Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers.

BACKGROUND: Shift work is associated with insufficient sleep, which can compromise worker alertness with ultimate effects on occupational health and safety. Adapting shift work schedules may reduce adverse occupational outcomes. OBJECTIVES: To assess the effects of shift schedule adaptation on sleep quality, sleep duration, and sleepiness among shift workers. SEARCH METHODS: We searched CENTRAL, PubMed, Embase, and eight other databases on 13 December 2020, and again on 20 April 2022, applying no language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and non-RCTs, including controlled before-after (CBA) trials, interrupted time series, and cross-over trials. Eligible trials evaluated any of the following shift schedule components. • Permanency of shifts • Regularity of shift changes • Direction of shift rotation • Speed of rotation • Shift duration • Timing of start of shifts • Distribution of shift schedule • Time off between shifts • Split shifts • Protected sleep • Worker participation We included studies that assessed sleep quality off-shift, sleep duration off-shift, or sleepiness during shifts. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of the records recovered by the search, read through the full-text articles of potentially eligible studies, and extracted data. We assessed the risk of bias of included studies using the Cochrane risk of bias tool, with specific additional domains for non-randomised and cluster-randomised studies. For all stages, we resolved any disagreements by consulting a third review author. We presented the results by study design and combined clinically homogeneous studies in meta-analyses using random-effects models. We assessed the certainty of the evidence with GRADE. MAIN RESULTS: We included 11 studies with a total of 2125 participants. One study was conducted in a laboratory setting and was not considered for drawing conclusions on intervention effects. The included studies investigated different and often multiple changes to shift schedule, and were heterogeneous with respect to outcome measurement. Forward versus backward rotation Three CBA trials (561 participants) investigated the effects of forward rotation versus backward rotation. Only one CBA trial provided sufficient data for the quantitative analysis; it provided very low-certainty evidence that forward rotation compared with backward rotation did not affect sleep quality measured with the Basic Nordic Sleep Questionnaire (BNSQ; mean difference (MD) -0.20 points, 95% confidence interval (CI) -2.28 to 1.89; 62 participants) or sleep duration off-shift (MD -0.21 hours, 95% CI -3.29 to 2.88; 62 participants). However, there was also very low-certainty evidence that forward rotation reduced sleepiness during shifts measured with the BNSQ (MD -1.24 points, 95% CI -2.24 to -0.24; 62 participants). Faster versus slower rotation Two CBA trials and one non-randomised cross-over trial (341 participants) evaluated faster versus slower shift rotation. We were able to meta-analyse data from two studies. There was low-certainty evidence of no difference in sleep quality off-shift (standardised mean difference (SMD) -0.01, 95% CI -0.26 to 0.23) and very low-certainty evidence that faster shift rotation reduced sleep duration off-shift (SMD -0.26, 95% CI -0.51 to -0.01; 2 studies, 282 participants). The SMD for sleep duration translated to an MD of 0.38 hours' less sleep per day (95% CI -0.74 to -0.01). One study provided very low-certainty evidence that faster rotations decreased sleepiness during shifts measured with the BNSQ (MD -1.24 points, 95% CI -2.24 to -0.24; 62 participants). Limited shift duration (16 hours) versus unlimited shift duration Two RCTs (760 participants) evaluated 80-hour workweeks with maximum daily shift duration of 16 hours versus workweeks without any daily shift duration limits. There was low-certainty evidence that the 16-hour limit increased sleep duration off-shift (SMD 0.50, 95% CI 0.21 to 0.78; which translated to an MD of 0.73 hours' more sleep per day, 95% CI 0.30 to 1.13; 2 RCTs, 760 participants) and moderate-certainty evidence that the 16-hour limit reduced sleepiness during shifts, measured with the Karolinska Sleepiness Scale (SMD -0.29, 95% CI -0.44 to -0.14; which translated to an MD of 0.37 fewer points, 95% CI -0.55 to -0.17; 2 RCTs, 716 participants). Shorter versus longer shifts One RCT, one CBA trial, and one non-randomised cross-over trial (692 participants) evaluated shorter shift duration (eight to 10 hours) versus longer shift duration (two to three hours longer). There was very low-certainty evidence of no difference in sleep quality (SMD -0.23, 95% CI -0.61 to 0.15; which translated to an MD of 0.13 points lower on a scale of 1 to 5; 2 studies, 111 participants) or sleep duration off-shift (SMD 0.18, 95% CI -0.17 to 0.54; which translated to an MD of 0.26 hours' less sleep per day; 2 studies, 121 participants). The RCT and the non-randomised cross-over study found that shorter shifts reduced sleepiness during shifts, while the CBA study found no effect on sleepiness. More compressed versus more spread out shift schedules One RCT and one CBA trial (346 participants) evaluated more compressed versus more spread out shift schedules. The CBA trial provided very low-certainty evidence of no difference between the groups in sleep quality off-shift (MD 0.31 points, 95% CI -0.53 to 1.15) and sleep duration off-shift (MD 0.52 hours, 95% CI -0.52 to 1.56). AUTHORS' CONCLUSIONS: Forward and faster rotation may reduce sleepiness during shifts, and may make no difference to sleep quality, but the evidence is very uncertain. Very low-certainty evidence indicated that sleep duration off-shift decreases with faster rotation. Low-certainty evidence indicated that on-duty workweeks with shift duration limited to 16 hours increases sleep duration, with moderate-certainty evidence for minimal reductions in sleepiness. Changes in shift duration and compression of workweeks had no effect on sleep or sleepiness, but the evidence was of very low-certainty. No evidence is available for other shift schedule changes. There is a need for more high-quality studies (preferably RCTs) for all shift schedule interventions to draw conclusions on the effects of shift schedule adaptations on sleep and sleepiness in shift workers.

