Association of respiratory symptoms and asthma with occupational exposures: findings from a population-based cross-sectional survey in Telemark, Norway

OBJECTIVES

The aim of this study was to estimate the prevalence of respiratory symptoms and physician-diagnosed asthma and assess the impact of current occupational exposure.

DESIGN

Cross-sectional analyses of the prevalence of self-reported respiratory health and association with current occupational exposure in a random sample of the general population in Telemark County, Norway.

SETTINGS

In 2013, a self-administered questionnaire was mailed to a random sample of the general population, aged 16-50, in Telemark, Norway. The overall response rate was 33%, comprising 16 099 responders.

OUTCOME MEASURES

The prevalence for respiratory symptoms and asthma, and OR of respiratory symptoms and asthma for occupational groups and exposures were calculated. Occupational exposures were assessed using self-reported exposure and an asthma-specific job-exposure matrix (JEM).

RESULTS

The prevalence of physician-diagnosed asthma was 11.5%. For the occupational groups, the category with agriculture/fishery workers and craft/related trade workers was associated with wheezing and asthma attack in the past 12 months, showing OR 1.3 (1.1 to 1.6) and 1.9 (1.2 to 2.8), respectively. The group including technicians and associated professionals was also associated with wheezing OR 1.2 (1.0 to 1.3) and asthma attack OR 1.4 (1.1 to 1.9). The JEM data show that exposure to flour was associated with wheezing OR 3.2 (1.4 to 7.3) and woken with dyspnoea OR 3.5 (1.3 to 9.5), whereas exposures to diisocyanates, welding/soldering fumes and exposure to vehicle/motor exhaust were associated with dyspnoea OR 2.9 (1.5 to 5.7), 3.2 (1.6 to 6.4) and 1.4 (1.0 to 1.8), respectively.

CONCLUSIONS

The observed prevalence of physician-diagnosed asthma was 11.5%. The 'manual' occupations were associated with respiratory symptoms. Occupational exposure to flour, diisocyanates, welding/soldering fumes and vehicle/motor exhaust was associated with respiratory symptoms in the past 12 months and use of asthma medication. However, prospective data are needed to confirm the observed associations.

Evaluation of factors influencing accumulation of stable Sr and Cs in lake and coastal fish

As a result of nuclear accidents and weapons tests, the radionuclides Cs-137 and Sr-90 are common contaminants in aquatic ecosystems. Concentration ratios (CR) based on concentrations of stable Cs and Sr in biota and media are used for the estimation of transfer of their radioisotopes for radiation dose calculations in environmental and human safety assessments. Available element-specific CRs vary by over an order of magnitude for similar organisms, thus affecting the dose estimates proportionally. The variation could be reduced if they were based on a better understanding of the influence of the underlying data and how that affects accumulation and potential biomagnification of stable Cs and Sr in aquatic organisms. For fish, relationships have been identified between water concentrations of K and CR of Cs-137, and between water concentrations of Ca and CR of Sr-90. This has not been confirmed for stable Cs and Sr in European waters. In this study, we analysed an existing dataset for stable Cs and Sr, as well as K and Ca, in four Swedish lakes and three Baltic Sea coastal areas, in order to understand the behaviour of these elements and their radioisotopes in these ecosystems. We found significant seasonal variations in the water concentrations of Cs, Sr, K and Ca, and in electrical conductivity (EC), especially in the lakes. CR values based on measurements taken at single or few time points may, therefore, be inaccurate or introduce unnecessarily large variation into risk assessments. Instead, we recommend incorporating information about the underlying variation in water concentrations into the CR calculations, for example by using the variation of the mean. The inverse relationships between fish CR(Cs)-[K]water and fish CR(Sr)-[Ca]water, confirmed that stable Cs and Sr follow the same trends as their radioisotopes. Thus, they can be used as proxies when radioisotope data are lacking. EC was also strongly correlated with K and Ca concentrations in the water and could potentially be used as a quick and cost-effective method to estimate water chemistry to obtain less variable CR. We also recommend some simple improvements to data collection that would greatly enhance our ability to understand Cs and Sr uptake by fish.

