We present the diagnostic inaccuracies encountered in a case of multiple fibroadenoma with malignant transformation. A 30-year-old lady presented with lump in the right breast of one month duration which on clinical examination, X-ray mammogram, sonomammogram were suggestive of multiple fibroadenomas. Fine needle aspiration cytology of the largest lump revealed features of malignancy and a core biopsy showed pleomorphic cells that could not be categorized. Due to the clinical, radiological and pathological diagnostic ambiguity, lumpectomy was performed and frozen section showed features of only conventional fibroadenoma. Representative bits on routine processing showed only features of fibroadenoma. Hence, complete submission of all lumps was done, which revealed fibroadenoma with invasive ductal carcinoma in one. Patient underwent modified radical mastectomy which showed multiple fibroadenomas, focal fibrocystic disease with a focus of residual invasive tumor and metastatic deposit in one axillary lymph node. This case report highlights the diagnostic challenges in detecting malignancy in fibroadenoma and a need for extensive tissue sampling in multiple fibroadenomas to detect the rare occurrence of carcinoma.

BackgroundPredicted rise in global mean temperatures of 2°C–3°C and much larger increases in some regions due to Climate Change is expected to impact workers’ health because of physiological limits due to the Wet Bulb Globe Temperature (WBGT). Such temperatures rise implies increasingly large increases in regions where outdoor and indoor work is restricted due to physiological decrements and reduced work capacity.AimWe compare the potential health and productivity risks for indoor and outdoor workers in select Indian workplaces.MethodsThe study population was a random sample of ∼1300 outdoor and indoor workers from various occupations in Indian workplaces. We conducted seasonal WBGT exposures, quantitative physiological heat-strain measurements and captured self-reported health symptoms through questionnaires. The risk definition included symptoms of heat-strain, self-reported heat-illness, and reduced work capacity/productivity loss.ResultsWBGT exceeded threshold limit values for moderate/heavy work for 73% outdoor workers (28.9°C±2.4°C) and 67% indoor workers (28.8°C±3.5°C). Heat stress and heat-strain indicators were significantly associated (p=0.0001) and outdoor workers had 2.2 times greater risk of heat-strain during hot seasons (95% CI: 1.695–2.937). Compared to indoor workers, the outdoor workers ran a higher risk of self-reported health decrements (OR: 6.4; 95% CI: 3.884–10.350; p=0.0001), dehydration (OR: 3.0; 95% CI: 2.352–3.999) and productivity losses (OR: 8.0; 95% CI: 4.911–13.382). In select occupations, while indoor workers exposed to chronic high-heat had a higher percentage of kidney stones (9%), the outdoor workers with long years of heat exposures had the higher risk of reduced kidney function (14%) due to repeated dehydration, volume depletion, and Acute Kidney Injury.ConclusionWe discuss implications for workers’ health and productivity as climate modeling shows seriously increasing outdoor and indoor heat problems without suitable control measures for cooling. Strong protective labor policies and research are imperative to avoid serious health impacts and to maintain productivity.

Rising global temperatures, coupled with decreasing access to clean drinking water, may enhance the effects of heat exposure to general and working populations across the globe. People working in jobs that require moderate or heavy manual labor in hot environments are at particular risk caused by the combined effect of exposures to high environmental heat and internal heat production. Exposures to heat can lead to a range of clinical health effects such as fatigue, exhaustion, heat syncope, fainting, heat stroke or even death. Furthermore, heat-related physical exhaustion leads to a reduction of the worker's ability to work with consequent productivity losses that may cause substantial economic losses for the businesses. The result of such continuous heat exposures, manual work and repeated dehydration are also known to cause acute kidney injuries that can further develop into chronic kidney diseases. With the predicted rise in temperatures due to climate change, the health effects for the working population are expected to become worse without appropriate interventions. With this background, the present review focuses on the heat-related health illnesses with special attention to kidney disease among workers engaged in manual physical labor in different occupational sectors.

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risk in tropical and subtropical regions with middle-and lowincome, when protective workplace policies and appropriate controls are insufficient. We examine epidemiological evidence from research studies undertaken in outdoor workplaces in India to evaluate the health consequences of occupational heat exposures, and also discuss critical future steps. Materials & Methods Epidemiological evidence from the author's seasonal studies with workers engaged in manual labour in outdoor workplaces collected over a 10-year period for occupational heat exposures (n=2000) was analysed to determine the magnitude of heat stress impacts on heat strain indicators, heat-related illnesses, and productivity losses.Results & Conclusion A significant proportion of workers (65%) were exposed to wet bulb globe temperatures (Avg. WBGT 28.8°C±3.3°C) that exceeded the Threshold Limit Values (TLVs). Workers who were exposed to WBGTs above-TLV had a significantly higher risk of adverse health outcomes (OR=2.1; 95% CI=1.4-2.8) than workers who were exposed to below-TLVs. Significantly higher prevalence of heat strain indicators was evident among heat-exposed workers, including an increase in Core Body Temperature, above-normal sweat rates, urine specific gravities, and dehydration (OR=1.8; 95% CI=1.3-2.4). Heat-exposed workers, particularly those with significant physical labour, had 2.8-times higher risk of compromised renal health issues (95%CI=2.1-3.7). Climate estimates predict that future temperature increases and heat waves will exacerbate health and productivity risks for workers.Occupational exposure standards must be reevaluated, optimised for tropical environments, and aligned with worker protection. Urgently necessary is in-depth research with a holistic approach to understand the ramifications of heat exposures. Even though interventions that reduce heat stress in the workplace have multiple benefits, adaptation and mitigation techniques, including policy changes, are required to address heat stress in the workplace in the climate change era.

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