Influence of CUREs on STEM retention depends on demographic identities

Research has shown that undergraduate research experiences can have substantive effects on retaining students in science, technology, engineering and mathematics (STEM). However, it is impossible to provide individual research experiences for every undergraduate student, especially at large universities. Course-based undergraduate research experiences (CUREs) have become a common approach to introduce large numbers of students to research. We investigated whether a one-semester CURE that replaced a traditional introductory biology laboratory course could increase retention in STEM as well as intention to remain in STEM, if the results differed according to demography, and investigated the possible motivational factors that might mediate such an effect. Under the umbrella of the Authentic Research Connection (ARC) program, we used institutional and survey data from nine semesters and compared ARC participants to non-participants, who applied to ARC but either were not randomly selected or were selected but chose not to enroll in an ARC section. We found that ARC had significant effects on demographic groups historically less likely to be retained in STEM: ARC participation resulted in narrowing the gaps in graduation rates in STEM (first vs continuing-generation college students) and in intention to major in STEM [females vs males, Persons Excluded because of Ethnicity or Race (PEERs) vs non-PEERs]. These disproportionate boosts in intending STEM majors among ARC students coincide with their reporting a greater sense of student cohesiveness, retaining more interest in biology, and commenting more frequently that the course provided a useful/valuable learning experience. Our results indicate that CUREs can be a valuable tool for eliminating inequities in STEM participation, and we make several recommendations for further research.

Do patient characteristics matter when calculating sample size for eczema clinical trials?

Background

The Patient‐Oriented Eczema Measure (POEM) is the core outcome instrument recommended for measuring patient‐reported atopic eczema symptoms in clinical trials. To ensure that the statistical significance of clinical trial results is meaningful, trials are often designed by specifying the target difference in the primary outcome as part of the sample size calculation. One method used to specify the target difference is a score that corresponds to a standardized effect size.

Objectives

to assess how the standardized effect size of POEM scores vary across age, gender, ethnicity and disease severity.

Methods

This study combined data from five UK‐based randomized clinical trials of eczema treatments in order to assess differences in self‐reported eczema symptoms (POEM) corresponding to a standardized effect size (0.5 SD of baseline POEM scores) across age, gender, ethnicity and disease severity.

Results

POEM scores corresponding to 0.5 SD_(baseline) were remarkably consistent across participants of varying ages, gender, ethnicity and disease severity from datasets of five UK trials in children (range 2.99–3.45).

Conclusions

This study provides information that can support those designing clinical trials to determine their sample size and can aid individuals interpreting trial results. Further exploration of differences in populations beyond the United Kingdom is needed.

A national Health and Work Strategy: a search for evidence

BACKGROUND

The Health and Safety Executive's new Health and Work Strategy is based on an up-to-date assessment of workplace health priorities. Rather than replicating traditional prioritization approaches, a broader assessment of health and work priorities was carried out using a range of stakeholders.

AIMS

To develop a set of health priorities for further research and intervention activity.

METHODS

Four exercises were carried out, including internal prioritization, two external web-hosted questionnaire studies of younger workers and occupational health professionals, focus groups and tele-depth interviews with workplace health and safety professionals.

RESULTS

The highest rated internal priorities (weighted priority scores) were identified as mesothelioma (70), lung cancer (69.25), chronic obstructive pulmonary disease (COPD; 69), musculoskeletal disorders (MSDs; 66.25), hearing loss (65.75), stress (65.5), asthma (64.5) and hand-arm vibration syndrome (61.5). Using the three highest ranked criteria developed by occupational health professionals ((i) the preventability of the condition, (ii) the impact of the condition and (iii) the number of workers affected), mesothelioma, lung cancer, COPD, MSDs, hearing loss, stress and asthma were identified as the top seven priorities. Generic issues identified included ageing and work, obesity, newer technologies, and ethnicity and cultures of workforces. Apprentices identified stress, depression, anxiety, musculoskeletal and respiratory disorders, fatigue and workload as important workplace health considerations.

CONCLUSIONS

This process identified a number of expected and new areas of health research interest. We believe the findings reflect the real world requirements of work as assessed by occupational health and safety practitioners and workers.

VIII. On the movements of the flame in the explosion of gases

(1.) On the Rate of Movement of the Flam, and the produced in theExplosion of Gases. Humphry Davy was the first to observe the rate at which an explosion of gases was propagated in a tube, and he also made the first rough experiment on the tem­perature reached in an explosion. When gas from the distillation of coal (which he found more inflammable than fire-damp) was mixed with eight times its volume ofair, and was fired in a glass tube 1 foot long and 1/4 inch in diameter, the flame took more than a second to traverse the tube. When cyanogen mixed with twice its volume of oxygen was fired in a bent tube over water, the quantity of water displaced showed that the gases had expanded fifteen times their original bulk. Bunsen, in 1867, made the first careful measurement of the rate at which an explosion is propagated in gases, and he also made the first systematic researches on the pressure and temperature produced by the explosion of gases in closed vessels. His results led him to the remarkable conclusion that there was a discontinuous combustion in explosions. When electrolytic gas, or when carbonic oxide with haltits volume of oxygen, is fired, only one-third of the mixture is burnt, according to Bunsen, raising the temperature of the whole to about 3000° C. No further chemical action then occurs until the gaseous mixture falls, by cooling, below 2500° C. Then a further combustion begins, and so on<italic>per Saltum</italic>. These deductions were criticised by Berthelot, who pointed out that they assumed the constancy of the specific heats of steam and of carbonic acid at high temperatures.

