Cancer risk in information technology workers: a UK Biobank study.

BACKGROUND: The information technology (IT) workforce has been growing more rapidly than others, with occupational health (OH) risks of sedentary behaviour, physical inactivity and poor diet, yet studies of their non-communicable disease risk, notably cancer, are lacking. AIMS: To investigate cancer risk in IT workers compared to others in employment and the nine major Standard Occupational Classification (SOC) groups. METHODS: We evaluated incident diagnosed cancers in the UK Biobank cohort through national cancer registry linkage. Cox proportional hazard regression models, with 15-year follow-up, were used to compare incident cancer risk among IT workers with all other employed participants and with the nine major SOC groups. RESULTS: Overall, 10 517 (4%) employed participants were IT workers. Adjusting for confounders, IT workers had a slightly lower cancer incidence compared to all other employed participants (Model 2: hazard ratio = 0.91, 95% confidence interval [CI] 0.83-1.01). Compared to the nine major SOC groups, they had a similar (Major Groups 2, 5 and 8) or lower (Major Groups 1, 3, 4, 6, 7 and 9) cancer incidence. CONCLUSIONS: Despite their occupational risks of sedentary behaviour, poor diet and physical inactivity, IT workers do not have an increased cancer incidence compared to all other employed participants and the nine major SOC groups. This study paves the way for large, longitudinal health outcome studies of this under-researched and rapidly growing occupational group.

Health, lifestyle and occupational risks in Information Technology workers.

BACKGROUND: Information technology (IT) and the IT workforce are rapidly expanding with potential occupational health implications. But to date, IT worker health is under-studied and large-scale studies are lacking. AIMS: To investigate health, lifestyle and occupational risk factors of IT workers. METHODS: We evaluated self-reported health, lifestyle and occupational risk factors for IT workers in the UK Biobank database. Using logistic regression, we investigated differences between IT workers and all other employed participants. Regression models were repeated for IT worker subgroups (managers, professionals, technicians) and their respective counterparts within the same Standard Occupational Classification (SOC) major group (functional managers, science and technology professionals, science and technology associate professionals). RESULTS: Overall, 10 931 (4%) employed participants were IT workers. Compared to all other employed participants, IT workers reported similar overall health, but lower lifestyle risk factors for smoking and obesity. Sedentary work was a substantially higher occupational exposure risk for IT workers compared to all other employed participants (odds ratio [OR] = 5.14, 95% confidence interval [CI]: 4.91-5.39) and their specific SOC group counterparts (managers: OR = 1.83, 95% CI: 1.68-1.99, professionals: OR = 7.18, 95% CI: 6.58-7.82, technicians: OR = 4.48, 95% CI: 3.87-5.17). IT workers were also more likely to engage in computer screen-time outside work than all other employed participants (OR = 1.42, 95% CI: 1.35-1.51). CONCLUSIONS: Improved understanding of health, lifestyle and occupational risk factors from this, the largest to date study of IT worker health, can help inform workplace interventions to mitigate risk, improve health and increase the work participation of this increasingly important and rapidly growing occupational group.

Peer review audit of non-specialist occupational physician reports.

BACKGROUND: With declining specialist occupational physician (OP) numbers, there is increasing recognition of the importance of non-specialist physicians in occupational health (OH) service delivery, yet to date, this physician group remains understudied and their competency requirements poorly understood. AIMS: To evaluate the quality of a sample of non-specialist OH reports and compare these with specialist reports. METHODS: A retrospective peer review audit of a convenience sample of 200 consecutive non-specialist and specialist OH reports from an Irish OH service using an assessment form based on the modified Sheffield Assessment Instrument for Letters SAIL(OH)1. RESULTS: Of the 200 peer reviewed OH reports, 159 (80%) were from non-specialists. For all questions, 87% and above of non-specialist reports were 'satisfactory' or 'above expected'. On the overall assessment, out of 10, the mean non-specialist report score was 6.8 (standard deviation (SD) 3-10) and the specialist score was 7.3 (SD 3-10). Comparatively, non-specialist reports highlighted legal/ethical issues marginally more and adhered slightly better to contractual/ethical/legal boundaries, while specialist reports fared better in addressing manager's questions, in their structure and clarity and in covering all significant aspects of the case, particularly if the case was complex. CONCLUSIONS: Our findings demonstrate a high standard of OH report quality in this sample of non-specialist OPs that is consistent across all key OH report components. Potential development areas are also identified that can inform education/training tailored to this physician group and assist in competency standard-setting.

