Assessing the profile and utility of diplomates in occupational medicine.

BACKGROUND: The utility of the occupational medicine diploma in the UK is yet to be explored. The NHS 'Growing Occupational Health (OH) and Wellbeing' programme provides opportunities for diplomates to increase their OH work. AIMS: To assess what proportion of diplomates carry out OH work, the type of work being undertaken, to identify obstacles impeding OH work, to capture their interest in future work opportunities and what additional support they require. METHODS: A link to an online questionnaire was sent to diplomates via several professional bodies; we estimate that 2428 diplomates received this. The survey was open from 24 March to 31 May 2022. RESULTS: Replies were received from 310/2428 (13%) diplomates. Fifty-two per cent of respondents were males and 35% were female. Respondents were diverse in terms of age and geographical region. Main employment settings: 13% primary care, 43% secondary care, 31% private sector, 24% public sector and 20% self-employed. Seventy-two per cent of diplomates had undertaken OH clinical work since completion of their diploma, and 90% of those were undertaking OH clinical work at the time of the survey. Specific obstacles to accessing OH work highlighted included existing workload constraints, lack of employment opportunities with OH providers and lack of time. CONCLUSIONS: Many (126/310; 41%) respondents had considered increasing their OH work in the previous 12 months. Increasing mentorship from senior OH clinicians to diplomates was suggested by 4% of respondents to enhance the utility of diplomates.

Developing and testing a case-management intervention to support the return to work of health care workers with common mental health disorders.

BACKGROUND: To assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of a new case-management intervention to facilitate the return to work of health care workers, on sick leave, having a common mental disorder (CMD). METHODS: A mixed methods feasibility study. RESULTS: Systematic review examined 40 articles and 2 guidelines. Forty-nine National Health Service Occupational Health (OH) providers completed a usual care survey. We trained six OH nurses as case managers and established six recruitment sites. Forty-two out of 1938 staff on sick leave with a CMD were screened for eligibility, and 24 participants were recruited. Out of them, 94% were female. Eleven participants received the intervention and 13 received usual care. Engagement with most intervention components was excellent. Return-to-work self-efficacy improved more in the intervention group than in the usual care group. Qualitative feedback showed the intervention was acceptable. CONCLUSIONS: The intervention was acceptable, feasible and low cost to deliver, but it was not considered feasible to recommend a large-scale effectiveness trial unless an effective method could be devised to improve the early OH referral of staff sick with CMD. Alternatively, the intervention could be trialled as a new stand-alone OH intervention initiated at the time of usual OH referral.

The impact of Covid-19 on research into work and health.

BACKGROUND: The global coronavirus (Covid-19) pandemic created a profound disruption to the delivery of planned scientific research with unknown immediate and potentially longer-term impacts. AIMS: We explored researchers' experiences of the impact of the pandemic on the continued development and delivery of research into work and health, and on research infrastructure in this field. METHODS: A cross-sectional study. RESULTS: Thirty-three questionnaires were completed, representing a response rate of 15%. Sixty-one per cent of respondents were female, the majority (78%) had over 11 years of research experience and 76% worked mainly in academia. Most respondents (88%) were able to progress with research during the pandemic. A small proportion (4%) had studies paused or suspended due to the pandemic, while a larger proportion (19%) had research staff redeployed to assist with other studies or furloughed. Respondents described a range of emerging practical and logistical issues for research into work and health during the pandemic. Some benefited from increased opportunities to collaborate on new multidisciplinary studies, opportunities to engage participants in work and health research, and more flexible and inclusive work practices. Others experienced challenges that had an adverse impact, such as hampering research delivery (e.g. barriers to participant screening and intervention delivery), poor (home) working environments, reduced team cohesion and isolation. A range of future priorities for research was highlighted. CONCLUSIONS: We describe lessons learned and opportunities that can be used to support or further research activities in the field of work and health research in the future.

Expanding the strategic and clinical leadership role of accredited specialists.

