# Draft paper for publication as a Commentary (IMH for authors)

ABSTRACT
Using the Glucometer finger-prick test in the maritime clinics and for personal control on board opens up a new frontier of screening and prevention for Prediabetes and Diabetes Type 2 in a much wider perspective than before. The Prediabetes-Remission Study now accepts either A1c or the Fasting/Postprandial Glucometer test as the inclusion criterion. Personal health coaching provides tailored support to individuals at risk of developing diabetes and empower them to take control of their health using the Glucometers, weight- and bloodpressure self-control onboard.
Keywords: Prediabetes, remission, reversion, maritime, seafarers, health-coaching, lifestyle, protocol

# Title: Glucometers for diagnosis of Prediabetes and Type 2 Diabetes in the maritime clinics.

Prediabetes, as part of the metabolic syndrome is a critical condition that indicates elevated blood sugar levels, although not yet high enough to be classified as Type 2 Diabetes Mellitus (T2D). This condition significantly increases the risk of progression to T2D, even without any prediabetes symptoms.(1) The growing evidence that Prediabetes can be reversed through lifestyle changes, forms the basis for the Prediabetes-Remission Study with the objectives: To educate and encourage seafarers to reverse their newly diagnosed prediabetes in a 16-week prediabetes coaching and learning intervention study – and to apply the course materials in educational programs on Prediabetes/T2D and Hypertension for seafarers and other maritime personnel.(2).
However, the early diagnosis of prediabetes is unfortunately often prohibited due to lack of the A1c test the maritime health clinics. Now the use of the cheaper Glucometer finger-prick test opens up for a new frontier in maritime health by screening for Prediabetes and early start of prevention in a much wider perspective than before. A glucometer is a handheld device used to measure the concentration of glucose in the blood. The inclusion criteria for the Prediabetes-Remission Study is updated to include either A1c, where this is possible, or Fasting- or Postprandial Glucometer test. The availability of Glucometers in the ship’s medicine chest and the seafarers bringing their personal test Glucometer kits on board, is encouraged. The use of glucometers in maritime medicine could greatly benefit health monitoring in developing countries for early diagnostics and prevention of prediabetes and T2D as was done excellently in Nepal recently.(3)
Internationally, the screening criteria for Prediabetes and T2D are homogenous based on A1c and/or the Fasting and Postprandial glucose laboratory blood test (Table 1). However, since the A1c blood test is not available in most of the maritime medical clinics, there is a need for specific criteria that allow the use of the cheaper Glucometers for diagnostics of Prediabetes and T2D.
The inclusing criteria for the Prediabetes-Remission study was originally A1c prediabetes values of 5.7–6.4% / (39–47 mmol/mol. However, being aware the A1c test is often not available, candidates for the Prediabetes-Remission Study cannot be selected and invited to the study and the searers don’t now not whe er they might have prediabetes or not for early prevention.
Our proposed criteria for the Glucometer mediated diagnostics for prediabetes (Table 2) is based on the American Diabetes Association (ADA) criteria for the Fasting glucose level and the Postprandial glucose level based on the two hour Oral Glucose Tolerance (OGTT) Test level(4)
By implementation of the economically feasible glucometer finger-prick test (0.20-0.27USD/test) (Website) with quick results, the seafarer and fishermen can travel to their destinations for embarcation immediately. They will also learn how to use the Glucometer for self control to adjust their dietary- and fitness status. Those with Glucometer based elevated fasting blood glucose and/or postprandial finger prick test (Table 2) can be referred to the GPs or visit a medical clinic in the next port for a A1c measurement. To participate in the study, the seafarers need to bring a glucometer, a blood pressure measurement and a travel weight scale on board for weekly self-testing (estimated total costs for all 3 items: 60-92 USD Website shopping). Application for funding of the 3 items is relevant where the ship does not bring them on board.
