The level of anxiety and depression before/after surgery.
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\r\n\t[4] P. Dombi, Z. Pápa, J. Vogelsang et al. Strong-field nano-optics. Reviews of Modern Physics, vol. 92, 2020, pp. 025003-1 – 025003-66.
\r\n\t[5] N. C. Panoiu, W. E. I. Sha, D.Y. Lei, G.-C. Li. Nonlinear optics in plasmonic nanostructures. Journal of Optics, 20, 2018, pp. 1-36.
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\r\n\t[8] Iam Choon Khoo. Nonlinear optics, active plasmonics and metamaterials with liquid crystals. Progress in Quantum Electronics, vol. 38, 2014, pp. 77- 117.
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Although Rozanski et al. extensively reviewed and found that anxiety and depression were psychological risk factors for coronary artery disease (CAD), and that depression was particularly a predictor of cardiac events, many research studies have been focused on psychological outcomes of patients with heart failure, myocardial infraction, and acute coronary syndromes among CAD [1]. Results of cardiovascular surgery have improved remarkably in recent years but psychological aspect in patients who underwent cardiovascular surgery has been less considered.
\nThe advances in both surgical and cardiopulmonary bypass perfusion techniques regarding cardiovascular surgery have been reducing mortality and relieving from patients’ symptoms. However, cognitive and psychological deficit has been concerning [2–4]. Selnes and Gottesman suggested that late cognitive changes do occur and these changes are not specific to coronary artery bypass grafting surgery (CABG) or more specifically to the use of cardiopulmonary bypass [2].
\nTherefore, out of various kinds of cardiovascular surgery using cardiopulmonary bypass, we found out coronary artery bypass grafting surgery (CABG), valve surgery (VS), ventricular device surgery (VDS), and thoracic aortic surgery (TAS) in terms of the adults’ main cardiovascular surgery and then reviewed the psychological outcomes of patients with these four surgical procedures. The articles in English language journals were collected by using PubMed (accessed on August 26, 2016) with keywords as follows: CABG, VS, TAS, VDS, cardiovascular surgery, depression, and anxiety. We also described nonpharmacological intervention research.
\nCoronary artery bypass grafting (CABG) surgery is performed more frequently than other cardiovascular surgeries. Tully and Baker reviewed about depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery [5]. They suggested the followings: (1) the approximate percentage of coronary artery bypass graft (CABG) surgery patients affected by depression (i.e., major, minor, dysthymia) was between 30 and 40% immediately leading up to and after surgery, (2) both depression and anxiety raised the risk for mortality and morbidity after CABG surgery independent of medical factors, although the behavioral and biological mechanisms are poorly understood, and (3) although neither depression nor anxiety seem to obviously affect neuropsychological dysfunction, depression contributes to a risk for incident delirium.
\nCompared to psychological condition immediately leading up to and after CABG surgery, the midterm or long-term psychological condition in CABG patients was limited. The long-term psychological research in CABG patients using a hospital anxiety and depression scale (HADS) has only been performed by Ben-Noun [6], who reported HADS results in 132 CABG patients in Israel 7–22 years after surgery. He found the following: (1) anxiety: 31 (23.5%) patients were severe, and two (1.5%) were mild, and (2) depression: 25 (18.9%) patients were severe and three (2.3%) were mild. We examined the psychological outcome of patients at intervals of 1–5 years after CABG using HADS and found that six (8.7%) of them were mild anxiety and five (7.2%) were severe anxiety [7]. Regarding to depression, seven (10.1%) were mild and seven (10.1%) were severe. Compared with his findings, our figures for patients in the significant range (HAD-A>10) of both anxiety and depression were lower, while our figures for patients in the borderline range (7<HAD-A<11) were higher. Ben-Noun’s study was conducted in Israel and there are long-running conflicts between the Palestinian and the Israeli people. Mataria et al. have found that the chronic and entrenched conflict over generations has resulted in a lower QOL for the population living in the occupied Palestinian territory [8]. Although it might be simplistic to suggest that these factors could influence levels of anxiety and depression, we thought that they might have been a contributing influence to the psychological aspects of the subjects of Ben-Noun’s study.
\n\n\nTable 1\n presents the trends of HADS anxiety and depression in studies preCABG to postCABG [4, 9–12]. Some studies have found that CABG patients without any intervention programs after surgery had improved scores of both anxiety and depression 3–6 months after CABG [4, 10, 11]. The means for anxiety 3–6 months after surgery in these studies ranged from 4.2 to 4.9, similar to our results, and for depression from 2.6 to 4.25. Our interpretation of these findings was that anxiety would decrease considerably for about 6 months after CABG and then level out for some time. In contrast, values for depression in our study ranged on the high side. That might have been influenced somewhat by life events because most patients were elderly and had survived several years after their operation [13].