Breath-taking jobs: a case-control study of respiratory work disability by occupation in Norway

Background

The current knowledge on respiratory work disability is based on studies that used crude categories of exposure. This may lead to a loss of power, and does not provide sufficient information to allow targeted workplace interventions and follow-up of patients with respiratory symptoms.

Objectives

The aim of this study was to identify occupations and specific exposures associated with respiratory work disability.

Methods

In 2013, a self-administered questionnaire was mailed to a random sample of the general population, aged 16–50, in Telemark County, Norway. We defined respiratory work disability as a positive response to the survey question: ‘Have you ever had to change or leave your job because it affected your breathing?’ Occupational exposures were assessed using an asthma-specific job-exposure matrix, and comparison of risks was made for cases and a median of 50 controls per case.

Results

247 workers had changed their work because of respiratory symptoms, accounting for 1.7% of the respondents ever employed. The ‘breath-taking jobs’ were cooks/chefs: adjusted OR 3.6 (95% CI 1.6 to 8.0); welders: 5.2 (2.0 to 14); gardeners: 4.5 (1.3 to 15); sheet metal workers: 5.4 (2.0 to 14); cleaners: 5.0 (2.2 to 11); hairdressers: 6.4 (2.5 to 17); and agricultural labourers: 7.4 (2.5 to 22). Job changes were also associated with a variety of occupational exposures, with some differences between men and women.

Conclusions

Self-report and job-exposure matrix data showed similar findings. For the occupations and exposures associated with job change, preventive measures should be implemented.

Deviation from accepted drug administration guidelines during anaesthesia in twenty highly realistic simulated cases

Deviations from accepted practice guidelines and protocols are poorly understood, yet some deviations are likely to be deliberate and carry potential for patient harm. Anaesthetic teams practice in a complex work environment and anaesthetists are unusual in that they both prescribe and administer the drugs they use, allowing scope for idiosyncratic practise. We aimed to better understand the intentions underlying deviation from accepted guidelines during drug administration in simulated cases. An observer recorded events that may have increased the risk of patient harm ('Events of Interest' [EOIs]) during 20 highly realistic simulated anaesthetic cases. In semi-structured interviews, details of EOIs were confirmed with participating anaesthetic teams, and intentions and reasoning underlying the confirmed deviations were discussed. Confirmed details of EOIs were tabulated and we undertook qualitative analysis of interview transcripts. Twenty-four EOIs (69% of 35 recorded) were judged by participants to carry potential for patient harm, and 12 (34%) were judged to be deviations from accepted guidelines (including one drug administration error). Underlying reasons for deviations included a strong sense of clinical autonomy, poor clinical relevance and a lack of evidence for guidelines, ingrained habits learnt in early training, and the influence of peers. Guidelines are important in clinical practice, yet self-identified deviation from accepted guidelines was common in our results, and all but one of these events was judged to carry potential for patient harm. A better understanding of the reasons underlying deviation from accepted guidelines is essential to the design of more effective guidelines and to achieving compliance.

Occupational exposures associated with severe exacerbation of asthma

BACKGROUND

The exacerbation of asthma by workplace conditions is common, but little is known about which agents pose a risk.

OBJECTIVE

We used data from an existing survey of adults with asthma to identify occupational exposures associated with severe exacerbation of asthma.

DESIGN

Questionnaires were completed by 557 working adults with asthma. Severe exacerbation of asthma in the past 12 months was defined as asthma-related hospitalization, or reports of both unplanned asthma care and treatment with a short course of oral corticosteroids. Occupational exposures for the same time period were assessed using an asthma-specific job exposure matrix. We modeled severe exacerbation to yield prevalence ratios (PRs) for exposures while controlling for potential confounders.

RESULTS

A total of 164 participants (29%) were positive for severe exacerbation, and 227 (40.8%) were assessed as being exposed to asthma agents at work. Elevated PRs were observed for several specific agents, notably the irritant subcategories of environmental tobacco smoke (PR 1.84, 95%CI 1.34-2.51) among all participants, inorganic dusts (PR 2.53, 95%CI 1.37-4.67) among men, and the low molecular weight subcategory of other highly reactive agents (PR 1.97, 95%CI 1.08-3.60) among women.

