Appraisal of quality and analysis of the similarities and differences between osteoarthritis Clinical Practice Guideline recommendations: A systematic review.

OBJECTIVE: Clinical Practice Guidelines (CPGs) aim to support management of hip and knee osteoarthritis (OA), but recommendations are often conflicting and implementation is poor, contributing to evidence-to-practice gaps. This systematic review investigated the contextual and methodological factors contributing to conflicting recommendations for hip and knee OA. METHOD: Our systematic review appraised CPGs for managing hip and knee OA in adults ≥18 years (PROSPERO CRD42021276635). We used AGREE-II and AGREE-REX to assess quality and extracted data on treatment gaps, conflicts, biases, and consensus. Heterogeneity of recommendations was determined using Weighted Fleiss Kappa (K). The relationship between (K) and AGREE-II/AGREE-REX scores was explored. RESULTS: We identified 25 CPGs across eight countries and four international organisations. The ACR, EULAR, NICE, OARSI and RACGP guidelines scored highest for overall AGREE-II quality (83%). The highest overall AGREE-REX scores were for BMJ Arthroscopy (80%), RACGP (78%) and NICE (76%). CPGs with the least agreement for pharmacological recommendations were ESCEO and NICE (-0.14), ACR (-0.08), and RACGP (-0.01). The highest agreements were between RACGP and NICE (0.53), RACGP and ACR (0.61), and NICE and ACR (0.91). Decreased internal validity determined by low-quality AGREE scores(<60%) in editorial independence were associated with less agreement for pharmacological recommendations. CONCLUSION: There were associations between guideline quality and agreement scores. Future guideline development should be informed by robust evidence, editorial independence and methodological rigour to ensure a harmonisation of recommendations. End-users of CPGs must recognise the contextual factors associated with the development of OA CPGs and balance these factors with available evidence.

Using SUpported Motivational InTerviewing (SUMIT) to increase physical activity for people with knee osteoarthritis: a pilot, feasibility randomised controlled trial.

OBJECTIVE: The objective of this study was to determine the feasibility and effectiveness of using SUpported Motivational InTerviewing (SUMIT) to increase physical activity in people with knee osteoarthritis (KOA). DESIGN: Randomised controlled trial. SETTING: We recruited people who had completed Good Life with osteoArthritis Denmark (GLA:D) from private, public and community settings in Victoria, Australia. INTERVENTIONS: Participants were randomised participants to receive SUMIT or usual care. SUMIT comprised five motivational interviewing sessions targeting physical activity over 10 weeks, and access to a multimedia web-based platform. PARTICIPANTS: Thirty-two participants were recruited (17 SUMIT, 15 control) including 22 females (69%). OUTCOME MEASURES: Feasibility outcomes included recruitment rate, adherence to motivational interviewing, ActivPAL wear and drop-out rate. Effect sizes (ESs) were calculated for daily steps, stepping time, time with cadence >100 steps per minute, time in bouts >1 min; 6 min walk distance, Knee Osteoarthritis Outcome Score (KOOS) subscales (pain, symptoms, function, sport and recreation, and quality of life (QoL)), Euroqual, systolic blood pressure, body mass index, waist circumference, 30 s chair stand test and walking speed during 40 m walk test. RESULTS: All feasibility criteria were achieved, with 32/63 eligible participants recruited over seven months; with all participants adhering to all motivational interviewing calls and achieving sufficient ActivPAL wear time, and only two drop-outs (6%).12/15 outcome measures showed at least a small effect (ES>0.2) favouring the SUMIT group, including daily time with cadence >100 steps per minute (ES=0.43). Two outcomes, walking speed (ES= 0.97) and KOOS QoL (ES=0.81), showed a large effect (ES>0.8). CONCLUSION: SUMIT is feasible in people with knee osteoarthritis. Potential benefits included more time spent walking at moderate intensity, faster walking speeds and better QoL. TRIAL REGISTRATION NUMBER: ACTRN12621000267853.

Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines.

