Is there a u-shaped relationship between load levels and fatigue and recovery? An examination of possible mechanisms.

In a previous study, an unexpected u-shaped relationship was observed between load level and fatigue/recovery responses. Moderate load levels resulted in lower perceived discomfort, pain, and fatigue, and shorter recovery times compared to either low or high load levels. This phenomenon has been reported in other studies, but no article has examined the possible mechanisms that might explain this u-shaped relationship. In this paper, we re-examined the previously published data and found that the phenomenon does not appear to be due to the experimental artefact; the u-shape may be due to unexpectedly lower fatigue effects at moderate loads, and higher fatigue effects at lower loads. We then conducted a literature review and identified several possible physiological, perceptual, and biomechanical explanatory mechanisms. No single mechanism explains the entirety of the phenomenon. Further research is needed on the relationship between work exposures, fatigue, and recovery, and the mechanisms related to the u-shaped relationship.Practitioner summary: We examine a previously observed u-shaped relationship between load level and fatigue/recovery, where moderate force resulted in lower perceived fatigue and shorter recovery times. A u-shaped fatigue response suggests that simply minimising load levels might not be an optimal approach to reduce the risk of workplace injuries.

Towards safety and autonomy in the home bathroom: Identifying challenges, needs and gaps.

This qualitative study aims to identify challenges, needs and gaps for home care bathroom tasks and gather information that will allow for user-centered, sustainable solutions for home care in the bathroom. Twenty-one interviews were carried out with participants with the perspective of client, health care worker or care organization. The data were analyzed using qualitative content analysis and interpretive description. The findings identify important factors for enabling both independent living for clients and a sustainable work environment for the health care workers. They include adequate space, access to assistive devices and regular risk assessments to recognize changing needs. Enabling independent living is one strategy that can be used to manage the ongoing demographic change as well as the expected future labor shortage in the care sector. Changes can be made in the physical environment (the residential bathroom) in order to facilitate safer task performance for both the clients and the health care workers.

A comparison of work-rest models using a "breakpoint" analysis raises questions.

OCCUPATIONAL APPLICATIONSDesigning sustainable cyclic work requires attention to both the workload amplitude as well as the duty cycle, the fraction of the work cycle with active workload, that therefore also defines the recovery phase of the cycle. A number of different approaches and models have been developed to calculate the required recovery time for a given load and duty cycle. We present a comparison of three types of models at the "breakpoint" that defines the boundary of load amplitude and duty cycle where fatigue begins to accumulate faster than recovery allows within the work cycle. This comparison shows considerable variation between models of the "allowable" load or duty cycle depending on the method used. Practitioners should thus be cautious applying these models indiscriminately in job design as their results can vary substantially. In particular, differences between the tasks used for model formulation and application may compromise validity, and model application in a given context should be verified before broad application.

TECHNICAL ABSTRACTRationale: There is a need for tools to help design sustainable work in which muscular capacity and other human resources can recover at least as quickly as they are used. Purpose: In this brief report, three different approaches presented in the literature to determining work-rest schedules in cyclic work are compared. Methods: First, a set of five different muscular endurance models coupled with a recovery time model were considered, both with and without a dynamic work correction factor. Second, we examined a model of "resumption time", and third a psychophysically-based model of maximum duty cycle was included. These models were compared using the concept of a "breakpoint" in fatigue accumulation­the point at which a given load amplitude and duty cycle combination begins to cause accumulation of fatigue in each cycle and from which there is inadequate time to recover. Results: While the five endurance time models all behaved similarly, both with and without the static-to-dynamic correction factor applied, the three different types of modeling approaches provided substantially different response patterns. The psychophysically based model provided the most protective guideline among the models compared. Conclusion: These models should be applied with caution to particular work scenarios. Further research is needed to test accuracy and effectiveness when applying such models to a range of task scenarios to establish safe workloads and loading times in the design of repetitive work.

The RAMP package for MSD risk management in manual handling - A freely accessible tool, with website and training courses.

In this paper the RAMP Package is presented with the objective to facilitate the application of the RAMP tool to systematically manage MSD risks. The package consists of the RAMP tool (Risk Assessment and Management tool for manual handling Proactively), the RAMP website, and free, globally available online, training courses (MOOCs). An Action module used for managing identified MSD risks is introduced. The tool, encompassing a wide range of risks, is applicable to the whole risk management process. Furthermore, RAMP is openly available for download, and free to use. The RAMP tool and training materials were developed using a participative iterative methodology including researchers and practitioners. RAMP was downloaded in 86 countries in the first 26 months since its' launch and over 2400 learners from high-, middle- and low-income countries have joined the MOOCs. The RAMP Package meets organisations' needs for an accessible, comprehensive risk assessment and management tool.