Using the cheap and rapid glucometer test could help to eliminate health disparities by promoting early diagnosis of prediabetes and comorbidities for seafarers and all the population in the developing countries. (5)
Keywords
Health disparities, Glucometer, A1c, prediabetes, type 2 diabetes, seafarers, fishermen.
Acknowledgments
To all colleagues and friends who supported strengthening the prevention of chronic non-infectious diseases, like Prediabetes, T2D, and the co-morbidities.
Conflict of interest: None declared.
References
1. Mulla IG, Anjankar A, Pratinidhi S, Agrawal SV, Gundpatil D, Lambe SD. Prediabetes: A Benign Intermediate Stage or a Risk Factor in Itself? Cureus. 2024 Jun;16(6):e63186.
2. Jensen OC. Invitation to do remission of pre-diabetes to normoglycemia. International Maritime Health. 2024;75(2):135–6.
3. Gyawali B, Sharma R, Mishra SR, Neupane D, Vaidya A, Sandbæk A, et al. Effectiveness of a Female Community Health Volunteer-Delivered Intervention in Reducing Blood Glucose Among Adults With Type 2 Diabetes: An Open-Label, Cluster Randomized Clinical Trial. JAMA Netw Open. 2021 Feb 1;4(2):e2035799.
4. Diabetes Diagnosis & Tests | ADA [Internet]. [cited 2024 Aug 21]. Available from: https://diabetes.org/about-diabetes/diagnosis
5. Guthrie BJ. Low cost blood glucose meters as an appropriate healthcare technology for developing countries. Vol. 2012, IET Conference Publications. 2012. 1 p.
6. Chandra Prabhakar M, Halder P. Reliability and accuracy of bedside capillary blood glucose measurement by glucometers compared to venous blood glucose in critically ill patients: A facility based cross-sectional study. Clinical Nutrition ESPEN. 2024 Apr 1;60:24–30.
7. Katz LB, Stewart L, Guthrie B, Cameron H. Patient Satisfaction With a New, High Accuracy Blood Glucose Meter That Provides Personalized Guidance, Insight, and Encouragement. J Diabetes Sci Technol. 2020 Mar;14(2):318–23.
8. Chen H, Yao Q, Dong Y, Tang Z, Li R, Cai B, et al. The accuracy evaluation of four blood glucose monitoring systems according to ISO 15197:2003 and ISO 15197:2013 criteria. Prim Care Diabetes. 2019 Jun;13(3):252–8.
9. Andes LJ, Cheng YJ, Rolka DB, Gregg EW, Imperatore G. Prevalence of Prediabetes Among Adolescents and Young Adults in the United States, 2005-2016. JAMA Pediatrics. 2020 Feb 3;174(2):e194498.
10. Spurr S, Bally J, Hill P, Gray K, Newman P, Hutton A. Exploring the Prevalence of Undiagnosed Prediabetes, Type 2 Diabetes Mellitus, and Risk Factors in Adolescents: A Systematic Review. Journal of Pediatric Nursing: Nursing Care of Children and Families. 2020 Jan 1;50:94–104.
11. Liu J, Li Y, Zhang D, Yi SS, Liu J. Trends in Prediabetes Among Youths in the US From 1999 Through 2018. JAMA Pediatrics. 2022 Jun 1;176(6):608–11.
12. Kushwaha S, Srivastava R, Bhadada SK, Khanna P. Prevalence of pre-diabetes and diabetes among school-age children and adolescents of India: A brief report. Diabetes Res Clin Pract. 2023 Aug;202:110738.
13. Hamrahian S, Falkner B. Approach to Hypertension in Adolescents and Young Adults. Current Cardiology Reports. 2022 Feb 1;24.
14. Indicator Metadata Registry Details [Internet]. [cited 2024 Aug 20]. Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/2380
Table 1. Criteria for the screening and diagnosis of prediabetes and diabetes :
| Diagnostic markers (1) | Prediabetes | Diabetes |
| American Diabetes Association (ADA) 2022 (4) |||
| A1c | 5.7–6.4% (39–47 mmol/mol) | ≥6.5% (48 mmol/mol) |
| Fasting plasma glucose level | 100–125 mg/dL (5.6–6.9 mmol/L) | ≥ 126 mg/dL (7.0 mmol/L) |
| World Health Organisation (WHO)(14) | | |
| Fasting plasma glucose level | 100–125 mg/dL (6.1–6.9 mmol/L) | ≥126 mg/dL (7.0 mmol/L) |
Table 2 Proposed criteria for screening for prediabetes and diabetes using the Glucometers (a) :
| Diagnostic markers | Prediabetes | Diabetes |
| Fasting plasma glucose level (8h) | 100-125 mg/dL (5,6-6.9 mmol/l). (4) | ≥126 mg/dL (7.0 mmol/L) |
| Postprandial glucose levels (b) | 140-199 mg/dL (7.8-11 mmol/L) (4) | ≥200 mg/dL (11.1 mmol/L) |
(a) To be repeated (b) ≥ 2 hours after a meal