Towards conceptualizing patients as partners in health systems: a systematic review and descriptive synthesis.

BACKGROUND: With the sharp increase in the involvement of patients (including family and informal caregivers) as active participants, collaborators, advisors and decision-makers in health systems, a new role has emerged: the patient partner. The role of patient partner differs from other forms of patient engagement in its longitudinal and bidirectional nature. This systematic review describes extant work on how patient partners are conceptualized and engaged in health systems. In doing so, it furthers the understanding of the role and activities of patient partners, and best practices for future patient partnership activities. METHODS: A systematic review was conducted of peer-reviewed literature published in English or French that describes patient partner roles between 2000 and 2021 in any country or sector of the health system. We used a broad search strategy to capture descriptions of longitudinal patient engagement that may not have used words such as "partner" or "advisor". RESULTS: A total of 506 eligible papers were identified, representing patient partnership activities in mostly high-income countries. These studies overwhelmingly described patient partnership in health research. We identified clusters of literature about patient partnership in cancer and mental health. The literature is saturated with single-site descriptive studies of patient partnership on individual projects or initiatives. There is a lack of work synthesizing impacts, facilitating factors and outcomes of patient partnership in healthcare. CONCLUSIONS: There is not yet a consolidated understanding of the role, activities or impacts of patient partners. Advancement of the literature has been stymied by a lack of consistently used terminology. The literature is ready to move beyond single-site descriptions, and synthesis of existing pockets of high-quality theoretical work will be essential to this evolution.

Key Informants in Applied Qualitative Health Research.

Identifying and recruiting key informants is a widely used sampling strategy in applied qualitative health research. Key informants were first conceptualized within ethnography, but there is little methodological guidance about how to use this technique outside of that research tradition. The objective of this article is to offer practical suggestions about how existing methods for data collection with key informants could be translated to methodologies commonly used in applied qualitative health research. This article delineates how key informants could be conceptualized and sampled and how data sufficiency can be approached. The article prompts deeper consideration of the politics of representation and epistemic power that are inherent to the use of key informants in applied qualitative health research.

Insecticide use and risk of non-Hodgkin lymphoma subtypes: A subset meta-analysis of the North American Pooled Project.

Insecticide use has been linked to increased risk of non-Hodgkin lymphoma (NHL), however, findings of epidemiologic studies have been inconsistent, particularly for NHL subtypes. We analyzed 1690 NHL cases and 5131 controls in the North American Pooled Project (NAPP) to investigate self-reported insecticide use and risk of NHL overall and by subtypes: follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL) and small lymphocytic lymphoma (SLL). Odds ratios (OR) and 95% confidence intervals for each insecticide were estimated using logistic regression. Subtype-specific associations were evaluated using ASSET (Association analysis for SubSETs). Increased risks of multiple NHL subtypes were observed for lindane (OR = 1.60, 1.20-2.10: FL, DLCBL, SLL), chlordane (OR = 1.59, 1.17-2.16: FL, SLL) and DDT (OR = 1.36, 1.06-1.73: DLBCL, SLL). Positive trends were observed, within the subsets with identified associations, for increasing categories of exposure duration for lindane (Ptrend = 1.7 × 10-4 ), chlordane (Ptrend = 1.0 × 10-3 ) and DDT (Ptrend = 4.2 × 10-3 ), however, the exposure-response relationship was nonlinear. Ever use of pyrethrum was associated with an increased risk of FL (OR = 3.65, 1.45-9.15), and the relationship with duration of use appeared monotonic (OR for >10 years: OR = 5.38, 1.75-16.53; Ptrend = 3.6 × 10-3 ). Our analysis identified several novel associations between insecticide use and specific NHL subtypes, suggesting possible etiologic heterogeneity in the context of pesticide exposure.

Pesticide use and risk of Hodgkin lymphoma: results from the North American Pooled Project (NAPP).

PURPOSE: The purpose of this study was to investigate associations between pesticide exposures and risk of Hodgkin lymphoma (HL) using data from the North American Pooled Project (NAPP). METHODS: Three population-based studies conducted in Kansas, Nebraska, and six Canadian provinces (HL = 507, Controls = 3886) were pooled to estimate odds ratios and 95% confidence intervals for single (never/ever) and multiple (0, 1, 2-4, ≥ 5) pesticides used, duration (years) and, for select pesticides, frequency (days/year) using adjusted logistic regression models. An age-stratified analysis (≤ 40/ > 40 years) was conducted when numbers were sufficient. RESULTS: In an analysis of 26 individual pesticides, ever use of terbufos was significantly associated with HL (OR: 2.53, 95% CI 1.04-6.17). In age-stratified analyses, associations were stronger among those ≤ 40 years of age. No significant associations were noted among those > 40 years old; however, HL cases ≤ 40 were three times more likely to report ever using dimethoate (OR: 3.76 95% CI 1.02-33.84) and almost twice as likely to have ever used malathion (OR: 1.86 95% CI 1.00-3.47). Those ≤ 40 years of age reporting use of 5 + organophosphate insecticides had triple the odds of HL (OR: 3.00 95% CI 1.28-7.03). Longer duration of use of 2,4-D, ≥ 6 vs. 0 years, was associated with elevated odds of HL (OR: 2.59 95% CI 1.34-4.97). CONCLUSION: In the NAPP, insecticide use may increase the risk of HL, but results are based on small numbers.

