 5%. From the data obtained it was concluded that higher risk for the development of respiratory symptoms due to
Prevalence of occupational allergic rhinitis (OAR) in
occupational
allergic stimuli was in the laboratory technicians, workers with plastic and rubber, farmers, painters, cleaners and agricultural workers [20]. Besides Park et al. evaluated prevalence of rhinitis among 187 workers in plant manufacturing automobile piston rings. In 99 workers rhinitis was medically confirmed and AR was diagnosed in 36 of them (~36%) [21].
Independently of the ECRHS, in 2001 a two-step, cross-sectional, population-based survey in Belgium, France, Germany, Italy, Spain, and the UK was held to measure the prevalence of AR among European adults. This survey showed that the prevalence of AR ranged from 17% in Italy to 29% in Belgium. The overall prevalence of AR calculated with stratification of population size in each country was 22% that corresponds to approximately 53 million people [22].
Table 1 shows the prevalence of OAR in various occupations whose workers are constantly subjected to allergic exposure at the workplace. These data have been obtained from the cross-sectional studies conducted in various working populations and then summarized by Siracusa et al. and adapted by Moscato et al. [18, 23]. In the Slovak Republic a total of 70 cases of OAR were reported between 1990 and 2011 of them 50% were registered in the workers of food industry, 17% in the workers of textile industry and 8% - in agriculture [24].
Table 1.
nployees of various occupations caused by most frequent >ents [18, 23]
Agents Occupation Prevalence (%)
High molecular weight agents
Grain dust Grain elevators 28-64
Flour Bakers 18-29
Laboratory animals Laboratory workers 6-33
Other animal-derived allergens Swine confinement workers 8-23
Insects and mites Laboratory workers, farm workers 2-60
Latex Hospital workers, textile factory workers 9-20
Other plant allergens Tobacco, carpet, hot pepper, tea, coffee, cocoa, dried fruit and saffron workers 5-36
Biological enzymes Pharmaceutical and detergent industries workers 3-87
Fish and seafood pro-teins Trout, prawn, shrimp, crab and clam workers; aquarists and fish-food factory workers 5-24
Low molecular weight agents
Diisocyanates Painters, urethane mould workers 36-42
Anhydrides Epoxy resin production, chemical workers, electric con-denser workers 10-48
Wood dust Carpentry and furniture making workers 16-36
Metals (platinum) Platinum refinery workers 43
Drugs (psyllium, spira-mycin, piperacillin) Health care and pharmaceutical workers 9-41
Chemicals Reactive dye, synthetic fiber, cotton, persulphate, hair-dressing, pulp and paper, shoe manufacturing workers 3-30
A study of prevalence of AR among bakers in Canada in in the research, 24.5% had symptoms of AR. In 15.3% of the 2013 concluded that from 229 bakers, who agreed to participate participants symptoms were work related [25]. A study of the
burden of AR in Canada showed that 29% of the participants had severe and 42% moderate symptoms of AR, moreover, 61% of participants reported that the symptom control was inadequate. Based on the data obtained the researchers concluded that AR extremely intercedes with the daily activities and new medications for better symptom control are necessary [26].
Unsolved aspects of the problem. The epidemiological data of OAR among employees in Latvia and their dynamics during the last decade are lacking. Due to global increase of the prevalence of AR it is important to examine and analyse the data about OAR as well. Only knowing the changes of these data within the last years, adequate and apropos actions may be undertaken to improve occupational health and work environment of the employees in Latvia.
Aim. The purpose of the research was to describe and analyze incidence of registered cases of OAR in relation to OBA among employees in Latvia between 2005 and 2014.
