Developing and testing a case-management intervention to support the return to work of health care workers with common mental health disorders.

BACKGROUND: To assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of a new case-management intervention to facilitate the return to work of health care workers, on sick leave, having a common mental disorder (CMD). METHODS: A mixed methods feasibility study. RESULTS: Systematic review examined 40 articles and 2 guidelines. Forty-nine National Health Service Occupational Health (OH) providers completed a usual care survey. We trained six OH nurses as case managers and established six recruitment sites. Forty-two out of 1938 staff on sick leave with a CMD were screened for eligibility, and 24 participants were recruited. Out of them, 94% were female. Eleven participants received the intervention and 13 received usual care. Engagement with most intervention components was excellent. Return-to-work self-efficacy improved more in the intervention group than in the usual care group. Qualitative feedback showed the intervention was acceptable. CONCLUSIONS: The intervention was acceptable, feasible and low cost to deliver, but it was not considered feasible to recommend a large-scale effectiveness trial unless an effective method could be devised to improve the early OH referral of staff sick with CMD. Alternatively, the intervention could be trialled as a new stand-alone OH intervention initiated at the time of usual OH referral.

A behaviour change package to prevent hand dermatitis in nurses working in the National Health Service: results of a cluster randomized controlled trial.

BACKGROUND: Occupational hand dermatitis poses a serious risk for nurses. OBJECTIVES: To evaluate the clinical and cost-effectiveness of a complex intervention in reducing the prevalence of hand dermatitis in nurses METHODS: This was a cluster randomized controlled trial conducted at 35 hospital trusts, health boards or universities in the UK. Participants were (i) first-year student nurses with a history of atopic conditions or (ii) intensive care unit (ICU) nurses. Participants at intervention sites received access to a behavioural change programme plus moisturizing creams. Participants at control sites received usual care. The primary outcome was the change of prevalent dermatitis at follow-up (adjusted for baseline dermatitis) in the intervention vs. the control group. Randomization was blinded to everyone bar the trials unit to ensure allocation concealment. The trial was registered on the ISRCTN registry: ISRCTN53303171. RESULTS: Fourteen sites were allocated to the intervention arm and 21 to the control arm. In total 2040 (69·5%) nurses consented to participate and were included in the intention-to-treat analysis. The baseline questionnaire was completed by 1727 (84·7%) participants. Overall, 789 (91·6%) ICU nurses and 938 (84·0%) student nurses returned completed questionnaires. Of these, 994 (57·6%) had photographs taken at baseline and follow-up (12-15 months). When adjusted for baseline prevalence of dermatitis and follow-up interval, the odds ratios (95% confidence intervals) for hand dermatitis at follow-up in the intervention group relative to the controls were 0·72 (0·33-1·55) and 0·62 (0·35-1·10) for student and ICU nurses, respectively. No harms were reported. CONCLUSIONS: There was insufficient evidence to conclude whether our intervention was effective in reducing hand dermatitis in our populations. Linked Comment: Brans. Br J Dermatol 2020; 183:411-412.

Multisite musculoskeletal pain in migrants from the Indian subcontinent to the UK: a cross-sectional survey.

BACKGROUND: Recent findings indicate that wide international variation in the prevalence of disabling regional musculoskeletal pain among working populations is driven by unidentified factors predisposing to pain at multiple anatomical sites. As a step towards identification of those factors, it would be helpful to know whether the prevalence of multisite pain changes when people migrate between countries with differing rates of symptoms; and if so, whether the change is apparent in first generation migrants, and by what age it becomes manifest. METHODS: To address these questions, we analysed data from an earlier interview-based cross-sectional survey, which assessed the prevalence of musculoskeletal pain and risk factors in six groups of workers distinguished by the nature of their work (non-manual or manual) and their country of residence and ethnicity (UK white, UK of Indian subcontinental origin and Indian in India). Prevalence odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression. RESULTS: Among 814 participants (response rate 95.4%), 20.6% reported pain at ≥3 anatomical sites. This outcome was much less frequent in Indian manual workers than among white non-manual workers in the UK (adjusted OR 0.06, 95%CI 0.01-0.36), while rates in Indian non-manual workers were intermediate (OR 0.29, 95%CI 0.12-0.72). However, within the UK, there were only small differences between white non-manual workers and the other occupational groups, including those of Indian sub-continental origin. This applied even when analysis was restricted to participants aged 17 to 34 years, and when second and later generation migrants were excluded. CONCLUSIONS: The observed differences in the prevalence of multisite pain seem too large to be explained by healthy worker selection or errors in recall, and there was no indication of bias from differences in understanding of the term, pain. Our findings suggest that whatever drives the higher prevalence of musculoskeletal pain in the UK than India is environmental rather than genetic, affects multiple anatomical sites, begins to act by fairly early in adult life, and has impact soon after people move from India to the UK.

