Systematic review: impact of liver transplantation on employment

Background

The majority of liver transplant recipients survive long term after the procedure.

Aim

To assess if this positive outcome is associated with improved employment post-transplant.

Methods

A systematic review of publications between 2001 and 2016 was performed. A standard procedure was used to search for suitable publications from two databases (PubMed and EMBASE). Duplicates were removed and abstracts screened by both authors for possible inclusion. Possible suitable publications were obtained and examined for the presence of pre- and post-employment information. Full articles that had this information were reviewed by standard methodology for assessment of bias.

Results

A total of 162 individual abstracts were screened. Thirty-five full papers were reviewed and 13 papers included in the detailed review. Risk of bias was considered high due to low response rates, poor assessment of prognostic and confounding factors and varying definitions of employment. Heterogeneous data precluded meta-analysis. Eight studies focused on return to work as a primary outcome and five on quality of life with employment as a secondary outcome. Follow-up varied between 2 and 13 years. Rates of employment fell in all studies assessed. Employment rates ranged from 26 to 80% pre-transplant and 18 to 44% post-transplant. The proportion of those categorized as ill-health retired was 24% greater after orthotopic liver transplantation.

Conclusions

Improved survival after liver transplantation was not reflected in a return to employment and retirement was common. Areas for further study include interventions to minimize physical deconditioning, depression associated with lower employment rates and type of work available after transplant.

Systematic review: plantar fasciitis and prolonged weight bearing

BACKGROUND

Plantar fasciitis (PF) is one of the most common causes of foot pain. Work can involve factors that may predispose to foot pain.

AIMS

To systematically review the evidence of the association between weight bearing (walking or standing) and PF among workers.

METHODS

Literature search of relevant indexing databases from inception to May 2012, grey literature, websites of relevant organizations and reference lists for all identified articles. Two reviewers independently selected studies for full review, assessed methodological quality and graded evidence. Findings were summarized qualitatively.

RESULTS

Four studies were included; all were assessed as high or unclear risk of bias. Three studies were case-control studies; two used clinic populations and one used volunteers. The other study was cross-sectional involving the workforce of an assembly plant. A number of associations between PF and risk factors were identified including sex, obesity, foot biomechanics and job factors (e.g. job tenure). Two case-control studies and the cross-sectional study found an association with weight bearing, but the assessment of weight bearing varied (e.g. time on feet, time walking or standing). There was low-quality evidence to confirm a causal relationship (Royal College of General Practitioners (RCGP) * grade).

CONCLUSIONS

This systematic review found low-quality evidence of an association between PF and weight-bearing tasks such as walking and standing on hard surfaces. The only occupations specifically identified as having higher risk were those associated with the engine assembly plant. Further research is required to fully determine the association between weight bearing and PF.

Using a symptom diary to investigate work-related urticaria

BACKGROUND

The strategy of keeping a diary may not be considered by many treating clinicians, but this approach has been recommended for occupational asthma and proved useful in this case of chronic urticaria associated with work.

AIMS

To report a case of a health care worker who had significant allergic reactions that were found to be associated with exposure to test allergens while working in an asthma clinic.

METHODS

The patient, a nurse working in a paediatric asthma clinic, was known to be allergic to common allergens that were used to test patients in the clinic. She developed reactions including swelling of the eyelids and urticarial reactions on the forehead, torso and upper and lower limbs on different occasions. A symptom diary was used to collect information on the reactions and the activity performed at the time they occurred.

RESULTS

She recorded symptoms that were mainly urticarial, with additional rhinitis or wheeze on occasion, on 20 (74%) working days and only 5 (28%) non-work days, indicating a significant association (P < 0.01) between her symptoms and working days.

CONCLUSIONS

Medical management had not controlled her symptoms, which improved on removal from the work activity and was confirmed by further diary recording.

Are endoscopy nurses at risk of infection with Helicobacter pylori from their work?