Materials and methods. The data in the study were obtained from the Latvian State Register of Patients with Occupational Diseases between 2005 and 2014. All the occupational diseases were coded using International Classification of Diseases 10th edition (ICD-10). The economic activities sectors, where patients were employed in, were coded using the 1st revision of Statistical classification of economic activities in the European Community (NACE 1). All employees with confirmed occupational diseases (further in the article patients) were included in the register after meticulous diagnostic procedures
(anamnestic data, including information about hazardous work factors, total length of employment under harmful conditions was collected; and specific diagnostic tests were performed) and scrupulous exclusion of non-work related etiological factors. The diagnosis of OAR was confirmed in patients in whom symptoms suggesting OAR were present and results of allergic tests were positive, additionally. The diagnosis of OBA was established in patients with symptoms suggesting of OBA and after undergoing spirometry test where reversible bronchoconstriction was registered. In both cases exposure to non-work related aeroallergens were excluded. The data about patients with occupational ear, nose and throat (ENT) diseases and OBA were selected and further analyzed: 2489 patients with 2562 cases of occu-pational ENT diseases and 397 cases of OBA. Out of them OAR was registered in 114 cases (Fig. 1). In total there were 1467 male patients (58.9%) and 1022 female patients (41.1%). The average age of patients of both genders together at the moment of diagnosis were 55.80 ± 7.08 years (age range 23-80) and the mode age was 57: in male patients 57.06 ± 6.97 and 59; in female patients 54.00 ± 6.84 and 56, respectively. The patients were divided and further analyzed by gender, age and the economic activity sector they were employed in, comparing these groups between each other. All the acquired data were analysed by Excel programme's mathematical and statistical functions and IBM SPSS using to the specific data parameters applicable tests (Pearson's Chi-squared test, Cramer's V value and odds ratio (OR)).
Analyzed in details
Latvian State Resiste]1 of Patients
rtiLh Occupational
Diseases
Data about patients (in total \T=24S9) with re eiste led OBA cases (N=397) and occupational ENT cases (N=2502) OAR cases (N-114)
OAR and OBA cases simultaneously (N=7-4)
OBA cases (N=397)
Fig. 1. The selection of data from the Latvian State Register of Patients with Occupational Diseases (OBA - occupational bronchial asthma; ENT - ear, nose and throat diseases; OAR - occupational allergic rhinitis)
Results. In total OAR was the fourth most frequently registered occupational ENT disease in Latvia between 2005 and 2014 after noise induced hearing loss, chronic laryngitis and chronic pharyngitis. Noise induced hearing loss was registered in 1699 cases (66.3% of all the registered cases of occupational ENT diseases): 1307 cases in male patients (76.89% from all the registered cases of noise induced hearing loss) and 392 cases in female patients (23.1%); chronic laryngitis - 380 cases (14.8%): 103 cases in male patients (27.1%) and 277 cases in female patients (72.9%) and chronic pharyngitis - 321 cases (12.5%): 73 cases in male patients (22.7%) and 248 cases in female patients (77.3%).
In 65 patients (57.0% from all the registered patients with OAR) OAR was the only occupational ENT disease registered; in 42 patients (36.8%) OAR and another occupational ENT disease was registered and in 7 patients (6.1%) OAR was registered with two other occupational ENT diseases.
In male and female patients with OAR altogether the mean age at the moment of diagnosis was 51.75 ± 9.04 years and the mode age 58 (age range 23- 68): in male employees 52.33 ± 9.20 and 61 year and in female employees 51.61 ± 9.04 and 54 years, respectively. The mean age in both male and female patients at the moment of diagnosis of OBA was 53.88 ± 7.83 years and the mode age 57 (age range 27-72): in male patients 53.83 ± 8.98 and 55 year and in female patients 53.90 ± 7.40 years and 57 years, respectively.
Pearson's Chi-squared test showed that female patients had statistically significantly more cases of OAR than male patients (p<0.001). 21 case of OAR was in male patients (18.4% from all the registered OAR cases or 1.5% from all the registered male patients with occupational ENT cases) and 93 cases were in female patients (81.6% from all the registered OAR cases or 10.6% from all the registered female patients with occupational ENT cases). The strength of association between gender and
OAR was weak (Cramer's V=0.18) and odds of females to acquire OAR was 6.19 times higher than for males (OR=6.19).
From 397 registered cases of OBA 104 cases were in male patients (26.2% of all the registered cases of OBA) and 293 cases in female patients (73.8%). Pearson's Chi-squared test showed that female patients had statistically significantly more cases of OBA (p<0.001) and the strength of association was medium (Cramer's V=0.29). The odds of females to acquire OBA was 5.26 times higher than in males (OR=5.26).
Most of the both OAR cases (48 cases; 42.8% from all the
registered cases of OAR) and OBA cases (190 cases; 47.9% from all the registered cases of OBA) were registered in patients aged 55-64, followed by patients aged 45-54. A total of 16 cases of occupational ENT diseases were registered in patients younger than 35 years, of them 6 cases of OAR (5.3% from all the registered OAR cases or 37.5% from all the registered cases of occupational ENT diseases in patients younger than 35 years) were registered. Similar tendency was revealed also for OBA (Table 2).