\nReferences/nation | \nNo. of subject | \nAnxiety and depression score: means (standard deviations) | \nResults | \n||||
---|---|---|---|---|---|---|---|
Before surgery/treatment | \n1–2 months after surgery/treatment | \n3–6 months after surgery/treatment | \n7–11 months after surgery/treatment | \n1 year or more after surgery/treatment | \n|||
\nCross-sectional study\n | \n|||||||
Okamoto et al. [7]/Japan | \n49 pts: TAS79 pts: CABGAnxiety & depression: HADS | \n\n | \n | \n | \n | 1–5 years | \n\n |
Oterhals et al.[17]/Denmark | \n593 pts: AVR369 pts: AVR+CABGAnxiety & depression: HADS | \n\n | \n | \n | \n | 1–13 years | \n\n |
\nLongitudinal study\n | \n|||||||
Thornton et al. [4]/UK | \n71 male pts; CABGAnxiety & depression: HADS | \n1 week before surgeryA: 6.4D: 4.7 | \n2 monthsA: 5.3D: 3.4 | \n6 monthsA: 4.9D: 2.6 | \n\n | \n | Anxiety and depression decreased | \n
Hallas et al. [9]/UK | \n22 pts: CABGAnxiety & depression: HADS | \n1 week before surgeryA: 8.4(4.6)D: 5.7(2.9) | \n2 monthsA: 3.4(2.3)D: 2.0(2.2) | \n\n | \n | \n | Anxiety and depression decreased | \n
Höfer et al. [10]/Austria | \n432 pts: CAD (CMT: 96 pts, PCI: 60 pts, CABG: 121pts)Anxiety & depression: HADS | \nBefore angiography/treatment | \n1 month | \n3 months | \n\n | \n | Anxiety and depression in CABG decreased | \n
Amonn et al. [25]/Swiitzerland | \n51 pts: transcatheter aortic valve implantation (TAVI)93 pts: surgical aortic valve replacement (AVR)Anxiety & depression: HADS | \n\n | \n | \n | \n | A mean follow-up of 15 + 10 months | \n\n |
Brouwers et al. [32]/Netherlands | \n54 pts: LVADAnxiety: Generalized Anxiety Disorder, GAD-7 (range: 0–21, cutoff: 10/9)Depression: Patient Health Questionnaires, PHQ-9 (range: 0–27, cutoff;10/9) | \n\n | 3–4 weeksA: 4.4(4.8)D: 6.9(4.5) | \n3 and 6 months: data was not shown | \n\n | 12 months: data was not shown | \nHigher scores on anxiety and depression over time were associated with poor health status | \n
Reynard et al. [29]/USA | \n66 pts: LVADAnxiety: Generalized Anxiety Disorder, GAD-7 (range: 0–21, cutoff: 10/9)Depression: Patient Health questionnaire, PHQ-9 (range: 0–27, cutoff;10/9) | \nBefore implantationA: 10.4(6.2)D: 12.1(7.5) | \nFollow-up (median:54 days, mean:126 days)A: 3.4(4.3)D: 5.7(5.4) | \n\n | \n | \n | Anxiety and depression scores improved after LVAD implantation and remained stable up to 1 year | \n
\nRandomized controlled trial\n | \n|||||||
Furze et al.[42]/UK | \nI. 100 pts: first elective CABGC: 104 pts: first elective CABGIntervention: cognitive-behavioral intervention, nurse counselingAnxiety: the State Trait Anxiety Inventory, STAI (range: 20–80, cutoff: 55/54)Depression: cardiac depression scale, CDS (range: 26–182, cutoff: 95 or 100) | \nBaseline: placed on the elective waiting list | \n\n | \n | \n | \n | Anxiety and depression in the intervention group decreased | \n
Rollman et al. [43]/USA | \nI_1: 150 depressed postCABG, telephone-delivered collaborative careI_2: 151 depressed post-CABG, usual careC: 151 nondepressed post-CABG, usual careDepression: the 17-items Hamilton Rating scale for depression (range: 0–68, cutoff: 8/7) | \n\n | DischargeI_ | \n\n | 8 months | \n\n | Anxiety and depression in the I_1 group decreased compared to the I_2 group | \n
Lie et al. [11]/Norway | \n185 pts: elective CABGIntervention: a structured informational and psychological support by a skilled nurse at each patient\'s homeAnxiety & depression: HADS | \n\n | \n6 weeksI | \n6 monthsI | \n\n | \n | Anxiety and depression in both group decreased.Not significant differences in two groups | \n
Trzcieniecka-Green et al. [12]/UK | \n50 pts: MI50 pts: CABGIntervention: therapist-guided relaxation and stress managementAnxiety & depression: HADS | \n\n | 2–3 months (Baseline) | \n5–6 months (3 months)I | \n8–9 months (6 months) | \n\n | Anxiety and depression in the intervention group decreased | \n
\nNonrandomized controlled trial\n | \n|||||||
Kugler et al. [36]/Germany | \nI: 34 LVADC: 36 LVADIntervention: nutrition management, physical recondition program, psychosocial support and counselingAnxiety & depression: HADS | \n\n | 6 weeks | \n6 months: shown in only graph | \n\n | 12 and 18 months: shown in only graph | \nAnxiety level in the control group increased over time relative to the intervention group.No significant changes and differences in depression level were detected for both groups. | \n
The level of anxiety and depression before/after surgery.