Evaluating the Impact and Benefits of Fluticasone Furoate/Vilanterol in Individuals with Asthma or COPD: A Mixed-Methods Analysis of Patient Experiences

Introduction

This study evaluated patients’ experiences with fluticasone furoate/vilanterol (FF/VI) combination therapy in UK patients with asthma or chronic obstructive pulmonary disease (COPD).

Methods

Participants aged ≥ 18 years, with self-reported, physician-diagnosed asthma or COPD (≥ 1 year) who had been receiving FF/VI (≥ 3 months) were recruited from UK primary care. This two-phase, mixed-methods study consisted of a semi-structured, telephone-interview phase (qualitative) and a self-completed online/paper-survey phase (quantitative).

Results

The telephone-interview phase included 50 individuals [asthma, n = 25; COPD, n = 25; mean age (SD) 56.7 years (13.3); 50% female]. Of these, 21 with asthma reported that their condition was stable/well controlled and 13 with COPD felt their condition was manageable. Most participants found FF/VI easy to use (asthma, 25; COPD, 23), easy to integrate into their daily routine (asthma, 25; COPD, 24), and able to control symptoms for ≥ 24 h (asthma, 14; COPD, 16). During the survey phase, 199 individuals were recruited [asthma, n = 100; COPD, n = 99; mean age (SD) 63.6 years (15.1); 59.3% female]. Most participants were satisfied/very satisfied with the efficacy of FF/VI in terms of all-day symptom relief (asthma, 84%; COPD, 75%) and found FF/VI easy/very easy to fit into their daily routine (asthma, 99%; COPD, 96%), easy/very easy to use (asthma, 97%; COPD, 92%), and convenient/very convenient to take as instructed (asthma, 95%; COPD, 93%). Significantly more individuals with asthma (87% versus 46%, P < 0.001) and numerically more individuals with COPD (84% versus 76%, P = 0.055) were satisfied/very satisfied with FF/VI compared with their most recent previous maintenance medication.

Conclusion

The majority of individuals in this study had confidence in FF/VI and were satisfied or very satisfied with various key attributes of the treatment.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0760-7) contains supplementary material, which is available to authorized users.

How should minimally important change scores for the Patient-Oriented Eczema Measure be interpreted? A validation using varied methods

Background

The Patient‐Oriented Eczema Measure (POEM), scored 0–28, is the core outcome instrument recommended for measuring patient‐reported atopic eczema symptoms in clinical trials. To date, two published studies have broadly concurred that the minimally important change (MIC) of the POEM is three points. Further assessment of the MIC of POEM in different populations, and using a variety of methods, will improve interpretability of the POEM in research and clinical practice.

Objectives

To calculate the smallest detectable change in the POEM and estimate the MIC of the POEM using a variety of methods in a trial dataset of children with moderate‐to‐severe atopic eczema.

Methods

This study used distribution‐based and anchor‐based methods to calculate the MIC of the POEM in children with moderate‐to‐severe eczema.

Results

Data were collected from 300 children. The smallest detectable change was 2·13. The MIC estimates were 1·07 (using 0·2 SD of baseline POEM scores) and 2·68 (using 0·5 SD of baseline POEM scores) based on distribution‐based methods; were 3·09–6·13 based on patient‐/parent‐reported anchor‐based methods; and were 3·23–5·38 based on investigator‐reported anchor‐based methods.

Conclusions

We recommend the following thresholds be used to interpret changes in POEM scores: ≤ 2, unlikely to be a change beyond measurement error; 2·1–2·9, a small change detected that is likely to be beyond measurement error but may not be clinically important; 3–3·9, probably a clinically important change; ≥ 4, very likely to be a clinically important change.

What's already known about this topic?

The Patient‐Oriented Eczema Measure (POEM) is recommended as the core outcome instrument for measuring patient‐reported symptoms in eczema clinical trials.

Two previous studies have examined the minimally important change (MIC) of the POEM; one in children with mild eczema and another in adults with very severe eczema.

These previous studies both concluded that the MIC in POEM is around three points.

What does this study add?

This study explored the impact of different methodologies for calculating the MIC of the POEM in children with moderate‐to‐severe eczema.

A change in POEM of less than two points is likely to be below the smallest detectable change (i.e. below measurement error) for the scale.

The MIC varied considerably depending on the method used, but a change in POEM score below three points is unlikely to be a clinically important change.

What are the clinical implications of this work?

This study aids sample size calculations for clinical trials and helps researchers, clinicians and patients to interpret changes in POEM scores in clinical trials and routine monitoring of eczema in clinical practice.

https://doi.org/10.1111/bjd.16611 available online

https://goo.gl/Uqv3dl

Underestimation of spirometry if recommended testing guidance is not followed

Background

Lung function measured at work is used to make important employment decisions. Improving its quality will reduce misclassification and allow more accurate longitudinal interpretation over time.

Aims

To assess the amount by which lung function (forced expiratory volume in 1 second [FEV1] and forced vital capacity [FVC]) values will be underestimated if recommended spirometry testing guidance is not followed.