Table 2.
Number of registered occupational allergic rhinitis (OAR) and bronchial asthma (OBA) cases and percentage in patients of
various age groups in Latvia between 2005 and 2014
Age Total number of registered OAR cases Percentage from all the registered OAR cases (%) Total number of registered OBA cases Percentage from all the registered OBA cases (%)
<35 6 5.3 8 2.0
35-44 17 14.9 44 11.1
45-54 39 34.2 131 33.0
55-64 48 42.1 190 47.9
65-74 4 3.5 24 6.0
Most frequently OAR and OBA were registered in patients employed in the following economic activities sectors (the 1st revision of Statistical classification of economic activities in the European Community (NACE) was used): 1) manufacturing (55 cases of OAR and 192 cases of OBA); 2) health and social work (24 cases; 59 cases) (Table 3). The third most common
economic activity sector where patients with OAR worked in was other community, social and personal service activities with 11 OAR cases, whereas in patients with diagnosed OBA it was agriculture, hunting and forestry industry (30 cases of OBA).
Table 3.
Number of registered occupational allergic rhinitis (OAR) and bronchial asthma (OBA) cases in the patients working in various economic activities sectors in Latvia between 2005 and 2014
Eonomic activity sector Number of registered OAR cases Percentage from all the registered OAR cases (%) Number of registered OBA cases Percentage from all the registered OBA cases (%)
Manufacturing 55 48.2 192 48.4
Health and social work 24 21.1 59 14.9
Other community, social and personal service activities 11 9.6 20 5.0
Construction 5 4.4 28 7.1
Transport, storage and commu-nication 5 4.4 24 6.0
Agriculture, hunting and forest-ry 3 2.6 30 7.6
Wholesale and retail trade; re-pair of motor vehicles, motorcycles and personal and household goods 3 2.6 14 3.5
Public administration and de-fence; compulsory social securi-ty 3 2.6 10 2.5
Education 2 1.8 7 1.8
Real estate, renting and business activities 2 1.8 5 1.3
Electricity, gas and water supply 1 0.9 8 2.0
A total of cases in 2005-2014 114 397
76.4% from all the registered OAR cases and 60.9% from all the registered OBA cases in manufacturing sector came from the: 1) manufacture of food products and beverages (13 cases of OAR and 22 cases of OBA); 2) manufacture of wood and of products of wood and cork, except furniture; manufacture of articles of straw and plaiting materials (11 cases; 31 case); 3) manufacture of textiles (9 cases; 38 cases); and 4) manufacture
of wearing apparel; dressing and dyeing of fur (9 cases; 26 cases). Moreover, 17.4% of all the registered cases of occupational ENT diseases in manufacture of chemicals and chemical products industry; 16.7% in publishing, printing and reproduction of recorded media industry; and 14.3% in tanning and dressing of leather; manufacture of luggage, handbags, saddlery, harness and footwear industry were OAR (Table 4).
Table 4.
Number and distribution of registered occupational allergic rhinitis (OAR) and bronchial asthma (OBA) cases in the patients employed in manufacturing activity sector in Latvia between 2005 and 2014
Industries of the Number of registered Percentage from all the registered OAR Number of registered Percentage from all the registered OBA
manufacturing sector OAR cas-es cases in manufacturing sector (%) OBA cas-es cases in manufacturing sector (%)
Manufacture of food 13 23.6 22 11.5
products and beverages
Manufacture of wood
and of prod-ucts of wood and cork,
except fur-niture; 11 20.0 31 16.1
manufacture of articles
of straw and plaiting materials
Manufacture of textiles 9 16.4 38 19.8
Manufacture of
wearing apparel; dressing and dyeing of fur 9 16.4 26 13.5
Manufacture of
chemicals and 4 7.3 12 6.3
chemical products
Publishing, printing and reproduc-tion of 3 5.5 10 5.2
recorded media
Manufacture of other 3 5.5 9 4.7
transport equipment
Manufacture of
fabricated metal
products, except machinery and 2 3.6 8 4.2
equipment
Tanning and dressing of leather; manufacture
of luggage, handbags, saddlery, harness and footwear 1 1.8 1 0.5
Manufacture of other
non-metallic mineral - - 17 8.9
products
Other - - 18 9.4
Incidence of OAR per 100 000 employees in Latvia in corresponding year in both genders together and in female employees separately the highest was in 2010: 2.59 cases per 100 000 both gender employees and 4.46 cases per 100 000 female employees, respectively, whereas in male employees - in 2009 (0.92 cases per 100 000 male employees). Incidence of OBA in both genders together an in female employees highest was in 2009: 7.59 cases per both gender employees and 12.04 cases per female employees, whereas in male employees - in 2010
(3.23 cases per 100 000 male employees). Afterwards incidence considerably dropped in both OAR and OBA reaching the lowest level in 2012. Starting from 2012 the incidence of OAR in female employees increased once more, reaching 1.12 cases per 100 000 female employees in 2014. It was noticed that the incidence of OBA in male employees starting from 2012 has begun to increase as well, reaching in 2014 2.96 cases per 100 000 male employees. (Table 5 and Fig. 2 and 3).
