Fit Note Use in UK Clinical Practice 2010–2016: A Systematic Review of Quantitative Research

Background

The fit note, introduced in England, Wales and Scotland in 2010, was designed to radically change the sickness certification process from advising on individuals’ inability to work to what they could do if adjustments were made available. Our review aimed to evaluate: (1) the percentage of fit notes utilizing the new “may be fit for work” option or advising on work adjustments, (2) the impact of the fit note on sickness absence and return to work, (3) demographic variation in fit note use.

Methods

We systematically searched in Embase, Cochrane CENTRAL, Pub Med, Worldcat, Ovid and PsychInfo from 1 Jan 2010–30 Nov 2016 for studies on working aged adults which included the search terms “fit note” or “fitnote”. Relevant abstracts were extracted and we assessed the quality of the papers and assessed bias using the modified Newcastle Ottawa Scale.

Results

Nine papers met the inclusion criteria, four of which were based on the same cohort. Maybe fit notes made up just 6.6% of all fit notes. Work adjustments were most often recommended for patients who were less deprived, female and patients with physical health problems. Fit note advice for patients with physical health problems increased over time, but the opposite was seen for patients with mental health problems.

Conclusions

Further research needed to evaluate the use, impact and potential of the fit note, especially for patients with mental illness.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Factors that affect stabilisation times of canine spontaneous hypoadrenocorticism

The objective of this retrospective study was to examine factors that may have affected the stabilisation times of 50 dogs with spontaneous hypoadrenocorticism that were being treated with fludrocortisone acetate, with particular emphasis on dosing frequency and the concurrent use of prednisolone. Stabilisation was defined as an absence of clinical signs with a sodium:potassium ratio >27:1 and both electrolyte concentrations within a laboratory reference range. It was found that the median time till stabilisation was three months. The frequency of fludrocortisone treatment (once, twice or changed from once to twice a day) had no effect on the stabilisation time. The two groups of dogs that were started and stabilised on once a day or twice a day dosing had a median stabilisation time of two months. However, dogs that failed to stabilise on once a day dosing of fludrocortisone and were then changed onto twice a day dosing then stabilised a median of one month later. Concurrent use of prednisolone resulted in significantly faster stabilisation times. It was concluded that dogs with hypoadrenocorticism should be continued on prednisolone therapy until they are stabilised. If a dog is failing to stabilise on once a day fludrocortisone acetate, a change to twice a day administration could be considered.

Ozanimod (RPC1063) is a potent sphingosine-1-phosphate receptor-1 (S1P1 ) and receptor-5 (S1P5 ) agonist with autoimmune disease-modifying activity

BACKGROUND AND PURPOSE

Sphingosine1-phosphate (S1P) receptors mediate multiple events including lymphocyte trafficking, cardiac function, and endothelial barrier integrity. Stimulation of S1P1 receptors sequesters lymphocyte subsets in peripheral lymphoid organs, preventing their trafficking to inflamed tissue sites, modulating immunity. Targeting S1P receptors for treating autoimmune disease has been established in clinical studies with the non-selective S1P modulator, FTY720 (fingolimod, Gilenya™). The purpose of this study was to assess RPC1063 for its therapeutic utility in autoimmune diseases.

EXPERIMENTAL APPROACH

The specificity and potency of RPC1063 (ozanimod) was evaluated for all five S1P receptors, and its effect on cell surface S1P1 receptor expression, was characterized in vitro. The oral pharmacokinetic (PK) parameters and pharmacodynamic effects were established in rodents, and its activity in three models of autoimmune disease (experimental autoimmune encephalitis, 2,4,6-trinitrobenzenesulfonic acid colitis and CD4(+) CD45RB(hi) T cell adoptive transfer colitis) was assessed.

KEY RESULTS

RPC1063 was specific for S1P1 and S1P5 receptors, induced S1P1 receptor internalization and induced a reversible reduction in circulating B and CCR7(+) T lymphocytes in vivo. RPC1063 showed high oral bioavailability and volume of distribution, and a circulatory half-life that supports once daily dosing. Oral RPC1063 reduced inflammation and disease parameters in all three autoimmune disease models.