The current burden of cancer attributable to occupational exposures in Canada.

Exposure to occupational carcinogens is often overlooked as a contributor to the burden of cancer. To estimate the proportion of cancer cases attributable to occupational exposure in Canada in 2011, exposure prevalence and levels of 44 carcinogens were informed by data from the Canadian carcinogen exposure surveillance project (CAREX Canada). These were used with Canadian Census (between 1961 and 2011) and Labour Force Survey (annual surveys between 1976 and 2013) data to estimate the number of workers ever exposed to occupational carcinogens. Risk estimates of the association between each carcinogen and cancer site were selected mainly from published literature reviews. Population attributable risks were estimated using Levin's equation and applied to the 2011 cancer statistics from the Canadian Cancer Registry. It is estimated that 15.5 million Canadians alive in 2011 were exposed, during at least one year between 1961 and 2001, to at least one carcinogen in the workplace. Overall, we estimated that in 2011, between 3.9% (95% CI: 3.1%-8.1%) and 4.2% (95% CI: 3.3%-8.7%) of all incident cases of cancer were due to occupational exposure, corresponding to lower and upper numbers of 7700-21,800 cases. Five of the cancer sites - mesothelioma, non-melanoma skin cancer, lung, female breast, and urinary bladder - account for a total of 7600 to 21,200 cancers attributable to occupational exposures such as solar radiation, asbestos, diesel engine exhaust, crystalline silica, and night shift work. Our study highlights cancer sites and occupational exposures that need recognition and efforts by all stakeholders to avoid preventable cancers in the future.

The impact of night shift work on breast cancer: Results from the Burden of Occupational Cancer in Canada Study.

BACKGROUND: We estimated the proportion and number of female breast cancer cases in Canada attributable to night shift work, a probable cause of breast cancer. METHODS: Levin's equation was used to calculate population attributable fractions (PAFs) among Canadian women who ever worked night/rotating shifts from 1961 to 2000, accounting for labor turnover and survival to the year 2011. The calculated PAFs were applied to 2011 Canadian breast cancer incidence statistics to obtain the number of attributable cases. RESULTS: Approximately 1.5 million women ever worked night/rotating shifts during 1961-2000 and survived to 2011. The PAFs ranged from 2.0% (95% confidence interval [CI]: 1.4-6.2) to 5.2% (95% CI: 3.7-13.6), and 470 to 1200 incident breast cancer cases in 2011 were likely due to shift work, of which 38% would have been diagnosed among women in health-related occupations. CONCLUSIONS: More research is needed to increase the certainty of this association, but current evidence supports workplace-based prevention.

Burden of lung cancer attributable to occupational diesel engine exhaust exposure in Canada.

OBJECTIVE: To estimate the population attributable fraction (PAF) and number of incident and fatal lung cancers in Canada from occupational exposure to diesel engine exhaust (DEE). METHODS: DEE exposure prevalence and level estimates were used with Canadian Census and Labour Force Survey data to model the exposed population across the risk exposure period (REP, 1961-2001). Relative risks of lung cancer were calculated based on a meta-regression selected from the literature. PAFs were calculated using Levin's equation and applied to the 2011 lung cancer statistics obtained from the Canadian Cancer Registry. RESULTS: We estimated that 2.4% (95% CI 1.6% to 6.6%) of lung cancers in Canada are attributable to occupational DEE exposure, corresponding to approximately 560 (95% CI 380 to 1570) incident and 460 (95% CI 310 to 1270) fatal lung cancers in 2011. Overall, 1.6 million individuals alive in 2011 were occupationally exposed to DEE during the REP, 97% of whom were male. Occupations with the highest burden were underground miners, truck drivers and mechanics. Half of the attributable lung cancers occurred among workers with low exposure. CONCLUSIONS: This is the first study to quantify the burden of lung cancer attributable to occupational DEE exposure in Canada. Our results underscore a large potential for prevention, and a large public health impact from occupational exposure to low levels of DEE.

Prostate cancer in firefighting and police work: a systematic review and meta-analysis of epidemiologic studies.