A: HADS anxiety; D: HADS depression; I: intervention group, C:control; TAS: thoracic aortic surgery, CABG: coronary artery bypass grafting, CMT: continuous medical treatment, PCI: percutaneous coronary intervention group.
In our study, the prevalence of anxiety and depression in patients more than 1 year after CABG was similar to other reported studies. The exceptions were Ben-Noun’s study [6] in Israel with the added effect of war-like conditions. Although most of the previous research on psychological aspects in CABG patients examined them within 1 year of the operation, in which case proximity to the surgical event might have had a great influence, our findings help to understand midterm psychological transitions, and suggest the possible need for further research such as a longitudinal study carried out over several years to better quantify the process of psychological transition.
\nNot only CABG but valve surgery (VS) procedures also are more common surgical treatment for cardiovascular disease, and some patients need both procedures. There were less psychological studies of patients with VS than those of patients with CABG.
\nThe postoperative psychological research studies revealed that some of patients with VS and/or CABG had anxiety and depression, which had associated with their self-management performance, readmission. Williams et al found that about 30% of patients before CABG and/or VS had moderate to high levels of anxiety [14]. Fredericks et al. reviewed systematically about psychological condition of patients with CABG and/or VS and revealed that moderate to severe levels of anxiety and depression existed during the first month of home recovery and appeared to have an effect on their performance of selfmanagement behaviors [15]. Sibilitz et al. conveyed a nationwide cohort study on patients 1 year after valve surgery in Denmark and found that anxiety and depression were present in 13.6 and 13.8%, respectively (hospital anxiety and depression scale score ≥8) and that higher HADS-D scores was one of the associated factors to readmission [16]. Oterhals et al. examined mid-term/long-term selfreported health status of patients 1 year or more after aortic valve replacement and/or CABG. The mean assessment interval since surgery was 6 years (range: 1–13 years) [17]. Compared to patients 1–5 years after CABG or TAS, the averages of both anxiety and depression were low (\nTable 1\n). That might be because the interval period after surgery in Oterhals’s study was much longer and psychological conditions of dead patients after surgery were unknown, who was afraid of moderate/severe level of anxiety/depression.
\nThere were a few prospective studies to patients with VS and/or CABG. Preoperative anxiety and/or depression would predict postoperative patient’s QOL [18–20], persistent depression [21], worse physical condition [18], mortality, and mobidity [14]. These studies did not show the mean of anxiety and depression of patients with VS and/or CABG.
\nSince transcatheter valve implantation (TVI) was carried out for the first time in 2002 [22], its technology has been developing speedily. TVI is less-invasive treatment than valve surgery and more patients with a high-risk for valve surgery have been undergoing TVI. Psychological research about patients who underwent TVI also has begun recently. Elmalem et al. found that 37% of patients had improved anxiety and depression both 1 month and 6 months after TVI [23]. Two studies reported that anxiety/depression had become better after TVI but there were no differences about anxiety/depression between TVI and valve surgery patients after adjustment for baseline characteristics [24, 25]. Amonn et al. assessed anxiety and depression using HADS after a mean follow-up of 15 + 10 months and found that anxiety disorder was present in 5.7% of AVR and 12.9% of TAVI patients and that depression disorder was apparent in 17.1% of AVR and 12.9% of TAVI patients [25].
\nLeft ventricular assist devices (LVADs) have been developing dramatically, and patient with end-stage heart failure can be treated it as a destination therapy or as a bridge to transplant. Continuous-flow LVADs have reduced incidence of morbidity and mortality [26]. The number of psychological research has been increasing gradually.
