Assessment and outcomes of firefighter applicants with possible asthma

BACKGROUND

Firefighter applicants (FFAs) with a history of asthma may be refused entry to the fire service because of potentially putting themselves and others at risk.

AIMS

We undertook a service evaluation to identify respiratory and employment outcomes of FFAs with a history of asthma who had undergone additional respiratory assessment at our specialist occupational lung disease clinic during 2005-19.

METHODS

We reviewed FFA medical records and categorized them as having either no current asthma or definite/probable asthma at the time of clinic assessment. 'No current asthma' was defined as negative non-specific bronchial hyper-responsiveness (BHR) to histamine/methacholine, and no symptoms or treatment within the 2 years before clinic. 'Definite/probable current asthma' was defined as either positive BHR, or negative BHR with symptoms and/or treatment within the previous 2 years. Around 1 year later, we contacted FFAs to enquire about their application outcome and current respiratory symptoms.

RESULTS

Data were available on 116 applicants; of whom, 45% (n = 52) had definite/probable current asthma and were significantly more likely to be older, atopic to common aeroallergens, report atopic disease and have a lower forced expiratory volume in one second/forced vital capacity ratio compared with applicants with no current asthma. Only two individuals' applications were rejected due to asthma. At follow-up, just 2 (2%) of the 90 operational firefighters reported any recent trouble with asthma.

CONCLUSIONS

A history of asthma alone is not sufficient to determine current asthma in FFAs. Even with a diagnosis of current asthma, FFAs are mostly successful in their application to join the fire service.

Development of a north-west London paracentesis simulation course for core medical trainees

We designed, implemented and evaluated a near-peer simulation training programme teaching diagnostic and therapeutic abdominal paracentesis to core medical trainees (CMTs). We taught diagnostic and therapeutic abdominal paracentesis to 77 north-west London CMTs over 8 training days over 4 years, 2015 to 2019. The programme was optimised by use of plan, do, study, act (PDSA) cycles and the content was evaluated by anonymous pre- and post-course questionnaires. There was a need for this training; 89% of participants reported inadequate training opportunities pre-course and only 28% felt 'confident' or 'very confident' to insert an ascitic drain. Simulation training appears effective when teaching these skills. Having been low in confidence before the course, all participants reported increased confidence after completing the course. Simulation training has been highlighted as a key aspect of the new internal medicine training programme, which replaces CMT. We would recommend using PDSA cycles to implement effective simulation programmes.

Follow-up survey of patients with occupational asthma

BACKGROUND

Occupational asthma (OA) is often associated with a poor prognosis and the impact of a diagnosis on an individual's career and income can be significant.

AIMS

We sought to understand the consequences of a diagnosis of OA to patients attending our clinic.

METHODS

Using a postal questionnaire, we surveyed all patients attending our specialist occupational lung disease clinic 1 year after having received a diagnosis of OA due to a sensitizer (n = 125). We enquired about their current health and employment status and impact of their diagnosis on various aspects of their life. Additional information was collected by review of clinical records.

RESULTS

We received responses from 71 (57%) patients; 77% were referred by an occupational health (OH) provider. The median duration of symptoms prior to referral was 18 months (interquartile range (IQR) 8-48). At 1 year, 79% respondents were no longer exposed to the causal agent. Whilst the unexposed patients reported an improvement in symptoms compared with those still exposed (82% versus 53%; P = 0.023), they had poorer outcomes in terms of career, income and how they felt treated by their employer; particularly those not currently employed. Almost all (>90%) of those still employed had been referred by an OH provider compared with 56% of those currently unemployed (P = 0.002)x.

CONCLUSIONS

The negative impact of OA on people's careers, livelihood and quality of life should not be underestimated. However, with early detection and specialist care, the prognosis is often good and particularly so for those with access to occupational health.

The GMC national training survey: Does it have an impact?

