Online acceptance and commitment therapy (iACT) for adults with persistent physical symptoms - 3-month follow-up study of a randomized controlled trial.

OBJECTIVE: Persistent physical symptoms (PPS) represent a major health problem affecting daily functioning. This RCT aimed to examine whether a guided Internet-based treatment based on acceptance and commitment therapy (ACT) provided additional benefits compared to Treatment as Usual (TAU) in reducing somatic complaints and psychological distress in adults with PPS. METHODS: A total of 103 adults with PPS related to indoor environments, chronic fatigue or both conditions were assigned to receive either either a 14-week intervention (video-based case conceptualization + Internet-based ACT) combined with TAU (iACT + TAU; n = 50) or TAU alone (n = 53). Somatic symptoms, depression, anxiety, insomnia, and psychological flexibility were assessed from pre-intervention to a 3-month follow-up. Additionally, the association between changes in psychological flexibility from pre- to post-intervention and changes in symptoms from pre to 3-month follow-up was explored. Analyses were conducted using a multigroup method with full information maximum likelihood estimator. RESULTS: The results revealed a significant interaction effect, indicating reductions in somatic symptoms and symptoms of depression and anxiety with moderate to large between-group effects (d = 0.71-1.09). No significant interaction effect was observed in insomnia and measures of psychological flexibility. CONCLUSION: Internet-based ACT, when combined with Treatment as Usual, demonstrated efficacy for individuals with PPS associated with indoor environments and chronic fatigue. These findings are pertinent for primary healthcare providers, suggesting that the current treatment model could serve as a low-threshold first-line treatment option. THE CLINICAL TRIAL REGISTRATION NUMBER: NCT04532827.

Prognosis of patients with post-Covid-19 condition: Prospective cohort cluster analysis at one year.

OBJECTIVE: We aimed to identify clinically relevant clusters among patients with post-Covid-19 condition (PCC) and assess prognosis overall and within clusters. METHODS: Prospective cohort study of patients with PCC attending a rehabilitation clinic. We monitored patient reported outcome measures (PROMs): EuroHIS quality of life and symptoms. Unsupervised hierarchical cluster analyses were performed to identify clusters of patients with different quantity of symptoms, and symptoms presenting together. Preliminary findings on symptom prevalence and quality of life at 12 months are reported. RESULTS: Among 409 patients, 70.4% were women, with an average baseline of 20.3 (SD 6.8) symptoms. Three clusters emerged based on symptom quantity, labelled by the average number of symptoms at baseline: Cluster-11 (17% of all patients), Cluster-17 (35%), and Cluster-25 (48%). Multinomial logistic regression showed female sex, multiple comorbidities predicting more symptoms. Four symptom-based clusters were defined: fatigue and cognitive complaints; pain, trouble sleeping, palpitations and other symptoms; gastrointestinal symptoms; and emotion-related symptoms. Linear regression models showed that female sex, multiple comorbidities, anxiety, use of antidepressants, BMI and smoking were among the determinants of symptom clusters. In 12-month follow-up, symptom count decreased, and quality of life improved across all clusters, with 9% having good quality of life at baseline and 33% at 12 months. CONCLUSION: Four patient clusters based on symptoms were identified in the PCC cohort. Prognosis was favorable across all clusters, with symptom reduction and improved quality of life observed. Female sex, comorbidities, BMI, and mental-health related variables predicted higher symptom burden, suggesting multifactorial origins of PCC.

Prognosis of patients with long COVID symptoms: a protocol for a longitudinal cohort study at a primary care referred outpatient clinic in Helsinki, Finland.

