spirometry

1
????? ? ???
???? ???? ??? ????? ?? ??? ? ????????? ????
2

• ?????? ??? ??? ???????? ?? ???? ??? ?????
  ????????? ???????? ?? ?? ???? ???? ?????.

3

• ?? ???? ?? ????? ??? ??????? ????? ?? ??? ???
  ????????? ??????? ?????? ?? ?? ???? ? ????? ?????
  ????? ??? ?????.
• ?? ???? ???? ????? ??? ????????? ?? ??? ???????
  ?? ???????? ?????? ?? ???? ???? ???.

4
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6
????? ????? ?? ?????

• ???? 8 ????? ????? ????? ?? ????? ?????.
• ??? ?????? ??????? ?????? ??? ????? ?? ???? ???.
• ?? ???? ???? ? ?? ?????? ?? ????? ?? ????? ??? ??
  ?? ???? ?? ???? ??????? ????? ???.

7
?? ????? ?? ????? ???2?????? 55 ?? 65 ????? ???
??? ?? ????? 45 ?? 50????? ???.
8
High blood sugar

• ????? ????? ?? ??? ????? ??? ????? ? ???? ???
  ???? ????? ? ?? ?????? ???? ??? ??? ????? ?????.

9
FPG

• Normal IFG DM

10
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HbA1C ??? ???????? ?????? OGTT?? 75 ??? ????? ??? ???????? ????? ?????
gt6.5 ??? ?????? 200 ????? ?? ????? 2hpg 200 ?? ???? FPG 126 ?????
5.7-6.4 140 2hpg lt 200 100 FPG 126 ??? ????? (IFG,IGT)
lt5.6 2hpg lt 140 FPG lt 100 ?????
13
??????? ?? ?????

• ?? ??????? ???? ?? ????? IGT?????? ?? ??????
  ????? ??? ?? ??????? ??? ????? ?? ??? 5-2 ?????
  ?? ????? ????? ??????.

14

• WHO??? ???? ???? ?? 15-10 ??? ????? ???? ??????
  ????? ?? ???????? ????? ????? ? ??????? ?? ?????
  ????? ??.

15
???????

• ????? ???? ?????
• ?????? ?????? ??? ???
• ????? ?? ??????? ?????
• ????? ?? ??????? ?????

16
????? ???? ?????

• ???? ??? ????? 7-5
• ???? ?????? ????
• ???? ?????? ??????? ??? ?????
• ?????? ?????? ????
• ????

17

• ?? ????? ?????? ????? ???? ? ?????? ??? ??????
  ????? ?????? ?? 60 ?? ???? ?????? ????? ??? ??
  ??????? ???.

18
????????

• ?? ???? ?????????? ?????
• ????? ????? 40 ???
• ????? ????? 30 ??? ???
• ???? ????? 30 ??? ?? ?????
• ???? ??????

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????? ????? 30 ??? ???

• BMI 25
• BP 140/90
• TG 250 , HDLlt 25
• ????? ?????? ?????
• ????? ????? ?? ????? ?????
• ??? ???? ???? ?? ?? ?????
• ????? ????????? ?????
• PCOS ?????

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???? ????? 30 ??? ?? ?????

• GDM
• ???? ????? ????? 4 ???????
• ???? ????
• 2??? ?? ????? ??? ??? ?? ????

21

Chronic Complications of Diabetes Mellitus
Microvascular
Eye disease
Retinopathy (nonproliferative/proliferative)
Macular edema
Neuropathy
Sensory and motor (mono- and polyneuropathy)
Autonomic
Nephropathy
Macrovascular
Coronary heart disease
Peripheral arterial disease
Cerebrovascular disease
Other
Gastrointestinal (gastroparesis, diarrhea)
Genitourinary (uropathy/sexual dysfunction)
Dermatologic
Infectious
Cataracts
Glaucoma
Periodontal disease
Hearing loss
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????

• ?????????????????? ???? ????? ?????.
• ????? ?????? ???? ?????? ????? ? ??????? ?????
  ?????? ?????.
• ???? ??? ???? ?? ??? ? ?? ?????? ?? ????? ??
  ????? ??? ????.
• ?????? ?? ?? ?? ??? ??? ????? ???????? ???? ???
  ??? ???? ?????? ???? ?? ?????? ???? ?? ????? ?
  ??? ?????? ??? ?????.

23
???? ?? ????? ????? ????? ???