BACKGROUND: We sought to explore the value and benefits of accredited specialists employed in the National Health Service (NHS), and proposed strategies for expanding their role. AIMS: To explore the core characteristics of accredited specialists and to examine how their skills could be further utilized to enhance occupational health (OH) services. METHODS: Mixed methods comprising a survey and qualitative work. RESULTS: OH survey was completed by 65 of 128 (51%) respondents. Nine accredited specialists and 16 stakeholders contributed qualitative data. Most OH departments were located in acute NHS trusts and additionally provided externally contracted services. We found a large variation in OH staffing and OH services delivered. The COVID pandemic created unprecedented challenges and required expansion in services to meet demand. The majority of respondents described greater recognition and appreciation by others of accredited specialists and OH teams for their specialist contribution during the pandemic. From the qualitative data, we identified two overarching themes. 'Professional credibility has currency' (Theme 1) and 'A visionary future' (Theme 2). A series of sub-themes are described. CONCLUSIONS: Accredited specialists employed in the NHS possess a core set of attributes and capabilities, and are skilful at delivering strong, influential and impactful clinical and strategic leadership across the NHS hierarchy and landscape. The COVID pandemic provided valuable opportunities for them to showcase their specialist clinical and leadership skills. The current wider reorientation of NHS clinical services offers bold new ways to expand their role beyond traditional clinical boundaries.

A national survey of skin health in nursing personnel.

BACKGROUND: Hand dermatitis is a well-established occupational risk in nursing staff. AIMS: To explore skin health in nursing staff and to develop resources and recommendations to promote good skincare at work. METHODS: Cross-sectional survey. RESULTS: We analysed data from 1,545 surveys. Forty-six percent reported 'poor' skin health and the majority (93%) experienced at least one skin problem over the previous 12 months, with only 22% seeking help from their employer. Only 2% took time off work due to skin problems, with many expressing concerns that taking sick leave would be viewed negatively by others. Over half (53%) had reduced or stopped using antibacterial rubs and soap, and 18% had reduced the use of gloves. Most respondents used hand cream and over half used products they had purchased themselves. Only 42% received skin health care information from employers, with fewer (26%) receiving training on how to identify early signs of skin disease. Only 16% had access to skin surveillance in line with regulatory requirements. Only 26% of respondents were aware of the support offered by their professional nursing association. Suggestions for improving skin health included increasing publicity concerning the importance of skin health in healthcare settings, improving access to hand creams, better quality products, enhanced education and training and more involvement from Occupational Health (OH). CONCLUSIONS: Results confirm that poor skin health remains a persistent problem for nurses. Employers could do more to promote skin health and nurses need to be made more aware of the support and guidance offered by professional bodies.

Exploring the importance of work outcomes in gynaecological patients.

BACKGROUND: There has been increasing evidence that physicians in gynaecology are not routinely enquiring about work during consultations. AIMS: To explore the effect gynaecological conditions can have on work functioning, the importance of work outcomes among patients and whether work considerations are discussed during clinical consultations. METHODS: A cross-sectional survey was administered to employed patients attending a gynaecological clinic at Guy's Hospital. The survey assessed four areas: demographics, gynaecological condition (including self-assessed severity), work status and perceived impact of the condition on work functioning and job satisfaction. Simple descriptive analysis and statistical techniques were used to interpret the data. RESULTS: One hundred and six participants participated (mean age: 37.49 ±â€…9.09). About 95% found it important to be able to work whilst receiving treatment and 82% of patients had reported at least a slight impact on their working ability due to their condition. Of the 31 patients for whom it was their first appointment, 77% said it would be useful to discuss the possible impacts their gynaecological condition could have on their work. About 66% (19/29) of the participants attending a follow-up appointment reported that their doctor had not discussed their work with them. CONCLUSIONS: The symptoms of gynaecological conditions can impact patients' ability to work. There is a lack of useful discussion from doctors about the perceived impact gynaecological conditions can have on a patient's ability to work, despite patients finding it important to be able to remain or return to work.

Assessing the psychosocial impact of stammering on work.