INTRODUCTION: After COVID-19, many continue to experience persistent debilitating symptoms, that is, long COVID. Its most prevalent symptoms are chest pain, difficulties with breathing, painful muscles, ageusia or anosmia, tingling extremities and general tiredness. This paper describes the protocol of the Long COVID Cohort Study to assess the prognosis and prognostic determinants of patients with long COVID by implementing patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs) and clinical examinations during a 1-year follow-up. METHODS AND ANALYSIS: This is a prospective, single-site cohort study consisting of administering questionnaires and clinical examinations to adult patients referred to the Clinic for Long-Term Effects of COVID-19 at Helsinki University Hospital (Hospital district of Helsinki and Uusimaa). The referrals are from all healthcare units within HUS and other hospital districts during years 2021-2023. All admitted patients have had laboratory-confirmed COVID-19. The targeted study sample size is 500 participants. The questionnaires are administered at 0, 3, 6 and 12 months. The main outcome variables are the changes in self-reported functional abilities and quality of life. In addition, we will evaluate functional abilities at baseline using neurocognitive evaluation, a 6MWT and a measurement of hand grip strength. The Long COVID Cohort Study will form a quality register for the clinic and characterise the first systematic collection of PROMs, PREMs, questionnaire and clinical examinations related to long COVID in Finland. The Study belongs to a study consortium Long COVID-HORIZON-HLTH-2021-DISEASE-04 that aims to reveal the biomechanisms of long COVID. ETHICS AND DISSEMINATION: This study has been approved by the Helsinki University Hospital research ethics committee board, ID HUS/1493/2021 on 6 March 2021. All study participants sign written informed consent for participation. The study findings will be reported for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05699512; Pre-results.

A randomized controlled trial protocol for persistent physical symptoms associated with indoor environment or chronic fatigue: Effectiveness of video-based functional case conceptualization and web-program for improving quality of life.

Introduction: Persistent physical symptoms (PPS) refer to symptoms that cannot be fully explained by structural bodily pathology or by environmental factors. Their impact on daily functioning varies from mild to severe disability. So far, evidence-based treatments for PPS have resulted in only small to moderate effects. Treatment protocols with a stronger orientation toward personalized approaches are needed to improve the efficacy and applicability of treatment. In this study, we aim to assess the effect of an online individual case conceptualization with web-based program for PPS. This study is conducted among two focus groups: patients with indoor air-related symptoms and patients with chronic fatigue syndrome. Methods and analyses: Using a randomized controlled design (RCT) with two parallel groups in a 1:1 ratio, we will compare individual video-based case conceptualization with a web-based program based on Acceptance and Commitment Therapy (ACT), combined with treatment as usual, with treatment as usual only. The web-based program consists of ten modules, each lasting 1 week and including training. The planned sample size is 124 eligible patients without attrition. The primary outcome will be the health-related quality of life as measured by the 15D questionnaire. The secondary outcome measures will include questionnaires on psychiatric and physical symptoms, illness perceptions, psychological flexibility, and work ability. We will also use national registers to obtain information on the use of healthcare and social benefits to complete patient-reported outcomes. Data collection began in August 2020 and will continue until 2023. Discussion: This trial will provide information on the effects and usefulness of an online administrated individual case conceptualization and an ACT-based web-program on PPS. Ethics and dissemination: The Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland, has granted approval for the study. The results will be published in peer-reviewed journals. Clinical Trial Registration: Clinicaltrials.gov, identifier NCT04532827 preresults.

Psychosocial treatments for employees with non-specific and persistent physical symptoms associated with indoor air: A randomised controlled trial with a one-year follow-up.

OBJECTIVE: Persistent physical symptoms (PPS) associated with indoor air without an adequate pathophysiological- or environmental-related explanation may lead to work disability and decreased health-related quality of life (HRQoL). We attempted to assess the effect of cognitive behavioural therapy (CBT) for PPS and also psychoeducation (PE) on these symptoms involving disability. METHOD: The intention-to-treat (ITT) sample included 52 employees recruited from an occupational healthcare service randomised as either controls undergoing treatment as usual (TAU) or TAU enhanced with CBT or PE. The primary outcome was HRQoL measuring the severity of symptoms and restrictions in everyday life caused by them. Secondary outcomes included depressive, anxiety and insomnia symptoms, and intolerance to environmental factors, assessed at baseline and at 3-, 6- and 12-month follow-ups. RESULTS: At the 12-month follow-up assessment point, no statistically significant differences between treatments emerged following adjustment for gender, age, and HRQoL before the waiting period in the ITT analysis [F(2,46)=2.89, p=.07]. The secondary analysis revealed a significant improvement in HRQoL in the combined intervention group as compared with controls [F(1,47)=5.06, p=.03, g=0.41]. In total, 15% of participants dropped out during follow-up. CONCLUSIONS: The results suggest that CBT for PPS or PE might not have a robust effect on HRQoL in PPS associated with indoor air, but the study did not achieve the planned power. Despite difficulties during the recruitment process, the final dropout rates remained low, and participants positively evaluated CBT, suggesting that it represents an acceptable treatment to them. Trial status This study was registered at the ClinicalTrials.gov registry (NCT02069002).