The General Medical Council (GMC) national trainee survey (NTS) monitors junior doctor training experience annually, which is then used by organisations such as Health Education England to inform quality management. Its validity as an assessment of the learning environment to drive improvement is frequently questioned; currently there are no published evidence-based studies to demonstrate its impact. To explore the effects of the GMC survey, we carried out a retrospective cohort study using publicly available GMC NTS survey data. We compared 2018 and 2019 scores in paediatrics in London across all 18 survey indicators, to identify any relationship between these 2 consecutive years of data. Our findings demonstrate that results of the GMC NTS in 1 year are associated with a change in the NTS the following year, with both an improvement in below average departments and deterioration in above average units. These findings suggest that annual GMC NTS results may have an impact on the quality of learning environments as measured in subsequent surveys - therefore they act as both a measure and a potential modifier of outcome.

Chronic Obstructive Pulmonary Disease and Breathlessness in Older Workers Predict Economic Inactivity. A Prospective Cohort Study

Rationale: There is an aspiration to retain increasing numbers of older workers in employment, and strategies to achieve this need to make provision for the increasing prevalence of chronic diseases with age. There is a consistent body of cross-sectional evidence that suggests that patients with chronic obstructive pulmonary disease are more likely to have adverse employment outcomes.Objectives: We report the findings of the first longitudinal study of this issue.Methods: We recruited full-time employed men and women in their 50s and followed them for a period of 18 months; we examined, after adjustment for potential confounders, the associations between breathlessness and airway obstruction at baseline and loss of employment in the intervening period.Measurements and Main Results: Among participants responding to the follow-up questionnaire (1,656 of 1,773 [93%]), the majority (78.5%) continued in full-time employment, but 10.6% were in part-time employment and 10.9% were no longer in paid employment. The adjusted risk of loss of employment was significantly increased for those with moderate or severe chronic obstructive pulmonary disease (risk ratio, 2.89; 95% confidence interval, 1.80-4.65) or breathlessness (risk ratio, 3.07; 95% confidence interval, 2.16-4.37) at baseline. There was no evident modification by sex or by manual/nonmanual work.Conclusions: Airway obstruction and breathlessness are independently associated with premature loss from the workforce in older workers; these observations provide strong support to the available cross-sectional evidence and suggest that interventions to help those with chronic obstructive pulmonary disease who wish to remain in work need to be tested.

Metal worker's lung: spatial association with Mycobacterium avium

BACKGROUND

Outbreaks of hypersensitivity pneumonitis (HP) are not uncommon in workplaces where metal working fluid (MWF) is used to facilitate metal turning. Inhalation of microbe-contaminated MWF has been assumed to be the cause, but previous investigations have failed to establish a spatial relationship between a contaminated source and an outbreak.

OBJECTIVES

After an outbreak of five cases of HP in a UK factory, we carried out blinded, molecular-based microbiological investigation of MWF samples in order to identify potential links between specific microbial taxa and machines in the outbreak zone.

METHODS

Custom-quantitative PCR assays, microscopy and phylogenetic analyses were performed on blinded MWF samples to quantify microbial burden and identify potential aetiological agents of HP in metal workers.

MEASUREMENTS AND MAIN RESULTS

MWF from machines fed by a central sump, but not those with an isolated supply, was contaminated by mycobacteria. The factory sump and a single linked machine at the centre of the outbreak zone, known to be the workstation of the index cases, had very high levels of detectable organisms. Phylogenetic placement of mycobacterial taxonomic marker genes generated from these samples indicated that the contaminating organisms were closely related to Mycobacterium avium.

CONCLUSIONS

We describe, for the first time, a close spatial relationship between the abundance of a mycobacterium-like organism, most probably M. avium, and a localised outbreak of MWF-associated HP. The further development of sequence-based analytic techniques should assist in the prevention of this important occupational disease.

Prevalence of sensitization to 'improver' enzymes in UK supermarket bakers

BACKGROUND

Supermarket bakers are exposed not only to flour and alpha-amylase but also to other 'improver' enzymes, the nature of which is usually shrouded by commercial sensitivity. We aimed to determine the prevalence of sensitization to 'improver' enzymes in UK supermarket bakers.