BACKGROUND

In response to studies suggesting risk of occupational transmission of Helicobacter pylori (HP) to endoscopy staff, this cross-sectional study of seroprevalence to HP in gastroscopy nurses working in West of Scotland hospitals (an area of high endemicity of HP infection) was performed to determine if they were at excess risk relative to peers working in surgical specialities but without gastroscopy exposure. The study aimed to fulfil employer's duties to carry out a suitable risk assessment required by health and safety legislation.

METHOD

This cross-sectional study compares the seroprevalence of HP in gastroscopy nurses and comparators drawn from orthopaedic and trauma units in 10 hospitals during 1998. A directly administered questionnaire collated exposure information on occupational and non-occupational risk factors for infection. Venepuncture was performed for latex agglutination test for IgG to HP. Confounding by socio-economic factors was controlled for by multivariate analysis.

RESULTS

Of the 222 participants, 74 were endoscopy staff (84% response) and 148 (59%) were comparators. Of these, 32.4% of gastroscopy and 33% of comparators were seropositive for HP (OR 0.97, P > 0.9, 95% CI 0.5-1.8). No association was found between gastroscopy exposure variables (frequency, years) or exposure to all endoscopy procedures and HP. Significant associations were found for age, childhood deprivation and greater number of siblings.

CONCLUSION

No excess HP infection was found in gastroscopy nurses. Duties imposed by the health and safety legislation appear discharged by normal infection control procedures. Socio-economic factors are key determinants of HP status.

Is there value in routinely obtaining a report from the general practitioner as part of pre-entry health screening of students for nursing studies?

BACKGROUND

Reports from general practitioners (GPs) are requested on applicants for nurse training, but there is no published evidence of the merit of this practice.

AIMS

To assess the benefit of GP report in health assessments of student nurse applicants.

METHODS

An audit was made of information obtained by health declaration form (HDF), nurse's assessment, GP report and, when performed, a physician's assessment for each applicant. Agreement between the health questionnaire and GP report was analysed by kappa statistics.

RESULTS

Of 254 applicants, 246 (97%) were declared 'fit to work', four (1.6%) were deemed 'fit with restrictions' and four (1.6%) were considered 'unfit to work'. The most common problems declared were psychiatric and skin problems. The agreement between health declaration and the information provided by GPs was classed as almost perfect for diabetes and only fair to moderate for all other measures. The reports provided additional information on problems not declared by applicants, but all of these were passive problems. The four unfit candidates all had psychiatric illness, but in all cases the occupational health assessment was sufficient to make this decision or to request further information. In the 'fit with restrictions' category, three of the four GP reports (75%) helped in correctly assigning the applicants to this category. In one of these eight cases a passive problem had not been declared.

CONCLUSIONS

The additional information in GP reports does not affect the conclusion regarding fitness for training in most cases and does not provide sufficient information to merit it being sought routinely.

Susceptibility to varicella-zoster virus in applicants for nurse training in Scotland

We investigated the immunity to varicella-zoster virus (VZV) of a cohort of applicants for nurse training and determined the relationship between immune status and history of chickenpox or shingles based on a self-completed questionnaire. Three hundred and fifty-six applicants for nurse training were enrolled at an occupational health department in NHS Scotland and 96% were immune to VZV. The positive predictive value of a history of VZV infection for seropositivity was 98% (286/292). The negative predictive value was 14% (9/64). History of chicken pox/shingles had a sensitivity of 84% (286/341) and specificity of 60% (9/15). Screening using past clinical history compatible with VZV infection would have missed 40% of those possibly susceptible to VZV on the basis of the ELISA IgG test. We conclude absence of past history of chickenpox or shingles is an unreliable identifier of susceptibility to VZV in healthcare workers. The Control of Substances Hazardous to Health (COSHH) Regulations 1999 require employers to make effective vaccines available for those employees who are not already immune to a biological agent to which they are exposed or liable to be exposed. Serological testing of healthcare workers would better identify those who are susceptible to VZV infection.

