>Painless microscopic blood in urine on routine dipstick testing and fitness for work

Microscopic Haematuria (microhaematuria) is one of the commonest abnormalities found during routine checkups. It is always to be considered an abnormality although frequently it is a transient finding and, even if shown to be persistent, the cause of the bleeding may not be obvious even after detailed investigation.

Blood in the urine can originate either from the kidney tissue or anywhere along the urinary tract.

In Australia, approximately five percent of randomly chosen adults over 25 years of age have microscopic haematuria on the first urine dipstick test. This is confirmed by a second test (dipstick or microscopy) in 2.5 percent.

Transient microhaematuria may be caused by exercise, sexual intercourse, menstrual contamination or mild trauma. It can persist for some weeks after urinary tract infection.

Asymptomatic microhaematuria identified on routine dipstick testing during pre-employment medical assessments at OccuMED are referred to the family general practitioner for follow up, specifically repeat dipstick test and microscopy.

In general terms, without specific concern on history and examination findings, this finding poses very little risk in terms of the candidate’s Fitness for Work (ability to undertake his/her job safely and effectively). This does not mean that further investigations are not required as there are potentially reversible serious and specific conditions that cause blood in the urine which pose limited risk to health if diagnosed and managed early.

It is therefore important for the patient to follow up with their general practitioner to repeat the urine test and map out a management strategy if required.

Dr. John Low
MBBS (UWA) Grad Dip OHS FAFOM
Occupational Physician
OccuMED Consulting

>Carpal tunnel syndrome (CTS) is the result of increased pressure in the carpal tunnel (CT) leading to pressure of the median nerve. About 3% of adults in the general population have symptomatic CTS confirmed by nerve conduction studies.

Clinical Features
CTS characteristically presents with pins/needles (paraesthesia), numbness and pain affecting the palmar side of the thumb, index finger, middle finger and radial half of the ring finger, as well as the radial side of the palm. These symptoms must last more than 1 week, or if intermittent, occur on multiple occasions before the diagnosis of CTS is considered. Another prominent feature is the occurrence of the symptoms at night relieved by flicking the hand.

Findings on physical examination indicative of CTS include a positive Tinel’s sign and Phalen’s test.

Other useful clinical tools in assisting diagnosis include the use of hand diagrams, and two-point discrimination test.

Investigations
Investigations used to establish the diagnosis of CTS include nerve conduction studies. The false positive rate of the investigation is ~ 76% (positive nerve conduction study in those without symptoms of CTS).

Response from steroid injection proximal to the carpal tunnel is also a useful tool.

Causes
As a general guide, occupational causes include work which involve:

• Repetitive use of the same or similar movements of the hand/wrist.

• Regular tasks requiring generation of high force by the hand.

• Regular or sustained tasks requiring awkward hand positions.

• Regular use of vibrating hand tools.

• Frequent or prolonged pressure over the wrist.

Interestingly, a recent survey done by the Mayo Clinic found that the frequency of CTS syndrome in computer users was similar to that in the general population.

Non-occupational conditions associated with CTS include:

• Unknown (idiopathic.

• Metabolic conditions such as hypothyroidism, diabetes, gout, acromegaly, pregnancy, alcoholism, obesity.

• Systemic inflammatory conditions such as rheumatoid arthritis, lupus, amyloid.

• Degenerative arthritis.

Other important conditions presenting similar symptoms include tendonitis/tenosynovitis, referred symptoms from the cervical spine and other causes of peripheral neuropathy.

Management
General management of this condition would have to include a worksite assessment and workplace modifications to ensure optimal work methods and workplace setup, together with avoidance of any aggravating activity.

Medical management options fall into the non-surgical and surgical groups.

Non-surgical treatment consists of steroid injection proximal to the carpal tunnel. The benefit of night splinting is unknown.

Surgical CT release can be done as an open procedure or endoscopically. Recovery to full function is said to occur after about 6-12 weeks for the open procedure and is somewhat shorter for the endoscopic technique.

Post-operative complications can occur in up to about 15%. Complications include residual palm discomfort for many months (Pillar pain), persistent CTS, local nerve trauma, wound problems, local bleeding, scar hypertrophy and tenderness and reflex sympathetic dystrophy.

Dr. John Low
MBBS (UWA) Grad Dip OHS FAFOM
Occupational Physician
OccuMED Consulting

>Diabetes

Diabetes is a condition in which the body loses the ability to self-regulate blood sugar levels. High blood sugar levels are associated with long term complications such as blindness, nerve damage, heart disease, kidney disease and vascular disease. Short term complications include blurred vision, frequent toiletting and fatigue. The aim of diabetic medical treatment is to keep the blood sugar levels within the normal range to minimise the risk of complications.

Diabetic treatment – 3 main treatment regimes

• Diet controlled – no risk of hypoglycaemia
• Oral medication – minimal to modest risk of hypoglycaemia
• Insulin – potentially highest risk of hypoglycaemia

Impact of diabetes on work

Diabetes can affect fitness for work in two ways. Firstly, treatment with medication (insulin, hypoglycaemics) may lead to episodes of low blood sugar (hypoglycaemia). When the blood sugar is low, a diabetic person can start to feel hungry, sweaty, agitated and aggressive. As the blood sugar falls further, the person will eventually become confused and lose consciousness. This has obvious safety implications.

Secondly, the long term complications from diabetes itself (blindness, nerve damage, kidney damage, heart disease) can directly affect work ability. For example, diabetes increases the risk of having a heart attack.

Impact of work on diabetes
The nature of the work can affect the management of diabetes. The following are some factors that can increase the difficulty of maintaining good diabetic control:

• Shiftwork
• Very physically demanding work
• Hot work
• Isolation from medical services
• Irregular meals
• Excessive alcohol

Minimising the risk

Diabetes is a common condition. Diabetes is not an automatic bar to employment and many diabetics are employed gainfully in a variety of industries including traditionally ‘high risk’ industries such as transport, rail and mining.

The risk of problems at work can be minimised by a careful risk assessment at the preplacement stage and regular medical review thereafter. Factors that the doctor takes into consideration are:

• Type of diabetes (insulin dependent, non-insulin dependent)
• Nature of diabetic control, compliance with treatment and self-monitoring of sugar levels
• Risk of episodes of low blood sugar (hypoglycaemia)
• Presence of diabetic complications
• Information from the treating doctor and treating specialist
• Nature of the work (eg. safety critical roles, shiftwork, remote work)
• Arrangements for ongoing medical management

Further reading
Guidance on assessing fitness to work for diabetics in safety critical roles are available in

Assessing fitness to drive – Commercial drivers

Rail guidelines

Dr. Roger Lai
MBBS (Hons)
Occupational Medicine Registrar
OccuMED Consulting