Factors influencing medium- and long-term occupational impact following COVID-19.

BACKGROUND: Significant numbers of individuals struggle to return to work following acute coronavirus disease 2019 (COVID-19). The UK Military developed an integrated medical and occupational pathway (Defence COVID-19 Recovery Service, DCRS) to ensure safe return to work for those with initially severe disease or persistent COVID-19 sequalae. Medical deployment status (MDS) is used to determine ability to perform job role without restriction ('fully deployable', FD) or with limitations ('medically downgraded', MDG). AIMS: To identify which variables differ between those who are FD and MDG 6 months after acute COVID-19. Within the downgraded cohort, a secondary aim is to understand which early factors are associated with persistent downgrading at 12 and 18 months. METHODS: Individuals undergoing DCRS had comprehensive clinical assessment. Following this, their electronic medical records were reviewed and MDS extracted at 6, 12 and 18 months. Fifty-seven predictors taken from DCRS were analysed. Associations were sought between initial and prolonged MDG. RESULTS: Three hundred and twenty-five participants were screened, with 222 included in the initial analysis. Those who were initially downgraded were more likely to have post-acute shortness of breath (SoB), fatigue and exercise intolerance (objective and subjective), cognitive impairment and report mental health symptoms. The presence of fatigue and SoB, cognitive impairment and mental health symptoms was associated with MDG at 12 months, and the latter two, at 18 months. There were also modest associations between cardiopulmonary function and sustained downgrading. CONCLUSIONS: Understanding the factors that are associated with initial and sustained inability to return to work allows individualized, targeted interventions to be utilized.

A moderated mediation analysis on the influence of social support and cognitive flexibility in predicting mental wellbeing in elite sport.

The purpose of this study was to examine the mechanism by which social support influences mental wellbeing. Using the thriving through relationships model to provide a theoretical underpinning, cognitive flexibility was hypothesised as a mediator. Additionally, the research examined the consistency of this pathway between elite athletes, retired athletes, and non-athletes. Survey responses from a sample of 247 participants (n = 49 elite athletes, n = 61 retired athletes, n = 137 convenience sample; of which 127 (51.4%) were males were included in the analysis. Initial mediation analysis revealed a significant indirect pathway from social support to mental wellbeing through cognitive flexibility. Moderated mediation analysis revealed this pathway was significant for retired athletes and the convenience sample, but not for elite athletes. Results provide additional insight into the mechanisms by which social support influences wellbeing. Cognitive flexibility interventions may not be as effective for elite athletes.

Rehabilitation post-COVID-19: cross-sectional observations using the Stanford Hall remote assessment tool.

INTRODUCTION: The multisystem COVID-19 can cause prolonged symptoms requiring rehabilitation. This study describes the creation of a remote COVID-19 rehabilitation assessment tool to allow timely triage, assessment and management. It hypotheses those with post-COVID-19 syndrome, potentially without laboratory confirmation and irrespective of initial disease severity, will have significant rehabilitation needs. METHODS: Cross-sectional study of consecutive patients referred by general practitioners (April-November 2020). Primary outcomes were presence/absence of anticipated sequelae. Binary logistic regression was used to test association between acute presentation and post-COVID-19 symptomatology. RESULTS: 155 patients (n=127 men, n=28 women, median age 39 years, median 13 weeks post-illness) were assessed using the tool. Acute symptoms were most commonly shortness of breath (SOB) (74.2%), fever (73.5%), fatigue (70.3%) and cough (64.5%); and post-acutely, SOB (76.7%), fatigue (70.3%), cough (57.4%) and anxiety/mood disturbance (39.4%). Individuals with a confirmed diagnosis of COVID-19 were 69% and 63% less likely to have anxiety/mood disturbance and pain, respectively, at 3 months. CONCLUSIONS: Rehabilitation assessment should be offered to all patients suffering post-COVID-19 symptoms, not only those with laboratory confirmation and considered independently from acute illness severity. This tool offers a structure for a remote assessment. Post-COVID-19 programmes should include SOB, fatigue and mood disturbance management.