Heavy manual work throughout the working lifetime and muscle strength among men at retirement age.

INTRODUCTION: Reductions in heavy manual work as a consequence of mechanisation might adversely impact muscle strength at older ages. We investigated the association between grip strength at retirement age and lifetime occupational exposure to physically demanding activities. Grip strength is an important predictor of long-term health and physical function in older people. METHODS: Grip strength (maximum of three readings in each hand) was measured in men from the Hertfordshire Cohort Study at a single examination when their mean age was 65.8 (SD 2.9) years. Associations with lifetime occupational exposure (ascertained by questionnaire) to three activities (standing/walking ≥ 4 h/day; lifting ≥ 25 kg; and energetic work sufficient to induce sweating) were assessed by multivariable linear regression with adjustment for various potential confounders. RESULTS: Complete data were available from 1418 men who had worked for at least 20 years. After adjustment for age, height and weight, those with longer exposures to walking/standing and heavy lifting had lower grip strength, but the relationship disappeared after further adjustment for confounders. Working at physical intensity sufficient to induce sweating was not significantly associated with grip strength. CONCLUSIONS: We found no evidence that physically demanding occupational activities increase hand grip strength at normal retirement age. Any advantages of regular physical occupational activity may have been obscured by unmeasured socioeconomic confounders.

Do exposure limits for hand-transmitted vibration prevent carpal tunnel syndrome?

BACKGROUND: An apparently high frequency of carpal tunnel syndrome (CTS) among shipyard workers undergoing health surveillance because of exposure to hand-transmitted vibration (HTV) prompted concerns that current regulatory limits on exposure might not protect adequately against the disorder. AIMS: To explore whether within regulatory limits, higher exposures to HTV predispose to CTS. METHODS: As part of a retrospective audit, we compared duration and current intensity of exposure to HTV in cases with new-onset CTS and controls matched for age. Conditional logistic regression was used to quantify associations, which were summarized by odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: There were 23 cases and 55 controls. After adjustment for body mass index and previous diagnosis of diabetes, no clear associations were observed either with duration of exposure to HTV or with current intensity of exposure. Risk was non-significantly elevated in men with ≥30 years' exposure to HTV (OR 1.6), but in the highest category of current exposure [8-h energy-equivalent frequency-weighted acceleration (A8) ≥ 4.0 m/s(2)], risk was lower than that in the reference category (A8 < 2.5 m/s(2)). Moreover, there was a significantly reduced risk of CTS in men with a previous diagnosis of hand-arm vibration syndrome (HAVS) (OR 0.2, 95% CI 0.1-0.9). CONCLUSIONS: We found no evidence that below the current limit for A(8) of 5 m/s(2), higher exposures to HTV predispose to CTS. However, care should be taken not to overlook the possibility of treatable CTS when workers with diagnosed HAVS present with new or worsening sensory symptoms in the hand.

Will NICE guidance for employers improve workers' mental health?