CONCLUSIONS AND IMPLICATIONS

S1P receptor selectivity, favourable PK properties and efficacy in three distinct disease models supports the clinical development of RPC1063 for the treatment of relapsing multiple sclerosis and inflammatory bowel disease, differentiates RPC1063 from other S1P receptor agonists, and could result in improved safety outcomes in the clinic.

Effect of experimental stress on the small bowel and colon in healthy humans

BACKGROUND

Symptoms of irritable bowel syndrome (IBS) are frequently reported to be exacerbated by stress. Animal studies suggest that corticotrophin releasing hormone (CRH) mediates the effect of stress on the bowel. We have shown that stressed IBS patients with diarrhea have constricted small bowels. We hypothesized that we could mimic this effect by applying experimental stress in the form of either hand immersion in ice water or CRH injection in healthy volunteers (HV).

METHODS

The postprandial effect of the cold pressor test (repeated hand immersion in ice cold water) and injection of CRH, were assessed vs control in two groups of 18 HVs.

KEY RESULTS

CRH produced a significant rise from baseline salivary cortisol levels (p = 0.004) not seen with the cold pressor test. Small bowel water content (SBWC) fell postprandially on all four treatments. SBWC was significantly reduced by both stressors but CRH caused a greater effect (anova, p < 0.003 vs p = 0.02). Ascending colon (AC) volume was greater after CRH injection compared with saline (p = 0.002) but no differences were seen with the cold pressor test vs warm water. Postprandial increase in colon volume was also reduced by CRH which also increased the sensations of distension and bloating.

CONCLUSIONS & INFERENCES

Two experimental stressors were shown to constrict the small bowel, mimicking the effect previously seen in IBS-D patients. CRH increased the volume of the AC. We speculate that stress accelerates transfer of water from the small bowel to the AC.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

Structure activity relationships of novel antiepileptic drugs

Despite notable success over years in the discovery and development of new antiepileptic drugs (AEDs), about 30-40% of the patients are resistant to drug treatment. There is a still significant need to develop novel AEDs that demonstrate superior efficacy, broad spectrum of activities and good safety profile. The synaptic vesicle glycoprotein 2A (SV2A), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPA-R) and voltage-gated potassium channels (KCNQ2/Q3) are clinically validated as new molecular targets for epilepsy. The discovery of SV2A as a target for levetiracetam, 2,3-benzodiazepine GYKI 52466 as a non-competitive AMPA-R antagonist and retigabine as a KCNQ2/Q3 channels activator provided a rational basis to develop novel AEDs. The optimization of SV2A binding affinity of levetiracetam led to the discovery of novel high affinity SV2A ligands that displayed superior efficacy and protective index in animal models of epilepsy. The high-throughput screening (HTS) and medicinal chemistry efforts yielded many non-competitive AMPA-R antagonists of which perampanel was recently approved as a first-in-a new class. The efficacy and lack of sub-type selectivity of retigabine prompted many research efforts to discover several potent and selective KCNQ2/Q3 channel activators of distinct chemical scaffolds that are at various stages of clinical development. Despite the known role of galanin and galanin receptor (Gal-R) in epilepsy over a decade, development of potent and brainpenetrant Gal-R agonists is very challenging. The discovery of selective Gal-R2 positive allosteric modulator, CYM 2503, offers a valuable and an alternative approach. The review focuses on the available structure-activity relationships and preclinical efficacy of novel antiepileptic compounds that are distinct from most of the approved AEDs, specifically SV2A ligands, non-competitive AMPA-R antagonists, KCNQ2/Q3 channels activators and Gal-R modulators.

Antibodies against Haemophilus influenzae type b in The Gambia: investigating the extent of protection across age groups

Following a landmark clinical trial, the vaccine against Haemophilus influenzae type b (Hib) was introduced in The Gambia in 1997. Whilst the immunogenicity of this vaccine is well established subsequent to the doses administered under the EPI schedule, little data exists assessing longevity of protection, using serology. Such data are needed however to predict the susceptibility to Hib at the population level. To determine antibody persistence in 5-6 year old fully vaccinated Gambian children compared with older children, adolescents and young adults, 427 serum samples from healthy 5-37 year old participants were tested for Hib antibodies using VaccZyme Human Anti-Hib ELISA kits. 86% of the children who had received 3 doses of Hib vaccine in infancy had Hib antibody concentrations ≥0.15 mg/l at the age of 5-6 years. This proportion was 76% for adolescents who had also largely been vaccinated and 90% for adults who had never received Hib vaccine. Although most participants had anti-Hib antibody above concentrations putatively defined as protective, significantly fewer had concentrations thought to confer long-term protection. This suggests a population with insufficient or waning antibody that may be susceptible to breakthrough disease and transmission.