Cardiopulmonary exercise testing excludes significant disease in patients recovering from COVID-19.

OBJECTIVE: Post-COVID-19 syndrome presents a health and economic challenge affecting ~10% of patients recovering from COVID-19. Accurate assessment of patients with post-COVID-19 syndrome is complicated by health anxiety and coincident symptomatic autonomic dysfunction. We sought to determine whether either symptoms or objective cardiopulmonary exercise testing could predict clinically significant findings. METHODS: 113 consecutive military patients were assessed in a comprehensive clinical pathway. This included symptom reporting, history, examination, spirometry, echocardiography and cardiopulmonary exercise testing (CPET) in all, with chest CT, dual-energy CT pulmonary angiography and cardiac MRI where indicated. Symptoms, CPET findings and presence/absence of significant pathology were reviewed. Data were analysed to identify diagnostic strategies that may be used to exclude significant disease. RESULTS: 7/113 (6%) patients had clinically significant disease adjudicated by cardiothoracic multidisciplinary team (MDT). These patients had reduced fitness (V̇O2 26.7 (±5.1) vs 34.6 (±7.0) mL/kg/min; p=0.002) and functional capacity (peak power 200 (±36) vs 247 (±55) W; p=0.026) compared with those without significant disease. Simple CPET criteria (oxygen uptake (V̇O2) >100% predicted and minute ventilation (VE)/carbon dioxide elimination (V̇CO2) slope <30.0 or VE/V̇CO2 slope <35.0 in isolation) excluded significant disease with sensitivity and specificity of 86% and 83%, respectively (area under the receiver operating characteristic curve (AUC) 0.89). The addition of capillary blood gases to estimate alveolar-arterial gradient improved diagnostic performance to 100% sensitivity and 78% specificity (AUC 0.92). Symptoms and spirometry did not discriminate significant disease. CONCLUSIONS: In a population recovering from SARS-CoV-2, there is reassuringly little organ pathology. CPET and functional capacity testing, but not reported symptoms, permit the exclusion of clinically significant disease.

Reproductive biology of wild and domesticated Ensete ventricosum: Further evidence for maintenance of sexual reproductive capacity in a vegetatively propagated perennial crop.

Loss of sexual reproductive capacity has been proposed as a syndrome of domestication in vegetatively propagated crops, but there are relatively few examples from agricultural systems. In this study, we compare sexual reproductive capacity in wild (sexual) and domesticated (vegetative) populations of enset (Ensete ventricosum (Welw.) Cheesman), a tropical banana relative and Ethiopian food security crop. We examined floral and seed morphology and germination ecology across 35 wild and domesticated enset. We surveyed variation in floral and seed traits, including seed weight, viability and internal morphology, and germinated seeds across a range of constant and alternating temperature regimes to characterize optimum germination requirements. We report highly consistent floral allometry, seed viability, internal morphology and days to germination in wild and domesticated enset. However, seeds from domesticated plants responded to cooler temperatures with greater diurnal range. Shifts in germination behaviour appear concordant with a climatic envelope shift in the domesticated distribution. Our findings provide evidence that sexual reproductive capacity has been maintained despite long-term near-exclusive vegetative propagation in domesticated enset. Furthermore, certain traits such as germination behaviour and floral morphology may be under continued selection, presumably through rare sexually reproductive events. Compared to sexually propagated crops banked as seeds, vegetative crop diversity is typically conserved in living collections that are more costly and insecure. Improved understanding of sexual propagation in vegetative crops may have applications in germplasm conservation and plant breeding.

Factors that affect fractured neck of femur outcome: Clinical commissioning groups influence length of stay and discharge destination.