## Occupational Health WHO

Occupational safety and health (OSH)is a multidisciplinary field concerned with the safety, health, and welfare of people at work. Occupational medicine, is a part of Occupational Health which deals with the maintenance of health in the workplace, including the prevention and treatment of diseases and injuries. It is the branch of clinical medicine most active in the field of occupational health and safety.

## Work place risk assessment

One of the most important tools in occupational health is hazard identification in the workplace. This is the process of systematic identifying all hazards in the workplace to be used for prioritation of the prevention actions. A job hazard analysis is one component of the larger commitment of a safety and health management system. Work place risk identification is the share point for all types of profesionals working in occupational health and safety. https://en.wikipedia.org/wiki/Job_safety_analysis

## Knowledge on the incidence/prevalence, causes and prevention occupational diseases

Scientific studies on occupational medicine in developing countries is scares. The task is to select, search and make a review of epidemiological studies on selected specific type of industry, type of diseases, the exposures and the prevention. Select for example studies on dust exposure, respiratory health problems in agriculture and other industries, the students learn and produce useful learning materials. Ergonomic work hazards and rheumatological diseases is another example. Click to open the page to add more knowledge of your personal interest: Work related diseases in the tropics, exposures and prevention This would be an excellent student´s task. The students can produce important learning materials and learn at the same time (revision and update) Occupational Diseases, Diagnosis, Causality, Prevention and Prognosis

## Under-reporting of occupational diseases

Under-reporting of occupational diseases is a problem globally. As an example the under-reporting rate of musculo-skeletal diseases in 10 regions of France was estimated at 59% for CTS, 73% for elbow MSD, 69% for shoulder MSD, and 63% for lumbar spine MSD. Several methods can be used to solve this problem. It would be an excellent training for students to do a systematic review in the scientific articles e for useful methods on haoe to establish systematic registration of work-related diseases.

## Preventive healthcare

Occupational medicine is a medical specialty that aims for the prevention among workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health need to be studied so epidemiological research is an important part of the speciality; placing and maintenance of a worker in an occupational environment adapted to his physiological and psychological equipment and the promotion and maintenance of physical, mental and social well-being of workers.

## Social determinants of health

The association between socio-economic status and health has been known for centuries. The socioeconomic derterminants of health is a sine qua non in all medical specialties including occupational medical research and clinical practice. Socio-economic status is related to mainly three indicators: education, income and occupational status. Powerty is a strong indicator for mental and physical occupational diseases Today the field of social medicine is most commonly addressed by public health efforts to understand what are known as social determinants of health. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Hippocrates sought to show a connection between the climate of the area and the diseases that plagued that area, still he also must have known the impact of the socio-economic indicators for disease

## Natural history of disease and exposure

Natural history of disease refers to the progression of a disease process in an individual over time, in the absence of treatment. Most of the diseases have a characteristic natural history with variations in the specific manifestations of disease individual to individual and influenced by preventive and therapeutic measures.