Development and evaluation of RAMP II - a practitioner's tool for assessing musculoskeletal disorder risk factors in industrial manual handling.

RAMP II is an observation-based tool developed for assessing a wide range of musculoskeletal disorder risk factors related to industrial manual handling. RAMP II, which is part of the RAMP tool, is based on research studies and expert judgments. The assessment relies mainly on direct or video observations of the work being assessed, but additionally on measured push/pull forces and weights of handled objects, and on perceived workload and discomfort. Over 80 practitioners participated in the development of the tool. According to the evaluations, 73% of the assessment items evaluated had acceptable reliability, and the majority of the potential end-users reported that RAMP II is usable for assessing risks and as a decision base. It is concluded that this study provides support that RAMP II is usable for risk assessment of musculoskeletal disorder risk factors in industrial manual handling. Practitioner summary: RAMP II is an observation-based assessment tool for screening and assessing major musculoskeletal exposures in industrial manual handling jobs. Over 80 practitioners participated in the development of the tool. This study provides support that RAMP II is usable for risk assessment of musculoskeletal disorder risk factors in industrial manual handling. Abbreviations: CTS: carpal tunnel syndrome; HARM: the Hand Arm Risk Assessment method; IMP: intramuscular pressure; κw: linearly weighted kappa; LBD: lower back disorders; LBP: lower back pain; MAWL: maximum acceptable weight of lift; MHO: manual handling operations; MSD: musculoskeletal disorder; MNSD: neck-shoulder disorder; NSP: neck-shoulder pain; OCRA: the Occupational Repetitive Action methods; OHS: occupational health and safety; PABAK: prevalence and bias adjusted kappa; p0: proportion of agreement; RAMP: Risk Assessment and Management tool for manual handling Proactively; ROM: range of motion; RPL: risk and priority level; RSI: the Revised Strain Index; RULA: the Rapid Upper Limb Assessment; SWEA: Swedish Work Environment Authority; UEMSDs: upper-extremity work-related musculoskeletal disorders; WMSD: work-related musculoskeletal disorder; WRMSD: work-related musculoskeletal disorder; workday8h: eight hours workday.

ISOPT Clinical Hot Topic Panel Discussion on Cornea Anterior Segment Disease.

The cornea and its adnexa pose a unique situation of a tightly defined set of requirements for its function. This includes: transparency, perfect built to obtain appropriate refractive power, protective barrier from microbial invaders. Moreso, the cornea also endures extreme external physical conditions (temperature, high and low humidity, winds and alike). All these functions are maintained while preserving a constant state of homogenous wetting. Toward that end the cornea is equipped with an elaborated network of sensory neural network. While enabling the blinking reflex and maintaining the physiological steady state of wetting, this neural network also makes the cornea prone to the discomfort that with or without associated changes seen on medical examination. ISOPT Clinical 2018 discussion touched upon this hypercomplex situation, addressing the role of inflammation and its resulting discomfort in dry eye conditions. The discussion also engulfed the emerging neuropathic pain syndrome that is recently gaining more attention. Another related topic was the utilization of autologous serum tears and its ability to provide amelioration to desperate patients. Finally, the panel discussed the issue of treating corneal infection, including when and how to utilize steroids in the course of therapy. We assume the reader will find interest in this discussion that directly addresses issues seen day in and day out in our busy clinics.

Development and evaluation of RAMP I - a practitioner's tool for screening of musculoskeletal disorder risk factors in manual handling.

RAMP I is a screening tool developed to support practitioners in screening for work-related musculoskeletal disorder risk factors related to manual handling. RAMP I, which is part of the RAMP tool, is based on research-based studies combined with expert group judgments. More than 80 practitioners participated in the development of RAMP I. The tool consists of dichotomous assessment items grouped into seven categories. Acceptable reliability was found for a majority of the assessment items for 15 practitioners who were given 1 h of training. The usability evaluation points to RAMP I being usable for screening for musculoskeletal disorder risk factors, i.e., usable for assessing risks, being usable as a decision base, having clear results and that the time needed for an assessment is acceptable. It is concluded that RAMP I is a usable tool for practitioners.