Methods

Lung function was measured in a population of workers. Knowledge of the final reproducible FEV1 and FVC for each worker allowed estimation of the underestimates that would have occurred if less forced manoeuvres than recommended had been performed.

Results

A total of 667 workers (661 males, mean age 43 years, range 18-66) participated. Among them, 560 (84%) achieved reproducible results for both FEV1 and FVC; 470 (84%) of these did so after three technically acceptable forced expiratory manoeuvres, a cumulative total of 533 after four, 548 after five, 557 after six, 559 after seven and 560 after eight blows. If only one (or first two) technically acceptable blow(s) had been performed, mean underestimates were calculated for FEV1 of 115.1 ml (35.4 ml) and for FVC of 143.4 ml (42.3 ml).

Conclusions

In this study, reproducible spirometry was achievable in most workers. Not adhering to standards underestimates lung function by clinically significant amounts.

Life Impact and Treatment Preferences of Individuals with Asthma and Chronic Obstructive Pulmonary Disease: Results from Qualitative Interviews and Focus Groups

INTRODUCTION

The impact of asthma and chronic obstructive pulmonary disease (COPD) on individuals' lives may be substantial, yet clinical practice often focuses only on symptoms. We aimed to better understand the perspective of asthma or COPD patients and to identify condition-related burden, life impact, priorities, unmet needs, and treatment goals.

METHODS

Individuals aged at least 18 years with asthma or COPD were identified by a recruitment panel via clinical referrals, support groups, consumer networks, and a patient database. Interviews were carried out individually (by telephone) or in focus groups (with no more than five participants per group). A semi-structured interview guide was used with prespecified topics, informed by a literature review, that were considered impactful in asthma or COPD (symptoms and daily-life impact, satisfaction with current treatment, important aspects of treatment, adherence, and ideal treatment).

RESULTS

Overall, 72 people participated in focus groups/individual interviews (asthma n = 18/n = 21; COPD n = 15/n = 18). "Shortness of breath" was the most frequently reported symptom; however, participants discussed the life impact of their condition more than symptoms alone. Reported physical impacts included the inability to sleep and socialize, while emotional impacts included "embarrassment, stigma, and/or self-consciousness", "fear and/or panic", and "sadness, anxiety, and/or depression". Coping mechanisms for normal activities included continuing at reduced pace and avoidance. Treatment preferences centered on resolving impacts; improved sleep, "speed of action", and "length of relief" were the most frequently reported ideal treatment factors.

CONCLUSION

Patients with asthma or COPD experience substantial quality of life limitations and tend to focus on these in their expressions of concern, rather than symptoms per se. Life impacts of these conditions may have implications beyond those commonly appreciated in routine practice; these considerations will be applied to a future discrete choice experiment survey.

FUNDING

GSK funded study (H0-15-15502/204821).

Labour induction near term for women aged 35 or over: an economic evaluation

OBJECTIVE

Induction of labour at 39 weeks for nulliparous women aged 35 years and over may prevent stillbirths and does not increase caesarean births, so it may be popular. But the overall costs and benefits of such a policy have not been compared.

DESIGN

A cost-utility analysis alongside a randomised controlled trial (the 35/39 trial).

SETTING

Obstetric departments of 38 UK National Health Service hospitals and one UK primary-care trust.

POPULATION

Nulliparous women aged 35 years or over on their expected due date, with a singleton live fetus in a cephalic presentation.

METHODS

Costs were estimated from the National Health Service and Personal Social Services perspective and quality-adjusted life-years (QALYs) were calculated based on patient responses to the EQ-5D at baseline and 4 weeks.

MAIN OUTCOME MEASURES

Data on antenatal care, mode of delivery, analgesia in labour, method of induction, EQ-5D (baseline and 4 weeks postnatal) and participant-administered postnatal health resource use data were collected.

RESULTS

The intervention was associated with a mean cost saving of £263 and a small additional gain in QALYs (though this was not statistically significant), even without considering any possible QALY gains from stillbirth prevention.

CONCLUSION

A policy of induction of labour at 39 weeks for women of advanced maternal age would save money.

TWEETABLE ABSTRACT

A policy of induction of labour at 39 weeks of gestation for women of advanced maternal age would save money.

Occupational chronic obstructive pulmonary disease: a standard of care

BACKGROUND

Consistent evidence from population studies report that 10-15% of the total burden of chronic obstructive pulmonary disease (COPD) is associated with workplace exposures. This proportion of COPD could be eliminated if harmful workplace exposures were controlled adequately.

AIMS

To produce a standard of care for clinicians, occupational health professionals, employers and employees on the identification and management of occupational COPD.

METHODS

A systematic literature review was used to identify published data on the prevention, identification and management of occupational COPD. Scottish Intercollegiate Guidance Network grading and the Royal College of General Practitioner three star grading system were used to grade the evidence.

RESULTS

There are a number of specific workplace exposures that are established causes of COPD. Taking an occupational history in patients or workers with possible or established COPD will identify these. Reduction in exposure to vapours, gases, dusts and fumes at work is likely to be the most effective method for reducing occupational COPD. Identification of workers with rapidly declining lung function, irrespective of their specific exposure, is important. Individuals can be identified at work by accurate annual measures of lung function.