BACKGROUND: The average length of stay (LOS) following a hip fracture in hospitals around the UK has been approximately 20 days in recent years. This can vary between hospitals and there are numerous factors that can affect LOS. We had the impression that LOS varied by Clinical Commissioning Group (CCG) from which the patient originates. The aim of our study was to discover whether the concern was valid, and if so, what the reasons may be. METHODS: We analysed hip fracture data collected at our Trust between September 2008 and December 2014. LOS was compared for each of three CCGs in our Trust's catchment areas, and those patients admitted from outlying CCGs. Sub-analysis was performed by patient age, ASA grade, abbreviated mental test score, procedure type and discharge destination to determine which factors influence LOS. RESULTS: 1847 patients were identified. After excluding deaths, missing data and extreme outliers, 1603 patients were included in the analysis. The median LOS varied from 14.9 to 23.4 days across CCGs. The major reason for this variation was discharge destination. CCGs associated with longer LOS had a significantly higher rate of discharge to the patient's own home, rather than institutional care. This was independent of patient age, mental status, ASA grade and promptness of surgery. CONCLUSION: We have shown that CCGs vary in their performance to aid discharge. This directly influences a Trust's performance on the National Hip Fracture Database. Compared with other hospitals, our results show a poor outcome in terms of length of stay, but much better performance regarding home discharge. We recommend that more emphasis in future be placed on discharge destination than LOS.

Bevacizumab as an adjunct to vitreoretinal surgery for diabetic retinopathy in East Africa.

PURPOSE: The purpose of this study is to evaluate the efficacy of preoperative intravitreal bevacizumab (IVB) for improving outcomes in vitrectomy for diabetic retinopathy-related non-clearing vitreous haemorrhage and/or tractional retinal detachment. METHODS: Medical record from patients undergoing vitrectomy for proliferative diabetic retinopathy (PDR) were retrospectively analysed (2003-2011). From 2007, IVB (1.25 mg 2-4 days before operating) was used on all eyes. Eyes receiving IVB were compared with those that did not receive IVB. Intraoperative complications, reoperation rates, and final visual acuity were the core outcome measures. RESULTS: Data were analysed for 88 patients (101 eyes). In all, 41 (41%) patients had received IVB, whereas 60 (59%) patients had not. Significant intraoperative haemorrhage occurred in six eyes (10%) in the non-IVB group and in one (2.4%) IVB eyes (P=0.24). Silicon oil was used in 29 (48%) non-IVB eyes and in 11 (27%) IVB eyes (P=0.03). The non-IVB eyes underwent significantly more vitreoretinal reoperations (P=0.01) and were significantly more likely to lose two or more lines of vision at the final follow-up (P=0.03). The numbers needed to treat (NNT) blindness (<3/60) was four for non-IVB eyes and two for the IVB group. CONCLUSIONS: IVB reduces surgical complications, the use of silicon oil, and the need for further retinal surgery. The NNT to restore useful vision (≥3/60) to a blind eye were significantly lower in the IVB group. Vitreoretinal surgery for the complications of PDR is effective in an East African context, and IVB should be considered a valuable adjunct.

The clinical efficacy of triclosan/copolymer and other common therapeutic approaches to periodontal health.

The maintenance of an effective level of oral hygiene is the cornerstone of all attempts to prevent and control periodontal disease, and yet the widespread prevalence of the disease indicates the inability of most people to maintain a level of plaque control commensurate with periodontal health. The inclusion of antibacterial agents, such as chlorhexidine and triclosan, in oral care products has provided a means to improve oral health. Randomised, controlled clinical trials have demonstrated that the unsupervised use of a dentifrice (toothpaste) containing triclosan/copolymer significantly improves gingival health, prevents the onset of periodontitis and reduces further progression of tissue destruction. The delivery of such benefits has positive implications for the oral health of individuals and populations.

A cluster randomised controlled trial to evaluate the effectiveness of fluoride varnish as a public health measure to reduce caries in children.