CONCLUSION

Among working adults with asthma, severe exacerbation was associated with several occupational agents.

Strength training improves muscle aerobic capacity and glucose tolerance in elderly

The primary aim of this study was to investigate the effect of short-term resistance training (RET) on mitochondrial protein content and glucose tolerance in elderly. Elderly women and men (age 71 ± 1, mean ± SEM) were assigned to a group performing 8 weeks of resistance training (RET, n = 12) or no training (CON, n = 9). The RET group increased in (i) knee extensor strength (concentric +11 ± 3%, eccentric +8 ± 3% and static +12 ± 3%), (ii) initial (0-30 ms) rate of force development (+52 ± 26%) and (iii) contents of proteins related to signaling of muscle protein synthesis (Akt +69 ± 20 and mammalian target of rapamycin +69 ± 32%). Muscle fiber type composition changed to a more oxidative profile in RET with increased amount of type IIa fibers (+26.9 ± 6.8%) and a trend for decreased amount of type IIx fibers (-16.4 ± 18.2%, P = 0.068). Mitochondrial proteins (OXPHOS complex II, IV, and citrate synthase) increased in RET by +30 ± 11%, +99 ± 31% and +29 ± 8%, respectively. RET resulted in improved oral glucose tolerance measured as reduced area under curve for glucose (-21 ± 26%) and reduced plasma glucose 2 h post-glucose intake (-14 ± 5%). In CON parameters were unchanged or impaired. In conclusion, short-term resistance training in elderly not only improves muscular strength, but results in robust increases in several parameters related to muscle aerobic capacity.

The effect of incline on sprint and bounding performance in cross-country skiers

AIM

Aim of the present study was to investigate performance and kinematics of cross-country skiers during sprint running and bounding on different inclines, in relationship to maximal strength, power and skiing performance.

METHODS

On day one, the maximal strength of 14 elite skiers was tested using a mid-thigh isometric pull and maximal relative leg power determined using squat and countermovement jumps. Day two involved 15-m maximal sprints and 5-step bounding at 0º, 7.5° and 15º inclines. From video recordings sprint, step, contact and flight times; step length and frequency; total number of sprint steps and average bounding velocity were determined. Skiing performance was assessed using International Ski Federation (FIS) points from the preceding season and compared to strength, power, bounding and sprint performance, and kinematics.

RESULTS

On steeper inclines sprint time was higher and bounding distance shorter (both P<0.001), and step frequency during sprinting and bounding, reduced and increased respectively (P<0.001). Isometric maximal strength correlated strongly with bounding distance on the two steeper inclines (r=0.76 and 0.83). Squat and countermovement jump heights correlated moderately with sprint performance at both 7° and 15°, and bounding performance on all three inclines (r=0.55-0.65). The distance bounded uphill correlated moderately with FIS points (r=-0.55 and -0.67).

CONCLUSION

Incline influenced sprinting and bounding performance and kinematics. Maximal leg power is important for both sprinting and bounding uphill, while maximal strength is important for the latter. The skiers with better FIS rankings bounded farther on steeper inclines, suggesting that this capacity is beneficial for cross-country skiing performance.

Incidence of chronic bronchitis: a prospective study in a large general population

SETTING

A county in western Sweden.

OBJECTIVE

To prospectively investigate the incidence rate of chronic bronchitis (CB) in relation to smoking, age, sex, atopy and asthma in a large sample of the general population.

DESIGN

Subjects from a county in western Sweden born between 1943 and 1973, who had participated in our previous study in 1993, were mailed a new questionnaire in 2003. Altogether 11 463 (72%) answered the questionnaire, which comprised items about smoking, atopy, respiratory symptoms and age at onset of CB symptoms. CB was defined as chronic productive cough for at least 3 months per year for 2 consecutive years.

RESULTS

There were 98 new cases of CB during 1993-2003 in the study population aged 30-60 years at follow-up. The incidence rate was 0.9/1000 person-years (py); there was no significant difference between women and men or different age groups. However, CB incidence was higher in women in relation to smoking (incidence rate ratio 3.6, 95%CI 1.9-7.3) and in those with ever asthma (hazard ratio 5.6, 95%CI 3.5-9.0).