CONCLUSIONS

Early identification of cases with COPD is important so that causality can be considered and action taken to reduce causative exposures thereby preventing further harm to the individual and other workers who may be similarly exposed. This can be achieved using a combination of a respiratory questionnaire, accurate lung function measurements and control of exposures in the workplace.

Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer

BACKGROUND

Robust data on patient-reported outcome measures comparing treatments for clinically localized prostate cancer are lacking. We investigated the effects of active monitoring, radical prostatectomy, and radical radiotherapy with hormones on patient-reported outcomes.

METHODS

We compared patient-reported outcomes among 1643 men in the Prostate Testing for Cancer and Treatment (ProtecT) trial who completed questionnaires before diagnosis, at 6 and 12 months after randomization, and annually thereafter. Patients completed validated measures that assessed urinary, bowel, and sexual function and specific effects on quality of life, anxiety and depression, and general health. Cancer-related quality of life was assessed at 5 years. Complete 6-year data were analyzed according to the intention-to-treat principle.

RESULTS

The rate of questionnaire completion during follow-up was higher than 85% for most measures. Of the three treatments, prostatectomy had the greatest negative effect on sexual function and urinary continence, and although there was some recovery, these outcomes remained worse in the prostatectomy group than in the other groups throughout the trial. The negative effect of radiotherapy on sexual function was greatest at 6 months, but sexual function then recovered somewhat and was stable thereafter; radiotherapy had little effect on urinary continence. Sexual and urinary function declined gradually in the active-monitoring group. Bowel function was worse in the radiotherapy group at 6 months than in the other groups but then recovered somewhat, except for the increasing frequency of bloody stools; bowel function was unchanged in the other groups. Urinary voiding and nocturia were worse in the radiotherapy group at 6 months but then mostly recovered and were similar to the other groups after 12 months. Effects on quality of life mirrored the reported changes in function. No significant differences were observed among the groups in measures of anxiety, depression, or general health-related or cancer-related quality of life.

CONCLUSIONS

In this analysis of patient-reported outcomes after treatment for localized prostate cancer, patterns of severity, recovery, and decline in urinary, bowel, and sexual function and associated quality of life differed among the three groups. (Funded by the U.K. National Institute for Health Research Health Technology Assessment Program; ProtecT Current Controlled Trials number, ISRCTN20141297 ; ClinicalTrials.gov number, NCT02044172 .).

Clinical implications of machine-probe combinations on obstetric ultrasound measurements used in pregnancy dating

OBJECTIVE

To investigate the effect of use of different machine-probe combinations on measurement variability and to assess how this variability impacts on accuracy of pregnancy dating.

METHODS

Sixteen different ultrasound machine-probe combinations were used for lateral measurement of targets spaced 10 and 40 mm apart and axial measurement of targets spaced 10 and 50 mm apart in an ultrasound phantom, and differences between the measured and true values were determined. The mean of the 40-mm lateral measurements was used to estimate gestational age using standard obstetric dating tables for crown-rump length (CRL) and femur length (FL) and the mean of the 50-mm axial measurements was used to estimate gestational age using the obstetric dating tables for biparietal diameter (BPD).

RESULTS

As absolute measurements became larger, differences observed using different machine-probe combinations exceeded those due to intraobserver variability. Maximum dating differences for first-trimester CRL of 2 days (based on a measured CRL range of 39-42 mm), second-trimester BPD of 4 days (based on a measured BPD range of 49-52 mm) and FL of 9 days (based on a measured FL range of 39-42 mm) were observed when measurements were transposed to the equivalent gestational age using standard charts.

CONCLUSION

Differences between measured and true values of biometric measurements reflect both machine-probe and intraobserver variability. Incremental first-trimester CRL growth with time is rapid, but second-trimester FL growth is much less so, leaving this lateral measurement more prone to both observer and machine-probe errors. The only axial growth measurement commonly performed is BPD where the measurement differences were intermediate between those of CRL and FL. The differences that can be ascribed to different equipment combinations are in many cases greater than those expected in clinical practice and are of potential importance in determining how fetal biometry is used for dating pregnancies.

Medium-density fibreboard and occupational asthma. A case series

BACKGROUND

Medium-density fibreboard (MDF) is a wood composite material, composed primarily of softwood, bonded with a synthetic formaldehyde-based resin. It is increasingly used, as it has various advantages over natural woods.

METHODS

Enquiry of the national reporting scheme data and three case reports were used to further the evidence base linking this exposure to occupational asthma (OA).

RESULTS

From 1991 to 2007, 21 cases of occupational sensitization to MDF were reported to the UK voluntary reporting scheme, Surveillance of Work Related Occupational Respiratory Disease (SWORD): 18 reported as occupational asthma (OA) and 3 as occupational rhinitis. All workers were male, with a mean age of 48 years, working in education, furniture manufacturing or joinery among other employments.

CONCLUSIONS

Whilst reporting scheme data identified relatively small numbers of cases of OA likely to be due to MDF, the evidence base supporting this link is generally lacking. The three cases presented, where OA was attributed to MDF exposure, add to this evidence.

Self-reported work-related symptoms in hairdressers

BACKGROUND

Detailed studies of current symptoms reported by hairdressers and of the training received to reduce the health risks associated with this work are uncommon.

AIMS

To document current levels of self-reported health problems in hairdressers, compared to non-hairdressing controls.