OBJECTIVES: Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines. METHODS: Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154). RESULTS: Seven higher-quality and 18 lesser-quality guidelines were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., acupuncture) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty. CONCLUSION: Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.

Osteoarthritis management care pathways are complex and inefficient: A qualitative study of physiotherapist perspectives from specialised osteoarthritis services.

OBJECTIVE: Hip and knee osteoarthritis guidelines internationally provide consistent first-line care recommendations. However, uptake of these recommendations remains suboptimal. This qualitative study explores factors influencing guideline-based care from the perspectives of physiotherapists working in specialised osteoarthritis services across different models of care. METHODS: Nineteen semi-structured interviews were conducted with physiotherapists working in specialist osteoarthritis services across three different Australian models of care (OsteoArthritis Hip and Knee Service n = 10; OsteoArthritis Chronic Care Programme n = 4; Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services n = 5). Interviews were audio recorded and transcribed verbatim. Data were coded and analysed inductively using thematic analysis. RESULTS: The overarching theme to emerge was that accessing first-line osteoarthritis care is complex and difficult, regardless of model of care. Subthemes indicated that: (i) services are either unavailable or inadequately funded, (ii) referral pathways are labyrinthine and lengthy, (iii) patients and other health professionals often believe that surgery is the only/best option and (iv) managing patient co-morbidities is challenging. CONCLUSION: Physiotherapists working in specialised osteoarthritis services perceive multiple and complex factors influencing adherence to first-line care. Barriers occur at various levels in all models of care, including patient and health professional beliefs, health service, and system levels. These results suggest improving healthcare for people with osteoarthritis requires urgent system reform.

Osteoarthritis Hip and Knee Service (OAHKS) in a community health setting compared to the hospital setting: A feasibility study for a new care pathway.

AIM: OsteoArthritis Hip and Knee Service (OAHKS) clinics involve assessment and triage by advanced musculoskeletal physiotherapists for patients referred to orthopaedic clinics in public hospitals. This study explored the feasibility of implementing an OAHKS clinic in a community setting. METHODS: The domains of feasibility explored in this mixed methods study were acceptability (patient, general practitioner and orthopaedic surgeon), demand (referrals, waiting times) efficacy potential (management decision, conversion-to-surgery rates) and practicality (number and type of discussions between advanced musculoskeletal physiotherapist and doctors, adverse events). Results from a community-based OAHKS were compared with hospital-based OAHKS over a 9-month period in the same metropolitan health region. RESULTS: A total of 91 eligible patients attended an OAHKS clinic (40 community-based, 51 hospital-based). Both the community-based and hospital-based OAHKS had high patient and general practitioner satisfaction, with small differences in favour of community-based OAHKS. Waiting times were significantly shorter in community-based OAHKS for both initial appointment [community-based OAHKS mean 17 days (SD11), hospital-based OAHKS mean 155 days (SD38)] and commencing non-surgical management [community-based OAHKS mean 32 days (SD22), hospital-based OAHKS mean 67 days (SD32)]. Referral rate to orthopaedics was substantially lower from community-based OAHKS (3%) compared with hospital-based OAHKS (33%) [odds ratio 0.05 (95% CI 0.01-0.41)]. There were no adverse events. CONCLUSION: Community-based OAHKS is feasible, and acceptable to patients and general practitioners, with potential benefits indicated in this study including shorter waiting times for assessment and commencing non-surgical management programs.

Obesity Increases Prevalence of Colonic Adenomas at Screening Colonoscopy: A Canadian Community-Based Study.