• ????? ??? ???? ????? ????? ????? ??? ????? ?????
  ???. ???? ?? BMI 35???? ??? ???? ?????? ?????
  ???. ???? ????? ?????? ?????? ??? ? ??????? ??
  ????? ?? ???.

24
???? ?????

• ?? ?? ??? ????? ?????? ?? ?? ?????? ?? ?????
  ????? ??????? ??????? ???.
• ?? ????? Orlistat ?? ?? ??? ?? ??? ???? ???? ???
  ?????? ??????? ???.
• ????? ?? ???? ???? ?? ??????? ?????? ???? ?????
  ???.

25
????? ?? ?? ??????? ????? ?? ?????
????????? ???? ?????????? ?????????? ???? ????????? ?? ?????? ???????? ????
??????? ??????????? ???????? ?? ?????? ??? ?????? ??? ??????
???? ??? ????? ?? ???? ?????? ??? ? ????? ??????? ??? ??? ???? ?? ???? ??????? ???? ????? ???? ????? ??? ?? ???? ???????
26
??????? ???? ????? ?????

• ??????? ?????? ?? ????? ???????? ?? ???? ??????
  ???? ???????? ???? ?? ?? ?????????? ?? ??????????
  ?? ???????? ???? ??
• ??????? ?????? ??? ??? ????????
• ??????? ?????? ???

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• ????? ????? ??? ????? ??? ????? ???. ??? ?? 2 ???
  ?????? FBS ??? ?? ?? ??????. ??? ???? ???? ????
  ?? ???? ???? ????? ??????. ???? ?? ?????? ????
  ????? ?? ??????? ?? ???? ???????? ???? ??? ???
  ???? ?????? ? ?????? ????????? ???? ????.

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The focus should be to intensify pharmacological
treatment

• GLP-1 Analoga
• Exenatide
• Liraglutide

• DPPIV-Inhibitors
• Sitaglipin
• Vildagliptin
• Saxagliptin
• Linagliptin

Insulinotropic agents
GI-tract
Brain

• Meglitinides
• Repaglinide
• Nateglinide

Pancreas
Pancreas
Pancreas
Insulin
Pancreas

• Sulfonylurea
• Glibencamid
• Glimepiride

• Biguanidas

Liver
GUT
Adipose lissue
Liver
Muscle

• Thiazolidindiones
• Pioglitazone
• Rosiglitazone

• Alpha glucosidase inhibities (AGI)
• Acarbose
• Miglitol

Non- insulinotropic agents
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????? ?? ????? ??????

• ?? ???? ????? ????? ????? ???? ????? ???? ???.
• ????? ?? ????? ?????? ?? ???? ???????? ????
  ?????. ??? ???????????????? ???? ?? ?????? ????
  ?????? ???? ????? ?? ?? ?????? ???? ???? ??????
  ???.(2-1 ??????? ?? ?? ?? ??? ?? ???)

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Glycemic management of type 2 DM
31
??????????

• ???? ?? ??????? ???? ?? ?????? ????? ? ????
  ?????? ?? ?????????? ????? ???? ???. (??????
  ????? ??? ?? ?????? ?? ??????? ????)

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??? ?? ???? ????? ??????

• FBS
• HbA1C
• LFT
• Cr

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??????

• ????? ???? ? ????? ??????? ?????? ?? ?? ???? ????
  FBS ?????? ???? ??? ? ?? ???? ?? ??? ???? ?????
  ????.

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?? ??????? ??? ????? ?????? ? ????? ???

• ?? 3 ??? FBS- HbA1C - 2hpp
• ?? 6 ???Cr LFT

35
??????? ??????

• ?? ???? ?? ????? ???????? ????? ??? ?? ??? 80-70
  ??????? ??? ?? 10-7 ??? ?? ????? ?? ??????? ????
  ???? ??????.

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????????????? ???? ???????

• FBSgt300
• HbA1Cgt10
• ???????
• ???? ?????
• ????? ???? ??????? ??????
• ?????? ?? ?? ??????? ????? ?????? ? ??????? ?????
  ???? ????? ???? ??? ??? ?? HA1C???? ?????? ?? ???
  ???.

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????? ??

• ???? ??????? ???? ??? ?? ???? ?????? ?????? ????
  ? ??????? ?????? ????? ???? ???.
• ???? ??? ???? ???? ????? ?? ??????? ????? ??
  ????????? ????? ???.
• ????? ????? ???? ???? ??? ?? ????? ????? ????
  ???? ????.
• FBS???? ?????? ????? ???.