METHODS

An interviewer-led questionnaire recording demographic information, work history, health training levels and the presence of self-reported respiratory, skin, musculoskeletal and non-specific symptoms was administered.

RESULTS

In total, 147 hairdressers, 86% of whom were female (median age 27 years) and 67 non-hairdressing controls, all female (median age 38 years) were recruited. Following adjustment for age, smoking and years worked, hairdressers reported significantly higher levels of musculoskeletal problems, including work-related shoulder pain (OR 11.6, 95% CI 2.4-55.4), work-related wrist and hand pain (2.8, 1.1-7.6), work-related upper back pain (3.8, 1.0-14.9), work-related lower back pain (4.9, 1.5-15.9) and work-related leg/foot pain (31.0, 3.8-267.4). The frequency of self-reported asthma was similar in both groups (hairdressers 16%, controls 17%) as was chest tightness and wheeze. Work-related cough was significantly more frequently reported in hairdressers than in controls (13.2, 1.3-131.5). While hairdresser training was commonplace, such training did not always appear to have resulted in awareness of potential workplace health risks.

CONCLUSIONS

This study identified frequently reported musculoskeletal, skin and respiratory symptoms in hairdressers. This points to a need to develop training that not only deals with risk assessment but also informs hairdressers about the health risks of their work.

Knowledge and utilisation of occupational asthma guidelines in primary care

AIMS

To develop an occupational asthma learning module, which could be used both as an educational tool and to evaluate awareness and usage of clinical guidelines in primary care.

METHODS

Healthcare professionals were invited to undertake an interactive BMJ Learning module, developed from existing national occupational asthma guidelines. Participants were invited to record immediate post-module feedback, and were also sent an e-mail questionnaire six weeks later to assess the impact of the module.

RESULTS

In total 1041 healthcare professionals completed the learning module within the first six months, which was associated with significant improvements in knowledge, and predominantly positive feedback. The e-mail follow-up questionnaire demonstrated improved usage and awareness of national occupational asthma guidelines.

CONCLUSIONS

Significant barriers remain in ensuring that evidence-based occupational medicine guidelines are adopted in primary care. This project has demonstrated that e-learning offers one method of improving postgraduate medical education in this area, particularly where evidence-based guidelines have already been developed.

Agreement in diagnosing occupational asthma by occupational and respiratory physicians who report to surveillance schemes for work-related ill-health

OBJECTIVES

To assess diagnostic agreement for occupational asthma, and to identify case and rater characteristics associated with this diagnosis.

METHODS

Summaries of possible occupational asthma cases were sent to 104 occupational and respiratory physicians. Raters assigned likelihood scores (0-100%) of occupational asthma based on case histories (phase 1), and on histories plus investigative procedures (phase 2). Interclass correlation coefficients were calculated as statistical measures of reliability for occupational asthma scores. Comparisons between mean scores were assessed for statistical significance using tests based on multilevel models. RRs were calculated to summarise effects of raters' demographics, and of supplying investigative procedures information.

RESULTS

Occupational asthma scores showed limited agreement within each group of (occupational or respiratory) physicians, but scores were not systematically different. The difference between mean overall scores was 2.1% (52.1% occupational physicians; 50.0% respiratory physicians) in phase 1 (95% CI -2.6 to 6.8, p=0.37). In phase 2, mean overall scores were 46.1% (occupational physicians) and 41.5% (respiratory physicians); the difference in mean overall scores was 4.6% (95% CI -3.5 to 12.5, p=0.27). Raters with General Medical Council registration > or =1986 were more likely to give a positive occupational asthma diagnosis. In phase 2, male raters were more likely to label cases as occupational asthma than female raters (RR 4.5, 95% CI 3.3 to 6.0).

CONCLUSIONS

The RR of a positive occupational asthma diagnosis was unaffected by clinical specialty. Further work on why physicians consider cases to be occupational asthma will assist better diagnosis and prevention of this disease.

Are we failing workers with symptoms suggestive of occupational asthma?

AIMS

To assess the route to secondary care for patients with possible occupational asthma, and to document the duration of workrelated symptoms and referral times.

METHODS

Consecutive patients with suspected occupational asthma were recruited to a case series from six secondary care clinics with an interest in occupational asthma. Semi-structured interviews were performed and hospital case notes were reviewed to summarise relevant investigations and diagnosis.

RESULTS

97 patients were recruited, with a mean age of 44.2 years (range 24-64), 51 of whom (53%) had occupational asthma confirmed as a diagnosis. Most (96%) had consulted their general practitioner (GP) at least once with work-related respiratory symptoms, although these had been present for a mean of 44.6 months (range 0-320 months) on presentation to secondary care. Patients experienced a mean delay for assessment in secondary care of 4 years (range 1-27 years) following presentation in primary care.

CONCLUSIONS

Significant diagnostic delay currently occurs for patients with occupational asthma in the UK.

Facilities for investigating occupational asthma in UK non-specialist respiratory departments

BACKGROUND

The facilities which should be available to physicians offering specialist occupational asthma services have recently been agreed upon by a UK panel of experts.

AIMS

This study aimed to investigate whether these facilities are available in UK non-specialist secondary care respiratory departments and to document tertiary care referral patterns.