BACKGROUND: The UK National Institute for Health and Clinical Excellence (NICE) has published guidance for employers on promoting mental wellbeing. A national audit in 2011 found wide variation between English National Health Service (NHS) trusts (organizations providing health care) in the implementation of this guidance, but it is not known whether fuller compliance with the guidance results in improved mental wellbeing of staff. AIMS: To explore whether there is an association between implementation of NICE guidance on mental wellbeing by NHS trusts in England and mental health outcomes as reported by staff. METHODS: A cross-sectional analysis relating mental health outcomes by trust from the NHS staff surveys in 2009 and 2010 to findings from the 2011 audit of compliance with NICE guidelines. RESULTS: NHS staff survey scores for mental health were significantly poorer in mental health and ambulance trusts than in acute trusts and mental health problems were significantly more frequent in London than in most other areas of England. Mental health scores tended to be better in trusts where the audit showed that staff health and wellbeing was a regular board agenda item, although not significantly so. There was no indication of better scores in trusts with policies on mental wellbeing or those that provided psychological therapies for staff. CONCLUSIONS: No clear relationship was found between implementation of the NICE guidance and self-reported mental health outcomes. There are several possible explanations for this finding which require further exploration.

Exposure to heavy physical occupational activities during working life and bone mineral density at the hip at retirement age.

BACKGROUND: People in sedentary occupations are at increased risk of hip fracture. Hip fracture is significantly associated with low bone mineral density (BMD) measured at the hip. Physical activity is important in the development and maintenance of BMD, but the effects of occupational physical activity on bone health are unclear. We investigated the influence of lifetime physical activity on BMD at the hip. METHODS: This was a cross-sectional epidemiological study of the associations between total hip BMD measured by dual-energy X-ray absorptiometry at retirement age and lifetime exposure to occupational physical workload (standing/walking ≥4 h/day; lifting ≥25 kg; energetic work sufficient to induce sweating and manual work). RESULTS: Complete data on occupational exposures were available for 860 adults (488 men and 372 women) who had worked ≥20 years. Their mean age was 65 years, and many reported heavy physical workplace activities over prolonged durations. There were no statistically significant associations between total hip BMD and any of these measures of lifetime occupational physical activity in men or women. CONCLUSIONS: Lifetime cumulative occupational activity was not associated with hip BMD at retirement age. Our findings suggest that, if sedentary work conveys an increased risk of hip fracture, it is unlikely that the mechanism is through reductions in BMD at the hip and may relate to other physical effects, such as falls risk. Further studies will be needed to test this hypothesis.

Solid fuel use is a major risk factor for acute coronary syndromes among rural women: a matched case control study.

OBJECTIVES: Almost half of the world's population uses solid fuel for cooking, exposing women to high levels of particulate pollution in indoor air. The risk of acute coronary syndrome (ACS) was assessed among rural women, according to their use of solid fuel. STUDY DESIGN: Matched case control study. METHODS: Data were collected at a public tertiary care hospital in a rural district of Pakistan. Seventy-three women with ACS were compared with controls, individually matched for sex and age (± 5 years), who were admitted to hospital for other reasons. Fuels used for cooking and exposures to potentially confounding variables were ascertained through a questionnaire administered at interview and measurement of height and weight. Conditional logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (95% CIs). RESULTS: After adjustment for potential confounding factors, current use of solid fuel was strongly associated with ACS (OR 4.8, 95% CI: 1.5-14.8), and risk was lowest in women who had last used solid fuel more than 15 years earlier. The population attributable fraction for ACS in relation to current use of solid fuel was 49.0% (95% CI: 41.3%-57.4%). CONCLUSIONS: These findings support the hypothesis that indoor air pollution from use of solid fuel is an important cause of ACS. Our study demonstrates the feasibility of case-control studies in rural populations of women to address this question, and is an encouragement to larger and statistically more powerful investigations.

Epilepsy, diabetes mellitus and accidental injury at work.

AIMS: To assess the contribution of epilepsy and diabetes to occupational injury. METHODS: The Clinical Practice Research Datalink logs primary care data for 6% of the British population, coding all consultations and treatments. Using this, we conducted a population-based case-control study, identifying patients aged 16-64 years, who had consulted over two decades for workplace injury, plus matched controls. By conditional logistic regression, we assessed risks for diabetes and epilepsy overall, several diabetic complications and indices of poor control, occurrence of status epilepticus and treatment with hypoglycaemic and anti-epileptic agents. RESULTS: We identified 1348 injury cases and 6652 matched controls. A total of 160 subjects (2%) had previous epilepsy, including 29 injury cases, whereas 199 (2.5%) had diabetes, including 77 with eye involvement and 52 with a record of poor control. Odds ratios (ORs) for occupational injury were close to unity, both in those with epilepsy (1.07) and diabetes (0.98) and in those prescribed anti-epileptic or hypoglycaemic treatments in the previous year (0.87-1.16). We found no evidence of any injury arising directly from a seizure and no one had consulted about their epilepsy within 100 days before their injury consultation. Two cases and six controls had suffered status epilepticus (OR versus never had epilepsy 1.61). Risks were somewhat higher for certain diabetic complications (OR 1.44), although lower among those with eye involvement (OR 0.70) or poor diabetic control (OR 0.50). No associations were statistically significant. CONCLUSIONS: No evidence was found that diabetes or epilepsy are important contributors to workplace injury in Britain.