This cluster randomised controlled study assessed the effectiveness of twice-yearly applications of fluoride varnish as a public health measure to reduce dental caries in children living in relatively deprived communities. The test (n = 334) and control (n = 330) children in 2 school years (unit of randomisation) attended 24 state primary schools and were 6-8 years of age at the start. Good baseline balance was found. Duraphat varnish was applied at school on 5 occasions over 26 months, by dental therapists. A combined visual and fibre-optic transillumination examination included all surfaces of primary and first permanent molars at baseline and after 26 months for small and large enamel and dentine lesions. At the final examination the only statistically significant difference was in the caries increment for small enamel lesions in the primary dentition, with the test children having fewer lesions. This study failed to demonstrate that the twice-yearly application of fluoride varnish provided at school reduced dental caries in children living in this community. The low level of response and a lower than expected caries increment had a major impact on the effectiveness of the intervention, since the children who participated were least likely to have benefited from the programme, whereas those who might have benefited did not consent.

Challenges associated with the evaluation of a dental health promotion programme in a deprived urban area.

OBJECTIVE: This paper reports the results of a community trial to measure the clinical impact of a linked series of interventions on Early Childhood Caries (ECC) and general caries levels among five-year-old children. It exemplifies the problems of undertaking population based interventions in deprived communities. RESEARCH DESIGN: Two health districts (Primary Care Groups) were matched for dental disease levels and socio-demographic factors. One was randomly allocated to be the active intervention PCG, the other the comparison PCG. Children in the active PCG received a series of interventions to support positive dental health behaviour from the age of 8 to 32 months. Clinical examinations were undertaken on a cohort of 5-year-old children in both active and comparison PCGs. SETTING: In the active PCG, children who attended designated clinics for their 8-month developmental checks and/or MMR inoculations at 12 to 15 months, were given gift bags, the first contained a trainer cup, the second fluoride toothpaste (1450 ppm F) and toothbrush. Parents were also given written, pictorial and verbal advice on oral care. Further supplies of toothpaste and brushes were posted to the children's homes at 20, 26 and 32 months. When five years of age children in the two PCGs were examined in school. OUTCOME MEASURES: Severity and prevalence of ECC and general caries. Levels of participation. RESULTS: Among participants in the active PCG the prevalence of ECC, general caries and extraction experience and mean dmft (20%: 54%: 3%: 2.2) were lower than in 'participants' in the comparison area (32%: 64%: 12%: 3.7). All differences were statistically significant. When all children (participants and non-participants) in the two PCGs were compared, the differences were much reduced (30%: 63%: 6%: 3.1 vs. 32%: 64%: 12%: 3.6). A higher proportion of children in the active PCG area (47%) were found not to have participated in the interventions, when compared to 21% in the comparison area. Disease levels in the non-participants in the active PCG were particularly high. The impact of participation bias, changes in baseline balance, population mobility and alternative study design on outcomes are explored. CONCLUSION: The impact of non-participation in a deprived, urban conurbation with high levels of population mobility are sufficient to dilute the impact of a health intervention such that few benefits are discernible at a population level.

Agreement amongst examiners assessing dental fluorosis from digital photographs using the TF index.

OBJECTIVE: To compare the scoring of dental fluorosis by experienced examiners from digital photographs using the TF index. BASIC RESEARCH DESIGN: 120 images were selected from 703 photographs obtained during a clinical trial (Tavener et al., 2004). The selection process was stratified so that the full range of defects seen in the main study was included. The children, aged 8-10 years, were from deprived areas of Manchester, England with fluoride levels in the drinking water of less the 0.1 ppm F. The photographs of the upper and lower anterior sextants were taken after cleaning and drying the teeth. The examiners were identified by searching Medline for individuals who had previously used the TF index or had experience of scoring dental fluorosis. Of the 12 examiners identified, 10 agreed to take part. Each examiner was provided with identical CDs containing a PowerPoint presentation of the images. Twelve images were duplicated and interspersed amongst the 120 images to assess intra examiner agreement. Each examiner was also supplied with a table listing the criteria and illustrations for each of the TF index scores (Fejerskov et al., 1988). RESULTS: The prevalence of fluorosis (TF > 0) amongst the 10 examiners ranged from 43% to 70% and from 2% to 13% for the more severe scores (TF 3 or 4). Paired agreements amongst subject scores for the 10 examiners, measured using a weighted Kappa score, ranged from 0.40 to 0.71. CONCLUSION: It is concluded that although the criteria for the TF index are well defined, it is possible that examiners may interpret the criteria in different ways and conditions in which images are viewed may need to be standardised. This study may explain some of the differences in the prevalence and severity of fluorosis reported in different studies. There is a need to standardise the methods used to score dental fluorosis.