Fasting and postprandial volumes of the undisturbed colon: normal values and changes in diarrhea-predominant irritable bowel syndrome measured using serial MRI

BACKGROUND

Previous assessments of colon morphology have relied on tests which were either invasive or used ionizing radiation. We aimed to measure regional volumes of the undisturbed colon in healthy volunteers (HV) and patients with diarrhea-predominant irritable bowel syndrome (IBS-D).

METHODS

3D regional (ascending, transverse, and descending) colon volumes were measured in fasting abdominal magnetic resonance (MR) images of 75 HVs and 25 IBS-D patients. Thirty-five of the HV and all 25 IBS-D subjects were fed a standard meal and postprandial MRI data obtained over 225 min.

KEY RESULTS

Colonic regions were identified and 3D maps from cecum to sigmoid flexure were defined. Fasted regional volumes showed wide variation in both HVs being (mean ± SD) ascending colon (AC) 203 ± 75 mL, transverse (TC) 198 ± 79 mL, and descending (DC) 160 ± 86 mL with no difference from IBS-D subjects (AC 205 ± 69 mL, TC 232 ± 100 mL, and DC 151 ± 71 mL, respectively). The AC volume expanded by 10% after feeding (p = 0.007) in the 35 HV possibly due to increased ileo-colonic inflow. A later rise in AC volume occurred from t = 90 to t = 240 min as the meal residue entered the cecum. In contrast, IBS-D subjects showed a much reduced postprandial response of the AC (p < 0.0001) and a greater increase in TC volume after 90 min (p = 0.0244) compared to HV.

CONCLUSIONS & INFERENCES

We have defined a normal range of the regional volumes of the undisturbed colon in fasted and fed states. The AC in IBS-D appeared less able to accommodate postprandial inflow which may account for faster colonic transit.

Studies on the effect of temperature and pH on the inactivation of fish viral and bacterial pathogens

Disposal of fish by-products in the European Community must comply with Regulation (EC) No 1069/2009 which categorizes animal by-products according to risk, and specifies methods of disposal of by-products according to that risk. There is provision under the regulation for composting or ensiling to be used for by-products from aquatic animals. Biosecurity considerations require knowledge of the parameters of time and temperature, or time and pH, required to inactivate any fish pathogens that may be present. To provide those data, we undertook laboratory studies on the inactivation of a number of fish pathogenic viruses and bacteria at 60 °C, pH 4.0 and pH 12.0 as a preliminary to conducting subsequent trials with the most resistant viruses and bacteria in fish tissues. The most resistant bacterium to 60 °C, pH 4.0 as well as pH 12.0 was Lactococcus garvieae. Its concentration was reduced to the level of sensitivity of the test after 24-48 h exposure to 60 °C, but it survived for at least 7 days at pH 4.0 and 14 days at pH 12.0. The most resistant virus to 60 °C was infectious pancreatic necrosis virus, and to pH 12.0 was infectious salmon anaemia virus. The majority of the viruses tested survived exposure to pH 4.0 for up to 28 days. The results suggest that the process of acid ensiling alone is not an effective method for the inactivation of many viral and bacterial pathogens, and fish by-products would need further treatment by a method approved under the regulation following ensiling, whereas alkaline or heat treatment are likely to provide an increased degree of biosecurity for on-farm processing of mortalities.