CONCLUSION

This prospective general population-based study shows an incidence rate of CB of 0.9/1000 py. Smoking and asthma were both associated with an increased risk of CB.

Long-term efficacy of Internet-based cognitive behavior therapy for obsessive-compulsive disorder with or without booster: a randomized controlled trial

BACKGROUND

As relapse after completed cognitive behavior therapy (CBT) for obsessive-compulsive disorder (OCD) is common, many treatment protocols include booster programs to improve the long-term effects. However, the effects of booster programs are not well studied. In this study, we investigated the long-term efficacy of Internet-based CBT (ICBT) with therapist support for OCD with or without an Internet-based booster program.

METHOD

A total of 101 participants were included in the long-term follow-up analysis of ICBT. Of these, 93 were randomized to a booster program or no booster program. Outcome assessments were collected at 4, 7, 12 and 24 months after receiving ICBT.

RESULTS

The entire sample had sustained long-term effects from pre-treatment to all follow-up assessments, with large within-group effect sizes (Cohen's d = 1.58-2.09). The booster group had a significant mean reduction in OCD symptoms compared to the control condition from booster baseline (4 months) to 7 months, but not at 12 or 24 months. Participants in the booster group improved significantly in terms of general functioning at 7, 12 and 24 months, and had fewer relapses. Kaplan-Meier analysis also indicated a significantly slower relapse rate in the booster group.

CONCLUSIONS

The results suggest that ICBT has sustained long-term effects and that adding an Internet-based booster program can further improve long-term outcome and prevent relapse for some OCD patients.

Effectiveness of internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care

OBJECTIVE

Guided Internet-based cognitive behaviour therapy (ICBT) for panic disorder has been shown to be efficacious in several randomized controlled trials. However, the effectiveness of the treatment when delivered within routine psychiatric care has not been studied. The aim of this study was to investigate the effectiveness of ICBT for panic disorder within the context of routine psychiatric care.

METHOD

We conducted a cohort study investigating all patients (n = 570) who had received guided ICBT for panic disorder between 2007 and 2012 in a routine care setting at an out-patient psychiatric clinic providing Internet-based treatment. The primary outcome measure was the Panic Disorder Severity Scale-Self-report (PDSS-SR).

RESULTS

Participants made large improvements from screening and pretreatment assessments to posttreatment (Cohen's d range on the PDSS-SR = 1.07-1.55). Improvements were sustained at 6-month follow-up.

CONCLUSION

This study suggests that ICBT for panic disorder is as effective when delivered in a routine care context as in the previously published randomized controlled trials.

Natural sex change in the temperate protogynous Ballan wrasse Labrus bergylta

Wild Ballan wrasse Labrus bergylta were sampled monthly over 2 years in western Norway to identify the natural process of sex change in this species. Light microscopy of standard histological-stained and immunohistochemistry-treated gonad tissue showed that spermatogonial germ cells tended to proliferate around the periphery of the lamellae before filling into the slowly receding, apoptotic central areas of the lamellae. Sex change occurred following the breeding season. From July to September, fish were most often in an early state of gonadal transition (ET), characterized by degenerating previtellogenic oocytes and pockets of proliferating spermatogonia in the germinative epithelia. The majority of fish with late transitional gonads, that were typically dominated by spermatogenic cells, developing efferent ducts and the beginning of lobule formation, were found between October and November. Sex steroid profiles of fish representing the different sexual phases showed that breeding females had the highest concentrations of 17β oestradiol (E2 ) and the lowest concentration of 11 ketotestosterone (11KT). Concentrations of E2 decreased greatly in ET fish at the beginning of sex change and remained low in all subsequent phases. The opposite trend was demonstrated in 11KT profiles. Initial-phase female fish had minimal concentrations of 11KT, but these increased during subsequent transitions. Sex change occurred most often in fish 34-41 cm total length (L(T)) and the median of fish in the size-frequency overlap of female and male fish was 36 cm L(T).