Clinical Characteristics of Disability in Patients with Indoor Air-Related Environmental Intolerance.

BACKGROUND: Chronic nonspecific symptoms attributed to indoor nonindustrial work environments are common and may cause disability, but the medical nature of this disability is unclear. The aim was to medically characterize the disability manifested by chronic, recurrent symptoms and restrictions to work participation attributed to low-level indoor pollutants at workplace and whether the condition shares features with idiopathic environmental intolerance. METHODS: We investigated 12 patients with indoor air-related work disability. The examinations included somatic, psychological, and psychiatric evaluations as well as investigations of the autonomic nervous system, cortisol measurements, lung function, and allergy tests. We evaluated well-being, health, disability, insomnia, pain, anxiety, depression, and burnout via questionnaires. RESULTS: The mean symptom history was 10.5 years; for disabling symptoms, 2.7 years. Eleven patients reported reactions triggered mainly by indoor molds, one by fragrances only. Ten reported sensitivity to odorous chemicals, and three, electric devices. Nearly all had co-occurrent somatic and psychiatric diagnoses and signs of pain, insomnia, burnout, and/or elevated sympathetic responses. Avoiding certain environments had led to restrictions in several life areas. On self-assessment scales, disability showed higher severity and anxiety showed lower severity than in physician assessments. CONCLUSION: No medical cause was found to explain the disability. Findings support that the condition is a form of idiopathic environmental intolerance and belongs to functional somatic syndromes. Instead of endless avoidance, rehabilitation approaches of functional somatic syndromes are applicable.

Health-related quality among life of employees with persistent nonspecific indoor-air-associated health complaints.

OBJECTIVE: Nonspecific health complaints associated with indoor air are common in work environments. In some individuals, symptoms become persistent without an adequate explanation. The aim was to study factors that associate with the health-related quality of life (HRQoL) of employees with persistent, nonspecific indoor-air-related symptomatology. METHODS: We present baseline results of a randomized controlled trial of interventions targeted on the HRQoL of the employees with indoor-air-associated nonspecific symptoms. The main participant-inclusion criterion was the presence of persistent indoor-air-related multiorgan symptoms with no known pathophysiological or environment-related explanation. As a comparison for participants´ HRQoL (n = 52) we used data from the general-population Health 2011 study (BRIF8901) including information on subjects matched to the participants´ working status and age and subjects with asthma, anxiety or depressive disorder, or other chronic conditions with work disability. RESULTS: The participants showed greater and a clinically significant impairment of HRQoL [M = 0.83, SE = 0.013] than individuals from the general population [M = 0.95, SE = 0.001, p < .001, Hedges´ g = 2.33] and those with asthma [M = 0.93, SE = 0.005, p < .001, Hedges´ g = 1.46], anxiety and depressive disorder [M = 0.89, SE = 0.006, p < .001, Hedges´ g = 0.73], or a chronic condition with work disability [M = 0.91, SE = 0.003, p < .001, Hedges´ g = 1.11]. Prevalent symptoms of depression, anxiety, and insomnia and poor recovery from work were associated with a poor HRQoL. CONCLUSIONS: Individuals with nonspecific indoor-air-associated symptoms have a poorer HRQoL than individuals in the general population with a globally burdensome disease. Psychological distress associated with a poor HRQoL should be considered in the making of decisions about the treatment of these patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02069002.