Modelling endurance and resumption times for repetitive one-hand pushing.

This study's objective was to develop models of endurance time (ET), as a function of load level (LL), and of resumption time (RT) after loading as a function of both LL and loading time (LT) for repeated loadings. Ten male participants with experience in construction work each performed 15 different one-handed repetaed pushing tasks at shoulder height with varied exerted force and duration. These data were used to create regression models predicting ET and RT. It is concluded that power law relationships are most appropriate to use when modelling ET and RT. While the data the equations are based on are limited regarding number of participants, gender, postures, magnitude and type of exerted force, the paper suggests how this kind of modelling can be used in job design and in further research. Practitioner Summary: Adequate muscular recovery during work-shifts is important to create sustainable jobs. This paper describes mathematical modelling and presents models for endurance times and resumption times (an aspect of recovery need), based on data from an empirical study. The models can be used to help manage fatigue levels in job design.

Breastfeeding Practices and Opinions of Latina Mothers in an Urban Pediatric Office: A Focus Group Study.

INTRODUCTION: The purpose of this qualitative study was to explore beliefs about breastfeeding among Latina mothers. The focus groups were part of a sequential mixed methods study. METHODS: Two focus groups were conducted. Participants were Spanish-speaking mothers with infants younger than 12 months. Focus groups were conducted in Spanish and audiorecorded. The researchers performed open coding of the data, compared and converged codes, and identified common themes and relationships among the themes. RESULTS: Mothers described concerns about adequacy of breastfeeding for their infants' needs, the continued goodness of breast milk, and weaning. They expressed lack of knowledge about using breast pumps and other assists that could help them breastfeed. DISCUSSION: Culturally tailored breastfeeding education and support have not been adequately implemented in this urban clinic and likely in other similar settings. More targeted attention to this population could improve exclusive breastfeeding of infants and ultimately result in better child health.

Subtenon Injections of Ranibizumab Arrest Growth in Early Recurrent Pterygium.

IMPORTANCE: Currently the only treatment for recurrent pterygium is surgery. This is a phase 1 trial investigating ranibizumab as a medical treatment for recurrent pterygium. OBJECTIVE: To assess the safety and efficacy of subtenon Ranibizimab for recurrent pterygia. DESIGN: Subjects with recurrent pterygium received subtenon ranibizumab and were followed for 1 year. Safety parameters were measured. Photographs were taken and quantitatively analyzed to measure the short-term (2 months) and long-term (5-26 months) response to treatment. SETTING: University of New Mexico Eye Clinic. PARTICIPANTS: Eight subjects with recurrent pterygia. INTERVENTIONS: Subtenon delivery of 0.5 to 2 mg of ranibizumab, at day 0, month 1, and month 2. MAIN OUTCOME MEASURES: Safety parameters included visual acuity, intraocular pressure, and assessment of ocular surface. Efficacy was assessed by comparing photographs taken at day 0 with a short-term follow-up photograph taken at month 2 and a long-term follow-up image taken at the final patient visit (range 5-26 months). Quantitative analysis of photographs was performed to measure vascularity in the treated zone. RESULTS: Four subjects had an arrest of pterygium growth with a visual reduction in vascularity and a quantitative reduction in the area of vascularization (average vascularized area in short-term follow-up images was 51% of the baseline photos at day 0, and in the long-term photos was 36% of day 0). The other four subjects had a less marked reduction in their vascularity in the short-term photos (69% of their baseline photos). This resulted in two subjects withdrawing from the study early. Long-term quantitative analysis for the two remaining "nonresponders," who completed the study, showed an average vascularized area that was 71% of that in their baseline photos. The long-term photos in these subjects did not appear to have a clinically relevant difference from the short-term photos. CONCLUSIONS: In half of the subjects, subtenon ranibizumab appeared to arrest growth. Although the response is variable, this may warrant the drug's use when attempting to control growth of recurrent pterygia, and may prevent consecutive surgery for some patients.

Fatigue and recovery during and after static loading.

Subjectively assessed endurance time (ET), resumption time (RT) and perceived discomfort, pain or fatigue (PD), and objectively measured maximum force-exerting capacity were investigated for varying loads and durations of a pushing task with two repeated trials. Beyond the main results quantifying how the load scenario affected ET, RT and PD, three additional results are of note: (1) although the maximum pushing force did not change between trials, shorter ET, longer RT and higher PD indicated accumulation of fatigue in Trial 2; (2) the PD ratings showed a trend with a linear increase during loading and a curvilinear decrease during recovery; and (3) the RT and the load level for different relative loading times were found to have an unexpected U-shaped relationship, indicating lowest fatigue at the intermediate load level. These results can be used to model a more sustainable and productive work-recovery ratio.