Risks of respiratory disease in the heavy clay industry

OBJECTIVES

Little information is available on the quantitative risks of respiratory disease from quartz in airborne dust in the heavy clay industry. Available evidence suggested that these risks might be low, possibly because of the presence in the dust of other minerals, such as illite and kaolinite, which may reduce the harmful effects of quartz. The aims of the present cross sectional study were to determine among workers in the industry (a) their current and cumulative exposures to respirable mixed dust and quartz; (b) the frequencies of chest radiographic abnormalities and respiratory symptoms; (c) the relations between cumulative exposure to respirable dust and quartz, and risks of radiographic abnormality and respiratory symptoms.

METHODS

Factories were chosen where the type of process had changed as little as possible during recent decades. 18 were selected in England and Scotland, ranging in size from 35 to 582 employees, representing all the main types of raw material, end product, kilns, and processes in the manufacture of bricks, pipes, and tiles but excluding refractory products. Weights of respirable dust and quartz in more than 1400 personal dust samples, and site histories, were used to derive occupational groups characterised by their levels of exposure to dust and quartz. Full size chest radiographs, respiratory symptoms, smoking, and occupational history questionnaires were administered to current workers at each factory. Exposure-response relations were examined for radiographic abnormalities (dust and quartz) and respiratory symptoms (dust only).

RESULTS

Respirable dust and quartz concentrations ranged from means of 0.4 and 0.04 mg.m-3 for non-process workers to 10.0 and 0.62 mg.m-3 for kiln demolition workers respectively. Although 97% of all quartz concentrations were below the maximum exposure limit of 0.4 mg.m-3, 10% were greater than this among the groups of workers exposed to most dust. Cumulative exposure calculations for dust and quartz took account of changes of occupational group, factory, and kiln type at study and non-study sites. Because of the importance of changes of kiln type additional weighting factors were applied to concentrations of dust and quartz during previous employment at factories that used certain types of kiln. 85% (1934 employees) of the identified workforce attended the medical surveys. The frequency of small opacities in the chest radiograph, category > or = 1/0, was 1.4% (median reading) and seven of these 25 men had category > or = 2/1. Chronic bronchitis was reported by 14.2% of the workforce and breathlessness, when walking with someone of their own age, by 4.4%. Risks of having category > or = 0/1 small opacities differed by site and were also influenced by age, smoking, and lifetime cumulative exposure to respirable dust and quartz. Although exposures to dust and to quartz were highly correlated, the evidence suggested that radiological abnormality was associated with quartz rather than dust. A doubling of cumulative quartz exposure increased the risk of having category > or = 0/1 by a factor of 1.33. Both chronic bronchitis and breathlessness were significantly related to dust exposure.

CONCLUSIONS

Although most quartz concentrations at the time of this study were currently below regulatory limits in the heavy clay industry, high exposures regularly occurred in specific processes and occasionally among most occupational groups. However, there are small risks of pneumoconiosis and respiratory symptoms in the industry, although frequency of pneumoconiosis is low in comparison to other quartz exposed workers.

Ill-health retirement and diabetes mellitus

Five hundred and five subjects retired for medical reasons in 1987. Two hundred and ninety-nine were male and 206 female. Thirty (5.94 per cent) subjects had diabetes of whom 4 were insulin-treated. Twelve of these subjects retired because of diabetes and diabetic complications; 10 retired because of the former and other pathology and 8 retired because of other pathology but had diabetes incidentally at the time of assessment. The expected prevalence of diabetes in the 20-69-year-old group from recent population studies is 9.2-10.1/1000 population. The figure of 59.4/1000 is significantly greater than this. Excluding those who had diabetes incidentally at the time of assessment reduces this figure to 43.6/1000 which still remains significant. After age-standardization the results remain significant. Morbidity from diabetes as assessed by numbers of retirements with diabetes indicates that this is greater than expected.