## Critical thinking

Critical thinking and asking questions is significant in academics, research and especially important in occupational medicine. One basic question for the physicians is to ask the patient about his/her job and to pursue the causalities of the disease in order to propose prevention in the branch and for the patient. Critical thinking is closely related to Evidence Based Medicine, as described below

## Evidence-Based Medicine

Evidence based medical practice is an approach to clinical decision making that has gained considerable interest and influence during the decades. The phrase 'evidence based medicine' originated in the 1980s as a way of describing the problem based learning approach

## Medical diagnosis

Medical diagnostics is "sine qua non" in occupational medical practice with patients and epidemiological research. The occupational clinical diagnosis is closely related to the establishment of the causality, as the diagnostic and compensation of an occupational disease involve the diagnosis and the probability of the etiology as well as needed for the proper prevention.

## Medical causality

Medical causality or etiology is "sine qua non" in medical practice with patients and research for adequate treatment and prevention with roots back to Aristotle Wikipedia Aristotle. Especially for occupational medicine, the development of causality is closely related to the diagnostic process of the single patients and epidemiological research. The importance of the work as possible contribution factor to many diseases was stated by Doctor B.Ramazinni from Italy some 300 years agoArticle in Wikipedia

## Medical prognosis

Occupational medical prognosis depends the seriousness and the type of the disease and the possibility to change/remove the hazardous working conditions. If the hazardous exposures cannot be removed, the patient is advised to change job function, change to other type of industry and be trained to a new job function, or if nothing else is possible to leave the labor market. Whatever happens, the work related disease should be reported to the relevant authorities and with financial compensation be given in relevant cases.

## Code of Medical Ethics

The international Code of Medical Ethics forms the basic content of the specific demands of ethics in all the medical specialities. The Spanish version is more elaborated than the English Spanish version. The ethics for occupational physicians are normally seen from two main viewpoints: 1) the legal standing and ethics in job execution; 2) ethics in research on occupational medicine. Among lots of guidelines we choose for a start the International Code of Ethics for Occupational Health Professionals from the ICOH code of ethics and the translation into Spanish ICOH Ethics code in Spanish.

## Occupational diseases

The under-reporting of occupational accidents and occupational diseases, globally is well recognised. However, the degree of underreporting is especially high in Latinamerca.For 2010 in Panama (1,5 million economic active) 66 occupational diseases. For comparison in Denmark with 2,6 million economic actives there were reported about 20000 occupational diseases. Of course any comparison depends on a lot of different conditions on the labor market, of the definition of the inclusion criteria and the degree of underreporting. These issues will be debated in the text.

## Occupational accidents

The under-reporting of occupational accidents and occupational diseases, globally is well recognised. However, the degree of underreporting is especially high in Latinamerca.For 2010 in Panama (1,5 million economic active) there were reported 10,311 occupational accidents, 66 occupational diseases and 135 fatal accidents. For comparison in Denmark with 2,6 million economic actives there were reported about 20000 occupational diseases, 44000 occupational accidents (at least 1 day off from work) and only 39 fatal accidents. It is supposed that the underreporting for non-fatal accidents is about 50%. From 10 different information sources the estimate was 8.3 per 100,000 in 2005 100,000 employed

## Occupational medicine in general practice

General practice and occupational medicine share close similarities in their focus on disease prevention and health promotion. The workforce constitutes a significant part of the population and thus the patient load of a typical primary healthcare practice. Moreover, with an ageing population and rising retirement age, we can expect that there will be an increasing number of health issues to be addressed among older working people. Both occupational and non-occupational factors are important in determining an individual's health. Thus, family physicians need to adequately understand occupational medicine and vice versa .Most occupational health care will continue to be provided by family physicians, who may also be the physicians closest to the workers and their families. There are many opportunities for family physicians to develop their skills in occupational health care and to incorporate occupational medicine into their practices