\nBrouwers et al. reviewed systematically 16 quantitative studies with a sample size ≥10 that examined the impact of LVAD therapy, including both pulsatile devices and continuous-flow devices, on patients’ health status and anxiety/depression [27]. They suggested that patients had improved their health status, anxiety, and depression in the first few months after LVAD implantation and that those scores of patients receiving LVAD therapy were still below for physical, social, and emotional functioning compared with transplant recipients. After Brouwer’s study, some studies [28, 29] found decreasing of anxiety/depression after introducing LVADs, but two studies [30, 31], whose sample size were about 10, did not found the significant improvement in anxiety and depression. Higher scores on anxiety/depression over time were associated with poor health status [32] and rehospitalization [33]. Family of patients with LVAD was also increasing anxiety or depression level after implantation [34, 35].
\nNonrandomized intervention research was carried out by Kugler et al. [36]. It used behavior-modifying strategies and consisted of nutrition management by a dietician, physical reconditioning program, psychosocial support, and counseling. Thirty-four patients were intervention group and 36 patients were the control group. Baseline was 6 weeks after implantation and patients were reassessed at 6, 12, and 18 months during their LVAD support time. The anxiety level in the control group increased over time relative to the intervention group. No significant changes and differences in depression level were detected. Physical health status scores in the intervention group increased significantly but mental health status scores in both groups did not change.
\nPatients’ psychological status would improve after LVAD implantation. That might be because they relieve from bad physical conditions. Heart failure patients are not always in good physical conditions and have psychological problems. After implantation, patients need anticoagulation treatment and monitoring function of devices, etc., in addition to maintain healthier lifestyle for secondary prevention. Moreover, they have several risk-like malfunction device, infection, neurological dysfunction ,etc. So patients need both physical and psychological care, and further research needs to develop better programs for their support.
\nInstead of recent improvement of the surgical treatment of cardiovascular diseases, the hospital mortality rate for thoracic aortic surgery (TAS) is still high (approximately 10.5% in Japan) compared to coronary artery bypass grafting (CABG) surgery (approximately 2.2% in Japan) [37]. Some adverse complications of TAS can be extremely serious (e.g., brain injury, spinal cord injury, and bleeding, etc.). TAS is included in the same surgical repertoire as CABG in terms of open heart surgery, but it has a worse postoperative outcome. A few studies on psychological outcome have been conducted in TAS patients [38].
\nWe surveyed 190 patients who underwent TAS or CABG at intervals of 1–5 years after the procedure, and then analyzed 128 patients with TAS (n = 49) or CABG (n = 79) as the primary surgery. Psychological outcomes were assessed using the hospital anxiety and depression scale (HADS). The incidence of mild (8–10) anxiety in TAS and CABG patients was five (11.6) vs. six (8.7%), respectively, and depression was present in nine (19.1%) and seven (10.1%), respectively. The incidence of severe (11 and more over) anxiety in TAS and CABG patients was four (8.5) vs. seven (10.1%), respectively, and depression was present in four (8.5%) and seven (10.1%), respectively. Psychological outcomes scores for the two groups did not differ significantly [7].
\nFukuhara and Suzuki has reported that 5.6% of general Japanese (n = 2279) were suffering from severe depression using HADS on nationwide survey [39]. Kawakami reviewed that the prevalence of major depression among community-dwelling Japanese was 1–2% and estimated that of those who were seen in a general practice in Japan were approximately 5% [40]. He also reviewed that the prevalence of major depression among community-dwellers in the world was 1–8%. Compared to these community-based previous studies, not only CABG patients, as we mentioned in Section 2, but also TAS patients at intervals of 1–5 years after the procedure might have higher percentage of depressive patients. Psychological outcomes in TAS patients might improve in the same manner as CABG.
\nEmergency surgery was revealed only one significant factor associated with depression in TAS, and there was no significant associated factor about anxiety in TAS. Symptoms such as chest pain and fatigue were associated with both anxiety and depression in CABG. We found that the frequency in TAS survivors was nearly equal to that in CABG survivors and that variables related to anxiety or depression were not so apparent in TAS patients compared to CABG patients [7]. Interestingly, emergency operation was related to depression in TAS patients but not in CABG patients, suggesting that awareness of their disease before surgery was related to depression. Generally speaking, many patients with TAS are asymptomatic until diagnosis [41], and some of them had to undergo an emergency operation just after diagnosis. This might have had an influence on depression in TAS patients who had undergone an emergency operation even if they had survived for some time afterward. On the other hand, even if CABG patients had undergone an emergency operation, they were already aware of their own disease because of the presence of symptoms such as chest pain, and shortness-of-breath. This would have lessened the impact on their psychological wellbeing after surgery compared with the TAS patients.