Environmental Intolerance, Symptoms and Disability Among Fertile-Aged Women.

The purpose was to study the prevalence of environmental intolerance (EI) and its different manifestations, including behavioral changes and disability. Fertile-aged women (n = 680) of the Kuopio Birth Cohort Study were asked about annoyance to 12 environmental factors, symptoms and behavioral changes. We asked how much the intolerance had disrupted their work, household responsibilities or social life. We chose intolerance attributed to chemicals, indoor molds, and electromagnetic fields to represent typical intolerance entities. Of the respondents, 46% reported annoyance to chemicals, molds, or electromagnetic fields. Thirty-three percent reported symptoms relating to at least one of these three EIs, 18% reported symptoms that included central nervous system symptoms, and 15% reported behavioral changes. Indicating disability, 8.4% reported their experience relating to any of the three EIs as at least "somewhat difficult", 2.2% "very difficult" or "extremely difficult", and 0.9% "extremely difficult". Of the latter 2.2%, all attributed their intolerance to indoor molds, and two thirds also to chemicals. As the number of difficulties increased, the number of organ systems, behavioral changes and overlaps of the three EIs also grew. EI is a heterogeneous phenomenon and its prevalence depends on its definition. The manifestations of EI form a continuum, ranging from annoyance to severe disability.

Subjective and objective measures of function and return to work: an observational study with a clinical psychiatric cohort.

PURPOSE: To evaluate the association between two measurement tools (Social and Occupational Functioning Assessment Scale, SOFAS and Sheehan Disability Scale, SDS), returning to work (RTW) and their inter-correlation. METHODS: 132 psychiatric patients referred to assessment of work ability participated. The association between SOFAS and SDS Work to RTW were assessed by logistic regression. Inter-correlations between SOFAS and SDS were assessed with the Spearman's rho correlation coefficient. RESULTS: SOFAS and SDS Work scores were associated with a 1-year RTW and SOFAS and SDS were inter-correlated. CONCLUSIONS: When assigning the ability to work, both subjective and objective measures of function predict RTW.

[New self-assessment tools for evaluating work ability].

Assessment and support of the work ability and function is an elementary responsibility of health care. The focus of assessment lies in the remaining functional capacity and its sufficiency with respect to occupational demands. Objective and subjective perspectives, personal resources and limitations, and the subject's relationship to the environment are taken into account according to biopsychosocial models of work ability. We recommend three useful self-report measurement tools for work ability and function. Return-to-Work-Readiness Questionnaire (RTW-RQ), Return-to-Work Self-Efficacy (RTW-SE) and Sheehan Disability Scale (SDS). These tools structure an interactive evaluation providing possibilities for follow-up. They provide means to discuss one's personal resources and limitations and to promote return-to-work.

Comparing cognitive-behavioural psychotherapy and psychoeducation for non-specific symptoms associated with indoor air: a randomised control trial protocol.

INTRODUCTION: Indoor air-related conditions share similarities with other conditions that are characterised by medically unexplained symptoms (MUS)-a combination of non-specific symptoms that cannot be fully explained by structural bodily pathology. In cases of indoor air-related conditions, these symptoms are not fully explained by either medical conditions or the immunological-toxicological effects of environmental factors. The condition may be disabling, including a non-adaptive health behaviour. In this multifaceted phenomenon, psychosocial factors influence the experienced symptoms. Currently, there is no evidence of clinical management of symptoms, which are associated with the indoor environment and cannot be resolved by removing the triggering environmental factors. The aim of this study is to compare the effect of treatment-as-usual (TAU) and two psychosocial interventions on the quality of life, and the work ability of employees with non-specific indoor air-related symptomatology. METHODS AND ANALYSES: The aim of this ongoing randomised controlled trial is to recruit 60 participants, in collaboration with 5 occupational health service units. The main inclusion criterion is the presence of indoor air-related recurrent symptoms in ≥2 organ systems, which have no pathophysiological explanation. After baseline clinical investigations, participants are randomised into interventions, which all include TAU: cognitive-behavioural psychotherapy, psychoeducation and TAU (control condition). Health-related quality of life, measured using the 15D-scale, is the primary outcome. Secondary outcomes include somatic and psychiatric symptoms, occupational factors, and related underlying mechanisms (ie, cognitive functioning). Questionnaires are completed at baseline, at 3, 6 and 12-month follow-ups. Data collection will continue until 2017. The study will provide new information on the individual factors related to indoor air-associated symptoms, and on ways in which to support work ability. ETHICS AND DISSEMINATION: The Coordinating Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland, has granted approval for the study. The results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02069002; Pre-results.