Effect of whitening gels on the surface roughness of restorative materials in situ.

Peroxide gels are effective in changing tooth colour but their effect on restorative materials has been poorly studied. The purpose of this investigation was to assess the impact of a commercially available whitening gel containing hydrogen peroxide and a sodium percarbonate formulation on the surface of restorative materials. A total of 12 subjects participated in a double-blinded crossover study. Each wore an intra-oral appliance containing five bovine enamel blocks restored with amalgam, posterior composite, microfilled composite, glass ionomer cement and porcelain. Appliances were worn continuously for 14 days and whitening products were applied twice daily. After 14 days the appliances were removed and values for roughness (R(a)) were obtained using atomic force microscopy. Mean values of R(a) were assessed between baseline and 14 days, and although minor variations were seen, there were no statistically significant differences detected for any material or any whitening product.

The prevalence and severity of fluorosis in children who received toothpaste containing either 440 or 1,450 ppm F from the age of 12 months in deprived and less deprived communities.

This study compared fluorosis in the upper central incisors of children from socially diverse backgrounds who had received either 440- or 1,450-ppm F toothpaste from 12 months of age. The children were resident in non-fluoridated districts in the north-west of England. They received either 440- or 1,450-ppm F toothpaste and advice regarding its use until the age of 5-6 years. Dental fluorosis (TF index) was assessed on digital images of dried teeth when the children (n = 1,268) were 8-10 years old. In the less deprived districts the prevalences of fluorosis (TF >or=0) for the 1,450- and 440-ppm F groups were 34.5 and 23.7% (p = 0.006). In the deprived districts the prevalences of fluorosis were 25.2 and 19.5% (p = 0.2). Overall the prevalences of TF >or=2 were 7 and 2.1% for the 1,450- and 440-ppm F groups and 2.2 and 0.2% for TF >or=3. These differences were statistically significant (p < 0.003). There was a strong association between the deprivation status of wards and fluorosis. Only 1 subject with a TF score of 3 was identified in the two most deprived quintiles of the Townsend score. It is concluded that careful targeting of programmes of this type to children living in high caries risk deprived communities carries only a small risk of aesthetically objectionable fluorosis (TF >2) whether low or high fluoride toothpastes are used. High fluoride (1,450 ppm F) toothpastes should not be provided on a community basis to very young children in less deprived communities.

The effects of illumination and focal distance on light-induced fluorescence images in vitro.

When using quantitative light-induced fluorescence a number of factors can influence illumination level. The purpose of this study was to investigate, using a high-resolution camera and fibre-optic light source, the impact of illumination level and focal distance on common quantitative light-induced fluorescence outcomes. Twenty-four extracted teeth were examined using 6 illumination levels and 4 focal distances. Analysis was conducted using multiple linear regression models fitted to log DeltaQ, log DeltaF and log area with clustering of teeth and robust standard errors. Separate models were used for the different light and focal levels. The regression coefficients were significant for both DeltaQ and DeltaF but not area. Despite the significant regressions the actual effect was very small, and unlikely to confound clinical trial or practice results.

The effect of video repositioning on the reliability of light-induced fluorescence imaging: an in vivo study.

The ability to monitor longitudinally the development, arrest or resolution of early demineralised lesions is one strength of quantitative light-induced fluorescence (QLF). When taking sequential images of an individual's teeth for monitoring it has been suggested that the subsequent images should be taken from the same position the baseline image. To assist in this process, video repositioning software is available that enables automatic capture of images once the system identifies that they are similar enough to the baseline comparator. The purpose of this study was to determine if the use of such software-assisted capture improves the reliability of subsequent QLF analysis. 20 subjects had 34 surfaces (buccal and occlusal) imaged by 2 examiners at baseline, and again 1 week later using both manual and software-assisted (VidRep) systems. Analysis of the three key reportable values for QLF (DeltaF, lesion area, DeltaQ) suggested that there is no significant improvement in reliability using VidRep although VidRep demonstrates additional advantages above and beyond image geometry, relating to the speed of subsequent image analysis.