## Occupational psychiatry

Organisational and occupational psychiatry (OOP) is the subspecialty of psychiatry that focuses on work, its importance in the lives of individuals and work organizations. The psychiatrists do many important occupational health functions. For example they help the patients to stay in the job or to get another change position without the mental hazards they have been exposed to. As the psychiatry include much occupational medicine, a specific chapter will be written about the occupational psychiatry. However there is a gap of knowledge on how much mental disease and symptoms are related to job hazards not only in Panamá but globally. Therefore it is found relevant to do a prevalence study of the proportion of mental disease associated with job hazards. The study is similar to a study planned for general practice. The objective is to answer the questions: How many per cents of the mental health disease can be related to hazards in the work-place? Why should the study be done a psychiatry hospital and not in general practice? The answer is that the patients in the psychiatric clinics are selected via the General Practice. So the main part of the patients have an established psychiatric diagnosis. The questionnaire page 2 is different than that for general practice. On page two the psychiatrist will mark the general area of the ICD-10 diagnosis and not the International Classification of Primary Care (ICPC) that is used for general practice. This has the methodical advance that the diagnosis is on a specialist level and less patients is needed to make conclusions about the percentage of work-related psychiatric diseases. Psychiatry questionnaire % related to work

## Occupational dermatology

(the linked page is just one of many private clinics) Dermatologic complaints are among the most common occupational illnesses. Many occupational exposures can cause skin disease. The most frequent occupational skin disease is contact dermatitis. This may be either irritant or allergic contact dermatitis but often is a combination of both. Irritations may occur from chemical factors including caustics, solvents, detergents, and even plain water. Physical factors that cause irritation include friction, repeated trauma, heat, and low humidity. Contact allergy may be caused by several thousand chemicals and substances, but relatively few agents are common causes of allergic contact dermatitis. Some of the more important include metals (nickel, cobalt, chrome), preservatives, rubber additives, and plastic components (epoxy resins, acrylates). Contact urticaria is an immediate hypersensitivity reaction distinct from allergic contact dermatitis. Latex allergy is the most well-known cause of immunologic contact urticaria, but many other substances, usually protein-based, can also cause contact urticaria. A variety of other skin conditions can also be occupationally related. Skin cancer caused by ultraviolet light (sunlight) exposure or certain chemicals can be attributed in some cases to occupational exposure. Chloracne, a specific acneiform eruption caused by exposure to various halogenated hydrocarbons, is a sensitive indicator of systemic exposure to these agents. Various cutaneous infections are seen more commonly in some occupations, such as warts in meat cutters or erysipelothrix in fishermen. Cutaneous hypopigmentation (chemical leukoderma) can be seen in certain workers who are exposed to depigmenting agents such as phenolic germicides. Systemic sclerosis has been occasionally seen in association with certain job exposures. In evaluating a patient with a possible occupational dermatosis, accurate diagnosis is essential. Certain diagnostic tests, especially the patch test, are important adjuncts to the clinical evaluation. Consideration of nonoccupational components of the disease (confounders) is necessary to arrive at a proper assessment of causation. Fowler Jr JF. Occupational dermatology. Current Problems in Dermatology. 1998 Nov;10(6):211–44.

## The needs for public-,scientific- and political interest in occupational medicine

Occupational health remains neglected in developing countries because of competing social, economic, and political challenges. Occupational health research in developing countries should recognize the social and political context of work relations, especially the fact that the majority of developing countries lack the political mechanisms to translate scientific findings into effective policies.

## Impact of unions and safety representatives

Research on safety representatives effectiveness and impact on occupational health lend support to the notion that trade unions, joint arrangements, and trade union representation on occupational health and safety are associated with higher levels of compliance, lower workplace injury rates and ill-health problems, and better overall health and safety performance Unions importance for occupational health & safety (Shannon et al., 1997; Milgate et al., 2002; Walters 2006).