\nInterestingly, there were no variables on symptoms significantly related to anxiety and depression in TAS patients but there were some significantly related to both anxiety and depression in CABG patients. As Herrmann has suggested in cardiac patients HADS anxiety or depression is correlated with some symptoms, but there have been differences across studies [13]. Although the reason why TAS patients with some symptoms were not positive for anxiety or depression remains unknown, we suggest that TAS patients might be less fearful of death postoperatively because the surgical removal or repair of their aortic lesion had, in their minds, reduced the risk of a cardiac event, even if they were still experiencing some symptoms.
\nSeveral behavioral and psychological RCT intervention research have been carried out toward patients with CABG. In this section, one research prior to CABG surgery and three ones after CABG surgery were introduced.
\nRegarding intervention before CABG surgery, Furze et al. evaluated the addition of a brief, cognitive-behavioral RCT intervention (the HeartOp Program) to routine nurse counseling for people waiting for CABG surgery [42]. When patients in the intervention group were introduced, for the first time, in the outpatient clinic by nurses using a booklet that covered cardiac myths and misconceptions, reducing risk factors for secondary prevention and recovery process after surgery. The HeartOp program also included relaxation program on audiotape or CD and a diary for recording activity and risk factor reduction goals. Nurses followed by telephone at 1, 3, and 6 weeks and then monthly until they were hospitalized. At 8 weeks after baseline, there were no differences in anxiety. There were significant differences in depression (cardiac depression scale: difference = 7.79, p = 0.008, 95% CI = 2.04–13.54). There was no data after CABG surgery.
\nRollman et al. had tested the effectiveness of an 8 month, biweekly, nurse-led telephone-delivered collaborative care for post-CABG depression vs. usual physician care in a randomized controlled trial [43]. A nurse telephoned to intervention patients and provided basic psychoeducation about depression and its impact on cardiac disease using a workbook. The nurse also adjusted antidepressant drugs prescribed under their physicians’ direction, monitoring, and referral to a mental health specialist if needed. Not only physical functioning (duke activity status index: delta=4.6 points, 95% CI=1.9-7.3) but also depression (Hamilton rating scale for depression: delta=3.1 points; 95% CI=1.3-4.9) had improved at 8 months after baseline. But the average HRQL and physical functioning of intervention patients did not recover that of the nondepressed comparison group.
\nLie et al. evaluated the effects of a home-based intervention program (HBIP) on anxiety and depression 6 months after CABG [11]. An HBIP for the intervention group was performed 2 and 4 weeks after surgery. A skilled nurse provided education about angina symptoms, medication, how to emergency attention, and so on with emotional support at 2 and 4 weeks after surgery. Although the improvements of anxiety and depression symptoms did not differ significantly between the groups, on 6-week and 6-month follow-ups, significant improvements in anxiety and depression symptoms were found in both groups.
\nTrzcieniecka-Green and Steptoe assessed the impact of group-based stress management training on emotional wellbeing, functional status, social activity, and chest pain in patients following acute myocardial infarction or coronary bypass surgery, within a randomized controlled trial [12]. Experimental patients underwent a 10 group-based weekly sessions about relaxation-based stress management program by therapists. Significantly greater improvements in both anxiety and depression were found in the experimental groups than control groups, and improvements were maintained at 6-month follow-up.
\nIn the nonpharmacology intervention, patients received behavioral and psychological education, etc., by a nurse or a therapist, and their depression would be improved after the intervention. Further research needed to clarify the effect of intervention group compared to control group.
\nThe prevalence of anxiety and depression of patients after cardiovascular surgeries has varied from 10 to 60% and has been likely higher than that of general people. Although there were several studies about patients within 6 months after surgery, studies about patients over 6 months after surgery were limited. From the limited studies about patients over 6 months after surgery, we guessed the followings about the trends of anxiety and depression of patients with CABG without any other additional intervention programs before/after surgery: (1) patients improved scores of anxiety and depression 3–6 months after surgery, (2) anxiety decreased considerably for about 6 months after CABG and then leveled out for some time, and (3) depression remained a bit higher 6 months and more after CABG. Patients’ longitudinal psychological conditions would have been influenced by not only invasive cardiovascular surgery using cardiopulmonary bypass perfusion techniques but also life events. The nonpharmacology intervention consisting of behavioral and psychological education, etc., by a nurse or a therapist would have improved patients’ psychological conditions. Further research needed to clarify the long-term psychological outcome and to develop the more effective intervention programs toward patients with cardiovascular surgery.