Research and teaching activity in UK occupational physicians.

BACKGROUND: For all doctors, including occupational physicians (OPs), research and teaching are considered core requirements of medical education and continuing professional development. Academic skills are also vital to evidence-based practice and advancement of occupational health (OH) as a specialty. In recent years, attention has focussed on the declining UK OH academic base and the research- practice gap, and increased practitioner participation in research is encouraged. AIMS: To establish a baseline of research and teaching activity among UK OPs, identify related barriers and inform strategies to overcome them. METHODS: An online survey including specific career profile questions derived from consensus following expert panel discussions. It formed part of a larger Delphi study on UK OH research priorities. RESULTS: We received 213 responses, about 18% of 1207 practising UK OPs. Of these, 162 (76%) undertook research at some career-point, of which 44 (27%) were currently research-active. Similarly, 154 (72%) undertook teaching at some career-point, of which 99 (64%) were currently teaching-active. Of those who had never undertaken research (n = 51) or teaching (n = 59), 40 and 42% were interested in doing so, respectively. Key barriers were lack of time and opportunity, the former particularly for respondents practising in industry, where 'commercial' demands take priority, rather than healthcare. CONCLUSIONS: This study establishes a benchmark of academic activity among UK OPs and identifies related barriers. These 'target' barriers can shape research funding priorities and education to increase participation and develop the UK OH academic base.

Three phylogenetic groups have driven the recent population expansion of Cryptococcus neoformans.

Cryptococcus neoformans (C. neoformans var. grubii) is an environmentally acquired pathogen causing 181,000 HIV-associated deaths each year. We sequenced 699 isolates, primarily C. neoformans from HIV-infected patients, from 5 countries in Asia and Africa. The phylogeny of C. neoformans reveals a recent exponential population expansion, consistent with the increase in the number of susceptible hosts. In our study population, this expansion has been driven by three sub-clades of the C. neoformans VNIa lineage; VNIa-4, VNIa-5 and VNIa-93. These three sub-clades account for 91% of clinical isolates sequenced in our study. Combining the genome data with clinical information, we find that the VNIa-93 sub-clade, the most common sub-clade in Uganda and Malawi, was associated with better outcomes than VNIa-4 and VNIa-5, which predominate in Southeast Asia. This study lays the foundation for further work investigating the dominance of VNIa-4, VNIa-5 and VNIa-93 and the association between lineage and clinical phenotype.

A randomized controlled trial of fresh frozen plasma for coagulopathy in Russell's viper (Daboia russelii) envenoming.

Essentials Russell's viper envenoming is a major health issue in South Asia and causes coagulopathy. We studied the effect of fresh frozen plasma and two antivenom doses on correcting coagulopathy. Fresh frozen plasma did not hasten recovery of coagulopathy. Low-dose antivenom did not worsen coagulopathy. SUMMARY: Background Russell's viper (Daboia russelii) envenoming is a major health issue in South Asia and causes venom-induced consumption coagulopathy (VICC). Objectives To investigate the effects of fresh frozen plasma (FFP) and two antivenom doses in correcting VICC. Methods We undertook an open-label randomized controlled trial in patients with VICC at two Sri Lankan hospitals. Patients with suspected Russell's viper bites and coagulopathy were randomly allocated (1 : 1) to high-dose antivenom (20 vials) or low-dose antivenom (10 vials) plus 4 U of FFP. The primary outcome was the proportion of patients with an International Normalized Ratio (INR) of < 2 at 6 h after antivenom administration. Secondary outcomes included anaphylaxis, major hemorrhage, death, and clotting factor recovery. Results From 214 eligible patients, 141 were randomized: 71 to high-dose antivenom, and 70 to low-dose antivenom/FFP; five had no post-antivenom blood tests. The groups were similar except for a delay of 1 h in antivenom administration for FFP patients. Six hours after antivenom administration, 23 of 69 (33%) patients allocated to high-dose antivenom had an INR of < 2, as compared with 28 of 67 (42%) allocated to low-dose antivenom/FFP (absolute difference 8%; 95% confidence interval - 8% to 25%). Fifteen patients allocated to FFP did not receive it. Severe anaphylaxis occurred equally frequently in each group. One patient given FFP developed transfusion-related acute lung injury. Three deaths occurred in low-dose antivenom/FFP patients, including one intracranial hemorrhage. There was no difference in recovery rates of INR or fibrinogen, but there was more rapid initial recovery of factor V and FX in FFP patients. Conclusion FFP after antivenom administration in patients with Russell's viper bites did not hasten recovery of coagulopathy. Low-dose antivenom/FFP did not worsen VICC, suggesting that low-dose antivenom is sufficient.