Evaluation of a case management service to reduce sickness absence.

BACKGROUND: It is unclear whether and to what extent intensive case management is more effective than standard occupational health services in reducing sickness absence in the health care sector. AIMS: To evaluate a new return to work service at an English hospital trust. METHODS: The new service entailed intensive case management for staff who had been absent sick for longer than 4 weeks, aiming to restore function through a goal-directed and enabling approach based on a bio-psycho-social model. Assessment of the intervention was by controlled before and after comparison with a neighbouring hospital trust at which there were no major changes in the management of sickness absence. Data on outcome measures were abstracted from electronic databases held by the two trusts. RESULTS: At the intervention trust, the proportion of 4-week absences that continued beyond 8 weeks fell from 51.7% in 2008 to 49.1% in 2009 and 45.9% in 2010. The reduction from 2008 to 2010 contrasted with an increase at the control trust from 51.2% to 56.1%-a difference in change of 10.7% (95% CI 1.5-20.0%). There was also a differential improvement in mean days of absence beyond 4 weeks, but this was not statistically significant (1.6 days per absence; 95% CI -7.2 to 10.3 days). CONCLUSIONS: Our findings suggest that the intervention was effective, and calculations based on an annual running cost of £57 000 suggest that it was also cost-effective. A similar intervention should now be evaluated at a larger number of hospital trusts.

Mortality from asbestosis and mesothelioma in Britain by birth cohort.

BACKGROUND: Analysis of occupational mortality in England and Wales during 1991-2000 showed no decline in work-attributable deaths from asbestosis. AIMS: To explore why there was no decline in mortality from asbestosis despite stricter controls on asbestos exposure over recent decades. METHODS: Using data from registers of all deaths in Great Britain with mention of mesothelioma or asbestosis on the death certificate, we plotted death rates by 5 year age group within 5 year birth cohorts for(a) mesothelioma and (b) asbestosis without mention of mesothelioma. RESULTS: Analysis was based on a total of 33,751 deaths from mesothelioma and 5396 deaths from asbestosis. For both diseases, mortality showed a clear cohort effect; within birth cohorts, death rates increased progressively with age through to 85 years and older. However, highest mortality from mesothelioma was in men born during 1939-43, whereas, mortality from asbestosis peaked in men born during 1924-38. CONCLUSIONS: Our findings suggest that mortality, in Britain, from asbestosis has been determined mainly by cumulative exposure to asbestos before 45 years of age and that the effect of such exposure continues through to old age. That mortality from asbestosis peaked in earlier birth cohorts than mortality from mesothelioma may reflect a difference in exposure-response relationships for the two diseases. The discrepancy could be explained if risk of asbestosis increased more steeply than that of mesothelioma at higher levels of exposure to asbestos and if the highest prevalence of heavy exposure occurred in earlier birth cohorts than the highest prevalence of less intense exposures.

Musculoskeletal pain in four occupational populations in Sri Lanka.