Cost-effectiveness and long-term effectiveness of internet-based cognitive behaviour therapy for severe health anxiety

BACKGROUND

Severe health anxiety is a common condition associated with functional disability, making it a costly disorder from a societal perspective. Internet-based cognitive behaviour therapy (ICBT) is a promising treatment but no previous study has assessed the cost-effectiveness or long-term outcome of ICBT for severe health anxiety. The aim of this study was to investigate the cost-effectiveness and 1-year treatment effects of ICBT for severe health anxiety.

METHOD

Cost-effectiveness and 1-year follow-up data were obtained from a randomized controlled trial (RCT) comparing ICBT (n = 40) to an attention control condition (CC, n = 41). The primary outcome measure was the Health Anxiety Inventory (HAI). A societal perspective was taken and incremental cost-effectiveness ratios (ICERs) were calculated using bootstrap sampling.

RESULTS

The main ICER was -£1244, indicating the societal economic gain for each additional case of remission when administering ICBT. Baseline to 1-year follow-up effect sizes on the primary outcome measure were large (d = 1.71-1.95).

CONCLUSIONS

ICBT is a cost-effective treatment for severe health anxiety that can produce substantial and enduring effects.

Biomechanical analysis of the herringbone technique as employed by elite cross-country skiers

This investigation was designed to analyse the kinematics and kinetics of cross-country skiing at different velocities with the herringbone technique on a steep incline. Eleven elite male cross-country skiers performed this technique at maximal, high, and moderate velocities on a snow-covered 15° incline. They positioned their skis laterally (25 to 30°) with a slight inside tilt and planted their poles laterally (8 to 12°) with most leg thrust force exerted on the inside forefoot. Although 77% of the total propulsive force was generated by the legs, the ratio between propulsive and total force was approximately fourfold higher for the poles. The cycle rate increased with velocity (1.20 to 1.60 Hz), whereas the cycle length increased from moderate up to high velocity, but then remained the same at maximal velocity (2.0 to 2.3 m). In conclusion, with the herringbone technique, the skis were angled laterally without gliding, with the forces distributed mainly on the inside forefoot to enable grip for propulsion. The skiers utilized high cycle rates with major propulsion by the legs, highlighting the importance of high peak and rapid generation of leg forces.

Perceived information after surgery for colorectal cancer--an explorative study

AIM

With fast track surgery and shorter hospital stay, discharge from hospital after cancer surgery is becoming more challenging for the individual patient. The aim of this study was to explore how patients perceive information after surgery for colorectal cancer, what their information needs are and to determine factors affecting received information.

METHOD

A hundred patients filled in the questionnaires QLQ-C30, CR38 and INFO25 created by the European Organization for Research and Treatment of Cancer, the Eastern Cooperative Oncology Group (ECOG) instrument and the SOC (sense of coherence) instrument and provided written comments within the first 2 weeks after discharge following surgery for colorectal cancer. The questionnaires were analysed using hierarchical cluster analysis and a multiple linear regression analysis. The written comments were analysed using content analysis.

RESULTS

In all, 49% of the patients expressed a need for more information. In the written comments they specified these areas of information: they lacked information concerning their surgery, how to handle symptoms and problems at home, someone to contact after discharge and prognostic information about their future. Patients reported most received information in areas of medical tests and disease but less on other services and support in outpatient care. The variation in INFO25 was best explained by gender (P = 0.045) and preoperative health status (American Society of Anesthesiologists score 3, P = 0.022).

CONCLUSION

The results from this study indicate that women and patients with a poorer preoperative health status scored less on information received and would need more time and support to prepare for discharge. The patients expressed a desire for more information about the surgery, how to handle symptoms at home and prognostic information about their future.

Internet-based cognitive behaviour therapy for obsessive-compulsive disorder: a randomized controlled trial

BACKGROUND

Cognitive behaviour therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD) but access to CBT is limited. Internet-based CBT (ICBT) with therapist support is potentially a more accessible treatment. There are no randomized controlled trials testing ICBT for OCD. The aim of this study was to investigate the efficacy of ICBT for OCD in a randomized controlled trial.

METHOD

Participants (n=101) diagnosed with OCD were randomized to either 10 weeks of ICBT or to an attention control condition, consisting of online supportive therapy. The primary outcome measure was the Yale-Brown Obsessive Compulsive Scale (YBOCS) administered by blinded assessors.