Paprika rhinoconjunctivitis case reveals new occupational Capsicum allergens.

No allergens related to paprika or cayenne respiratory allergy have been identified thus far. We describe a previously healthy 28-year woman who developed work-related rhinoconjunctivitis after four years of kebab-restaurant work. The allergy was studied using skin prick tests, serum specific IgE and nasal provocation tests. Specific IgE protein reactions were studied by Western blot analysis. Paprika, cayenne and curry allergens were identified from the strongest immunoblot bands using tandem mass spectrometry. A positive skin prick test, high specific IgE and positive nasal provocation test confirmed occupational rhinoconjunctivitis from Capsicum spices. Defensin J1 and Vicilin were identified as major paprika and cayenne allergens in this case. Vicilin was detected also from the curry ingredients. Two new occupational respiratory allergens from the Capsicum species were identified. These differ from previously reported bell pepper allergens. We emphasize that substantial spice handling at work poses an allergy risk.

Decreased work ability associated to indoor air problems--An intervention (RCT) to promote health behavior.

INTRODUCTION: Indoor air problems may induce respiratory irritation and inflammation. In occupational settings, long-lasting non-specific building-related symptomatology, not fully medically explained, is encountered. The symptomatology may lead to illness, avoidance behavior and decreased work ability. In Finland, investigations of workers suspected of occupational asthma have revealed excess disability. There are no well-established clinical practices for the condition. OBJECTIVE: The aim was to develop a clinical intervention for patients with non-specific indoor air-related symptoms and decreased work ability. METHODS: A randomized controlled trial including psychoeducation and promotion of health behavior was carried out in 55 patients investigated for causal relationship between work-related respiratory symptoms and moisture damaged workplaces. Inclusion criteria for disability was the work ability score (WAS)≤7 (scale 0-10) and indoor air-related sick leave ≥14 days the preceding year. After medical evaluation and the 3-session counseling intervention, follow-up at 6-months was assessed using self-evaluated work-ability, sick leave days, quality of life, and illness worries as outcome measures. RESULTS: The mean symptom history was 55.5 months. 82% (45 out of 55) had asthma with normal lung function tests in most cases, although reporting abundant asthma symptoms. 81% of patients (39/48) had symptomatology from multiple organ systems without biomedical explanation, despite environmental improvements at work place. At the psychological counseling sessions, 15 (60%) patients of the intervention (INT, n=25) group showed concerns of a serious disease and in 5 (20%), concerns and fears had led to avoidance and restricted personal life. In the 6-month follow-up, the outcomes in the INT group did not differ from the treatment as usual group. CONCLUSION: No intervention effects were found. Patients shared features with medically unexplained symptoms and sick building syndrome or idiopathic environmental intolerance. Long environment-attributed non-specific symptom history and disability may require more intensive interventions. There is a need for improved recognition and early measures to prevent indoor-associated disability. TRIAL REGISTRATION NUMBER: Single-center randomized controlled trial (ISRCTN33165676).

Role of dermal exposure in systemic intake of methylenediphenyl diisocyanate (MDI) among construction and boat building workers.