\nOccupational noise is the most common health hazard that is predominant in most workplaces. In a recent survey of working adults in Canada, 42% reported being exposed to hazardous noise levels in the workplace [1]. Exposure to excessive occupational noise can cause permanent hearing loss through sensory-neural damage in the cochlea. In general, hearing is first affected in a specific range of audible frequencies (3000 to 6000 Hz) and then spreads to higher and lower frequencies. Hearing loss is often accompanied by other long-term auditory effects, such as tinnitus (ringing in the ears); increased sensitivity to loud noise; and poorer frequency selectivity (i.e., decreased ability to hear sounds in background noise) compared to individuals with normal hearing. It can also cause other, non-auditory adverse effects, the most common been the cardiovascular (e.g., changes in heart rate, increasing blood pressure). Being a stressor, noise causes also important psychological effects [2].
Noise levels in the workplace vary in level, duration and frequency content. In general, they are of high levels and are persistent for most of the work shift. They can be continuous, impulsive or interrupted. From the frequency point of view, most are of the wide band type, although they can be rich in high or low frequencies, especially if vibrations are also present in the workplace.
Reduction of the sound levels and, consequently the risk of noise induced hearing loss is the objective of every hearing conservation program in the industrial world [3].
The approach to the reduction of the risk follows several steps. The first is finding and recognizing potentially hazardous areas in the workplace. This tends to be done as a result of personal, subjective observations, the principal been difficulties in understanding speech: people ask frequently questions and answers to be repeated. Complaints of excessive noise are also important indications that the noise may be so loud as to create a health risk. This first step is usually performed through a walk-through survey. Sometimes, spot noise level measurements are also done using a sound level meter.
Once the areas with high noise levels have been found, the next step is to quantify the risk. This is done by measuring the noise exposure of individuals or groups of workers working in those areas. This procedure is known as the exposure survey.
Also, the extent of the exposed population (number of exposed persons) is also quantified to find out the magnitud of the problem.
Noise exposure is a fundamental concept in assessing the risk from high noise levels.
It is universally accepted that hearing loss occurs as a consequence of long duration exposures to high noise levels. What is usually not too clear is how long the “long duration” is and how high are the “high noise levels”. There is no, however discussion regarding that the effect is caused by a combination of both: duration and level. The concept of noise exposure combines both causes and that makes it so important. As mentioned above, in determining the risk of occupational hearing loss, measuring workers’ noise exposure is an essential part of any hearing conservation program.
It all derives from an ISO standard [4] that estimates the probability of acquiring noise induced hearing loss after being exposed to a given noise exposure level for different periods of time. As an example, after 40 years of been exposed to 85 dBA for 8 hs a day, 50% of the population will acquire an average of extra 5 dB hearing loss between 500 Hz and 6 KHz, on top of the hearing loss due to age.
On the basis of the above statement, the limit of 85 dBA has been adopted almost internationally for a workday of 8 hs.
Reference [5] lists important standards from different institutions, related to noise exposure
Noise exposure is a complex combination of sound levels a person has been exposed to and the duration of each one of those sound levels [5, 6, 7, 8]. The closer analogy is to think in terms of noise energy that enters the persons’ ears and damage the delicate organ of hearing. So, two variables are involved there: sound levels and time duration [9].
There are several concepts involved that need to be explained and defined. Their understanding is essential when dealing with this issue.
Equivalent sound level, Leq, t in dBA is the first of them. The easier way to understand it is as follows: In real life, sound levels constantly vary with time. They rise when the worker is using a power tool and diminish between operations, while changing continuously. Leq, t is a kind of an “average”, constant sound level for the entire period of exposure (working) time, encompassing all “quiet” and “noisy” periods, with the same energy of the real one. It is defined as the value of a noise of constant sound level that contains the same total A-weighted acoustical energy as the sound of interest. In other words, while the real noise is of a varying sound level, the equivalent has a constant level of the same energy.
Now is the time to clarify the meaning of the letter “t” at the end of the Leq, t. It is there to signify that the Leq in question is for the period of time the worker has been exposed to.
Here we arrive at another important point that needs to be stated: whenever Leq is mentioned, the duration of the exposure (t), should also be stated. Otherwise the Leq has no meaning. This is not too difficult to understand as per the following example: suppose we have two workers. One of them is exposed every day to 90 dBA for 4 hs. The other one is exposed also to 90 dBA, but for 8 hs. It is obvious that the effect to the hearing of the second worker will be larger. In other words even though Leq,4 of the first is equal to the Leq,8 of the second, their effects are not the same.
The numerical definition of Leq, t is as follows: ten times the logarithm (base 10) of the time integral over a stated time, t hours, of the squared A-weighted sound pressure relative to 20 μPa, divided by that time.