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Guidelines for Ongoing Medical Care for Patients
with Diabetes
Self-monitoring of blood glucose (individualized frequency)
A1C testing (24 times/year)
Patient education in diabetes management (annual)
Medical nutrition therapy and education (annual)
Eye examination (annual)
Foot examination (12 times/year by physician daily by patient)
Screening for diabetic nephropathy (annual)
Blood pressure measurement (quarterly)
Lipid profile and serum creatinine (estimate GFR) (annual)
Influenza/pneumococcal immunizations
Consider antiplatelet therapy
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????? ????? ?? ?????? ?????

• ?? ???? ??? ???? LDL???? 36 ???? ?? ??????
  ?????? ????
• ???? ??mmHg 10???? ??? ????????? ???? ???? 15
  ??? ??? ?? ??? ????????? ???? ????? ?? 10 ???
  ?????
• ?? ???? ?? 1 ??HA1C ???? 21 ??? ??? ?? ???
  ????? ? 14 ?? ??? MI??10 ??? ?????

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Treatment Goals for Adults with Diabetes Treatment Goals for Adults with Diabetes
Index Goal
Glycemic control
A1C lt7.0
Pre-prandial capillary plasma glucose 3.97.2 mmol/L (70130 mg/dL)
Peak postprandial capillary plasma glucose lt10.0 lt1.7 mmol/L (lt180 mg/dL)
Blood pressure lt130/80
lipids
Low-density lipoprotein lt2.6 mmol/L (100 mg/dL)
High-density lipoprotein gt1 mmol/L (40 mg/dL) in men gt1.3 mmol/L (50 mg/dL) in women
Triglycerides lt1.7 mmol/L (150 mg/dL)
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Diabetes impairment(1/2)

• The risk of hypoglycemia and visual impairment
  may legitimately debar those with poorly
  controlled type 1 diabetes from jobs where safety
  is an important factor,

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Diabetes impairment(2/2)

• ,but people with diabetes are not invalids and
  most can work normally and should not be
  discriminated against in job selection.
  

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Type 1

• If untreated, will develop sever hyperglycemia
  and ketonemia, resulting in dehydration, weight
  loss and sever weakness, progressing into stupor,
  coma and death.(usually begins in young but may
  occur at any age)

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Type 2

• In early years, these peoples do not develop
  sever hyperglycemia and symptoms. In later when
  insulin production falls hyperglycemic symptoms
  become more evident.(generally over 40 years old)

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Disability Discrimination Act(1/2)

• Within the meaning of the DDA, type 1 DM must be
  regarded as a disability.
• Type 2 may be different, as this people may be
  asymptomatic and have no complication.

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Disability Discrimination Act(2/2)

• Where complication such as retinopathy exist,
  they will be covered by the act.

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DDA

• ?? ??? 20 ? ??? ??? 21 ?????? ?? ?????? ??? ???
  ????? ????.
• ??? ??? ?????? ?? ??? ???? ????? ???? disability
  ? ????? ??????? ????????.
• DDA??? ???? ??? ???? ???? ???????? ????????
  ?????? ? ???? ?? ??? ???? ?????.
• ?????? ?????? ?? ???? ????? ????? ? ?????? ?????.

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Summary of Act(1/2)

• Mobility
• Manual dexterity
• Physical co-ordination
• Continence
• The ability of life, carry, or otherwise move
  every day objects
• Hearing, speech, eyesight

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Summary of Act(2/2)

• Memory or ability to concentrate, learn or
  understand
• Perception of risk of physical danger
  
• (long term is defined) lasting for 12 months
  or more or
• For the rest of the affected person
• Or likely to recure if in remission

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DDA

• ??????? ??????? ??? ?????? ?? ??????? ???? ???
  ????? ???? ???. (???? ?????? ?? ??? 2002 ??? ????
  ????? ???????? ?? ?????? ????? ??????? ?? ???
  2010)
• ?? ?????? ??? ????? (American Disability Act)??
  ???? ????ADA??? ??? ???. )??? 4)

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Disability

• One is considered disabled only if unable to
  perform abroad class of occupations rather than
  just one job.
• Example LBP, restriction lifting no more than
  50 pounds.

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• BMI???? ?? ?????????? ??????? ???? disability???
  ??? ??? ????? ??.
• ????? ??? ????? ??? AMA guide ?? ??? impairment
  ????? ????? ? ??? ????? ???? ?????? ???????
  ??????? ???? ?? ???? ???? ????? ????
  combine?????.
• .