The causal relationship between inhalation exposure to methylenediphenyl diisocyanate (MDI) and the risk of occupational asthma is well known, but the role of dermal exposure and dermal uptake of MDI in this process is still unclear. The aims of this study were to measure dermal exposure to and the dermal uptake of MDI among workers (n=24) who regularly handle MDI-urethanes. Dermal exposure was measured by the tape-strip technique from four sites on the dominant hand and arm. The workers with the highest exposure (n=5) were biomonitored immediately after their work shift, in the evening and the next morning, using urinary 4,4´methylenedianiline (MDA) as a marker. Dermal uptake was evaluated by comparing workers' MDA excretions both when they were equipped with respiratory protective devices (RPDs) and when they did not use them. The measured amounts of MDI on their hands varied from below 0.1 to 17 µg/10 cm(2) during the test. MDI concentrations were in the range of 0.08 to 27 µg m(-3) in the breathing zone outside the RPDs. MDA concentrations varied from 0.1 to 0.2 µmol mol(-1) creatinine during the test period. The decreasing effect of RPDs on inhalation exposure was absent in the next morning urine samples; this excretion pattern might be an indication of dermal uptake of MDI.

Permeation tests of glove and clothing materials against sensitizing chemicals using diphenylmethane diisocyanate as an example.

Diphenylmethane diisocyanate (MDI) is a sensitizing chemical that can cause allergic contact dermatitis and asthma. Protective gloves and clothing are necessary to prevent skin exposure. Breakthrough times are used for the selection of chemical protective gloves and clothing. In the EN 374-3:2003 European standard, breakthrough time is defined as the time in which the permeation reaches the rate of 1.0 µg min(-1) cm(-2) through the material. Such breakthrough times do not necessarily represent safe limits for sensitizing chemicals. We studied the permeation of 4,4'-MDI through eight glove materials and one clothing material. The test method was derived from the EN 374-3 and ASTM F 739 standards. All measured permeation rates were below 0.1 µg min(-1) cm(-2), and thus, the breakthrough times for all the tested materials were over 480min, when the definitions of EN 374-3 and ASTM F 739 for the breakthrough time were used. Based on the sensitizing capacity of MDI, we concluded that a cumulative permeation of 1.0 µg cm(-2) should be used as the end point of the breakthrough time determination for materials used for protection against direct contact with MDI. Using this criterion for the breakthrough time, seven tested materials were permeated in <480min (range: 23-406min). Affordable chemical protective glove materials that had a breakthrough time of over 75min were natural rubber, thick polyvinylchloride, neoprene-natural rubber, and thin and thick nitrile rubber. We suggest that the current definitions of breakthrough times in the standard requirements for protective materials should be critically evaluated as regards MDI and other sensitizing chemicals, or chemicals highly toxic via the skin.

[Psychiatric evaluation of functional and work capacity--why, when and how?]. / Psykiatrinen työ- ja toimintakykyarvio--miksi, milloin ja miten?

Evaluation and support of functional capacity are an essential part of treatment and rehabilitation of mental disorders. The evaluation requires objective observations from the examination situation and functional environment and is best effected multi-professionally and in network collaboration. In addition to functional limitations it is important to elucidate the remaining functional capacity, resources, strengths and coping mechanisms of the examined person and the possibilities of the workplace to support continuation in the work. Functional activity, social environment and suitably planned working will support mental health, prevent dropouts and lowering of the quality of life.

Traumatic injuries of children and adolescents--are they associated with psychiatric contacts?

Our aim was to investigate whether a large number of hospital visits by children and adolescents because of injuries are associated with psychiatric treatments and subsequent suicides. We examined the case records of 250 randomly chosen patients, 156 (62%) boys and 94 (38%) girls, out of 2306 outpatients who were 0-16 years old and had been treated because of traumatic injuries in Oulu University Hospital in 1984 and were alive in 1997. Boys with seven or more accidents had had psychiatric treatments more commonly than did boys with fewer accidents (39% vs. 8%). In addition, the case records of the patients who had died before the end of 1997 out of the 2306 patients were examined. Twenty-one (0.9%) patients (20 males and one female) had died, and seven (0.3%) of them had committed suicide. The traumatically injured male patients had a twofold suicide rate compared to the national average. The researchers also re-coded the causes of death from the death certificates. There seems to be a tendency to interpret adolescent suicides as accidental, as one of the seven registered suicides (14%), but six of the seven re-coded suicides (86%) had occurred before the age of 20.