BACKGROUND: Stammering (stuttering) is a speech condition with high heterogeneity, affecting approximately 1% of adults. Research shows it can limit career progression, impact job performance and quality of life. AIMS: To assess the psychosocial impact of stammering among healthcare workers and to develop a new workplace support intervention. METHODS: A cross-sectional questionnaire of healthcare workers who stammer with qualitative work and a survey of occupational health (OH) usual care to assess the need for a workplace intervention. RESULTS: Data from 470 staff questionnaires and 32 OH clinicians were analysed. Eighty-four per cent rated their stammering severity as mild-to-moderate, with the majority reporting adverse impact on job performance and career progression. Most experienced a high degree of anxiety and embarrassment at work, with avoidance behaviours commonplace. Four per cent of respondents sought OH advice for work difficulties. Qualitative data highlighted practical challenges staff experience in the workplace. Sixty-five per cent supported the proposal for a new workplace intervention. We found workplace stress and anxiety were the most common reasons for OH referrals, and we found wide variation in the scope of OH assessments and work adjustments recommended. Most OH respondents reported insufficient clinical knowledge of speech disorders and their impact on work. CONCLUSIONS: Stammering can have a negative impact of workers' job performance and job satisfaction. This can precipitate feelings of stress and anxiety, and can affect self-identity at work. We found wide variation in the provision of OH usual care. The results informed the development of a new workplace intervention.

A self-report questionnaire to detect hand dermatitis in nurses.

BACKGROUND: Hand dermatitis is highly prevalent among nurses due to their frequent exposure to wet work. Providing cost-effective dermatological health surveillance for this occupational group presents a challenge to health service providers. AIMS: To ascertain the predictive value of nurses' self-assessment of whether they had current hand dermatitis using a screening questionnaire when compared with the assessment made by a dermatologist of the nurses' hand photographs. METHODS: We conducted a cross-sectional study comparing the self-report decision made by student and intensive care nurses using a single hand dermatitis screening question with the clinical assessment of their hand photographs made by dermatologists using a standardized photographic guide. RESULTS: We analysed data collected at study baseline (n = 1599). The results showed that the screening question had a high negative predictive value (91%; 95% CI 89-93), but a low positive predictive value (39%; 95% CI 34-45). It demonstrated acceptable accuracy in distinguishing those with and without the disease (area under the receiver operator curve = 0.7) and had a high specificity (86%; 95% CI 84-88) but a sensitivity of only 52% (95% CI 46-59) in identifying hand dermatitis. CONCLUSIONS: We found that nurses were able to accurately self-assess themselves as not having any signs of hand dermatitis. By contrast, they were less able to accurately self-assess positive cases suggesting under-recognition of early disease. We propose that a questionnaire containing a single hand dermatitis screening question should be considered as a tool for screening out clear cases as part of a workplace health surveillance programme for detecting hand dermatitis.

The quality of e-fit notes issued in secondary care.

BACKGROUND: Few data are available on the pattern of use of fit notes issued in secondary care settings. AIMS: To evaluate the pattern and quality of e-fit notes issued in an NHS Trust. METHODS: Anonymized data on patients admitted to Guy's and St Thomas' NHS Foundation Trust (London, UK) who had an e-fit note issued from 1 January to 31 August 2017 were analysed using descriptive statistical methods. Thematic analysis was used to group the free-text comments into distinct categories and themes. RESULTS: A total of 815 fit notes were issued during the study period. A total of 659 (81%) fit notes advised that patients were 'not fit' for work, whilst 156 (19%) advised that they 'may be fit' for work. The specialty with the highest proportion of patients assessed as may be fit was plastic surgery 46/104 (44%), whilst the lowest was ear, nose and throat surgery 0/57 (0%). The majority 151/156 (97%) of fit notes which advised that patients may be fit for work used the tick-box sections on the fit note to recommend work modifications. Of the free-text comments in section 4 of the 'may be fit' e-fit notes issued, 91/114 (80%) were related to the functional ability of patients. CONCLUSIONS: Our study suggests that doctors in secondary care are more willing to use the 'may be fit' option on the fit note than primary care practitioners. Most fit notes, which advised that a patient may be fit for work, suggested workplace modifications.

A behaviour change package to prevent hand dermatitis in nurses working in the National Health Service: results of a cluster randomized controlled trial.