BACKGROUND AND AIMS: Obesity is a risk factor for colorectal neoplasia. We examined the influence of obesity and metabolic syndrome (MetS) on prevalence of neoplasia at screening colonoscopy. METHODS: We evaluated 2020 subjects undergoing first screening colonoscopy. Body mass index (BMI) was calculated at enrolment. Hyperlipidemia (HL), hypertension (HT), and diabetes mellitus (DM) were identified. Details of colonoscopy, polypectomy, and histology were recorded. Odds for adenomas (A) and advanced adenomas (ADV) in overweight (BMI 25.1-30) and obese (BMI > 30) subjects were assessed by multinomial regression, adjusted for covariates. Analyses included relationships between HL, HT, DM, age, tobacco usage, and neoplasia. Discriminatory power of HT, HL, DM, and BMI for neoplasia was assessed by binary logistic regression. Odds were calculated for neoplasia in each colonic segment related to BMI. RESULTS: A and ADV were commoner in overweight and obese males, obese females, older subjects, and smokers. HL, HT, and DM were associated with increased odds for neoplasia, significantly for A with hypertension. BMI alone predicted neoplasia as well as HT, HL, DM, or combinations thereof. All segments of the colon were affected. Multiple polyps were particularly prevalent in the obese. CONCLUSIONS: Obesity and MetS are risk factors for colonic neoplasia in a Canadian population.

Effect of vitamin D supplementation on oral glucose tolerance in individuals with low vitamin D status and increased risk for developing type 2 diabetes (EVIDENCE): A double-blind, randomized, placebo-controlled clinical trial.

AIMS: Low serum 25-hydroxyvitamin-D (25(OH)D) concentrations are associated with insulin resistance, ß-cell dysfunction and type 2 diabetes. We conducted a 24-week double-blind, randomized, placebo-controlled trial to examine the effect of 28 000 IU of vitamin D3 once weekly on plasma glucose after a 2 hour-75 g oral glucose tolerance test (2hrPC glucose), insulin sensitivity and ß-cell function. STUDY DESIGN AND METHODS: A total of 71 participants with serum 25(OH)D ≤65 nmol/L, impaired fasting glucose and elevated glycated hemoglobin were randomly assigned to receive 28 000 IU of vitamin D3 (VitD; n = 35) or placebo (n = 36) in cheese once weekly for 24 weeks. The primary outcome was the change in 2hPC glucose. Secondary outcomes were fasting glucose, fasting and postprandial insulin, indices of insulin sensitivity and ß-cell function, glycated hemoglobin and lipid profile. Participants underwent an oral glucose tolerance test to determine 2hPC glucose. RESULTS: Mean baseline serum 25(OH)D was 48.1 and 47.6 nmol/L in the VitD and placebo groups, respectively. Serum 25(OH)D significantly increased to 98.7 nmol/L (51 nmol/L increase; P < .0001) in the VitD group. No significant differences in fasting ( P = .42) or 2hPC glucose ( P = .55) or other indices of glucose metabolism, including ß-cell function and insulin sensitivity, were observed between groups. A subgroup analysis of individuals with 25(OH)D < 50 nmol/L and prediabetes did not change these results. The VitD group exhibited a significant reduction in LDL cholesterol (-0.27 vs 0.01 mmol/L, P = .03). CONCLUSION: Weekly doses of vitamin D3 in individuals with suboptimal vitamin D levels who were at risk for type 2 diabetes did not improve oral glucose tolerance or markers of glycaemic status.

Bioactive oat ß-glucan reduces LDL cholesterol in Caucasians and non-Caucasians.