Noise exposure level, Lex, T, in dBA, is another important measure. This is the one used to predict noise-induced hearing loss as per [4]. It is derived from the measured Leq,t by a simple adjustment to account for the longer or shorter duration of the workday on the workers’ hearing. In other words, it answers the following question: what will be the value of Leq,t if the energy that entered the worker’s ear during t hs would enter during 8 hs. By calculating Lex,T (with capital T), Leq,t for working days of different durations can be compared directly.
The following formula converts Leq,t into Lex,T:
Where: t is the duration of the actual exposure, in hr. and
T is the normalized duration, usually = 8 hr.
As an example, if a worker is exposed to 85 dBA for four hours a day (Leq,4), his exposure for a normalized 8 hs duration will be:
If, on the contrary, he is exposed to 85 dBA for 12 hs (Leq,12), his exposure for a normalized 8 hs duration will be:
The above example shows again how two workers with the same Leq,t, have different Leq,T and, consequently, different risk of hearing loss.
Mathematically, Lex,T is defined as ten times the logarithm (base 10) of the time integral of the squared A-weighted sound pressure relative to 20 μPa for the time actually worked, divided by T hours (usually the standardized shift duration of 8 h).
Finally, it has to be stated that while Leq,t is essentially measured, Leq,T is calculated from the Leq,t value. As it will be described further, the actual measuring instrument, the dosimeter, performs both the measurement and the calculation. Both values, Leq,t and Leq,T can be read on the same device. This greatly simplifies the task of the person performing the noise exposure survey. On the other hand, it can create misunderstandings if the operator does not has clear knowledge of the difference between Leq,t and Leq,T. As mentioned above, the one that is to be used when assessing the risk of hearing loss is the noise exposure level, Leq,T.
Noise dose in % is another important measure. Although the use of the noise dose is declining lately, many instruments still allow its measurement. The concept is familiar mainly to Occupational Hygienists and commonly used when dealing with hazardous substances. The idea is quite simple: it defines the relation between the amount of a substance absorbed by a person in a given period of time (usually 8 hs) and the maximum allowed by a local jurisdiction. For example, if this limit is set to 85 dBA for an exposure of 8 hs and the actual exposure for the same period of time has been 88 dBA, then his dose will be 200%1.
The following equation allows for the calculation of Leq,t from a given dose2:
where D = dose in % for 8 h.
T = duration of the daily exposure in hours.
Lc = criterion sound level in dBA3.
For example, a dose of 100% acquired during 4 hs (using Lc = 85 dBA) will result in
Criterion level (LC) in dBA is a constant sound level which, if it continues for the criterion duration (usually 8 hs), will result in the worker’s allowable noise exposure. ISO (the International Organization for Standardization), as well as most Canadian provinces [10] and NIOSH (the USA National Institute for Occupational Safety and Health) [11] has adopted LC = 85 dBA for 8 hs.
Exchange rate is the increase (decrease) in sound level for which permissible exposure time is halved (doubled)4.ISO, most Canadian provinces and NIOSH has adopted 3 dB exchange rate. So, for instance, if a person is allowed to have Lex(8) = 85 dBA for 8 hs, he is also allowed to Lex(4) = 88 dBA for 4 hs.
There are two issues involved in the measurement of Leq,t: one is related to the instrumentation involved and the other deals with the measurement technique and procedures. Although managing the instrument itself is a relatively simple task, the measurement procedure requires basic knowledge of noise as well as practical knowledge regarding where to put the dosimeter, for how long to measure, etc. Measuring noise exposure of groups is more complex and requires some knowledge on statistics to be able to decide how many individuals to sample and for how long.
Noise exposure can be measured using regular sound level meters and integrating sound level meters. However, there is a device specifically designed to measure Leq,t. It is the noise dosimeter. In its basic version it consists of an ¼” diameter microphone connected through a long cord to a container with the battery and the electronic components of the instrument. It also includs a readout device that allows for reading of the measured Leq,t. The microphone is to be attached close to the ear of the person whose exposure will be measured. The rest of the instrument is usually worn on the belt or in the shirt pocket (see photographs in Figure 1a and b).
Dosimeters with separate microphones.
Recently, manufactures have opted for compact, small size dosimeters called Noise Badges that contain both the microphone and the microprocessor of the instrument. By having the entire instrument in a single body, they eliminate the cord that is a nuisance and also can be a workplace hazard. Measurement results can still be read on the dosimeter itself. Thay can also be transmitted via Bluetooth technology to another device with facilities for recording for future use. This is especially handy when a noise exposure survey is carried out on several workers simultaneously, while each is carrying his own dosimeter. In some models, the receiver is also a charger for the batteries of all instruments. Figure 2a and b shows Noise Badges from two manufacturers.