Sickness absence and control of insulin-treated diabetes as assessed by glycosylated haemoglobin

The sickness absence records for 1986 were obtained for 63 employed insulin-treated diabetic patients who had glycosylated haemoglobin (HbA1) measurements during that year. One subject whose absence was associated with attempts to improve control because of pregnancy was excluded from the analysis. Fifteen had good control (HbA1 8.5 per cent or less) and 47 had poor control (HbA1 greater than 8.5%). The groups were similar for age, sex, duration of diabetes and occupation. The distribution of sickness absence showed greater frequency of absence (p less than 0.05), greater number of working days lost (p less than 0.02), and greater average duration of absence (p less than 0.04) among those diabetic workers with poor control compared to those with good control. Because some individuals with poor control had no absence, HbA1 measurement cannot be recommended on its own to identify those workers who will be absent from work. Its use may lie in indicating a level below which sickness absence is minimized.

Sickness absence among insulin-treated diabetic employees

The aim of the present study was to investigate the sickness absence of insulin-treated diabetic employees. A case-control study using company sickness absence records for 1986 was performed on 59 diabetic patients and 59 control subjects matched by age, sex, and occupation. The patients had a similar frequency of absence to the control subjects (2.0 (range 0-7) and 1.7 (0-7) episodes yr-1, respectively). However, diabetic employees lost a larger number of working days (13.3 (0-101) vs 5.7 (0-52) days yr-1, p less than 0.03), and had a greater average length of episode of absence (5.6 (0-55) vs 2.5 (0-28) days, p less than 0.02). Males, manual workers, and those under 40 years of age accounted for significantly greater absence, but absence was also greater for diabetic employees than for control subjects in the other groups. Ten or more days were lost by 21 diabetic employees, but only 10 control subjects in 1986 (p less than 0.05).

Employment and diabetes: a survey of the prevalence of diabetic workers known by occupational physicians, and the restrictions placed on diabetic workers in employment

A postal survey of occupational physicians identified a prevalence of known diabetes among workers of 7.5 per 1000. The prevalence of insulin-treated diabetes was 2.6 per 1000 and of other diabetes was 4.9 per 1000. The figure for insulin-treated diabetes is lower than expected from population studies. The restrictions placed on diabetic workers in employment include shift-work, heights, dangerous areas, driving, civil aviation, emergency teams, offshore oil work, and work overseas. Certain companies within the chemical, oil, steel, confectionery, and drinks industries had lower than expected numbers of diabetic workers and merit further detailed study.

A comparison of treatment with metformin and gliclazide in patients with non-insulin-dependent diabetes

Twenty-seven obese non-insulin-dependent diabetic patients, treated with dietary carbohydrate restriction and metformin, were recruited from the diabetic outpatient clinic and entered into an open crossover study with gliclazide. Twenty-one patients completed the study. During three months observation on metformin, the mean weight of the group fell by 1.0 kg with 14 patients losing a mean of 1.8 kg with 14 patients losing a mean of 1.8 kg, 3 remaining unchanged and 4 gaining a mean weight of 1.1 kg. Over the subsequent three months on gliclazide, the mean weight of the group rose by 1.4 kg with 16 patients gaining a mean of 2.2 kg, two remaining unchanged and 3 losing a mean of 2.0 kg. In addition, 10 patients were heavier after gliclazide than at the time of recruitment (mean 2.6 kg), 3 were unchanged and 8 had lost weight since commencing the trial (mean 2.1 kg), mostly due to greater loss on metformin than gain on gliclazide. Glycaemic control did not improve significantly during the observed period on metformin but lower concentrations of fasting glucose and total glycosylated haemoglobin were achieved with gliclazide. Mean plasma insulin concentration was significantly higher and mean serum lactate was significantly lower during treatment with gliclazide. In conclusion, gliclazide does not support weight loss in obese non-insulin-dependent diabetic patients to the same extent as metformin but the difference between the two drugs is small. Gliclazide is a suitable oral hypoglycaemic agent for use in the obese diabetic who cannot be controlled by diet alone.