BACKGROUND: There is increasing global acceptance that viscous soluble fibers lower serum LDL cholesterol (LDL-C), but most evidence for this comes from studies in Caucasians. To see if oat ß-glucan lowers LDL-C in Caucasians and non-Caucasians we conducted a post-hoc analysis of the results of a randomized, controlled, double-blind, multi-center clinical trial whose primary aim was to determine if molecular-weight (MW) influenced the LDL-C-lowering effect of oat ß-glucan. RESULTS: Caucasian and non-Caucasian subjects with LDL-C-C ≥ 3.0 and ≤ 5.0 mmol/L (n = 786 screened, n = 400 ineligible, n = 19 refused, n = 367 randomized, n = 345 completed, n = 1 excluded for missing ethnicity) were randomly assigned to consume cereal containing wheat-fiber (Control, n = 74:13 Caucasian:non-Caucasian) or 3 g high-MW (3H, 2,250,000 g/mol, n = 67:19), 4 g medium-MW (4 M, 850,000 g/mol, n = 50:17), 3 g medium-MW (3M, 530,000 g/mol, n = 54:9) or 4 g low-MW (4 L, 210,000 g/mol, n = 51:12) oat ß-glucan daily for 4 weeks. LDL-C after 4 weeks was influenced by baseline LDL-C (p < 0.001) and treatment (p = 0.003), but not ethnicity (p = 0.74). In all subjects, compared to control, 3 H, 4 M and 3 M reduced LDL-C significantly by 4.8 to 6.5%, but 4 L had no effect. Compared to control, the bioactive oat ß-glucan treatments (3H, 4M and 3M) reduced LDL-C by a combined mean (95% CI) of 0.18 (0.06, 0.31) mmol/L (4.8%, n = 171, p = 0.004) in Caucasians, a value not significantly different from the 0.37 (0.09, 0.65) mmol/L (10.3%, n = 45, p = 0.008) reduction in non-Caucasians. CONCLUSION: We conclude that oat ß-glucan reduces LDL-C in both Caucasians and non-Caucasians; there was insufficient power to determine if the magnitude of LDL-C-lowering differed by ethnicity. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00981981.

Physicochemical properties of oat ß-glucan influence its ability to reduce serum LDL cholesterol in humans: a randomized clinical trial.

BACKGROUND: Consumption of 3 g oat ß-glucan/d is considered sufficient to lower serum LDL cholesterol, but some studies have shown no effect. LDL cholesterol lowering by oat ß-glucan may depend on viscosity, which is controlled by the molecular weight (MW) and amount of oat ß-glucan solubilized in the intestine (C). OBJECTIVES: Our 2 primary objectives were to determine whether consumption of 3 g high-MW oat ß-glucan/d would reduce LDL cholesterol and whether LDL cholesterol lowering was related to the log(MW × C) of oat ß-glucan. DESIGN: In a double-blind, parallel-design, multicenter clinical trial, subjects with LDL cholesterol ≥3.0 and ≤5.0 mmol/L (n = 786 screened, n = 400 ineligible, n = 19 refused, n = 367 enrolled, and n = 345 completed) were randomly assigned to receive cereal containing wheat fiber (n = 87) or 3 g high-MW (2,210,000 g/mol, n = 86), 4 g medium-MW (850,000 g/mol, n = 67), 3 g medium-MW (530,000 g/mol, n = 64), or 4 g low-MW (210,000 g/mol, n = 63) oat ß-glucan/d (divided doses, twice daily) for 4 wk. RESULTS: LDL cholesterol was significantly less with 3 g high-MW, 4 g medium-MW, and 3 g medium-MW oat ß-glucan cereals than with the wheat-fiber cereal by 0.21 (5.5%; 95% CI: -0.11, -0.30; P = 0.002), 0.26 (6.5%; 95% CI: -0.14, -0.37; P = 0.0007), and 0.19 (4.7%; 95% CI: -0.08, -0.30; P = 0.01) mmol/L, respectively. However, the effect of 4 g low-MW oat ß-glucan/d (0.10 mmol/L) was not significant (2.3%; 95% CI: 0.02, -0.20). By analysis of covariance, log(MW × C) was a significant determinant of LDL cholesterol (P = 0.003). Treatment effects were not significantly influenced by age, sex, study center, or baseline LDL cholesterol. CONCLUSIONS: The physicochemical properties of oat ß-glucan should be considered when assessing the cholesterol-lowering ability of oat-containing products; an extruded breakfast cereal containing 3 g oat ß-glucan/d with a high-MW (2,210,000 g/mol) or a medium-MW (530,000 g/mol) lowered LDL cholesterol similarly by ≈0.2 mmol/L (5%), but efficacy was reduced by 50% when MW was reduced to 210,000 g/mol. This trial was registered at www.clinicaltrials.gov as NCT00981981.

The Canadian Trial of Carbohydrates in Diabetes (CCD), a 1-y controlled trial of low-glycemic-index dietary carbohydrate in type 2 diabetes: no effect on glycated hemoglobin but reduction in C-reactive protein.