OBJECTIVES: We conducted a systematic review and meta-analysis to evaluate potential associations between firefighting and police occupations, and prostate cancer incidence and mortality. METHODS: Original epidemiological studies published from 1980 to 2017 were identified through PubMed and Web of Science. Studies were included if they contained specific job titles for ever/never firefighting and police work and associated prostate cancer risk estimates with 95% confidence intervals (CI). Study quality was assessed using a 20-point checklist. Prostate cancer meta-risk estimates (mRE) and corresponding 95% CIs were calculated for firefighting and police work separately and by various study characteristics using random effects models. Between-study heterogeneity was evaluated using the I2 score. Publication bias was assessed using Begg's and Egger's tests. RESULTS: A total of 26 firefighter and 12 police studies were included in the meta-analysis, with quality assessment scores ranging from 7 to 19 points. For firefighter studies, the prostate cancer incidence mRE was 1.17 (95% CI = 1.08-1.28, I2 = 72%) and the mortality mRE was 1.12 (95% CI = 0.92-1.36, I2 = 50%). The mRE for police incidence studies was 1.14 (95% CI = 1.02-1.28; I2 = 33%); for mortality studies, the mRE was 1.08 (95% CI = 0.80-1.45; I2 = 0%). By study design, mREs for both firefighter and police studies were similar to estimates of incidence and mortality. CONCLUSION: Small excess risks of prostate cancer were observed from firefighter studies with moderate to substantial heterogeneity and a relatively small number of police studies, respectively. There is a need for further studies to examine police occupations and to assess unique and shared exposures in firefighting and police work.

Devices for preventing percutaneous exposure injuries caused by needles in healthcare personnel.

BACKGROUND: Percutaneous exposure injuries from devices used for blood collection or for injections expose healthcare workers to the risk of blood borne infections such as hepatitis B and C, and human immunodeficiency virus (HIV). Safety features such as shields or retractable needles can possibly contribute to the prevention of these injuries and it is important to evaluate their effectiveness. OBJECTIVES: To determine the benefits and harms of safety medical devices aiming to prevent percutaneous exposure injuries caused by needles in healthcare personnel versus no intervention or alternative interventions. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL, Nioshtic, CISdoc and PsycINFO (until 11 November 2016). SELECTION CRITERIA: We included randomised controlled trials (RCT), controlled before and after studies (CBA) and interrupted time-series (ITS) designs of the effect of safety engineered medical devices on percutaneous exposure injuries in healthcare staff. DATA COLLECTION AND ANALYSIS: Two of the authors independently assessed study eligibility and risk of bias and extracted data. We synthesized study results with a fixed-effect or random-effects model meta-analysis where appropriate. MAIN RESULTS: We included six RCTs with 1838 participants, two cluster-RCTs with 795 participants and 73,454 patient days, five CBAs with approximately 22,000 participants and eleven ITS with an average of 13.8 data points. These studies evaluated safe modifications of blood collection systems, intravenous (IV) systems, injection systems, multiple devices, sharps containers and legislation on the implementation of safe devices. We estimated the needlestick injury (NSI) rate in the control groups to be about one to five NSIs per 1000 person-years. There were only two studies from low- or middle-income countries. The risk of bias was high in 20 of 24 studies. Safe blood collection systems:We found one RCT that found a safety engineered blood gas syringe having no considerable effect on NSIs (Relative Risk (RR) 0.2, 95% Confidence Interval (95% CI) 0.01 to 4.14, 550 patients, very low quality evidence). In one ITS study, safe blood collection systems decreased NSIs immediately after the introduction (effect size (ES) -6.9, 95% CI -9.5 to -4.2) but there was no further decrease over time (ES -1.2, 95% CI -2.5 to 0.1, very low quality evidence). Another ITS study evaluated an outdated recapping shield, which we did not consider further. Safe Intravenous systemsThere was very low quality evidence in two ITS studies that NSIs were reduced with the introduction of safe IV devices, whereas one RCT and one CBA study provided very low quality evidence of no effect. However, there was moderate quality evidence produced by four other RCT studies that these devices increased the number of blood splashes when the safety system had to be engaged actively (relative risk (RR) 1.6, 95% CI 1.08 to 2.36). In contrast there was low quality evidence produced by two RCTs of passive systems that showed no effect on blood splashes. Yet another RCT produced low quality evidence that a different safe active IV system also decreased the incidence of blood leakages. Safe injection devicesThere was very low quality evidence provided by one RCT and one CBA study showing that introduction of safe injection devices did not considerably change the NSI rate. One ITS study produced low quality evidence showing that the introduction of safe passive injection systems had no effect on NSI rate when compared to safe active injection systems. Multiple safe devicesThere was very low quality evidence from one CBA study and two ITS studies. According to the CBA study, the introduction of multiple safe devices resulted in a decrease in NSI,whereas the two ITS studies found no change. Safety containersOne CBA study produced very low quality evidence showing that the introduction of safety containers decreased NSI. However, two ITS studies evaluating the same intervention found inconsistent results. LegislationThere was low to moderate quality evidence in two ITS studies that introduction of legislation on the use of safety-engineered devices reduced the rate of NSIs among healthcare workers. There was also low quality evidence which showed a decrease in the trend over time for NSI rates.Twenty out of 24 studies had a high risk of bias and the lack of evidence of a beneficial effect could be due to both confounding and bias. This does not mean that these devices are not effective. AUTHORS' CONCLUSIONS: For safe blood collection systems, we found very low quality evidence of inconsistent effects on NSIs. For safe passive intravenous systems, we found very low quality evidence of a decrease in NSI and a reduction in the incidence of blood leakage events but moderate quality evidence that active systems may increase exposure to blood. For safe injection needles, the introduction of multiple safety devices or the introduction of sharps containers the evidence was inconsistent or there was no clear evidence of a benefit. There was low to moderate quality evidence that introduction of legislation probably reduces NSI rates.More high-quality cluster-randomised controlled studies that include cost-effectiveness measures are needed, especially in countries where both NSIs and blood-borne infections are highly prevalent.