Core competencies for UK occupational health nurses: a Delphi study.

BACKGROUND: Occupational health nurses (OHNs) play a pivotal role in the delivery of occupational health (OH) services. Specific competency guidance has been developed in a number of countries, including the UK. While it is acknowledged that UK OHN practice has evolved in recent years, there has been no formal research to capture these developments to ensure that training and curricula remain up-to-date and reflect current practice. AIMS: To identify current priorities among UK OHNs of the competencies required for OH practice. METHODS: A modified Delphi study undertaken among representative OHN networks in the UK. This formed part of a larger study including UK and international occupational physicians. The study was conducted in two rounds using a questionnaire based on available guidance on training competencies for OH practice, the published literature, expert panel reviews and conference discussions. RESULTS: Consensus among OHNs was high with 7 out of the 12 domains scoring 100% in rating. 'Good clinical care' was the principal domain ranked most important, followed by 'general principles of assessment & management of occupational hazards to health'. 'Research methods' and 'teaching & educational supervision' were considered least important. CONCLUSIONS: This study has established UK OHNs' current priorities on the competencies required for OH practice. The timing of this paper is opportune with the formal launch of the Faculty of Occupational Health Nursing planned in 2018 and should inform the development of competency requirements as part of the Faculty's goals for standard setting in OHN education and training.

Trends in NHS doctor and dentist referrals to occupational health.

BACKGROUND: Ill-health in doctors can affect performance and fitness to practice, and consequently patient care and safety, placing an important responsibility on National Health Service (NHS) occupational health (OH) services. Anecdotal discussions amongst NHS occupational physicians suggest an increase in the number of doctor attendances over time, with continuing focus on mental illness. AIMS: To analyse OH referrals in doctors and dentists over 3 years. METHODS: A retrospective evaluation of all doctor and dentist referrals to the OH service in one Scottish NHS board from April 2011 to March 2014, comparing this to management-reported sickness absence (SA) data held by the organization. RESULTS: We found no significant change in overall OH referrals for doctors and dentists during the evaluation period. Mental illness was the commonest referral reason in all 3 years at 32, 38 and 30%, respectively, but no significant change in mental health referrals was demonstrated within the study period. SA events significantly increased during the three study years (356, 426 and 469, respectively; P < 0.05). OH referrals for those absent from work increased significantly between Years 1 and 3 (16 and 30, respectively; P < 0.05). CONCLUSIONS: SA events and OH referrals for those absent from work significantly increased between April 2011 and March 2014, but there was no commensurate (statistically significant) increase in overall OH referrals. These findings do not support anecdotal suggestions of increasing OH (or mental ill-health) attendances but can be used as a benchmark for other NHS organizations and for future trend comparisons.

Impact of peer review audit on occupational health report quality.

BACKGROUND: In a previous report, we described the implementation of a formal process for peer review of occupational health (OH) reports and a method of assessment of the outcomes of this process. The initial audit identified that 27% of OH reports required modifications. AIMS: To assess formally, following implementation of this process, if changes in practice had occurred, i.e. whether fewer deficiencies were being identified in reports. METHODS: We repeated a prospective internal audit of all peer reviewed OH reports between September and November 2011. We used an abbreviated assessment form, based on questions 4-8 and 10-12 of the modified SAIL (Sheffield Assessment Instrument for Letters), with four possible outcomes: no action, no changes made to report following discussion with author, changes made without discussion with author and changes made following discussion with author. RESULTS: One hundred seventy-three reports by 10 clinicians were audited. The audit identified a 13% reduction in OH reports requiring modifications (from 27 to 14%) compared with the previous cycle. Where modifications were required, 8% of these were related to minor typographical, spelling and grammar errors and 6% were for more complex reasons. Implementation of this process also produced a reduction in clinical complaints about OH reports from customers, from three in the preceding year to none 2 years later. CONCLUSIONS: Peer review improved the standard of OH reports and was associated with a reduction in customer complaints about reports.