BACKGROUND: Factors influencing work-related musculoskeletal disorders might differ in developing and developed countries. AIMS: To assess the prevalence and determinants of musculoskeletal pain in four occupational populations in Sri Lanka. METHODS: As part of the international Cultural and Psychosocial Influences on Disability study, samples of postal workers, sewing machinists, nurses and computer operators were interviewed about pain at each of six anatomical sites in the past month, and about possible physical and psychosocial risk factors. Associations with prevalent pain were assessed by binomial regression. RESULTS: Analysis was based on 852 participants (86% response rate). Overall, the lower back was the most common site of pain, with 1-month prevalence ranging from 12% in computer operators to 30% in nurses. Postal workers had the highest prevalence of shoulder pain (23%), but pain in the wrist/hand was relatively uncommon in all four occupational groups (prevalence rates ranged from 8% to 9%). Low mood and tendency to somatize were consistently associated with pain at all six sites. After adjustment for psychosocial risk factors, there was a higher rate of low back pain in nurses and postal workers than in computer operators, a higher rate of shoulder pain in postal workers than in the other occupational populations, and a relatively low rate of knee pain in computer operators. CONCLUSIONS: Rates of regional pain, especially at the wrist/hand, were lower than have been reported in Western countries. As elsewhere, pain was strongly associated with low mood and somatizing tendency. Differences in patterns of pain by occupation may reflect differences in physical activities.

Lung cancer mortality in a cohort of UK cotton workers: an extended follow-up.

BACKGROUND: A recent systematic review and meta-analysis suggested that occupational exposure to endotoxins protects against lung cancer. To explore this hypothesis further, the follow-up of mortality of a cohort of 3551 workers, who were employed in the British cotton industry during 1966-1971, was extended by 23 years. METHODS: Subjects had originally been recruited to a survey of respiratory disease, which collected information about occupation and smoking habits. Cumulative exposures to endotoxins were estimated from data on endotoxin levels by work areas in cotton mills. Risks of lung cancer were estimated using survival modelling. RESULTS: During follow-up, 2018 deaths were recorded before the age of 90 years, including 128 deaths from lung cancer. After adjustment for smoking, hazard ratios (95% confidence intervals) for cumulative endotoxin exposures of ≤30,000, >30,000 and ≤200,000, >200,000 and ≤400,000, >400,000 and ≤600,000 and >600,000 endotoxin units (EU) m(-3) years were 1, 0.8 (0.5-1.6), 0.7 (0.4-1.3), 0.6 (0.3-1.0) and 0.5 (0.3-0.9), respectively (P for trend=0.005). CONCLUSION: Our findings strengthen the evidence that occupational exposure to endotoxins protects against lung cancer, and suggest that the effect depends on cumulative dose and persists after exposure ceases.

Shift work and pregnancy outcomes: a systematic review with meta-analysis of currently available epidemiological studies.

BACKGROUND: Varying work schedules are suspected of increasing risks to pregnant women and to fetal wellbeing. In particular, maternal hormonal disturbance arising from sleep deprivation or circadian rhythm disruption might impair fetal growth or lead to complications of pregnancy. Two independent meta-analyses (from 2000 to 2007) reported a small adverse effect of shift work on the risk of preterm delivery (PTD). However, these reviews were based on few high-quality studies. OBJECTIVES: To provide an updated review of the associations of shift work with PTD, low birthweight (LBW), small-for-gestational-age (SGA) infants and pre-eclampsia. SEARCH STRATEGY AND SELECTION CRITERIA: We conducted a systematic search of MEDLINE using combinations of keywords and MeSH terms. DATA COLLECTION AND ANALYSIS: For each relevant paper we abstracted standard details, used to summarise design features and rate methodological quality. We calculated pooled estimates of relative risk (RR) in random-effect meta-analyses. MAIN RESULTS: We retrieved 23 relevant studies. The pooled estimate of RR for PTD was 1.16 (95% CI 1.00-1.33, 16 studies), but when five reports of poorer methodological quality were excluded, the estimated RR decreased to 1.03 (95% CI 0.93-1.14). We also observed increased RRs for LBW (RR 1.27, 95% CI 0.93-1.74) and for SGA (RR 1.12, 95% CI 1.03-1.22), which varied little by study quality. Little evidence was found on pre-eclampsia. CONCLUSIONS: These findings suggest that overall, any risk of PTD, LBW, or SGA arising from shift work in pregnancy is small.

Skin disease in sheep farmers.