Pesticide exposures and the risk of multiple myeloma in men: An analysis of the North American Pooled Project.

Multiple myeloma (MM) has been consistently linked with agricultural activities, including farming and pesticide exposures. Three case-control studies in the United States and Canada were pooled to create the North American Pooled Project (NAPP) to investigate associations between pesticide use and haematological cancer risk. This analysis used data from 547 MM cases and 2700 controls. Pesticide use was evaluated as follows: ever/never use; duration of use (years); and cumulative lifetime-days (LD) (days/year handled × years of use). Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression adjusted for age, province/state of residence, use of proxy respondents and selected medical conditions. Increased MM risk was observed for ever use of carbaryl (OR = 2.02, 95% CI = 1.28-3.21), captan (OR = 1.98, 95% CI = 1.04-3.77) and DDT (OR = 1.44, 95% CI = 1.05-1.97). Using the Canadian subset of NAPP data, we observed a more than threefold increase in MM risk (OR = 3.18, 95% CI = 1.40-7.23) for ≤10 cumulative LD of carbaryl use. The association was attenuated but remained significant for >10 LD of carbaryl use (OR = 2.44; 95% CI = 1.05-5.64; ptrend = 0.01). For captan, ≤17.5 LD of exposure was also associated with a more than threefold increase in risk (OR = 3.52, 95% CI = 1.32-9.34), but this association was attenuated in the highest exposure category of >17.5 LD (OR = 2.29, 95% CI = 0.81-6.43; ptrend = 0.01). An increasing trend (ptrend = 0.04) was observed for LD of DDT use (LD > 22; OR = 1.92, 95% CI = 0.95-3.88). In this large North American study of MM and pesticide use, we observed significant increases in MM risk for use of carbaryl, captan and DDT.

Devices for preventing percutaneous exposure injuries caused by needles in healthcare personnel.

BACKGROUND: Needlestick injuries from devices used for blood collection or for injections expose healthcare workers to the risk of blood borne infections such as hepatitis B and C, and human immunodeficiency virus (HIV). Safety features such as shields or retractable needles can possibly contribute to the prevention of these injuries and it is important to evaluate their effectiveness. OBJECTIVES: To determine the benefits and harms of safety medical devices aiming to prevent percutaneous exposure injuries caused by needles in healthcare personnel versus no intervention or alternative interventions. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL, Nioshtic, CISdoc and PsycINFO (until January 2014) and LILACS (until January 2012). SELECTION CRITERIA: We included randomised controlled trials (RCT), controlled before and after studies (CBA) and interrupted time-series (ITS) designs on the effect of safety engineered medical devices on needlestick injuries in healthcare staff. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study eligibility and risk of bias and extracted data. We synthesized study results with a fixed-effect or random-effects model meta-analysis where appropriate. MAIN RESULTS: We included four RCTs with 1136 participants, two cluster-RCTs with 795 participants and 73,454 patient days, four CBAs with approximately 22,000 participants and seven ITS with an average of seven data points. These studies evaluated safe modifications of blood collection systems, intravenous (IV) systems, injection systems, multiple devices and sharps containers. The needlestick injury (NSI) rate in the control groups was estimated at about one to five NSIs per 1000 person-years. There was only one study from a low- or middle-income country. The risk of bias was high in most studies.In one ITS study that evaluated safe blood collection systems, NSIs decreased immediately after the introduction (effect size (ES) -6.9, 95% confidence interval (CI) -9.5 to -4.2) and there was no clear evidence of an additional benefit over time (ES -1.2, 95% CI -2.5 to 0.1). Another ITS study used an outdated recapping shield.There was very low quality evidence that NSIs were reduced with the introduction of safe IV devices in two out of four studies but the other two studies showed no clear evidence of a trend towards a reduction. However, there was moderate quality evidence in four other studies that these devices increased the number of blood splashes where the safety system had to be engaged actively (relative risk (RR) 1.6, 95% CI 1.08 to 2.36).There was no clear evidence that the introduction of safe injection devices changed the NSI rate in two studies.The introduction of multiple safety devices showed a decrease in NSI in one study but not in another. The introduction of safety containers showed a decrease in NSI in one study but inconsistent results in two other studies.There was no evidence in the included studies about which type of device was better, for example shielding or retraction of the needle. AUTHORS' CONCLUSIONS: For safe blood collection systems, we found very low quality evidence in one study that these decrease needlestick injuries (NSIs). For intravenous systems, we found very low quality evidence that they result in a decrease of NSI compared with usual devices but moderate quality evidence that they increase contamination with blood. For other safe injection needles, the introduction of multiple safety devices or the introduction of sharps containers the evidence was inconsistent or there was no clear evidence of a benefit. All studies had a considerable risk of bias and the lack of evidence of a beneficial effect could be due both to confounding and bias. This does not mean that these devices are not effective.Cluster-randomised controlled studies are needed to compare the various types of safety engineered devices for their effectiveness and cost-effectiveness, especially in low- and middle-income countries.

Gloves, extra gloves or special types of gloves for preventing percutaneous exposure injuries in healthcare personnel.