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????? ??? 1 ?? ??? 2 ?? ?? ??????? ????? ?????
?????? ? ????? ??? ????? ?? ?? ???????? ????? ????????? ???? ?? ? ?????????? ???????? ????? ????????? ???? ??? ????? ????? ??????? ????? ??? ? ??? ???? ????? ? ???? ??????? ??????
-??? ???? ??? -??? ???? ??? -??? ???? ??? -??? ???? -????? ??????????? ?? 2 ??? ???? -????? ????? ???? -?? ??? ??? ???? ????? ?? ??????? ?? ?????? ????? ?? ????? ????? ????? ??????? (???? ?? ??????) ?? ?? ?? ??? ????? -???? ?????? ?????? ?????? ?? ????????? ?????? ???????? ?? ??? ???????? ????? ??? ?? ???? ?????? ?? ??? ??? ?????? ????? ???. -????? ?????????? ?? 6 ??? ???? -????? ????? ???? -?? ??? ??? ???? ????? ?? ??????? ?? ?????? ????? ?? ????? ????? ????? ???????(???? ?? ??????) ?? ?? ????? ????? -???? ?????? ?????? ?????? ?? ????????? ?????? ???????? ?? ??? ???????? ????? ??? ?? ???? ?????? ?? ??? ??? ?????? ????? ???.
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???????? ????? ????????? ???? ?? ? ?????????? ???????? ????? ????????? ???? ??? ????? ????? ??????? ????? ??? ? ??? ???? ????? ? ???? ??????? ??????? ?????
-??? ?? ???? ?? ?? ???? ????? ???? ?? 5/10 ???? -??? ?????? ?? ?? ???? ????? ???? ?? 7/10 ? ??? ??? ???? ?? ?? ???? ????? ???? ?? 2/10 ???? ??? ??????
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????? ??? ?????? ?? ???????
?????? ? ????? ??? ????? ?? ?? ???????? ????? ????????? ???? ?? ? ?????????? ???????? ????? ????????? ???? ?? ????? ????? ??????? ????? ??? ???? ????? ? ???? ??????? ??????
-??? ???? -??? ??? ?? ????? ????? -???? ?????? ?????? ?????? ?? ????????? ?????? ???????? ?? ??? ???????? ????? ??? ?? ???? ?????? ?? ??? ??? ?????? ????? ???. -????? ??????????? ?? 2 ??? ???? -???? ?????? ?????? ?????? ?? ????????? ?????? ???????? ?? ??? ???????? ????? ??? ?? ???? ?????? ?? ??? ??? ?????? ????? ???. -????? ??????????? ?? 6 ??? ????
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????? ??? FBS????? ????? ?? ?? ?? ?? ??????? FBS
126???? ??? ????FBS ? HbA1c????? ?????? ??
???????? ????? ????? ????? ??? ?? FBS ????
HbA1c?? ?????.
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????? ???? HbA1c FBS
???? ???? lt7 lt126
???? ???? ? ????? ????? ??? ???? ?? ????? ????? ??? ??? lt7 gt126
???? ???? 6 ???? ?? ?? ?????? ?? ????? ????? ?? ??? ???? ??? ? ????? ??? 7-10 _
???? ???? ?? ???? ?? ?? ?????? ?? ????? ????? ?? ??? ???? ??? ? ????? ??? gt10 _
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??????? ???? ?? ????? ???????

• FBS ?? ????? ?? pre-employment lab test ?????
  ?????.(??? ???? ???? NIOSH)
• ?????? ???? ??? ??? ?? ????? 45 ??? ?? 3 ????
  ?? ???? ??? ???? ???? ???? ????????

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Written medical standards

• Unfortunately Written medical standards are
  rarely available for most jobs.
• Medical standards aid the physician in making
  decision on whether an applicant can or can not
  perform the job safely.

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restriclimitationstions limitations
medical restrictions functional limitations  
Person with diabetes Should avoid rotating shift work because of the adverse effects of circadian rhythm disruption on glycemic control None Fully capable of performing all tasks
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impairment

• The main chronic complications of DM are
  associated impairments.

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Criteria for Rating Permanent Impairment Due to
DM(5th)
Class 1(0-5) Class 2(6-10) Class 3(11-20) Class 4(21-40)
Type 2 DM can be controlled by diet May or may not have microangiopathy as retinopathy or albuminuria gt30mg/dl Type 2 DM Satisfactory control requires both diet medication (oral or insulin) Microangiopathy, may or may not visual impairment Type 1 DM, with or without Microangiopathy Type 1 DM Hypoglycemia or hyperglycemia occurs frequently despite efforts of both patient physician
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Example

• 4o years old woman.
• History Onset of DM1 20 years earlier.
  Originally presented with polydypsia, polyuria,
  weigh loss, BS350.
• Current symptoms Occasional visual changes with
  floaters, flashes decreased visual acuity.