BACKGROUND: Occupational hand dermatitis poses a serious risk for nurses. OBJECTIVES: To evaluate the clinical and cost-effectiveness of a complex intervention in reducing the prevalence of hand dermatitis in nurses METHODS: This was a cluster randomized controlled trial conducted at 35 hospital trusts, health boards or universities in the UK. Participants were (i) first-year student nurses with a history of atopic conditions or (ii) intensive care unit (ICU) nurses. Participants at intervention sites received access to a behavioural change programme plus moisturizing creams. Participants at control sites received usual care. The primary outcome was the change of prevalent dermatitis at follow-up (adjusted for baseline dermatitis) in the intervention vs. the control group. Randomization was blinded to everyone bar the trials unit to ensure allocation concealment. The trial was registered on the ISRCTN registry: ISRCTN53303171. RESULTS: Fourteen sites were allocated to the intervention arm and 21 to the control arm. In total 2040 (69·5%) nurses consented to participate and were included in the intention-to-treat analysis. The baseline questionnaire was completed by 1727 (84·7%) participants. Overall, 789 (91·6%) ICU nurses and 938 (84·0%) student nurses returned completed questionnaires. Of these, 994 (57·6%) had photographs taken at baseline and follow-up (12-15 months). When adjusted for baseline prevalence of dermatitis and follow-up interval, the odds ratios (95% confidence intervals) for hand dermatitis at follow-up in the intervention group relative to the controls were 0·72 (0·33-1·55) and 0·62 (0·35-1·10) for student and ICU nurses, respectively. No harms were reported. CONCLUSIONS: There was insufficient evidence to conclude whether our intervention was effective in reducing hand dermatitis in our populations. Linked Comment: Brans. Br J Dermatol 2020; 183:411-412.

Managing common mental health disorders in healthcare workers.

BACKGROUND: Approximately a quarter of sickness absence in the UK National Health Service (NHS) is attributed to common mental health disorders (CMHDs). This is costly to the NHS and impacts on patient care and staff morale. Little is known about the occupational health (OH) management of NHS staff who take sick leave for CMHDs. AIMS: To explore the current OH management of NHS staff on sick leave for CMHDs. METHODS: We invited providers of NHS OH services identified from the NHS Health at Work Network and Commercial OH Providers Association to complete a survey on the management of employees off work because of CMHDs. Analysis involved descriptive statistics and content analysis. RESULTS: Forty-nine (39%) of the 126 OH departments approached responded. The majority (98%) had an organizational sickness absence policy that included triggers for referral for staff absent with CMHDs. In 63%, referral occurred 8-28 days after the onset of absence; in 92%, the consultation was completed by an OH nurse or OH physician. Content of the first consultation often included assessment of symptoms and medication for CMHDs. Case management and regular reviews were least commonly used despite evidence on their effectiveness in supporting return to work. All providers offered some support for managers of staff with CMHDs. CONCLUSION: Variation existed between providers of NHS OH services in the timing of referrals, use of case management and regular reviews for staff with CMHDs. Our findings suggest that current evidence-based guidance on interventions to improve return to work is not being implemented consistently.

Influences on use of hand moisturizers in nurses.

Background: Nurses are at high risk of hand dermatitis. Regular hand moisturizing can prevent dermatitis, but nurses' use of hand moisturizers is suboptimal. Aims: To establish (i) what beliefs about hand dermatitis and hand moisturizer use are associated with hand moisturizer use by nurses at home and at work and (ii) if hand moisturizer use behaviours in nurses are associated with the prevalence of hand dermatitis. Methods: We used a questionnaire to investigate nurses' knowledge, beliefs and behaviours regarding hand dermatitis and use of hand moisturizers. Results: The response rate was 55/65 (85%). Forty-two (76%) participants agreed that applying hand moisturizers reduced the risk of dermatitis, and 53 (96%) agreed that dermatitis increased the risk of skin carrying pathogenic organisms. Frequent moisturizer application was associated with beliefs that it was part of the nurse's role to apply hand creams, a belief that they had had training in the use of moisturizers and believing that patients approved of them moisturizing their hands. Conclusions: Hand moisturizer use by nurses can be improved by enhancing their beliefs that it is part of their professional role to apply hand cream regularly.

Mixed contact methods to improve response to a postal questionnaire.