BACKGROUND: Healthcare workers are at risk of acquiring viral diseases such as hepatitis B, hepatitis C and HIV through exposure to contaminated blood and body fluids at work. Most often infection occurs when a healthcare worker inadvertently punctures the skin of their hand with a sharp implement that has been used in the treatment of an infected patient, thus bringing the patient's blood into contact with their own. Such occurrences are commonly known as percutaneous exposure incidents. OBJECTIVES: To determine the benefits and harms of extra gloves for preventing percutaneous exposure incidents among healthcare workers versus no intervention or alternative interventions. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL, NIOSHTIC, CISDOC, PsycINFO and LILACS until 26 June 2013. SELECTION CRITERIA: Randomised controlled trials (RCTs) with healthcare workers as the majority of participants, extra gloves or special types of gloves as the intervention, and exposure to blood or bodily fluids as the outcome. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study eligibility and risk of bias, and extracted data. We performed meta-analyses for seven different comparisons. MAIN RESULTS: We found 34 RCTs that included 6890 person-operations as participating units and reported on 46 intervention-control group comparisons. We grouped interventions as follows: increased layers of standard gloves, gloves manufactured with special protective materials or thicker gloves, and gloves with puncture indicator systems. Indicator gloves show a coloured spot when they are perforated. Participants were surgeons in all studies and they used at least one pair of standard gloves as the control intervention. Twenty-seven studies also included other surgical staff (e.g. nurses). All but one study used perforations in gloves as an indication of exposure. The median control group rate was 18.5 perforations per 100 person-operations. Seven studies reported blood stains on the skin and two studies reported self reported needlestick injuries. Six studies reported dexterity as visual analogue scale scores for the comparison double versus single gloves, 13 studies reported outer glove perforations. We judged the included studies to have a moderate to high risk of bias.We found moderate-quality evidence that double gloves compared to single gloves reduce the risk of glove perforation (rate ratio (RR) 0.29, 95% confidence interval (CI) 0.23 to 0.37) and the risk of blood stains on the skin (RR 0.35, 95% CI 0.17 to 0.70). Two studies with a high risk of bias also reported the effect of double compared to single gloves on needlestick injuries (RR 0.58, 95% CI 0.21 to 1.62).We found low-quality evidence in one small study that the use of three gloves compared to two gloves reduces the risk of perforation further (RR 0.03, 95% CI 0.00 to 0.52). There was similar low-quality evidence that the use of one fabric glove over one normal glove reduces perforations compared to two normal gloves (RR 0.24, 95% CI 0.06 to 0.93). There was moderate-quality evidence that this effect was similar for the use of one special material glove between two normal material gloves. Thicker gloves did not perform better than thinner gloves.There was moderate to low-quality evidence in two studies that an indicator system does not reduce the total number of perforations during an operation even though it reduces the number of perforations per glove used.There was moderate-quality evidence that double gloves have a similar number of outer glove perforations as single gloves, indicating that there is no loss of dexterity with double gloves (RR 1.10, 95% CI 0.93 to 1.31). AUTHORS' CONCLUSIONS: There is moderate-quality evidence that double gloving compared to single gloving during surgery reduces perforations and blood stains on the skin, indicating a decrease in percutaneous exposure incidents. There is low-quality evidence that triple gloving and the use of special gloves can further reduce the risk of glove perforations compared to double gloving with normal material gloves. The preventive effect of double gloves on percutaneous exposure incidents in surgery does not need further research. Further studies are needed to evaluate the effectiveness and cost-effectiveness of special material gloves and triple gloves, and of gloves in other occupational groups.

Multiple pesticide exposures and the risk of multiple myeloma in Canadian men.

Multiple myeloma (MM) has been linked to certain agricultural exposures, including pesticides. This analysis aimed to investigate the association between lifetime use of multiple pesticides and MM risk using two exposure metrics: number of pesticides used and days per year of pesticide use. A frequency-matched, population-based case-control study was conducted among men in six Canadian provinces between 1991 and 1994. Data from 342 MM cases and 1,357 controls were analyzed using logistic regression to calculate odds ratios (OR) and 95% confidence intervals. Pesticides were grouped by type, chemical class and carcinogenic potential, using a composite carcinogenic probability score. Selected individual pesticides were also examined. Regression models were adjusted for age, province of residence, use of proxy respondents, smoking and selected medical history variables. The overall pattern of results was complex. Positive trends in risk were observed for fungicides (ptrend=0.04) and pesticides classified as probably carcinogenic or higher (ptrend=0.03). Excess risks of MM were observed among men who reported using at least one carbamate pesticide (OR=1.94, 1.16-3.25), one phenoxy herbicide (OR=1.56, 1.09-2.25) and ≥3 organochlorines (OR=2.21, 1.05-4.66). Significantly higher odds of MM were seen for exposure to carbaryl (OR=2.71, 1.47-5.00) and captan (OR=2.96, 1.40-6.24). Use of mecoprop for >2 days per year was also significantly associated with MM (OR=2.15, 1.03-4.48). Focusing on multiple pesticide exposures is important because this more accurately reflects how exposures occur in occupational settings. Significant associations observed for certain chemical classes and individual pesticides suggest that these may be MM risk factors.

How do perceptions of Covid-19 risk impact pregnancy-related health decisions? A convergent parallel mixed-methods study protocol.