Table 5.
Incidence of registered occupational allergic rhinitis (OAR) and bronchial asthma (OBA) in the employees in Latvia
between 2005 and 2014
Year 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Total incidence of OAR per 100 000 employees in the corresponing year (absolute number of cases) 1.23 (12) 0.97 (10) 0.76 (8) 1.52 (16) 2.42 (22) 2.59 (22) 1.28 (11) 0.23 (2) 0.56 (5) 0.68 (6)
Incidence of OAR per 100 000 female employees in the corresponing year (absolute number of cases) 2.10 (10) 1.58 (8) 0.97 (5) 2.48 (13) 3.80 (18) 4.46 (20) 1.80 (8) 0.22 (1) 1.10 (5) 1.12 (5)
Incidence of OAR per 100 000 male employees in the corresponing year (absolute number of cases) 0.40 (2) 0.38 (2) 0.56 (3) 0.56 (3) 0.92 (4) 0.50 (2) 0.72 (3) 0.23 (1) 0.00 (0) 0.23 (1)
Total incidence of OBA per 100 000 employees in the corresponing year (absolute number of cases) 3.19 (31) 3.30 (34) 4.54 (48) 5.78 (61) 7.59 (69) 5.64 (48) 4.06 (35) 1.60 (14) 2.80 (25) 3.62 (32)
Incidence of OBA per 100 000 female employees in the corresponing year (absolute number of cases) 4.84 (23) 4.16 (21) 5.99 (31) 9.17 (48) 12.04 (57) 7.81 (35) 5.84 (26) 2.46 (11) 4.85 (22) 4.26 (19)
Incidence of OBA per 100 000 male employees in the corresponing year (absolute number of cases) 1.61 (8) 2.47 (13) 3.15 (17) 2.45 (13) 2.76 (12) 3.23 (13) 2.16 (9) 0.70 (3) 0.68 (3) 2.96 (13)
'Borh ytiidtrs Tflfnbef l:fii(iait iiinpkA'eia l№k HUftoyi
Fig. 2. Incidence of registered occupational allergic rhinitis (OAR) per 100 000 employees in Latvia between 2005 and 2014
200? 20Qf> 2ВД7 2<Н5Я 2009 20Ю 2011 J 2 2013 20H
Both genders to^ellwi -FoiHle employees -Male employees
Fig. 3. Incidence of registered occupational bronchial asthma (OBA) per 100 000 employees in Latvia between 2005 and 2014
Statistically significant association was found between OAR and OBA (OR=11.75). Co-existence of OAR and OBA was registered in 74 employees (64.9% of all the employees with registered OAR). Additionally, it was calculated that in those employees who had both OAR and OBA, OBA association with gender was not statistically significant (p=0.852; Cramer's V=0.17; OR=0.91), whereas in those employees who did not
have diagnosed OAR but did have OBA, OBA was statistically significantly associated with gender (p<0.001; Cramer's V=0.27; OR=5.04). No statistically significant association was found between OAR and gender when both OBA and OAR was diagnosed in an employee (p=0.114; Cramer's V=0.08; OR=1.65) as well, however, in employees with only OAR without OBA, OAR was statistically significantly associated
with gender (p<0.001; Cramer's V=0.14; OR=9.19).