A staged intervention dental health promotion programme to reduce early childhood caries.

OBJECTIVE: This paper reports the results of a community trial to assess the effects of a multi-stage dental health promotion programme in reducing Early Childhood Caries (ECC). RESEARCH DESIGN: Two health districts (Primary Care Groups) were matched for dental disease levels and socio-demographic factors. One was randomly allocated to be the test Primary Care Group (PCG), the other the control PCG. Children in the test PCG received a series of interventions to support positive dental health behaviour from the age of 8 to 32 months. Interviews were conducted with parents of children aged 21 months and clinical examinations were undertaken on a larger cohort of children aged 3-4 years in test and control PCGs. SETTING: The interventions were gift bags containing a trainer cup, toothpaste containing 1,450 ppm F and toothbrush, and advice given to the children's parents on attendance at designated clinics and medical practices and further paste and brushes posted to the children's homes. Parents were interviewed on the telephone. Examinations took place at Children's Centres and nursery departments attached to primary schools. OUTCOME MEASURES: Severity and prevalence of ECC and general caries and proportion of parents reporting adopting dentally healthy behaviours. RESULTS: In the test PCG the prevalence of ECC in children who had received the interventions was 16.6% compared with 23.5% of children in the control area, a reduction of 29% (p=0.003). The mean dmft (1.17) and prevalence of general caries experience (28.7%) in the test children were also significantly lower than for children in the control PCG (1.72: 39.2%) (p=0.001). Analysis from a community perspective, which included data from all children examined in both areas, showed the prevalence of ECC in the test and control PCGs was 21.3% and 22.8% respectively and the mean dmft 1.47 and 1.72. The proportion with general caries experience remained statistically significant in favour of the test area 33.8% vs 39.9% (p=0.01). Parents in the test PCG were more likely to report cessation of bottle use (33% vs 18%), use of sugar-free drinks (49% vs 24%), commencement of brushing before first birthday (45% vs 27%) and twice daily brushing (52% vs 34%). CONCLUSION: The parents who received this multi-stage intervention were more likely to report adoption of three positive oral health behaviours; using a trainer cup from one year of age, using safe drinks and brushing twice daily with a fluoride toothpaste. The programme failed to reduce the prevalence of ECC in the community but the prevalence of ECC and general caries experience among the children who participated was less than among children in the control PCG.

The effectiveness of a toothpaste containing triclosan and polyvinyl-methyl ether maleic acid copolymer in improving plaque control and gingival health: a systematic review.

OBJECTIVE: To compare the effectiveness of triclosan/copolymer and fluoride dentifrices in improving plaque control and gingival health. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, MEDLINE (1986 to March 2003) and EMBASE (1986 to March 2003). Personal files and the reference lists of all articles were checked for further studies. SELECTION CRITERIA: Trials were selected if they met the following criteria: random allocation of participants; participants were adults with plaque and gingivitis; unsupervised use of dentifrices for at least 6 months; and primary outcomes - plaque and gingivitis after 6 months. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted information. For each plaque and gingivitis index, the mean differences for each study were pooled as weighted mean differences (WMDs) with the appropriate 95% confidence intervals (CIs) using the random effect models. MAIN RESULTS: Sixteen trials provided data for the meta-analysis. The triclosan/copolymer dentifrice significantly improved plaque control compared with a fluoride dentifrice, with a WMD of -0.48 (95% CI: -0.64 to -0.32) for the Quigley-Hein index and WMD of -0.15 (95% CI: -0.20 to -0.09) for the plaque severity index. When compared with a fluoride dentifrice, the triclosan/copolymer dentifrice significantly reduced gingivitis with WMDs -0.26 (95% CI: -0.34 to -0.18) and -0.12 (95% CI: -0.17 to -0.08) for the Loe and Silness index and gingivitis severity index, respectively.