METHODS

We examined the prevalence of sensitization to enzymes in 300 bakers, employed by one of two large supermarket bakeries, who had declared work-related respiratory symptoms during routine health surveillance. Sensitization was determined using radioallergosorbent assay to eight individual enzymes contained in the specific 'improver' mix used by each supermarket.

RESULTS

The prevalence of sensitization to 'improver' enzymes ranged from 5% to 15%. Sensitization was far more likely if the baker was sensitized also to either flour or alpha-amylase. The prevalence of sensitization to an 'improver' enzyme did not appear to be related to the concentration of that enzyme in the mix.

CONCLUSIONS

We report substantial rates of sensitization to enzymes other than alpha-amylase in UK supermarket bakers; in only a small proportion of bakers was there evidence of sensitization to 'improver mix' enzymes without sensitization to either alpha-amylase or flour. The clinical significance of these findings needs further investigation, but our findings indicate that specific sensitization in symptomatic bakers may not be identified without consideration of a wide range of workplace antigens.

Welding, longitudinal lung function decline and chronic respiratory symptoms: a systematic review of cohort studies

While the acute respiratory risks of welding are well characterised, more chronic effects, including those on lung function, are less clear. We carried out a systematic review of published longitudinal studies of lung function decline in welders. Original cohort studies documenting two or more sequential measurements of lung function were reviewed. Meta-analysis was carried out on studies with suitable data on forced expiratory volume in 1 s (FEV1). Seven studies were included; their quality (measured on the Newcastle-Ottawa scale) was good, although exposure assessment was limited and the studies showed significant heterogeneity. Five had data suitable for meta-analysis; the pooled estimate of the difference in FEV1 decline between welders and nonwelders was -9.0 mL · year(-1) (95% CI -22.5-4.5; p=0.193). The pooled estimates of difference in annual FEV1 decline between welders and referents who smoked was -13.7 mL · year(-1) (95% CI -33.6-6.3; p=0.179). For welders and referents who did not smoke the estimated difference was -3.8 mL · year(-1) (95% CI -20.2-12.6; p=0.650). Symptom prevalence data were mainly narrative; smoking appeared to have the greatest effect on symptom evolution. Collectively, available longitudinal data on decline of lung function in welders and respiratory symptoms suggest a greater effect in those who smoke, supporting a focus on smoking cessation as well as control of fume exposure in this trade. Further prospective studies are required to confirm these findings.

Paternity leave experiences of NHS doctors

This study assesses NHS doctors' experiences of paternity leave and evaluates whether practices have changed since the introduction of additional paternity leave (APL) in April 2011. An anonymised online survey designed to discover experiences and uptake of APL and ordinary paternity leave (OPL) was distributed to all members of the London Deanery Synapse® network. In total, 364 fathers responded. Their seniority ranged from foundation trainees to consultants. Following the formal introduction of OPL in 2003, the number of fathers taking any paternity leave increased (from 50% to 95.6%). The majority of respondents (76.7%) felt well supported by their employer. Since the introduction of APL, 3% of respondents took additional leave. Reasons for the low uptake of APL included the impracticalities of the law, poor awareness and perceived attitudes and implications for training. Problems with OPL included the inadequate provision of cover and difficulties in timing the leave appropriately.

Occupational asthma

Population-based studies suggest that one in 10 cases of new, recurrent, or deteriorating asthma in adulthood is related to the workplace environment. Nonspecific, irritant exposures at work can upset symptom control in pre-existing disease (work-exacerbated asthma); where disease arises de novo from the workplace (occupational asthma) it generally has an allergic basis, arising from airborne exposure to a sensitizing agent. Over 350 workplace substances have been identified as asthmagens; most are either proteins or highly reactive chemicals. The diagnosis of occupational asthma should be rapid but precise because definitive identification of the causative exposure provides the greatest opportunity for appropriate workplace adaptations and functional improvement. The majority of cases can be diagnosed through a combination of a careful history, appropriate immunology (where available), and the detection of work-related variability in measurements of lung function made serially at work and at home. Occupational asthma is a disease that is potentially preventable and often curable; positive outcomes are dependent more on changes in the workplace than on pharmacological therapy.