Discussion. Incidence of OAR and OBA among employees in Latvia was calculated using only the officially registered cases of OAR and OBA obtained from the Latvian State Register of Patients with Occupational Diseases. However, not all of the employees with the symptoms of OAR or OBA seek medical attention. This most probably is due to the fact that the symptom severity in these employees is mild and intermittent, without a significant effect on daily activities and work productivity. Additionally, the diagnostic procedure of OAR and OBA requests scrupulous acquisition of anamnestic data, as well as active questioning about profession, work environment and possible allergen presence at work, which is not always done by a physician, therefore the diagnosis of OAR and OBA is missed [27]. Due to aforementioned, the true incidence rate of OAR and OBA among the employees most probably was higher than measured in this research.
Increase in OAR and OBA incidence 2007-2010 that was followed by a drop might be explained by economic instability in Latvia, which started around 2008 and continued for the next couple of years. During this period of time a significant number of employees was dismissed from their employment, therefore increased number of those who sought help of an occupational physician. One of the main reasons why these persons looked for a consultation with occupational physician was for their medical condition caused by hazardous work factors to be officially registered as the occupational disease. In such a way they were able to receive economic support from the government of Latvia while looking for a new job opportunity.
The higher incidence of OAR and OBA among female employees probably is due to the fact that females in Latvia tend to seek medical help more frequently and earlier in progression of the disease than males. Additionally, female sex hormone has a significant influence on the immune cells involved in the pathophysiological mechanisms of allergic reactions. First of all, estrogen by binding to the estrogen receptor-a expressed on mast cells promotes a rapid and continuous influx of extracellular Ca2+, which is crucial for the mast cell activity and subsequent release of stored and newly synthesised mediators [28]. Secondly, estrogen is able to intensify leukotriene C4 secretion and the Ig-E mediated mast cell degranulation, leading to more pronounced vasodilatation and oedema development. Additionally, estrogen may induce antibody synthesis in the plasma cells, while progesterone enhances precisely Ig-E generation, an essential antibody for the development of allergic reaction [29]. By the contrary, male sex hormone dehydroepiandrosterone seems to inhibit production of the T helper subtype 2 (TH2) cytokines IL-5, IL-10 and INFy and supresses immunological responses of T helper subtype 1 (TH1) and TH2 [29, 30].
Allergic reactions, including OAR and OBA, occur only in those persons who have been previously sensitized to a specific antigen. These antigens include a variety of high and low molecular weight agents that are broadly encountered in a work environment [23, 31]. OAR and OBA most commonly were registered in workers employed in the sectors of economic activity where the contact with potential allergens may happen on a daily basis. The results of this study correspond with the results of study by Siracusa et al. [23] that showed high
prevalence of OAR in those working with animals, in bakers and workers in food and beverage industry, textile and shoe manufacturing workers, carpenters and those working with wood and with products of wood, as well as in workers of chemical and pharmaceutical industries and health care professionals. In the study by Perecinsky et al. [24] similar results were obtained and in 19% of OAR cases co-occurrence with OBA was registered as well.
The awareness of the link between AR and BA appeared more than 50 years ago and since than it has increased and been widely recognised [2]. First of all the association of prevalence of both of these conditions had been noted [32]. Moreover, more than 80% of patients with diagnosed BA have AR as well. 76% of patients with BA have stated that before the onset of BA they had symptoms of AR [33]. AR and BA share similarities in the pathophysiological mechanisms as well. Both of these diseases are characterised as chronic inflammatory conditions with eosinophil and T lymphocyte predominance, additionally, higher numbers of mast cells have been found in patients with AR and BA compared with healthy individuals [32, 33]. Several mechanisms explaining the association between AR and BA have been proposed. First of all, patients with chronic inflammation of nasal mucosa due to AR have decreased protective and filtering function of nose, facilitating aeroallergen and other particle found in the air entrance and progression to the lower airways. Secondly, inflammatory cytokines synthesised and released in nasal mucosa due to AR and inflammatory cells from the upper airways may propagate into lower airways initiating inflammation there [34]. In some studies the link between aspiration and bronchial inflammation have been investigated, however, in patients without decreased con-sciousness no statistical association have been concluded [33].