Doctor and dentist contacts with an NHS occupational health service.

BACKGROUND: There is increasing acceptance that management of ill-health in doctors can be patchy and is not always optimal. Health can impact on performance and fitness to practice, placing an important responsibility on occupational health (OH) services. AIMS: To improve our understanding of OH contacts by doctors and dentists and make some comparison of this with available sickness absence records. METHODS: A retrospective descriptive evaluation of all doctor and dentist encounters with the OH service between April 2009 and March 2010 was undertaken. Doctor and dentist encounters from our electronic appointment system were analysed using Microsoft Excel. Comparisons were made with management-reported sickness absence data for this period. RESULTS: Blood tests, immunizations/immunization updates accounted for 49% (295) of contacts. Management and self-referrals accounted for 26% (157) of all OH contacts. Mental health conditions were the main reason for referral (approximately one-third of all cases referred). In this group, a much higher number presented to OH, absent from work, than were recorded with sickness absence by management. Musculoskeletal, infection and skin complaints were other predominant reasons for referral. CONCLUSIONS: Doctors and dentists do utilize this OH service and the issues for which they need services are wider than those of mental health. Inconsistency in the reporting of sickness absence in doctors with mental health problems has also been highlighted. This baseline information is a useful stepping stone to identifying and meeting the specific needs of doctors and dentists and can be used as a benchmark in other organizations.

Detection of herpes viruses in the cerebrospinal fluid of adults with suspected viral meningitis in Malawi.

PURPOSE: We looked for herpes simplex virus types 1 and 2 (HSV-1 and HSV-2, respectively), varicella zoster virus (VZV), Epstein-Barr virus (EBV) and cytomegalovirus (CMV) DNA in Malawian adults with clinically suspected meningitis. METHODS: We collected cerebrospinal fluid (CSF) from consecutive adults admitted with clinically suspected meningitis to Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi, for a period of 3 months. Those with proven bacterial or fungal meningitis were excluded. Real-time polymerase chain reaction (PCR) was performed on the CSF for HSV-1 and HSV-2, VZV, EBV and CMV DNA. RESULTS: A total of 183 patients presented with clinically suspected meningitis. Of these, 59 (32 %) had proven meningitis (bacterial, tuberculous or cryptococcal), 39 (21 %) had normal CSF and 14 (8 %) had aseptic meningitis. For the latter group, a herpes virus was detected in 9 (64 %): 7 (50 %) had EBV and 2 (14 %) had CMV, all were human immunodeficiency virus (HIV)-positive. HSV-2 and VZV were not detected. Amongst those with a normal CSF, 8 (21 %) had a detectable herpes virus, of which 7 (88 %) were HIV-positive. CONCLUSIONS: The spectrum of causes of herpes viral meningitis in this African population is different to that in Western industrialised settings, with EBV being frequently detected in the CSF. The significance of this needs further investigation.

Infectious diseases among travellers and migrants in Europe, EuroTravNet 2010.

To investigate trends in travel-associated morbidity with particular emphasis on emerging infections with the potential for introduction into Europe, diagnoses of 7,408 returning travellers presenting to 16 EuroTravNet sites in 2010 were compared with 2008 and 2009. A significant increase in reported Plasmodium falciparum malaria (n=361 (6% of all travel-related morbidity) vs. n=254 (4%) and 260 (5%); p<0.001), P. vivax malaria (n=51 (1%) vs. n=31 (0.5%) and 38 (1%); p=0.027) and dengue fever (n=299 (5%) vs. n=127 (2%) and 127 (2%); p<0.001) was observed. Giardia lamblia was identified in 16% of patients with acute diarrhoea, with no significant annual variation. The proportion of acute diarrhoea due to Campylobacter increased from 7% in 2008 to 12% in 2010 (p=0.001). We recorded 121 patients with pulmonary tuberculosis in 2010, a threefold increase in the proportionate morbidity from 2008 to 2010. In 2010, 60 (0.8%) cases of chronic Chagas disease, 151 (2%) cases of schistosomiasis and 112 (2%) cases of cutaneous larva migrans were reported. Illness patterns in sentinel travellers, captured by EuroTravnet, continue to highlight the potential role of travellers in the emergence of infectious diseases of public health concern in Europe and the relevance of offering medical travel advice and enforcing specific and adequate prophylaxis.