BACKGROUND: An unusual inflammation of the pinna has been reported to occur in some sheep farmers at the time of lambing. AIMS: To explore the prevalence of this disorder and its possible causal associations. METHODS: While on attachment to sheep farms during lambing, veterinary students used a standardized questionnaire to interview a sample of farmers about their work and about symptoms of skin inflammation in their hands, face and ears. RESULTS: Interviews were completed by 76 (67%) of the farmers approached. Among 74 farmers who had carried out lambing, 3 (4%, 95% CI 1-11%) had experienced temporally related ear symptoms, all on multiple occasions. No farmers with ear symptoms had ever been involved in calving or farrowing, and no ear symptoms were reported in relation to shearing or dipping sheep. There was also an excess of hand symptoms related to lambing outdoors (24% of those who had done such work) and indoors (also 24%) compared with other farming activities. CONCLUSIONS: Our findings suggest that temporally related ear inflammation occurs in at least 1% of farmers who carry out lambing but not in association with the other farming activities investigated. Lambing appears to be associated also with hand inflammation, but the pathology may differ from that in the pinna.

The burden of sickness absence from musculoskeletal causes in Great Britain.

BACKGROUND: National initiatives to prevent and/or manage sickness absence require a database from which trends can be monitored. AIMS: To evaluate the information provided by surveillance schemes and publicly available data sets on sickness absence nationally from musculoskeletal disorders (MSDs). METHODS: A grey literature search was undertaken using the search engine Google, supplemented by leads from consultees from academia, industry, employers, lay interest groups and government. We abstracted data on the outcomes and populations covered and made quantitative estimates of MSD-related sickness absence, overall and, where distinguishable, by subdiagnosis. The coverage and limitations of each source were evaluated. RESULTS: Sources included the Labour Force Survey (LFS) and its Self-reported Work-related Illness survey module, the THOR-GP surveillance scheme, surveys by national and local government, surveys by employers' organizations and a database of benefit statistics. Each highlighted MSDs as a leading cause of sickness absence. Data limitations varied by source, but typically included lack of diagnostic detail and restriction of focus to selected subgroups (e.g. work-ascribed or benefit-awarded cases, specific employment sectors). Additionally, some surveys had very low response rates, were completed only by proxy respondents or ranked only the perceived importance of MSD-related sickness absence, rather than measuring it. CONCLUSIONS: National statistics on MSD-related sickness absence are piecemeal and incomplete. This limits capacity to plan and monitor national policies in an important area of public health. Simple low-cost additions to the LFS would improve the situation.

Regional trends in awards of incapacity benefit by cause.

BACKGROUND: Since the early 1990s, rates of incapacity benefit (IB) in Britain for musculoskeletal complaints have declined, and they have been overtaken by mental and behavioural disorders as the main reason for award of IB. AIMS: To explore reasons for this change. METHODS: Using data supplied by the Department for Work and Pensions, we analysed trends in the ratio of new IB awards for mental and behavioural disorders to those for musculoskeletal disorders during 1997-2007 by Government region. RESULTS: In Great Britain overall, the above ratio more than doubled over the study period, as a consequence of falling numbers of new awards for musculoskeletal disorders. The extent to which the ratio increased was smallest in London (50%) and South-East England (56%), and was progressively larger in more northerly regions (>150% in North-East England and Scotland). CONCLUSIONS: The differences in trends between regions seem too large to be explained by differential changes in working conditions, patterns of employment or the rigour with which claims were assessed. An alternative explanation could be that the main driver for the trends has been culturally determined changes in health beliefs and expectations, and that these cultural changes began in London and the South-East, only later spreading to other parts of Britain.

Occupation and mortality related to alcohol, drugs and sexual habits.