BACKGROUND: The optimal source and amount of dietary carbohydrate for managing type 2 diabetes (T2DM) are unknown. OBJECTIVE: We aimed to compare the effects of altering the glycemic index or the amount of carbohydrate on glycated hemoglobin (HbA1c), plasma glucose, lipids, and C-reactive protein (CRP) in T2DM patients. DESIGN: Subjects with T2DM managed by diet alone (n=162) were randomly assigned to receive high-carbohydrate, high-glycemic-index (high-GI), high-carbohydrate, low-glycemic-index (low-GI), or low-carbohydrate, high-monounsaturated-fat (low-CHO) diets for 1 y. RESULTS: The high-GI, low-GI, and low-CHO diets contained, respectively, 47%, 52%, and 39% of energy as carbohydrate and 31%, 27%, and 40% of energy as fat; they had GIs of 63, 55, and 59, respectively. Body weight and HbA1c did not differ significantly between diets. Fasting glucose was higher (P=0.041), but 2-h postload glucose was lower (P=0.010) after 12 mo of the low-GI diet. With the low-GI diet, overall mean triacylglycerol was 12% higher and HDL cholesterol 4% lower than with the low-CHO diet (P<0.05), but the difference in the ratio of total to HDL cholesterol disappeared by 6 mo (time x diet interaction, P=0.044). Overall mean CRP with the low-GI diet, 1.95 mg/L, was 30% less than that with the high-GI diet, 2.75 mg/L (P=0.0078); the concentration with the low-CHO diet, 2.35 mg/L, was intermediate. CONCLUSIONS: In subjects with T2DM managed by diet alone with optimal glycemic control, long-term HbA1c was not affected by altering the GI or the amount of dietary carbohydrate. Differences in total:HDL cholesterol among diets had disappeared by 6 mo. However, because of sustained reductions in postprandial glucose and CRP, a low-GI diet may be preferred for the dietary management of T2DM.

The Berlin questionnaire for sleep apnea in a sleep clinic population: relationship to polysomnographic measurement of respiratory disturbance.

The Berlin questionnaire (BQ) has been used to help identify patients at high risk of having sleep apnea in primary care and atrial fibrillation patients. The BQ may be a useful adjunct in sleep medicine and research, but it has never been validated in a sleep clinic population. The aim of the study is to determine the specificity and sensitivity of the BQ compared to the respiratory disturbance index (RDI) values obtained from two nights of polysomnographic recording in a sleep clinic population. This is a retrospective chart review study of 130 sleep clinic patients. Patients' demographics, BQ scores, RDI measurements, and sleep study parameters were extracted from the patients' chart. Of the 130 charts reviewed, the BQ identified 76 (58.5%) as being at high-risk of having sleep apnea, but overnight polysomnography found only 34 of the 130 patients (26.2%) had an RDI > 10. The BQ performed with 0.62 sensitivity and 0.43 specificity at the RDI > 10 level. Due to the low sensitivity and specificity as well as the large number of false negatives and positives, the Berlin questionnaire is not an appropriate instrument for identifying patients with sleep apnea in a sleep clinic population.

Adrenergic receptors in the ptotic human eyelid: correlation with phenylephrine testing and surgical success in ptosis repair.

PURPOSE: To investigate the relationship between adrenergic receptors in Müller muscle and response to phenylephrine testing in patients undergoing ptosis surgery. This study also compares outcomes of Fasanella and Putterman approaches to posterior ptosis repair. METHODS: Prospective analysis of 71 patients undergoing posterior ptosis surgery. Eyelid height was measured before and after phenylephrine. Müller muscle was examined for alpha-1D, alpha-2C, beta-1, and beta-2 receptors. Specimens were graded on receptor staining intensity. Patients were seen 1 week and 6 weeks following surgery. Surgical outcomes were scored on a scale of 1 (most favorable) to 3 (least favorable). RESULTS: Adrenergic receptors were found in decreasing order: alpha-1D, beta-1, alpha-2C, and beta-2. Receptor grade significantly predicted eyelid height for alpha-2C receptors (p = .03). Mean outcome scores for 36 Putterman (1.10) and 35 Fasanella (1.27) procedures were not significantly different. CONCLUSIONS: Alpha 1D, alpha-2C, and beta-2 receptors are documented within human Müller muscle. Human eyelid elevation response to phenylephrine is inversely related to the amount of alpha-2C receptor staining in Müller muscle. Fasanella and Putterman procedures have equal outcomes, independent of adrenergic receptors.