BACKGROUND: Postal questionnaires remain an important method of collecting data in trials. However, a high non-response rate can lead to biases, which may undermine the validity of the study. AIMS: To assess a simple method of trying to improve response rates in an occupational health trial evaluating an intervention to prevent hand dermatitis in nurses. METHODS: The trial employed questionnaires at t = 0, t = 1 month and t = 12 months. The t = 1 month questionnaire was posted to study participants (student and intensive care nurses) together with a free postage reply envelope. After 2 weeks, an e-mail was sent to non-responders reinforcing the need for completed questionnaires to be returned. Two weeks later, non-responders were sent another hard copy of the questionnaire, along with an accompanying letter. Six weeks after posting the initial questionnaires, non-responders were sent an SMS text message or were telephoned to remind them to return the questionnaire. RESULTS: The response rates for the 744 student nurses were 8% (no reminder), 27% (after first reminder), 22% (after second reminder) and 27% (after the third reminder), resulting in a response rate of 63%. The response rates for the 959 intensive care nurses were 9% (no reminder), 24% (after first reminder), 24% (after second reminder) and 31% (after third reminder), resulting in a final response rate of 63%. CONCLUSIONS: We found that a series of regular reminders including a third, personalized reminder by SMS text or telephone had a positive impact on non-responders.

Venous thromboembolism in adults with sickle cell disease: experience of a single centre in the UK.

Venous thromboembolism (VTE) is a recognised complication of sickle cell disease (SCD), long considered to be a hypercoagulable state. While there is a good understanding of arterial thrombosis in SCD, the nature of VTE in SCD is less well-characterised. In this retrospective cohort study, we found that the incidence of VTE in our patient cohort was higher than in the non-SCD black population; patients of all SCD genotypes with VTE had significantly elevated steady-state platelet counts compared to those without. Recent hospitalisation (typically with acute sickle pain) was the commonest precipitating risk factor. These findings suggest consideration of longer VTE prophylaxis for acute hospital admissions in SCD.

Transcriptional regulation of 2',3'-cyclic nucleotide 3'-phosphodiesterase gene expression by cyclic AMP in C6 cells.

It was recently shown that the two transcripts encoding the isoforms of 2',3'-cyclic nucleotide 3'-phosphodiesterase (CNP1 and CNP2) are differentially regulated during the process of oligodendrocyte maturation. In oligodendrocyte precursors, only CNP2 mRNA is present, whereas in differentiating oligodendrocytes, both CNP1 and CNP2 mRNAs are expressed. This pattern of CNP expression is likely due to stage-specific transcriptional regulation of the two CNP promoters during the process of oligodendrocyte differentiation. Here, we report the influence of increased intracellular cyclic AMP (cAMP) levels on the transcription of both CNP1 and CNP2 mRNAs in rat C6 glioma cells. We found that the transcription of CNP1 mRNA was significantly increased in comparison with that of CNP2 mRNA in cells treated with cAMP analogues to elevate intracellular cAMP levels. This up-regulation of CNP1 expression (a) is due to an increase of transcription, (b) requires de novo protein synthesis, and (c) requires the activity of protein kinase A. These results are physiologically significant and support the idea that a cAMP-mediated pathway is part of the molecular mechanisms regulating the expression of CNP1 in oligodendrocytes. The regulation of CNP1 promoter activity by cAMP was then investigated in stably transfected C6 cell lines containing various deletions of the CNP promoter directing the bacterial chloramphenicol acetyltransferase gene. We showed that the sequence between nucleotides -126 and -102 was essential for the cAMP-dependent induction of CNP1 expression. Gel retardation analysis showed that two protein-DNA complexes are formed between this sequence and nuclear factors from C6 cells treated or not treated with cAMP. This suggests that the induction of CNP1 mRNA transcription is not mediated by changes in binding of nuclear factors that interact directly with the -126/-102 sequence. Sequence analysis of this region revealed the presence of a putative activator protein-2 (AP-2) binding site. It is interesting that mutagenesis of this region resulted in a significant reduction in transcriptional responses to cAMP, implying a possible role for the AP-2 factor in the expression of CNP1. In addition, we have shown that putative binding sites for activator protein-4 and nuclear factor-1 adjacent to the AP-2 site are required for efficient induction of CNP1 expression by cAMP. Taken together, our results show that the cAMP-dependent accumulation of CNP1 mRNA appears to depend on the synergistic interaction of several regulatory elements.

The prevalence of functional limitations and disability in older persons in the US: data from the National Health and Nutrition Examination Survey III.