METHODS

A random sample of 100 UK respiratory units was selected, and the lead consultant invited to participate. Face-to-face interviews were conducted to document information on departmental facilities available for investigating cases of occupational asthma and utilization of tertiary referral centres.

RESULTS

In total, 66% of consultants interviewed had seen a case of occupational asthma in the previous month, and 76% reported having ever referred a patient with suspected occupational asthma to a specialist centre for further investigation (referral distance range 1-111 miles). All the departments were able to perform the investigations previously deemed an absolute necessity in all patients. The availability of in-house facilities that were deemed as must be available varied between 3-100%.

CONCLUSIONS

The results of this study demonstrate that while the majority of basic facilities are widely available, many respiratory departments do not have direct access to investigations routinely required to investigate occupational asthma. Access to specialist occupational respiratory centres varies within the UK, and in some parts of the country involves long travelling distances for patients.

Occupational asthma: an assessment of diagnostic agreement between physicians

OBJECTIVES

To investigate the levels of agreement between expert respiratory physicians when making a diagnosis of occupational asthma.

METHODS

19 cases of possible occupational asthma were identified as part of a larger national observational cohort. A case summary for each case was then circulated to 12 physicians, asking for a percentage likelihood, from the supplied information, that this case represented occupational asthma. The resulting probabilities were then compared between physicians using Spearman's rank correlation and Cohen's kappa coefficients.

RESULTS

Agreement between the 12 physicians for all 19 cases was generally good as assessed by Spearman's rank correlation. For all 66 physician-physician interactions, 45 were found to correlate significantly at the 5% level. The agreement assessed by kappa analysis was more variable, with a median kappa value of 0.26, (range -0.2 to +0.76), although 7 of the physicians agreed significantly (p<0.05) with >or=5 of their colleagues. Only in one case did the responses for probability of occupational asthma all exceed the "on balance" 50% threshold, although 12 of the 19 cases had an interquartile range of probabilities not including 50%, implying "on balance" agreement. The median probability values for each physician (all assessing the identical 19 cases) varied from 20% to 70%. Factors associated with a high probability rating were the presence of a positive serial peak expiratory flow Occupation Asthma SYStem (OASYS)-2 chart, and both the presence of bronchial hyper-reactivity and significant change in reactivity between periods of work and rest.

CONCLUSIONS

Despite the importance of the diagnosis of occupational asthma and reasonable physician agreement, certain variations in diagnostic assessment were seen between UK expert centres when assessing paper cases of possible occupational asthma. Although this may in part reflect the absence of a normal clinical consultation, a more unified national approach to these patients is required.

The perceptions of occupational health in primary care

AIM

A random sample of general practitioners (GPs), practice nurses (PNs) and practice managers (PMs) in Sheffield and Manchester was recruited into a study to evaluate the perceptions of occupational health (OH) in primary care.

METHODS

Qualitative data were collected using focus groups with three groups of primary care sector professionals. Quantitative data were collected nationally from 295 GPs using a postal questionnaire.

RESULTS

GPs and PNs had minimal OH training, and 60% of GPs reported constraints in addressing OH matters with patients. The lack of referral routes (63 and 67%, respectively) was also seen as a barrier. OH was regarded as a speciality, and primary care professionals preferred to refer patients with OH problems to specialist centres because they perceived barriers to their dealing with the issues. A total of 74% of GPs surveyed thought that speedier access to secondary care would help them to address OH problems.

CONCLUSIONS

This study has identified some of the problems associated with delivering OH through primary care. It also demonstrated a need for greater emphasis on OH education in medical and nurse training, and a need for better advice for GPs, PNs and PMs regarding support services for OH.

Respiratory symptoms and lung function change in welders: are they associated with workplace exposures?

AIMS

This study investigates whether work-related respiratory symptoms and acute falls in forced expiratory volume in 1 second (FEV1), previously observed in current welders, are related to measured workplace exposures to total fume and metals.

METHODS

At four work sites in New Zealand, changes in pulmonary function (and reported respiratory symptoms) were recorded in 49 welding workers (and 26 non-welders) exposed to welding fume. We also determined the personal breathing zone levels of total fume and various metals.

RESULTS

Work-related respiratory symptoms were reported by 26.5% of welders and 11.5% of non-welders. These symptoms were related significantly to their personal breathing zone nickel exposure--with an adjusted odds ratio (OR) and 95% confidence interval [CI] of the high exposure group (compared to a low exposure group of 7.0 [1.3-36.6]). There were non-significant associations with total fume exposure (OR = 2.6, 95% CI 0.6-12.2), and exposure index of greater than 10 years (OR=2.8, 95% CI 0.5-15.0). A fall in FEV1 of at least 5% after 15 minutes of work was significantly associated with aluminium exposure (OR=5.8, 95% CI 1.7-20.6).

CONCLUSIONS

Nickel exposure from metal inert gas (MIG) and tungsten inert gas (TIG) welding is associated with work-related respiratory symptoms and aluminium exposure from welding is associated with a fall in FEV1 of at least 5 % after 15 minutes of work.

An evaluation of occupational health services within the NHS in London

AIMS

To establish the nature, extent and organization of occupational health service provision for employees within the National Health Service (NHS) in London and to review the systems for monitoring performance.

METHODS

Human resources directors and occupational health managers were contacted from a random selection of NHS trusts in the London area and invited to complete an interviewer-led questionnaire.