RESULTS

Both treatments lead to significant improvements in OCD symptoms, but ICBT resulted in larger improvements than the control condition on the YBOCS, with a significant between-group effect size (Cohen's d) of 1.12 (95% CI 0.69-1.53) at post-treatment. The proportion of participants showing clinically significant improvement was 60% (95% CI 46-72) in the ICBT group compared to 6% (95% CI 1-17) in the control condition. The results were sustained at follow-up.

CONCLUSIONS

ICBT is an efficacious treatment for OCD that could substantially increase access to CBT for OCD patients. Replication studies are warranted.

Clinical and genetic outcome determinants of Internet- and group-based cognitive behavior therapy for social anxiety disorder

OBJECTIVE

No study has investigated clinical or genetic predictors and moderators of Internet-based cognitive behavior therapy (ICBT) compared with cognitive behavioral group therapy for (CBGT) for SAD. Identification of predictors and moderators is essential to the clinician in deciding which treatment to recommend for whom. We aimed to identify clinical and genetic (5-HTTLPR, COMTval158met, and BDNFval66met) predictors and moderators of ICBT and CBGT.

METHOD

We performed three types of analyses on data from a sample comprising participants (N = 126) who had undergone ICBT or CBGT in a randomized controlled trial. Outcomes were i) end state symptom severity, ii) SAD diagnosis, and iii) clinically significant improvement.

RESULTS

The most stable predictors of better treatment response were working full time, having children, less depressive symptoms, higher expectancy of treatment effectiveness, and adhering to treatment. None of the tested gene polymorphisms were associated with treatment outcome. Comorbid general anxiety and depression were moderators meaning that lower levels were associated with a better treatment response in ICBT but not in CBGT.

CONCLUSION

We conclude that demographic factors, symptom burden, adherence, and expectations may play an important role as predictors of treatment outcome. The investigated gene polymorphisms do not appear to make a difference.

A large multi-centre European study validates high-sensitivity C-reactive protein (hsCRP) as a clinical biomarker for the diagnosis of diabetes subtypes

AIMS/HYPOTHESIS

An accurate molecular diagnosis of diabetes subtype confers clinical benefits; however, many individuals with monogenic diabetes remain undiagnosed. Biomarkers could help to prioritise patients for genetic investigation. We recently demonstrated that high-sensitivity C-reactive protein (hsCRP) levels are lower in UK patients with hepatocyte nuclear factor 1 alpha (HNF1A)-MODY than in other diabetes subtypes. In this large multi-centre study we aimed to assess the clinical validity of hsCRP as a diagnostic biomarker, examine the genotype-phenotype relationship and compare different hsCRP assays.

METHODS

High-sensitivity CRP levels were analysed in individuals with HNF1A-MODY (n = 457), glucokinase (GCK)-MODY (n = 404), hepatocyte nuclear factor 4 alpha (HNF4A)-MODY (n = 54) and type 2 diabetes (n = 582) from seven European centres. Three common assays for hsCRP analysis were evaluated. We excluded 121 participants (8.1%) with hsCRP values >10 mg/l. The discriminative power of hsCRP with respect to diabetes aetiology was assessed by receiver operating characteristic curve-derived C-statistic.

RESULTS

In all centres and irrespective of the assay method, meta-analysis confirmed significantly lower hsCRP levels in those with HNF1A-MODY than in those with other aetiologies (z score -21.8, p < 5 × 10(-105)). HNF1A-MODY cases with missense mutations had lower hsCRP levels than those with truncating mutations (0.03 vs 0.08 mg/l, p < 5 × 10(-5)). High-sensitivity CRP values between assays were strongly correlated (r (2) ≥ 0.91, p ≤ 1 × 10(-5)). Across the seven centres, the C-statistic for distinguishing HNF1A-MODY from young adult-onset type 2 diabetes ranged from 0.79 to 0.97, indicating high discriminative accuracy.

CONCLUSIONS/INTERPRETATION

In the largest study to date, we have established that hsCRP is a clinically valid biomarker for HNF1A-MODY in European populations. Given the modest costs and wide availability, hsCRP could translate rapidly into clinical practice, considerably improving diagnosis rates in monogenic diabetes.