Studies on the inactivation of selected viral and bacterial fish pathogens at high pH for waste disposal purposes

This study investigated the use of alkaline hydrolysis at ambient temperature for inactivation of selected fish pathogens in fish tissues under conditions approximating those that are likely to be found in the aquaculture industry. Infectious salmon anaemia virus (ISAV) and Lactococcus garvieae have been determined in a previous study to be the most resistant virus and bacteria to pH 12 from a wide range of viruses and bacteria tested. They were spiked at high titres into fish extracts that were then treated with 1 m sodium hydroxide (NaOH). Viable L. garvieae was not detected in the treated fish extract after 1 h, and ISAV was not detected after 24-h exposure. Field mortalities of Atlantic salmon, Salmo salar L., caused by infectious pancreatic necrosis virus were treated by alkaline hydrolysis at ambient temperature. The macerated fish mortalities contained a high titre of virus (3.38 × 10⁸ TCID₅₀ g⁻¹) that was reduced to approximately 2.2 × 10³ TCID₅₀ g⁻¹ after 24-h exposure to NaOH, and virus was not detected after exposure for 48 h. The results suggest that alkaline hydrolysis at ambient temperature has potential as a biosecure treatment method for fish by-products containing fish pathogens.

Factors that influence the childbearing intentions of Canadian men

BACKGROUND

The role of men in the childbearing decision process and the factors that influence men's childbearing intentions have been relatively unexplored in the literature. This study aimed to describe the factors that strongly influence the childbearing intentions of men and to describe differences in these factors according to men's age group.

METHODS

A telephone survey (response rate 84%) was conducted with 495 men between the ages of 20 and 45 living in an urban setting who, at the time of contact, did not have biological children. Men were asked about what factors strongly influence their intention to have children. Univariable and multivariable logistic regressions were conducted to determine if these factors were significantly associated with age.

RESULTS

Of those sampled, 86% of men reported that at some point in the future they planned to become a parent. The factors that men considered to be most influential in their childbearing intentions were: the need to be financially secure, their partner's interest/desire to have children, their partner's suitability to be a parent and their personal interest/desire to have children. Men who were 35–45 years old had lower odds of stating that financial security (crude OR: 0.32, 95% CI: 0.18–0.54) and partner's interest in having children (crude OR: 0.57, 95% CI: 0.33–0.99) were very influential, but had higher odds of stating that their biological clock (crude OR: 4.37, 95% CI: 1.78–10.76) was very influential in their childbearing intentions than men in the 20–24 year age group.

CONCLUSIONS

The factors that influence men's intentions about when to become a parent may change with age. Understanding what influences men to have children, and what they understand about reproductive health is important for education, program and policy development.

Micronutrient concentrations in respiratory syncytial virus and human metapneumovirus in Yemeni children

BACKGROUND

Acute respiratory infections (ARI) cause significant childhood mortality. Nutritional homeostasis, particularly micronutrient levels, is important in modulating response to infection. More information is required regarding micronutrient levels in ARI viral infections, especially newly identified viruses such as human metapneumovirus (HMPV).

AIM

To describe zinc, copper, selenium and vitamins A and E concentrations in children with respiratory syncytial virus (RSV) and/or HMPV in relation to levels of C-reactive protein (CRP).

METHODS

The presence of RSV/HMPV in nasopharyngeal aspirates (NPA) was identified in 246 children using RTPCR. Zinc, copper, selenium and vitamins A and E concentrations were measured using inductive coupled plasma mass spectrometry and high performance liquid chromatography.

RESULTS

183 children had RSV, 39 had HMPV and 24 were co-infected. Zinc concentrations were lower in children with HMPV than in children with RSV or RSV/HMPV co-infection. Copper concentrations were lower in children with RSV than in children with RSV/HMPV or HMPV and zinc/copper ratios were lower in children with HMPV/RSV or RSV than in children with HMPV alone. Retinol and a alpha-tocopherol were lower in children with RSV than in children with HMPV. Most children had low selenium concentrations. Children with RSV and raised CRP (>5 mg/L) had higher copper and lower zinc/copper ratios than those with low CRP (< or =5 mg/L). Children with HMPV and raised CRP had higher copper and lower zinc concentrations than children with low CRP. Children with RSV/HMPV and raised CRP had higher copper concentrations. Children with RSV/HMPV and raised CRP had higher a alpha-tocopherol concentrations.

CONCLUSION

The profiles of micronutrients differ in children with RSV and HMPV and are confounded by CRP. These results may guide strategies for micronutrient supplementation in ARI.