Cardiovascular health literacy and treatment adherence in persons with serious mental illness.

Persons with serious mental illnesses have shorter life spans than the general population, and their earlier death is often related to cardiovascular disease. This study examined health literacy and cardiovascular medication adherence in a sample of 98 participants with serious mental illness. Sixty-two percent of the participants had adequate health literacy as measured by the Test of Functional Health Literacy in Adults. The association between health literacy and medication adherence was not significant after controlling for education. There was a significant association between health literacy and education level, health literacy and site, and health literacy and the sodium intake subscale of the Hill-Bone adherence scale.

A pilot study on providing ophthalmic training to medical students while initiating a sustainable eye care effort for the underserved.

IMPORTANCE: We present a method to reintroduce ophthalmic training into the medical school curriculum. OBJECTIVES: To evaluate knowledge and skills acquired when participating in a service project, the Community Vision Project, and to develop a quantitative method for testing skills with the direct ophthalmoscope in patients. DESIGN: Second-year medical students participated in the study. After 1 month, their knowledge was compared with that of peers and graduates (internal medicine residents). Also at 1 month, their direct ophthalmoscope skills were compared with those of upperclassmen who had completed all core clerkships. One year later, after the participants had completed their core clerkships, long-term ophthalmoscope skills retention was tested, and their performance was compared with that of their classmates. SETTING AND PARTICIPANTS: Training occurred in mobile eye clinics. Knowledge and skills assessments were performed in the hospital eye clinic among students and residents at The University of New Mexico School of Medicine. Patients were recruited from the hospital eye clinic. Participants attended a 3-hour training session held by an attending physician in the hospital eye clinic and took part in at least 1 mobile eye clinic. MAIN OUTCOMES AND MEASURES: A knowledge assessment quiz was administered to participants (n = 12), their classmates (n = 18), and internal medicine residents (n = 33). Skills assessment with the direct ophthalmoscope was performed at 1 month and at 1 year in 5 participants and 5 nonparticipants. Tonometer skills were assessed by comparing participants' readings with those of an ophthalmologist's obtained in patients at the mobile eye clinics. RESULTS Participants' median knowledge assessment scores were 48% higher than those of their classmates and 37% higher than those of internal medicine residents (P < .001 for both). Short-term (1 month) direct ophthalmoscopy median scores were 60% (quartile 1 to quartile 3 range, 40%-80%) for participants and 40% (quartile 1 to quartile 3 range, 20%-60%) for nonparticipating upperclassmen (P = .24). Long-term direct ophthalmoscopy median scores were 100% (quartile 1 to quartile 3 range, 75%-100%) for participants and 0% (quartile 1 to quartile 3 range, 0%-25%) for nonparticipating classmates (P = .11). Participants' tonometer readings were similar to those of the ophthalmologist's; their median reading was 2 mm Hg (quartile 1 to quartile 3 range, 0-4 mm Hg) higher than that of the ophthalmologist's (P = .05, sign test). CONCLUSIONS AND RELEVANCE: Service-based learning offered an efficient model for incorporating ophthalmic training into the medical school curriculum. A viable tool for quantitatively testing ophthalmoscope skills is presented.

Exploring workplace violence among home care workers in a consumer-driven home health care program.

Nominal research has examined sexual harassment and workplace violence against home care workers within consumer-driven home care models such as those offered in Oregon. This study examined home care workers' experiences of violence while providing care to consumer employers, the patients who hire and manage home care workers. Focus groups and interviews were conducted in Oregon with 83 home care workers, 99 Oregon Department of Human Services (DHS) employees, and 11 consumer employers. Home care workers reported incidents of workplace physical violence (44%), psychological abuse (65%), sexual harassment (41%), and sexual violence (14%). Further, three themes were identified that may increase the risk of workplace violence: (1) real and perceived barriers to reporting violence; (2) tolerance of violence; and (3) limited training to prevent violence. To ensure worker safety while maintaining quality care, safety policies and training for consumer employers, state DHS employees, and home care workers must be developed.

A clinical academic practice partnership: a clinical education redesign.