Dosimeters with incorporated microphones (noise badges).
There is a wide variety or instruments in the market, able to perform different measurements and calculations. They all belong to the following two basic types of dosimeters: measuring and logging.
Measuring dosimeters allow for the straight measurement of Leq,t and, eventually calculate Lex,T. Although most allow for reading the results on the instruments themselves, some others relay on a separate measurement device. This is done to keep the results visible to the operators only.
Dosimeters measure sound levels at predetermined intervals of time. Measuring dosimeters do not allow for extracting individual readings, just the final results at the end of the measurement period. Logging dosimeters, on the contrary, allow for the extraction of individual Leq,t. In such a way one can obtain the entire history of the sound levels at predetermined time intervals. The results can then be downloaded into a computing device and shown as a graph, spreadsheet, etc. By analyzing the partial data, one can follow their variation with time. Then, by knowing where the person was located at different times of the day or what kind of operation he was involved in, one can pinpoint the important noise sources or operations. Noise history is a powerful tool used for the design of noise controls in the workplace.
Another advantage of the logging dosimeters is that by studying the noise history one can determine if there have been abnormal events and then “clean” false results caused from malingering or noises not normal in the particular workplace.
Measuring Leq,t of individuals using a dosimeter is a relatively simple exercise, generally explained in the manual supplied with the instrument5. Manuals contain also information on how to care and the main precautions that have to be taken to obtain proper results.
A most important task, often overlooked, is to inform the person(s) under test the reason for testing and how it will be done. In many instances not knowing the “why” and “how” lead to malingering and falls results. Often workers suspect that the instrument will in fact transmit their conversations to the supervisor. In other instances, some individuals created artificially loud noises to show levels that do not exist in reality.
After calibrating the instrument and ensuring that the batteries have enough charge to last during the testing period, the microphone of the dosimeter is attached close to the wearer’s ear (generally on the shoulder or close by, and switched on. Then the individual is sent to perform his tasks as usual. If the task is repetitive, then the measurement is done during a couple of repetitions, only. However, when the sound levels vary during the shift or if the worker works in different places, the measurement should last for the entire shift.
As mentioned above, if the measurement has been performed for the entire shift, then Lex,T is equal to Lex,t. In other words, the daily reading is his daily noise exposure, Lex,T. If that is not the case, then the Eq. [1] (page YYY) should be used to convert the measured Leq,t in Lex,T.
In many instances, there is a need to assess a group of workers that perform identical tasks or are located in the same environment. Providing each one of them with a dosimeter is not necessary or practical. There are procedures to be followed that reduce considerably the number of instruments needed and still obtain reliable, statistically significant results6.
Noise induced occupational hearing loss is the effect on a person being exposed to high noise levels for extended periods of time. Epidemiological data, used as bases for our present knowledge of hearing loss, were derived from populations working for many years in such high noise environments [12]. This is also the origin of the equal energy theory and the 3 dB exchange rate [13].
As explained above, when the measurement period t is different from T = 8 hs, Eq. 1 is to be used,. The formula is meant for 8 hs long work day where acoustical conditions repeat day after day, month after month, for the assumed 40 active years of a person.
Presently, in many occupations, the duration of the workday is 12 hs a day with several days off to equal to 40 hs a week or 80 hs every two weeks. The question is, shall we still use Eq. 1 with T = 8 hs? No official document exists for such a situation. However, common sense indicate that since the average duration of the workday is still T = 8 hs, (the average over the 2 or the 4 weeks), Eq. 1 is still valid and shall be used.
As an example [14], the total of hs worked by the musicians at the National Ballet of Canada is 350 hs. Therefore, the average Leq,t during their rehearsals/performances was corrected using Eq. 1 as follows:
Where t = 350 are the actual annual number of hours worked and.
T = 2000 the number of work hours in a year.
We do not really know what happens to ears exposed to 12 hs a day, for a 40 hs week. Nor we know about yearly exposures of less than 2000 hs, that is the average exposure resulting of 8 hs a day, 40 hs a week. We can only assume that the equal energy principle can be extended to cover exposures of different durations.
Using the equal energy principle, one can calculate exposures of different workday duration too. For example, if a worker whose workday is 8 hs and whose exposure measured for 5 hs was Leq,5 = 85 will be.
However, if his workday is t = 12 hs, then
In the case of temporary worker, that performs 350 hs a year, it will be t = 350 hs, T = 2000 hs and Eq. 1 will be
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