## Action research in the workplace

Bernardino Ramazzini (1633–1714) published his most famous book 1713, De Morbis Artificum Diatriba (Diseases of workers) Ramazzini . The book is a descriptive account of working conditions in more than fifty occupations and of the diseases of workers in these occupations. Ramazzini's observations were accurate and precise, although he provided no numerical information and made statements implying rather than expressing levels of risk, so readers could not determine, for example, whether pottery was a safer occupation than knife grinding. His accounts remain a good model for occupational health. We want to continue in his footsteps by describing the working conditions in the diferent occupations and the diseases of the workers but in a modernized form, action research. The descriptions will be based on the workers own descriptions and proposals for prevention and the existing scientific evidence about the exposure hazards and the health risks. The objective is to prepare the health professionals with knowledge about the workers´daily conditions so they are well prepared to establish the correct diagnosis, identify the causal factors and so to give the best treatment and guide for prevention. And possibly notify the disease or symptoms as work-related where relevant. Further it is the aim to increase the political interest for prevention of the specific problems.

## Community intervention programs

Health interventions applied on a community-wide basis have come into increasing use in public health and epidemiologic research over the past decades. The emphasis on interventions focusing on communities has created distinct methodological challenges for researchers. Effective program evaluation is a systematic way to improve and account for public health actions. Evaluation involves procedures that are useful, feasible, ethical, and accurate
It is important to develop a tool to measure success and to include these results in the promotion campaign. Even if the program is part of the global campain, it is essetial to establish goals and measure the progress against your goals. By reviewing the program’s successes and failures you can see how it has been the most effective. In conclusion there is a need to add research programs to the interventions. This could be an attractive research area for public health students in Panama and students from outside!

## Post-grade training courses

The intention is to offer short theoretical and practical courses, that are of relevance to improve the quality of the daily practice in not alone occupational medicine but all areas of medical and health practices and research

## 1. Epidemiology

Research is an indispensable part of occupational medicine and the epidemiology is traditionally viewed as the main research tool for occupational medical researchers, practitioners and administrators. Though many other disciplines are important to occupational medicine the epidemiology is often described as the ‘basic science of public health and occupational medicine. Unfortunately the university teaching in epidemiology rarely give the students sufficient interest and understanding of the basic principles of epidemiology. Therefore we want to amend the gab of skills and knowledge by offering an integrated course in Epidemiology. The course forms the scientific base for the other three courses (see below) This course will include epidemiology as an integrated part of EBM, OM and basic research. [[File:EBMfr.jpg|200px|th

## 2. Evidence Based Medicine

The participants will learn to pose relevant questions related to medical diagnosis, treatment, prevention and research. Further to search the relevant literature, read and get the information and be able to communicate the message and the answer to the question effectively and systematically. Some useful existing reviews and guidelines for occupational medicine diagnosis will be presented and explained how they were developed. https://en.wikipedia.org/wiki/Evidence-based_medicine

## 3. Occupational Medicine

We are planning to offer short OM courses for students, nurses, physicians at the hospitals, general practice and other health professionals. Later we pretend to offer more advanced courses when the course materials are sufficiently developed. The courses will be structured like the content of this Handbook. The intention is that the participants will add new knowledge to the Handbook and get a valuable learning at the same time. The course content reflect the content of the Handbook. The aim of the course is to improve the diagnostics, treatment and prevention of occupational diseases in Panamá by application of the Evidence Based Medicine. After the course the participants will be better to establish the diagnosis and give attention about the notification as occupational diseases. Also be better to try to discover any relevant relation between the work hazards (psychological, physical, chemical, ergonomic etc) and the symptoms. This in order to give the best advice on how to solve the problems for the patient and how to prevent the same could happen for others. The participant will learn to edit and to add text and new chapters to the Wikibook. The homework could be to write and add a chapter to this book, for example 1) diagnostic guidelines for occupational asthma or 2) description of the work processes and health risk factors for urban bus drivers.