Conclusions. In total OAR was the fourth most frequently registered occupational ENT disease among employees in Latvia between 2005 and 2014 after noise induced hearing loss, chronic laryngitis and chronic pharyngitis. Most of the patients with OAR and OBA were females aged 55-64. Significant statistical association was found between OAR and OBA, which is in accordance with literature data. Based on this association it is highly recommended for the physician to perform diagnostic tests for BA in those who have AR due to the fact that BA has a considerable negative effect on patient's live and well-being. Early diagnosis with early commenced treatment of BA prevents airway remodelling, maintains lung functions within a normal range for a longer time and improves patient's quality of live.
The research demonstrated that OAR and OBA most frequently is registered in the workers who are daily exposed to one or various aeroallergens (manufacturing; health and social work and other community; social and personal service activities sectors; agriculture, hunting and forestry). These results correspond with other studies and show workers of which economic activities sectors are at the highest risk for the development of OAR and OBA and which industries employees' occupational health should be closely monitored.
Analysing the incidence of OAR and OBA it was concluded that incidence level higher was in female employees and that it was highly influenced by socioeconomic processes in the
country. When the socioeconomic stability decreases, patients tend to actively seek occupational physicians help not only due to work environment and hazardous work factors, but also to gain economic support from the Latvian government once the occupational disease is officially registered.
Further studies are needed to evaluate the most frequent etiological factors of OAR and the length of exposure to the offending aeroallergen before the symptoms of OAR appear.
Acknowledgement:
Ethics Committee Approval: Not applicable.
Informed Consent: Not applicable.
Conflict of Interest: The authors declared no conflict of interest.
Financial Disclosure: The authors declared that this study received no financial support.
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SURGICAL OUTCOME OF CONGENITAL HEART DEFECTS WITH PULMONARY
HYPERTENSION IN INFANTS
Saitazizov Kh.B.
Pediatric cardiac surgeon, Republic Specialized Research Center of Pediatrics, Tashkent, Uzbekistan Aliev M.M. Doctor of medicine, professor, Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan Park Y.H. Doctor of medicine, professor, Yonsei University Cardiovascular Center, Seoul, South Korea
ABSTRACT
Background: Congenital heart diseases with large left-to-right shunt often have signs of pulmonary artery hypertension. It is an important determinant of morbidity and mortality in patients without educate surgical treatment especially in infants.
Methods: Ninety patients with congenital cardiac septal defects and pulmonary arterial hypertension had operation to close their septal defects. All the patients have been checked by Chest X-ray, EchoCG, ECG, selectively performed the cardiac catheterization and lung biopsy. Before and after surgery the PA pressure was compared to systemic by needle puncture measurement.
Results: Twenty patients died in the hospital after operation and there were no later deaths in follow-up. Hemodynamic changes after operation included a significant decrease in pulmonary artery pressure (mean pulmonary artery pressure, 28.3±2.4 mm Hg versus 58.45±1.69 mm Hg before repair). The follow-up period was from 3 months to 4 years (mean 1.3±0.6 years).
Conclusion: Studies from developed countries have shown that in term infants, young age is not a risk factor for adverse postoperative outcome after surgical closure of septal left-to-right defects. The data presented in this study shows that operations to close cardiac septal defects in the presence of severe pulmonary hypertension are effective, but must be done during first 6 month.
Key words: congenital heart disease, pulmonary hypertension, bypass, infants, cardiac surgery
Congenital heart defects (CHD) with left-to-right shunt carry high mortality in infancy due to development of pulmonary arterial hypertension. The natural mortality during the first year of life is about 8-11%. There are some reasons of high mortality: development of pulmonary arterial hypertension with congestive right heart failure, pulmonary hypertensive crisis, difficult for curing pneumonia, hypotrophy and septic conditions. In 30- 50% of this condition complicated with severe pulmonary arterial hypertension, which has a progressive character [1]. Pulmonary artery pressure is hyperkinetic in early phase but may eventually become a fixed elevation associated with fixed increase of pulmonary vascular resistance [2].
CHD with pulmonary hypertension requires urgent surgical treatment, which is caused by development of irreversible changes of in-lungs and critical condition of patients [3, 4]. This need requires surgical intervention in the first year of life.
During the past years many world leading hospitals have been excellently performing surgical interventions in infants. This report documents the experience and results of septal defects repair in a group of patients with pulmonary hypertension in infancy.
Material
90 patients with congenital cardiac defects and pulmonary hypertension had been operated in three institutions during the period from January 2, 2000, to May, 2008 (Fig 1). There were 69 patients with isolated ventricular septal defects, 2 patients