The clinical academic practice partnership (CAPP), a clinical redesign based on the dedicated education unit concept, was developed and implemented by large, private school of nursing in collaboration with 4 clinical partners to provide quality clinical education, to explore new clinical models for the future, and to test an innovative clinical education design. An executive steering committee consisting of nursing leaders and educators from the school of nursing and the clinical institutions was established as the decision-making and planning components, with several collaborative task forces initiated to conduct the work and to accomplish the goals. This article will describe methods to initiate and to organize the key elements of this dedicated education unit-type clinical model, providing examples and an overview of the steps and elements needed as the development proceeded. After 18 months of implementation in 4 different nursing programs in 4 different clinical institutions, the clinical redesign has shown to be a positive initiative, with students actively requesting CAPP units for their clinical experiences. Preliminary findings and outcomes will be discussed, along with nursing education implications for this new clinical redesign.

The context of condom use among young adults in the Philippines: implications for HIV prevention.

We examine current perceptions and constraints surrounding condom use among young adults in the Philippines to garner a deeper contextual understanding of this aspect of HIV prevention within Filipino society. Through thematic analysis of focus group data, we found three broad themes, all of which include societal and individual barriers to using condoms. The findings may provide insight for similar settings in which religion has a strong influence on society. To strengthen HIV prevention efforts in such settings, we suggest that the development of strategies to address these constraints and promote healthy sexuality in young adults is essential.

Pregnant women experiencing IPV: impact of supportive and non-supportive relationships with their mothers and other supportive adults on perinatal depression: a mixed methods analysis.

The current study explored the views of women experiencing interpersonal violence (IPV) and their relationship with their mothers or other supportive adult, and determines how this relationship affected perinatal depressive symptoms. The sample consisted of 30 urban and rural pregnant women enrolled in a larger ongoing randomized controlled trial. Data from quantitative instruments that measured depressive symptoms were examined in combination with qualitative interview data collected at baseline and six months post-natal. Women describing positive relationships with their mothers or another supportive adult reported statistically significant lower depressive symptoms scores (p < .05).

The role of mental health on maternal-fetal attachment in low-income women.

OBJECTIVE: To examine and describe the influence of maternal depressive symptoms on maternal-fetal attachment (MFA) in predominantly low-income women. DESIGN: Mixed method. SETTING: Three urban obstetric/gynecologic (OB/GYN) clinics serving predominantly low-income women. PARTICIPANTS: A convenience sample of 166 women participated in the quantitative component and a purposeful subsample of 12 women participated in the qualitative component; all women were between 24 and 28 weeks gestation at the time of data collection. METHODS: Linear regression models were used to examine the influence of depressive symptoms and social support on MFA. Individual in-depth interviews were conducted among a subsample of women to explore the influence of maternal depressive symptoms on MFA. RESULTS: Fifty-nine percent (n = 98) of participants had scores that were clinically significant for depressive symptoms. In the final model of social support and depressive symptoms regressed on MFA, social support (b = .23, 95% CI [0.09, .37], p = .002) and depressive symptoms (b = -1.02, 95% CI [-1.32, -.73], p < 0.001) were significant predictors. This multivariate linear regression model with two variables accounted for 65.2% of the total variance in overall MFA. Qualitative participants discussed the importance of social support in contributing to their mood state and MFA. CONCLUSIONS: Findings from this study highlight the importance of assessing for depressive symptoms during pregnancy given its influence on MFA. By understanding how important it was for these women to have a supportive person to experience their pregnancies with, nurses can improve the pregnancy experience for vulnerable populations.

Needs of persons with serious mental illness following discharge from inpatient treatment: patient and family views.

Patients with serious mental illnesses often struggle with persistent symptoms that interfere with daily functioning in the community. The first days and weeks following inpatient treatment for an acute episode may be a critical time for patients to connect with the recommended community follow-up. Residual symptoms may interfere with their ability to access and benefit from these services to meet their needs. A descriptive study was conducted to explore perceptions of patients and families of patients' needs, functioning, coping and social support in the first 4 weeks after inpatient treatment. Results suggested that these patients had residual symptoms after discharge that interfered with functioning despite the availability of follow-up services. Patients identified unmet needs related to their illness. Family members identified concerns related to the lack of improvement in their ill relatives over time. Patients expressed satisfaction with care and felt supported by their families. Both patients and families seemed to lack a thorough understanding of goals for follow-up care.