### Overview of the content of the course
## 4. Basic research course for health professionals

We are planning to offer a basic research training course for health professionals in the clinics and in the health administrations. The participants should have access to patients (handout the questionnaires) or access to administrative health data. The participants will stepwise learn how to plan and perform an epidemiological prevalence study based on a given questionnaire. See the questionnaires for general practice, dermatology and psychiatry. Training in the relevant computer programs like Epidata is included. The aim of the training is that the participants will add knowledge to the Handbook and get a relevant learning at the same time. Patient records in general practice (and health registers in the public administrations) are unique resources that can provide evidence to help to improve their understanding of research, improve patient diagnostics (attention to occupational medicine), patient treatment and prevention. We hope the course will be a valuable for general practitioners, administrative health professionals, medical and nurse students and other students so that many of them will enter in to active research activity. After the course the participants will be able to perform their own research, do literature searches and publish articles.
MODULE 1

## Education in Health Science research methodology

MODULE 2

## Module 2: Diagnosis, causality, prevention, and prognosis of occupational diseases

MODULE 3 MODULE 4

## Early diagnosis, prognosis, follow-up and prevention guidelines
### General Practice

Medico_familiar_Encuesta_sobre_enfermedades_del_trabajo

### Dermatology

Encuesta dermatologia

### Psychiatry

Encuesta psychiatria

### Research plan for each speciality

* Phase 1 Prevalence study of suspected occupational diseases (in general practice, dermatology, psychatry and rheumatology) 5 main group of industries with the standard questionnaire
* Phase 2 Prevalence study of suspected occupational diseases in the specific job categories, use of Standard Industrial classification
* Phase 3 Intervention study: Instruction is given to the physians, the list of ILO and the country specific recognised occupational diseases and compared without instruction

## Preventive Health Science journal Open here

The course participants are invited to publish their thesis as a scientific article in this journal. The academic requirements are less than for international indexed journals, but still contribute with important new knowledge for the development of the occupational medicine in Panama. The articles can later be published in revised form in indexed international scientific journals. Articles with relevant new original knowledge will be added to the Handbook. So there is a dynamic relation between the journal, the research courses and the Occupational Medicine Wikibook.

# Research protocols
## Rules for research in the CSS hospitals in Panama

The documents needed for a scientific study in the CSS hospitals are the following:
* Formulario para someter protocolos de investigación
* Declaración del Investigador.
* Guia para la redacción los protocolos de investigación - OPS
* Guia para redactar consetimiento informado
* Registro de Responsabilidades

