Compared to physician specialists, general practitioners, dentists and pharmacists were significantly more stressed. Reported stress was associated with job title, being a woman and long working hours. Also uncooperative patients and heavy workloads were significant problems. Being irritable and having headaches and common colds were the most frequent health issues.

Abstractchromate solution is helpful in making the specific diagnosis where doubt exists. Background -Exposure to chromium dur- (Thorax 1997;52:28-32) ing electroplating is a recognised though poorly characterised cause of occupational Keywords: occupational asthma, electroplating, asthma. The first series of such patients chrome, nickel, bronchial provocation testing. referred to a specialist occupational lung disease clinic is reported. Methods -The diagnosis of occupationalChromium is the major industrial contact allerasthma was made from a history of asthma gen that causes dermatitis 1 and is widely used with rest day improvement and confirmed in electroplating, dyes, leather tanning, and by specific bronchial provocation testing cement works. Single cases of asthma caused with potassium dichromate and nickel by chrome have been described since the ninechloride.teenth century and in the 1930s both Smith 2 Results -Seven workers had been exposed and Joules 3 reported chromium induced to chrome and nickel fumes from electro-asthma due to exposure at work. Since then plating for eight months to six years before there have been very few reports of respiratory asthma developed. One subject, although symptoms in workers associated with electroexposed for 11 years without symptoms, plating. developed asthma after a single severeElectroplating is the application of a metallic exposure during a ventilation failure. coating to articles using inorganic salts of metals This was the only subject who had never such as chromium or nickel. In the electrosmoked. The diagnosis was confirmed by plating process the gases released at the elecspecific bronchial challenges. Two workers trodes rise to the surface of the bath and genhad isolated immediate reactions, one a erate a fine aerosol. Nickel electroplating is late asthmatic reaction, and four a dual 95% efficient and gas generation is minimal response following exposure to nebulised whereas chromium electroplating is inefficient potassium dichromate at 1-10 mg/ml. Two and 80-90% of the total energy used may of the four subjects were also challenged be directed to the generation of potentially with nebulised nickel chloride at respirable aerosols of chromic acid. Epi-0.1-10 mg/ml. Two showed isolated late demiological studies have suggested increased asthmatic reactions, in one at 0.1 mg/ml, respiratory morbidity in electroplaters comwhere nickel was probably the primary pared with galvanisers that is related to exsensitising agent. Four workers carried out posure to chromium. 4 We report here our two hourly measurements of peak ex-experience with chromium induced asthma in piratory flow over days at and away workers referred to a specialist occupational from work. All were scored as having lung disease clinic over 10 years. occupational asthma using OASYS-2. Breathing zone air monitoring was carried out in 60 workers from four decorative Methods The Occupational Lung Disease Unit, and two hard chrome plating shops from Subjects were identified at a specialist oc-

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Outpatient clinics are demanding more consideration to enhance their performance and quality of care. This paper presents a thorough exploration of the outpatient clinics' environment at a local hospital. The ophthalmology outpatient clinic was selected for a case study. To this end, the total visit time and service times at stations were collected and fed into a Discrete Event Simulation (DES) model. The model was validated through a statistical comparison with the performance of the real system. Various improvement alternatives were then proposed and investigated using the DES model. Key performance indicators of the system, including expected waiting time and expected visit length, were traced. Findings indicated that many improvement scenarios could be applied with significant amounts of reduction in waiting time up to 29 % and visit length up to 19 % without investing in new resources.

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