INTRODUCTION: Pregnant people have a higher risk of severe COVID-19 disease. They have been disproportionately impacted by COVID-19 infection control policies, which exacerbated conditions resulting in intimate partner violence, healthcare access, and mental health distress. This project examines the impact of accumulated individual health decisions and describes how perinatal care and health outcomes changed during the COVID-19 pandemic. OBJECTIVES: Quantitative strand: Describe differences between 2019, 2021, and 2022 birth groups related to maternal vaccination, perinatal care, and mental health care. Examine the differential impacts on racialized and low-income pregnant people.Qualitative strand: Understand how pregnant people's perceptions of COVID-19 risk influenced their decision-making about vaccination, perinatal care, social support, and mental health. METHODS AND ANALYSIS: This is a Canadian convergent parallel mixed-methods study. The quantitative strand uses a retrospective cohort design to assess birth group differences in rates of Tdap and COVID-19 vaccination, gestational diabetes screening, length of post-partum hospital stay, and onset of depression, anxiety, and adjustment disorder, using administrative data from ICES, formerly the Institute for Clinical Evaluative Sciences (Ontario) and PopulationData BC (PopData) (British Columbia). Differences by socioeconomic and ethnocultural status will also be examined. The qualitative strand employs qualitative description to interview people who gave birth between May 2020- December 2021 about their COVID-19 risk perception and health decision-making process. Data integration will occur during design and interpretation. ETHICS AND DISSEMINATION: This study received ethical approval from McMaster University and the University of British Columbia. Findings will be disseminated via manuscripts, presentations, and patient-facing infographics. TRIAL REGISTRATION: Registration: Clinicaltrials.gov registration number: NCT05663762.

Pesticide use, immunologic conditions, and risk of non-Hodgkin lymphoma in Canadian men in six provinces.

Pesticide exposures and immune suppression have been independently associated with the risk of non-Hodgkin lymphoma (NHL), but their joint effect has not been well explored. Data from a case-control study of men from six Canadian provinces were used to evaluate the potential effect modification of asthma, allergies, or asthma and allergies and hay fever combined on NHL risk from use of: (i) any pesticide; (ii) any organochlorine insecticide; (iii) any organophosphate insecticide; (iv) any phenoxy herbicide; (v) selected individual pesticides [1,1'-(2,2,2-trichloroethylidene)bis[4-chlorobenzene]; 1,1,1-trichloro-2,2-bis(4-chlorophenyl) ethane (DDT), malathion, (4-chloro-2-methylphenoxy)acetic acid (MCPA), mecoprop, and (2,4-dichlorophenoxy)acetic acid (2,4-D); and (vi) from the number of potentially carcinogenic pesticides. Incident NHL cases (n = 513) diagnosed between 1991 and 1994 were recruited from provincial cancer registries and hospitalization records and compared to 1,506 controls. A stratified analysis was conducted to calculate odds ratios (ORs) adjusted for age, province, proxy respondent, and diesel oil exposure. Subjects with asthma, allergies, or hay fever had non-significantly elevated risks of NHL associated with use of MCPA (OR = 2.67, 95% confidence interval [CI]: 0.90-7.93) compared to subjects without any of these conditions (OR = 0.81, 95% CI: 0.39-1.70). Conversely, those with asthma, allergies, or hay fever who reported use of malathion had lower risks of NHL (OR = 1.25, 95% CI: 0.69-2.26) versus subjects with none of these conditions (OR = 2.44, 95% CI: 1.65-3.61). Similar effects were observed for asthma and allergies evaluated individually. Although there were some leads regarding effect modification by these immunologic conditions on the association between pesticide use and NHL, small numbers, measurement error and possible recall bias limit interpretation of these results.

Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff.

BACKGROUND: Surgeons and their assistants are especially at risk of exposure to blood due to glove perforations and needle stick injuries during operations. The use of blunt needles can reduce this risk because they don't penetrate skin easily but still perform sufficiently in other tissues. OBJECTIVES: To determine the effectiveness of blunt needles compared to sharp needles for preventing percutaneous exposure incidents among surgical staff. SEARCH METHODS: We searched MEDLINE and EMBASE (until May 2011), CENTRAL, NHSEED, Science Citation Index Expanded, CINAHL, Nioshtic, CISdoc, PsycINFO, and LILACS (until September 2010). SELECTION CRITERIA: Randomised controlled trials (RCTs) of blunt versus sharp suture needles for preventing needle stick injuries among surgical staff measured as glove perforations or self-reported needle stick injuries. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study eligibility and risk of bias in trials and extracted data. We synthesized study results with a fixed-effect model meta-analysis. MAIN RESULTS: We located 10 RCTs involving 2961 participating surgeons performing an operation in which the use of blunt needles was compared to the use of sharp needles. Four studies focused on abdominal closure, two on caesarean section, two on vaginal repair and two on hip replacement. On average, a surgeon that used sharp needles sustained one glove perforation in three operations. The use of blunt needles reduced the risk of glove perforations with a relative risk (RR) of 0.46 (95% confidence interval (CI) 0.38 to 0.54) compared to sharp needles. The use of blunt needles will thus prevent one glove perforation in every six operations.In four studies, the use of blunt needles reduced the number of self-reported needle stick injuries with a RR of 0.31 (95% CI 0.14 to 0.68). Because the force needed for the blunt needles is higher, their use was rated as more difficult but still acceptable in five out of six studies.The quality of the evidence was rated as high. AUTHORS' CONCLUSIONS: There is high quality evidence that the use of blunt needles appreciably reduces the risk of exposure to blood and bodily fluids for surgeons and their assistants over a range of operations. It is unlikely that future research will change this conclusion.