Peer review audit of occupational health reports--process and outcomes.

BACKGROUND: Peer review is widely used in the selection and publication of scientific research. Its application in clinical practice is emerging, particularly with increased emphasis on clinical governance and the imminent introduction of revalidation. AIMS: To formalize our peer review process of occupational health (OH) reports and formally assess the outcomes of this process. METHODS: A prospective internal audit was carried out of all peer reviewed OH reports between June and August 2010. An abbreviated assessment form, based on Questions 4-12 of the Sheffield Assessment Instrument for Letters (SAIL) was utilized. The report was assessed using the abbreviated SAIL, with one of four possible outcome options-no action, no changes made to report following discussion with author, changes made without discussion with author and changes made following discussion with author. RESULTS: The audit identified that 27% of OH reports required modifications. Eighteen per cent were related to typographical errors, spelling, grammar and administrative fields being incomplete. Nine per cent were related to more complex reasons, most commonly, all the manager's questions not being addressed, review arrangements not being clear and the report not being clear and understandable to the intended readership. CONCLUSIONS: Peer review can be a useful tool in improving the standard of OH reports, specifically picking up minor errors and potentially more significant areas of concern. It can also be a valuable educational tool in terms of personal feedback, benchmarking and exposure to different styles of report writing.

Use of nail and oral pigmentation to determine ART eligibility among HIV-infected Ugandan adults.

OBJECTIVES: To evaluate the use of grey/distal banded nails as an indicator of advanced immunosuppression, and thus eligibility for ART, in resource poor settings. METHODS: We tested whether grey/distal banded nails and/or oral pigmentation could be used to identify patients with low CD4 cell counts at two cut-offs: <200 and <350 cells/microl in ART naive adults. RESULTS: Four hundred and three nail and oral cavities were photographed and assessed. Grey/distal banded nails and/or oral pigmentation were significantly associated with a CD4 cell count <200 cells/microl (P < 0.001), with a sensitivity of 66%, a specificity of 50% and a negative predictive value of 77%. However, there was no association when a CD4 cell count cut-off of <350 cells/microl was used. Inter-observer agreement (k 0.46) was fair/moderate. CONCLUSIONS: While grey/distal banded nails and/or oral pigmentation are associated with low CD4 counts, the sensitivity and kappa score are too low for this method to be recommended as a tool to guide ART initiation; large number of individuals eligible for ART would be missed.

Neurophysiological findings in patients 1 year after snake bite induced neurotoxicity in Sri Lanka.

Snake bite causes significant morbidity and mortality in Sri Lanka. Snake venoms contain neurotoxins that block neuromuscular junction transmission. Presynaptic neurotoxicity most commonly causes destruction of nerve terminals with recovery by regrowth, whilst postsynaptic neurotoxicity usually involves competition at the acetylcholine receptor. The aim of this study was to investigate whether there were long-term clinical or neurophysiological changes in snake bite survivors 1 year after their envenoming. Detailed neurophysiological tests and clinical examinations were performed on 26 snake bite victims who had presented with neurotoxicity 12 months previously, and their results were compared with controls recruited from the same communities. Significant differences were observed in some nerve conduction parameters in some snake bite victims compared with controls, predominantly in those thought to have elapid bites, including prolongation of sensory, motor and F-wave latencies and reduction of conduction velocities. There was no evidence of any residual deficits in neuromuscular junction transmission. These results suggest a possible demyelinating type polyneuropathy. None of the cases or controls had abnormalities on clinical examination. This is one of the few studies to report possible long-term neurological damage following systemic neurotoxicity after snake bite. The clinical significance of these neurophysiological abnormalities is uncertain and further studies are required to investigate whether the abnormalities persist and to see whether clinical consequences develop.

A model for venom-induced consumptive coagulopathy in snake bite.