Equivalent glycemic load (EGL): a method for quantifying the glycemic responses elicited by low carbohydrate foods.

BACKGROUND: Glycemic load (GL) is used to quantify the glycemic impact of high-carbohydrate (CHO) foods, but cannot be used for low-CHO foods. Therefore, we evaluated the accuracy of equivalent-glycemic-load (EGL), a measure of the glycemic impact of low-CHO foods defined as the amount of CHO from white-bread (WB) with the same glycemic impact as one serving of food. METHODS: Several randomized, cross-over trials were performed by a contract research organization using overnight-fasted healthy subjects drawn from a pool of 63 recruited from the general population by newspaper advertisement. Incremental blood-glucose response area-under-the-curve (AUC) elicited by 0, 5, 10, 20, 35 and 50 g CHO portions of WB (WB-CHO) and 3, 5, 10 and 20 g glucose were measured. EGL values of the different doses of glucose and WB and 4 low-CHO foods were determined as: EGL = (F-B)/M, where F is AUC after food and B is y-intercept and M slope of the regression of AUC on grams WB-CHO. The dose-response curves of WB and glucose were used to derive an equation to estimate GL from EGL, and the resulting values compared to GL calculated from the glucose dose-response curve. The accuracy of EGL was assessed by comparing the GL (estimated from EGL) values of the 4 doses of oral-glucose with the amounts actually consumed. RESULTS: Over 0-50 g WB-CHO (n = 10), the dose-response curve was non-linear, but over the range 0-20 g the curve was indistinguishable from linear, with AUC after 0, 5, 10 and 20 g WB-CHO, 10 +/- 1, 28 +/- 2, 58 +/- 5 and 100 +/- 6 mmol x min/L, differing significantly from each other (n = 48). The difference between GL values estimated from EGL and those calculated from the dose-response curve was 0 g (95% confidence-interval, +/- 0.5 g). The difference between the GL values of the 4 doses of glucose estimated from EGL, and the amounts of glucose actually consumed was 0.2 g (95% confidence-interval, +/- 1 g). CONCLUSION: EGL, a measure of the glycemic impact of low-carbohydrate foods, is valid across the range of 0-20 g CHO, accurate to within 1 g, and at least sensitive enough to detect a glycemic response equivalent to that produced by 3 g oral-glucose in 10 subjects.

Fatigue and shift work.

Shift work is a ubiquitous phenomenon and its adverse effects on workers' physical and mental health have been documented. In the sleep literature, differentiating between the symptoms of fatigue and sleepiness, and developing appropriate objective and subjective measures, have become very important endeavors. From such research, fatigue and sleepiness have been shown to be distinct and independent phenomena. However, it is not known whether shift work differentially affects fatigue and sleepiness. In an attempt to answer this question, 489 workers from a major Ontario employer completed a series of subjective, self-report questionnaires, including the Fatigue Severity Scale (FSS) and the Epworth Sleepiness Scale. Workers were separated into four groups based on the frequency with which they are engaged in shift work (never, fewer than four times per month, 1-2 days per week, 3 days or more per week). The frequency of shift work was found to have a significant effect on subjective fatigue, but not on subjective sleepiness. Compared with the subjects who never had a shift schedule, those who worked in a shift for 3 days or more had significantly higher mean score of the FSS. In agreement with previous results, a low correlation was found between workers' subjective fatigue and sleepiness scores, providing further support for the concept of fatigue and sleepiness as distinct and independent phenomena. Future research should address the possibility of using the FSS as an indicator when the frequency of shift work has become high enough to adversely affect work performance or cause health problems.