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• PX Ophthalmologic exam Background retinopathy.
• Lab HbA1c 10.5
• DX DM1 with diabetic microangiopathy.

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Impairment?

• Impairmenting rate 20 Impairment of the whole
  person.
• Comment Referral to ophthalmologist
• (combine any visual impairment with endocrine
  impairment)

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Pancreas(islet of langerhans)

• Dx DM, Insulinoma, reactive hypoglycemia
• End organ damage Eyes, kidneys, skin,
• cardiovascular, nervous system.

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Criteria for Rating Impairment Due to DM(6th)
class 0 1 2 3 4
WPI() 0 1-5 6-10 11-15 16-28
Severity grade() 1. 2.3.4.5 ( ABCDE ) 6.7.8.9.10 ( ABCDE ) 11.12.13.14.15 (ABCDE) 16.19.22.25.28 (ABCDE)
History History of IFG, dose not require treat DM /or metabolic Syn treated with a single oral DM well controlled with 2-3 oral agents or insulin DM well controlled with 4 oral agents or use of insulin with oral agents DM that is not consistently controlled despite use of any treatment
HbA1c() lt6 6-6.5 6.6-8 8.1-10 gt10
BOTC 0 point 1-5 6-10 11-15 16
(Burden Of Treatment Compliance)
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Example

• Subject 40- year-old man
• HX DM discovered on a routine medical exam.
• Current symptoms Feels well, lost 24.5Kg in the
  last year. Able to perform all desired
  activities. Weight has been stable over the past
  6 months.
• PX Moderately obese. No diabetic retinopathy.
  Reminder of exam normal.
• Lab 1 glycosuria. No albuminuria. FBS160.
  after 6 months on a special diet, weight
  normal, FBS 110, 12 months after diet, FBS90,
  HbA1c5.5.

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• DX Type 2 DM controlled by diet, without
  microangiopathy.
• BOTC No points for medication, but 2 points for
  dietary modification.
• Impairment BTOC class1 but HbA1c class 0, WPI
  2.

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Association with occupation environment

• ?? ?????? ???? ???? ??? ???? ????? ??? ?? ??
  ?????? ?? ?? Agent Orange?? ???? ???? ??? ?????
  ??? ???.
• ??????? ??????? ??? ??? ???????? ??? ???? ????
  ?? ?????????????? ? ?? ????? ?????? ?? ???????
  ?????.

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Agent Orange

• AOHerbicide Orange Agent LNX
• Used by U.S military in Vietnam Warfare
• U.S military army helicopter spraying A.O over
  the Vietnamese agricultural lands.

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Association with occupation environment

• Rodenticide Vacur
• After human ingestion
• Anti-islet cell antibodies

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TCDD

• TCDD in workers exposed caused DM.
• ?????????? ?????? ????

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Susceptible population or synergistic toxicity

• Certain metals, solvents, gases, pesticides,
  substances used in plastics are known to be
  peripheral nervous system toxin.
• The disease may be produce more sever symptoms.
• Not any toxin to confirm this theory.

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77
???? ???? ???? ?? ?????? ??????????

• ??? ????? ??????? ??? ??? ?? ????? ????(?? ?????
  ????? ?? ????? task?????)
• ??? ????? ??? ??? ???? ????? ???? ???? ????? ??
  ?????? ???? ??? ? ?????? ???????
• ??? ????? ??? ???? ???? ??? ????? ???????
• ??? ?????? ?? ???? ??? ???? ????? ?? ??????? ??
  ????? ?????

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The work record of people with DM

• An individual basis for DM considered jointly by
  an occupational physician and diabetologist. (FFW)

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Advisory services

• The diabetologist can profiled detailed medical
  information,
• While the occupational physician is best placed
  to assess the suitability for particular
  occupation.
• For especially difficult decisions, the combine
  opinion of diabetologist and occupational
  medicine are particularly useful.

80
Suitability(periodic exam)

• Suitability for employment should be re-assessed
  annually by both an occupational physician and a
  diabetologist.

81

• pre post
  change
• FVC 4 4.26
  7
• FEV1 2.91 3.32
  14
• FEV1/ FVC 72.8 77.9
  7
• FEF25-75 2.32 3.09
  31

Thanks for your attention