BACKGROUND: To identify opportunities for targeted prevention, we explored differences in occupational mortality from diseases and injuries related to alcohol consumption, sexual habits and drug abuse. METHODS: Using data on all deaths among men and women aged 16-74 years in England and Wales during 1991-2000, we derived age- and social class-standardized proportional mortality ratios (PMRs) by occupation for cause of death categories defined a priori as potentially related to alcohol consumption, sexual habits or drug abuse. RESULTS: The highest mortality from alcohol-related diseases and injuries was observed in publicans and bar staff (both sexes) and in male caterers, cooks and kitchen porters and seafarers. Male seafarers had significantly elevated PMRs for cirrhosis (179), 'other alcohol-related diseases' (275), cancers of the liver (155), oral cavity (275) and pharynx (267) and injury by fall on the stairs (187). PMRs for human immunodeficiency virus infection (HIV)/acquired immunodeficiency syndrome (AIDS) were particularly high in tailors and dressmakers (918, 95% CI: 369-1890, in men; 804, 95% CI: 219-2060, in women) and male hairdressers (918, 95% CI: 717-1160). Most jobs with high mortality from HIV/AIDS also had more deaths than expected from viral hepatitis. Of seven jobs with significantly high PMRs for both drug dependence and accidental poisoning by drugs, four were in the construction industry (male painters and decorators, bricklayers and masons, plasterers, and roofers and glaziers). CONCLUSIONS: Our findings highlight major differences between occupations in mortality from diseases and injuries caused by alcohol, sexual habits and drug abuse. Priorities for preventive action include alcohol-related disorders in male seafarers and drug abuse in construction workers.

Mortality from infectious pneumonia in metal workers: a comparison with deaths from asthma in occupations exposed to respiratory sensitisers.

BACKGROUND: National analyses of mortality in England and Wales have repeatedly shown excess deaths from pneumonia in welders. During 1979-90 the excess was attributable largely to deaths from lobar pneumonia and pneumonias other than bronchopneumonia, limited to men of working age and apparent in other occupations with exposure to metal fumes. The findings for 1991-2000 were assessed and compared with the mortality pattern from asthma in occupations exposed to known respiratory sensitisers. METHODS: The Office of National Statistics supplied data on deaths by underlying cause among men aged 16-74 years in England and Wales during 1991-2000, including age and last held occupation. Data were abstracted on pneumonia for occupations with exposure to metal fumes and on asthma for occupations commonly reported to surveillance schemes as at risk of occupational asthma. The expected numbers of deaths were estimated by applying age-specific proportions of deaths by cause in the population to the total deaths by age in each occupational group. Observed and expected numbers were compared for each cause of death. RESULTS: Among men of working age in occupations with exposure to metal fumes there was excess mortality from pneumococcal and lobar pneumonia (54 deaths vs 27.3 expected) and from pneumonias other than bronchopneumonia (71 vs 52.4), but no excess from these causes at older ages or from bronchopneumonia at any age. The attributable mortality from metal fume exposure was 45.3 excess deaths compared with an estimated 62.6 deaths from occupational asthma. CONCLUSION: Exposure to metal fumes is a material cause of occupational mortality. The hazard deserves far more attention than it presently receives.

Long-term outcome following total knee arthroplasty: a controlled longitudinal study.

OBJECTIVES: To assess long-term outcome and predictors of prognosis following total knee arthroplasty (TKA) for osteoarthritis. METHODS: We followed-up 325 patients from 3 English health districts approximately 6 years after TKA, along with 363 controls selected from the general population. Baseline data, collected by interview and examination, included age, sex, comorbidity, body mass index (BMI), functional status and preoperative radiographic severity of osteoarthritis. Functional status at follow-up was assessed by postal questionnaire. Predictors of change in physical function were analysed by linear regression. RESULTS: Between baseline and follow-up, patients reported an improvement of 6 points in median Short Form 36 Health Survey (SF-36) physical function score, whereas in controls there was a deterioration of 14 points (p<0.001). Median SF-36 vitality score declined by 10 points in patients and 5 points in controls (p = 0.005), while their median SF-36 mental health scores improved by 12 and 13 points, respectively (p = 0.2). The improvement in physical function was smaller in patients who were obese than in patients who were non-obese, but compared favourably with a substantial decline in the physical function of obese controls. Better baseline physical function and older age predicted worse changes in physical function in patients and controls. Improvement in physical function tended to be greater in patients with more severe radiological disease of the knee, and was less in those who reported pain at other joint sites at baseline. CONCLUSIONS: Improvements in physical function following TKA for osteoarthritis are sustained beyond 5 years. The benefits are apparent in patients who are obese as well as non-obese, and there seems no justification for withholding TKA from obese patients solely on the grounds of their body mass index.