RESULTS

All seventeen trusts interviewed claimed to provide an occupational health service to their employees, with 88% providing this service in-house. The organization of the services varied, although most resided within the human resources function. Only 29% of the trusts could provide a written occupational health policy. Teaching hospital trusts had the most qualified and the highest numbers of medical staff. District/General hospital trusts had the least qualified clinical staff. Although most trusts were able to provide a comprehensive range of services, 87% of occupational health managers felt they could only provide a reactive service. Income was generated from non-NHS sources by 88% of the trusts and all were aware of NHS Plus. There was an indication that some trusts assigned NHS Plus status did not meet the standard of NHS Plus, although the survey took place only 3 months after the launch of NHS Plus.

CONCLUSIONS

There was a significant variation in the nature and extent of occupational health services in the NHS trusts. As a consequence, there may be differences in the level of occupational health service available to staff across the NHS in London.

Work-related respiratory symptoms in New Zealand farmers

BACKGROUND

The first national survey of the respiratory health of New Zealand farmers looked at the prevalence of respiratory symptoms by farm type and work exposure.

METHODS

An 8-page questionnaire was mailed to 2,203 farmers randomly selected from all over New Zealand.

RESULTS

Response rate was 77.6% of 2,203, or 1,706 participants. Breathing problems at work were reported by 17.6% of farmers. Working with oats was strongly associated with work-related breathing problems (OR = 3.3, 2.1-5.2). Dyspnea was more common in female farmers, whereas chronic bronchitis was higher in males. Orchardists (OR = 2.3, 1.3-4.0), those growing oat crops (OR = 3.0, 1.7-5.4) and using the grain mill (OR = 2.8, 1.3-6.3) reported the highest symptom rates of ODTS/FL. Having hay fever or eczema, and smoking were risk factors for all respiratory symptoms.

CONCLUSIONS

Working in the areas of pigs, poultry, horses, grains, and hay are associated with respiratory symptoms in New Zealand farmers.

Cumulative and single-dose design to assess the bronchodilator effects of beta2-agonists in individuals with asthma

With the development of different chlorofluorocarbon (CFC)-free metered dose aerosol and dry powder devices, it is necessary to study and validate the methods used for assessing and comparing their efficacy. This study evaluated the cumulative dose design by determining the bronchodilator response to salbutamol given according to either a high or a low cumulative dose regimen. Adults with asthma (n = 24) were studied in a placebo-controlled, randomized, double-blind, cross-over design. On separate days, cumulative doses of salbutamol (50+50+100+200 or 100+100+ 200+400 or 400+0+0+0 or 0+0+0+0 microg) were given via Turbuhaler with 30 min between doses. The two cumulative dose regimens produced almost identical bronchodilator responses at each time point. The relative dose-potency between the 800- and 400- microg cumulative dose regimens was 0.7 with a 95% confidence interval of 0.5-1.0, excluding the true value of 2. The 400-microg cumulative dose regimen resulted in a higher FEV1 at 115 min than the 400-microg single-dose regimen. There was no difference in the bronchodilator response to the single dose of 50, 100, or 400 microg of salbutamol after either 5 or 25 min. Thus, care should be exercised when using either a cumulative or single-dose design for comparing different beta2-agonists, or different inhalation devices, with respect to their relative dose-potency. In addition, this study provides further evidence that for short-acting beta2-agonists such as salbutamol, lower doses than those normally recommended may be used, and that repeated self-administration of low doses over a period of 60 min may give a better bronchodilator response than a single administration of a high dose.

Occupational respiratory symptoms in New Zealand hairdressers

BACKGROUND

A study of occupational respiratory symptoms in hairdressers was carried out in 26 salons in New Zealand.

METHODS

A questionnaire was administered to 100 hairdressers and 106 office and shop workers, recording respiratory symptoms, demographic data, and smoking habits. Pulmonary function was measured before each shift.

RESULTS

Hairdressers had a higher prevalence of asthma symptoms, diagnosed asthma, and asthma attacks in the previous 12 months, but these differences reduced markedly when adjusted for age, gender and smoking. Hairdressers had a significantly lower pulmonary function, even after adjustment for smoking, but this difference was entirely due to differences between hairdressers and office workers and there were no such differences between hairdressers and shop workers.

CONCLUSIONS

The excess symptom prevalence in hairdressers was largely due to the high smoking rates. Mean pulmonary function was lower in hairdressers but this finding requires further study.

Changes in work practice after a respiratory health survey among welders in New Zealand

AIMS

To assess changes in work practice among eight New Zealand engineering sites, following a study of occupational respiratory symptoms in welders two years previously.

METHODS

In 1996, we found that an acute decrease in lung function was more common in welders working without local exhaust ventilation. Findings were reported back to management, study participants and the media. Two years later we re-visited the eight welding sites.

RESULTS

Of the eight engineering sites, two had local exhaust ventilation present in both Study 1 and Study 2, one site had installed local exhaust ventilation in part of the site since Study 1 and one site had moved to larger premises. The remaining four sites had no exhaust ventilation or change to the workplace between studies. Five welders (12.8%) used respiratory protection in both Study 1 and Study 2, seven welders (18%) used respiratory protection in Study 1 but not Study 2, four welders (10.3%) did not have respiratory protection in Study 1 but did in Study 2 and nine welders (23.1%) did not use respiratory protection at all in Study 1 or Study 2.