Use of a Canadian Population-Based Surveillance Cohort to Test Relationships Between Shift Work and Breast, Ovarian, and Prostate Cancer.

OBJECTIVES: Shift work with circadian disruption is a suspected human carcinogen. Additional population-representative human studies are needed and large population-based linkage cohorts have been explored as an option for surveillance shift work and cancer risk. This study uses a surveillance linkage cohort and job-exposure matrix to test relationships. METHODS: We estimated associations between shift work and breast, ovarian, and prostate cancer using the population-based Canadian Census Health and Environment Cohort (CanCHEC), linking the 1991 Canadian census to national cancer registry and mortality databases. Prevalence estimates from population labour survey data were used to estimate and assign probability of night, rotating, or evening shifts by occupation and industry. Cohort members were assigned to high (>50%), medium (>25 to 50%), low (>5 to 25%), or no (<5%) probability of exposure categories. Cox proportional hazards modelling was used to estimate associations between shift work exposure and incidence of prostate cancer in men and ovarian and breast cancer in women. RESULTS: The cohort included 1 098 935 men and 939 520 women. Hazard ratios (HRs) indicated null or inverse relationships comparing high probability to no exposure for prostate cancer: HR = 0.96, 95% confidence interval (CI) = 0.91-1.02; breast cancer: HR = 0.94, 95% CI = 0.90-0.99; and ovarian cancer: HR = 0.99, 95% CI = 0.87-1.13. CONCLUSIONS: This study showed inverse and null associations between shift work exposure and incidence of prostate, breast, or ovarian cancer. However, we explore limitations of a surveillance cohort, including a possible healthy worker survivor effect and the possibility that this relationship may require the nuanced exposure detail in primary collection studies to be measurable.

Glyphosate use and associations with non-Hodgkin lymphoma major histological sub-types: findings from the North American Pooled Project.

Objectives Some epidemiological studies have suggested positive associations between glyphosate use and non-Hodgkin lymphoma (NHL), but evidence is inconsistent and few studies could evaluate histological sub-types. Here, associations between glyphosate use and NHL incidence overall and by histological sub-type were evaluated in a pooled analysis of case-control studies. Methods The analysis included 1690 NHL cases [647 diffuse large B-cell lymphoma (DLBCL), 468 follicular lymphoma (FL), 171 small lymphocytic lymphoma (SLL), and 404 other sub-types] and 5131 controls. Logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) for NHL overall and sub-types with self-reported ever/never, duration, frequency, and lifetime-days of glyphosate use. Results Subjects who ever used glyphosate had an excess of NHL overall (OR 1.43, 95% CI 1.11-1.83). After adjustment for other pesticides, the OR for NHL overall with "ever use" was 1.13 (95% CI 0.84-1.51), with a statistically significant association for handling glyphosate >2 days/year (OR 1.73, 95% CI 1.02-2.94, P-trend=0.2). In pesticide-adjusted sub-type analyses, the ordinal measure of lifetime-days was statistically significant (P=0.03) for SLL, and associations were elevated, but not statistically significant, for ever years or days/year of use. Handling glyphosate >2 days/year had an excess of DLBCL (OR 2.14, 95% CI 1.07-4.28; P-trend=0.2). However, as with the other sub-types, consistent patterns of association across different metrics were not observed. Conclusions There was some limited evidence of an association between glyphosate use and NHL in this pooled analysis. Suggestive associations, especially for SLL, deserve additional attention.

Non-Hodgkin lymphoma risk and organophosphate and carbamate insecticide use in the north American pooled project.

Organophosphates and carbamates have been among the most commonly used insecticides, with both agricultural and residential uses. Previous studies have suggested associations of non-Hodgkin lymphoma (NHL) with some of these chemicals; however, many studies have been limited in their ability to evaluate associations with lymphoma subtypes. We evaluated the use of eleven organophosphate and two carbamate insecticides in association with NHL in the North American Pooled Project, which includes data from case-control studies in the United States and Canada (1690 cases/5131 controls). We used unconditional logistic regression adjusting for potential confounders, including use of other pesticides, to estimate odds ratios (OR) and 95% confidence intervals (CI) for associations between these chemicals and NHL overall, and NHL subtypes, i.e., follicular (FL), diffuse large B-cell (DLBCL), small lymphocytic lymphoma (SLL) and others. Ever use of malathion was associated with increased risk of NHL overall (OR = 1.43; 95% CI: 1.14-1.81) compared with never users. Categories using tertiles of duration (<4 yrs., 4-12 yrs., and >12 yrs) also showed a significant exposure-response for increasing years of use of malathion and risk of NHL (OR<4vsUnex = 1.33 (0.88, 2.03), OR4-12vsUnex = 1.42 (1.02, 1.96), OR>12vsUnex = 1.55 (1.05, 2.28, p-trend < 0.01)). In addition, malathion use was statistically significantly associated with FL (OR = 1.58; 95% CI: 1.11-2.27) and DLBCL (OR = 1.61; 95% CI: 1.16-2.22) while there were no apparent associations with SLL or other subtypes, the p-value for heterogeneity across subtypes, however, was not significant. These results support previous studies suggesting an association between insecticide use and NHL overall, and provide new information on associations with NHL subtypes.