Many snake venoms contain procoagulant toxins that activate the coagulation cascade and cause venom-induced consumptive coagulopathy (VICC). We developed a semi-mechanistic model of the clotting cascade in order to explore the effects of the procoagulant toxin from taipan venom on this system as well as the effects of antivenom. Simulations of the time course in the change of clotting factors were compared to data collected from taipan envenomed patients. The model accurately predicted the observed concentration of clotting factors over time following taipan envenomation. Investigations from the model indicated that the upper limit of the half-life of the procoagulant toxin was 1h. Simulations from the model also suggest that antivenom for Australasian elapids has negligible effect on reducing the recovery time of the coagulation profile unless administered almost immediately after envenomation. The model has generality to be expanded to describe the effects of other venoms and drugs on the clotting cascade.

Artesunate versus quinine for treating severe malaria.

BACKGROUND: Severe malaria kills over a million people every year. We sought evidence of superiority of artesunate compared with the standard treatment quinine. OBJECTIVES: To compare artesunate with quinine for treating severe malaria. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group Specialized Register (January 2007), CENTRAL (The Cochrane Library 2006, Issue 4), MEDLINE (1966 to January 2007), EMBASE (1974 to January 2007), LILACS (1982 to January 2007), ISI Web of Science (1945 to January 2007), the metaRegister of Controlled trials (mRCT), conference proceedings, and reference lists of articles. We contacted researchers and the World Health Organization. SELECTION CRITERIA: Randomized controlled trials comparing intravenous, intramuscular, or rectal artesunate with intravenous or intramuscular quinine for treating adults and children with severe malaria who are unable to take medication by mouth. DATA COLLECTION AND ANALYSIS: Two authors assessed the eligibility and methodological quality of trials, extracted and analysed data, and drafted the review. The third author contributed to the design and writing of the review. Death was the primary outcome. Dichotomous outcomes were summarized using relative risks and continuous outcomes by mean differences. Where appropriate, we combined data in meta-analyses. Heterogeneity was investigated for the primary outcome using subgroup analyses. MAIN RESULTS: Six trials enrolling 1938 participants (1664 adults and 274 children) met our inclusion criteria. All six trials were conducted in Asia, and only one small trial enrolled only children. Five trials used intravenous artesunate and one trial intramuscular artesunate; all six used intravenous quinine. Treatment with artesunate significantly reduced the risk of death (RR 0.62, 95% CI 0.51 to 0.75; 1938 participants, 6 trials), reduced parasite clearance time (WMD 8.14 h, 95% CI 11.55 to 4.73; 292 participants, 3 trials), and hypoglycaemia detected by routine monitoring (RR 0.46, 95% CI 0.25 to 0.87; 185 participants, 2 trials). There was no evidence of a difference in neurological sequelae, coma recovery time, time to hospital discharge, fever clearance time, or adverse effects other than hypoglycaemia. AUTHORS' CONCLUSIONS: Intravenous artesunate is the drug of choice for adults with severe malaria, particularly if acquired in Asia. This review did not identify sufficient data to make firm conclusions about the treatment of children or the effectiveness of intramuscular artesunate. There is an urgent need to compare the effects of artesunate with quinine in African children with severe malaria. The applicability of these results to Asian children and the ethics of further research are points of debate.

Identifying the biting species in snakebite by clinical features: an epidemiological tool for community surveys.

The outcome of snakebite is related to the biting species but it is often difficult to identify the biting snake, particularly in community settings. We have developed a clinical scoring system suitable for use in epidemiological surveys, with the main aim of identifying the presumed biting species in those with systemic envenoming who require treatment. The score took into account ten features relating to bites of the five medically important snakes in Sri Lanka, and an algorithm was developed applying different weightings for each feature for different species. A systematically developed artificial data set was used to fine tune the score and to develop criteria for definitive identification. The score was prospectively validated using 134 species-confirmed snakebites. It correctly differentiated the bites caused by the three snakes that commonly cause major clinical problems (Russell's viper (RV), kraits and cobra) from other snakes (hump-nosed viper (HNV) and saw-scaled viper (SSV)) with 80% sensitivity and 100% specificity. For individual species, sensitivity and specificity were, respectively: cobra 76%, 99%; kraits 85%, 99%; and RV 70%, 99%. As anticipated, the score was insensitive in the identification of bites due to HNV and SSV.