CONCLUSION

Further effort is required to ensure that such studies lead to significant improvements in the work environment.

Two year follow up of pulmonary function values among welders in New Zealand

OBJECTIVES

To examine whether welding is a risk factor for an accelerated decline in pulmonary function.

METHODS

2 Year follow up of pulmonary function and respiratory symptoms among 54 welders and 38 non-welders in eight New Zealand welding sites.

RESULTS

There were no significant differences in age, height, smoking habits, ethnicity, or total time in industrial work between welders and non-welders. No overall differences were noted in the changes of pulmonary function variables between the two study groups. However, when the comparison was restricted to smokers, welders had a significantly greater (p = 0.02) annual decline (88.8 ml) in FEV1 than non-welders, who had a slight non-significant annual increase (34.2 ml). Also, welders without respiratory protection or local exhaust ventilation while welding had a greater annual decline both in forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) than welders with protection (p = 0.001 and 0.04, respectively). Among welders a significant association was found between the acute across shift change and the annual decline in FEV1. Chronic bronchitis was more common among welders (24%) than non-welders (5%). Only one welder (2%) but eight non-welders (21%) reported having asthma.

CONCLUSIONS

Welders who smoked and welders working without local exhaust ventilation or respiratory protection have an increased risk of accelerated decline in FEV1.

Asthma and allergy in New Zealand farmers

AIMS

To examine the prevalence of symptoms of asthma and allergy in different farming groups in New Zealand.

METHODS

A postal questionnaire was sent to a random sample of 2,500 farmers throughout New Zealand.

RESULTS

The response rate was 77% (1,706 of 2,203 eligibles). The 12-month period prevalence of current asthma was 11.8% overall, compared with 15% in the general population. Asthma prevalence was higher for horse breeders/groomers (16.5%), pig farmers (18.2%), poultry farmers (17.4%), and those working with oats (17.4%). Asthma was also significantly elevated among those working with cleaning powders (14.7%). Women were more likely to report current asthma than were men (OR 1.8, 95% CI 1.3-2.5). Hay fever was significantly higher in deer and crop farmers, and farmers working with horses and goats; eczema was higher for goat and deer farmers.

CONCLUSIONS

The lower overall prevalence of asthma in farmers may be due to the healthy worker effect. Among farmers, the types of farming associated with an elevated prevalence of asthma and allergy in New Zealand are deer and goat farming, working with horses, poultry, pigs, and crop farming. Females reported more current asthma than males.

Respiratory questionnaire responses: how they change with time

AIM

Responses to respiratory questionnaires are often used to identify individuals with asthma symptoms and may also be used to identify asymptomatic individuals. This study investigates the repeat responses over four years to such a questionnaire in a population of adult New Zealanders.

METHODS

Seven hundred and twenty three asthmatics were sent two almost identical questionnaires in three areas of New Zealand, separated by approximately four years. All of them had answered yes to at least one of the three questions under study in the first survey.

RESULTS

Following the second asthma questionnaire only 487 (67.4%) answered yes to at least one of the survey questions. Similarly, 51.1% of those who had reported having nocturnal shortness of breath in the first survey did so in the second survey, 69.9% of those who reported having had an asthma attack in the first survey did so in the second survey, and finally 74.8% of those who reported using asthma medication in the first survey did so in the second survey.

CONCLUSION

Even in a previously identified symptomatic asthmatic group, a large proportion did not report respiratory symptoms and asthma medication use four years later. This implies that the true prevalence pool of susceptibles is likely to be far greater than is identified in surveys of the 12-month period prevalence of asthma symptoms. This has implications not only for the design of epidemiological studies (e.g., it poses problems for the selection of a control group of non-asthmatics in prevalence case-control studies), but also for the planning of health services and educational programmes for people with asthma.

Under the volcano: fire, ash and asthma?

AIMS

To investigate the prevalence of respiratory symptoms in known asthmatics, following exposure to airborne volcanic ash particles caused by the eruptions of Mount Ruapehu, New Zealand, commencing September 1995.

METHOD

A one page postal questionnaire was sent to 1392 previously identified asthmatics 2 months after the first major eruption.

RESULTS

Two hundred and thirty seven subjects had moved from the area, died or gone overseas since the original contact 4 years previously; therefore the target population was 1155 subjects of whom 361 lived in the exposed area and 794 in the nonexposed areas. The response rates were 246 (68.1%) in the exposed group and 477 (60.1%) in the nonexposed group making a total of 723 individuals. The prevalence of nocturnal shortness of breath in the last two months was 29.3% in the exposed group and 24.7% in the nonexposed (OR = 1.26, 95% CI; 0.83-1.78). Similarly 30.9% of the exposed group had an asthma attack in the last 2 months compared to 31.9% of the nonexposed group (OR = 0.96, 95% CI; 0.69-1.33). Finally, 48.4% of the exposed group used asthma medication in the 2 months following the eruption in comparison to 53% of the nonexposed group (OR = 0.83, 95%, CI; 0.61-1.12).

CONCLUSIONS

The study showed no association between living in an area exposed to volcanic ash particles and either asthma symptoms or the use of asthma medication. There was a small but nonsignificant increase in nocturnal shortness of breath in the exposed group.