## 1. Estimate of the size of the chronic renal disease of undetermined origin (CKDu) problem in Panama

La insuficiencia renal crónica de causas no tradicionales

## 2 Clinical Case (CKDu)

Occupational Clinica Case Study protocol

## 3 Ethiological study on risk factors for chronic renal disease of undetermined origine

Etiological case-control study protocol

## References

* ↑ Rivière S, Penven E, Cadéac-Birman H, Roquelaure Y, Valenty M. Underreporting of musculoskeletal disorders in 10 regions in France in 2009. Am J Ind Med. 2014 Oct;57(10):1174–80.
* ↑ Feinstein JS. The relationship between socioeconomic status and health: a review of the literature. Milbank Q. 1993;71(2):279–322.
* ↑ 1. scientificamerican1205-92.pdf [Internet]. [cited 2016 Apr 19]. Available from: http://www.nature.com.proxy1-bib.sdu.dk:2048/scientificamerican/journal/v293/n6/pdf/scientificamerican1205-92.pdf
* ↑ Cruz-Coke R. [Hippocratic philosophy]. Rev Med Chil. 1999 May;127(5):611–4.
* ↑ Sally Bennett and John W. Bennett The process of evidence based practice in occupational therapy: Informing clinical decision. Australian Occupational Therapy Journal (2000), 47, 171-180
* ↑ Mora AM, Mora-Mora MG, Partanen T, Wesseling C. Registration of fatal occupational injuries in Costa Rica, 2005-2006. Int J Occup Environ Health. 2011 Sep;17(3):243–50.
* ↑ Vinda P, Acosta H, Alpírez M, Ureña K, Gordón C. Perfil de Salud Ocupacional Panamá. 2013 [cited 2014 Aug 7]; Available from: http://repositorio.una.ac.cr/handle/11056/8631
* ↑ Mora AM, Mora-Mora MG, Partanen T, Wesseling C. Registration of fatal occupational injuries in Costa Rica, 2005-2006. Int J Occup Environ Health. 2011 Sep;17(3):243–50.
* ↑ Vinda P, Acosta H, Alpírez M, Ureña K, Gordón C. Perfil de Salud Ocupacional Panamá. 2013 [cited 2014 Aug 7]; Available from: http://repositorio.una.ac.cr/handle/11056/8631
* ↑ López-Bonilla IM1, Flores-Urbina L, Partanen T, Wesseling C. Fatal occupational injuries in Nicaragua, 2005. Int J Occup Environ Health. 2011 Jul-Sep;17(3):238-42.
* ↑ Sng J, Lee SM, Koh D. Bridging the gap between occupational medicine and family medicine. Ann Acad Med Singap. 2008 Feb;37(2):158–61.
* ↑ http://www.sciencedirect.com/science/article/pii/S104004869890000X
* ↑ Iman A. Nuwayhid.Occupational Health Research in Developing Countries: A Partner for Social Justice. Am J Public Health. 2004 November; 94(11): 1916–1921.
* ↑ Johansson M, Partanen T. Role of Trade Unions in Workplace Health Promotion. International Journal of Health Services. 2002 Jan;32(1):179–93.
* ↑ CDC - A Framework for Program Evaluation [Internet]. [cited 2014 Jun 19]. Available from: http://www.cdc.gov/EVAL/framework/
* ↑ Gouda HN, Powles JW. The science of epidemiology and the methods needed for public health assessments: a review of epidemiology textbooks. BMC Public Health. 2014 Feb 10;14(1):139.
Content :
| Week 1 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 2 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 3 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 4 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list |
| Week 5 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 6 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 7 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 8 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list xxx |
| Week 9 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 10 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 11 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 12 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 13 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list |
| Week 14 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 15 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 16 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 17 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list xxx |
Content :
| Week 18 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 19 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 20 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 21 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list |
| Week 22 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 23 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 24 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 25 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list xxx |
| Week 26 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 27 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 28 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 29 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list |
| Week 30 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 31 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 32 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 33 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list xxx |
Content :
| Week 34 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 35 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 36 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 37 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list |
| Week 38 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 39 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 40 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 41 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list xxx |
| Week 42 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 43 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 44 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 45 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list |
| Week 46 | Welcome, Orientation of the program Next week self-study: Stress and Depression, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_stress http://workplacementalhealth.org/Mental-Health-Topics/Depression Search 5 articles and make a 200-word review with a reference list |
| Week 47 | Experience from last week Post-traumatic stress disorder (PTSD) |
| Self-study next week 5 hours | https://es.wikipedia.org/wiki/Trastorno_por_estr%C3%A9s_postraum%C3%A1tico Search articles from occupational burnout and make a 200-words review with reference list |
| Week 48 | Experience from last week Burnout workplace |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Occupational_burnout Search articles from occupational burnout and make a 200-words review with reference list |
| Week 49 | Experience from last week Carpal tunnel syndrome, work-related |
| Self-study next week 5 hours | https://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Search 5 articles from occupational burnout and make a 200-words review with reference list xxx |