OBJECTIVE: To provide estimates by sex and age and by sex and race/ethnicity of the proportion of older Americans who have difficulty with functional limitations and daily activities. SETTING: The Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994. DESIGN: A cross-sectional nationally representative survey. PARTICIPANTS: All persons aged 60 and older who completed a household interview (N = 6,866) during NHANES III (conducted 1988-1994). MEASUREMENTS: The self-reported physical and functional disability questions from NHANES III included: lower-extremity function, instrumental activities of daily living, basic activities of daily living, needing help with personal and routine daily activities, and use of assistive devices for walking. RESULTS: Non-Hispanic black and Mexican-American men and women generally reported significantly (P < .01) more disability than did non-Hispanic white men and women. Disability was greater for minority women than for men. For both men and women, the prevalence in disability increased significantly (P < .01) with age for each measure. CONCLUSIONS: These sex-age and sex-race/ethnicity national estimates of disability indicate that minority women may represent a vulnerable subpopulation.

Reliability and prevalence of physical performance examination assessing mobility and balance in older persons in the US: data from the Third National Health and Nutrition Examination Survey.

OBJECTIVE: This report provides reliability and prevalence estimates by sex, age, and race/ethnicity of an observed physical performance examination (PPE) assessing mobility and balance. SETTING: The Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994. DESIGN: A cross-sectional nationally representative survey. PARTICIPANTS: All persons aged 60 and older (n = 5,403) who performed the PPE either in the mobile examination center (MEC) or in the home during NHANES III (conducted 1988-1994). MEASUREMENTS: The PPE included timed chair stand, full tandem stand, and timed 8-foot walk. RESULTS: Timed chair stand and 8-foot timed walk were reliable measurements (Intraclass Correlations > 0.5). Women were significantly slower (P < .001) than men for both timed chair stands and timed walk. Non-Hispanic white men and women did the maneuvers in significantly less time than non-Hispanic black men and women and Mexican Americans women (P < .001). CONCLUSIONS: Lower extremity functions measured by timed chair stand and walk are reliable. Women at every age group were more physically limited than men.

Identification of a 37 kDa plant protein that interacts with the turnip mosaic potyvirus capsid protein using anti-idiotypic-antibodies.

Experimental data are provided for the presence of a plant protein that interacts with the capsid protein (CP) of turnip mosaic potyvirus (TuMV). The receptor-like protein was identified by exploiting the molecular mimicry potential of anti-idiotypic antibodies. A single-chain Fv molecule derived from the monoclonal antibody 7A (Mab-7A), which recognizes the CP of TuMV, was produced in Escherichia coli and the recombinant protein was used to raise rabbit antibodies. The immune serum reacted with Mab-7A but not with a monoclonal antibody of the same isotype, indicating that anti-idiotypic antibodies were produced. These anti-idiotypic antibodies recognized a 37 kDa protein from Lactuca sativa. Complex formation between the anti-idiotypic antibodies and the plant protein was inhibited by the CP of TuMV which indicates that the plant protein interacts with the viral protein. The 37 kDa protein was localized in chloroplasts and was detected in other plant species.

What is the value of the lateral chest radiograph in the follow-up thoracic lymphoma?

Lateral chest radiography in the investigation of thoracic lymphoma remains a feature of the current literature. This study assessed what information the lateral chest radiograph (CXR) adds in the follow-up of such patients. Eighty-eight patients with known lymphoma who had a CXR and thoracic CT within the same 4-week period were assessed. Five radiologists scored eight mediastinal and hilar nodal groups and eight extramediastinal regions on the frontal CXR as normal, equivocal or definitely abnormal (denoted 0, 1 and 2, respectively). This was repeated 1 week later with a combination of frontal and lateral films. Results were compared with the findings on CT which were scored similarly using accepted criteria for the presence of lymphadenopathy. Where the lateral CXR caused a change in score at any site, this change was compared with CT to determine the effect on diagnostic accuracy. For four of the five observers, the lateral film made no significant difference in diagnostic accuracy in the assessment of mediastinal lymph nodes. A fifth observer derived a small benefit from the addition of the lateral film, although almost 30 % of this was accounted for by changing from a wrong to an equivocal diagnosis. The lateral film did cause a small increase in the detection of pleuro-parenchymal lung lesions, although none of these were clinically significant. We conclude that routine lateral chest radiography is unhelpful in the follow-up of patients with lymphoma.