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PURPOSE Childhood cancer survivors (CCS) are at risk of developing subsequent malignant neoplasms (SMNs) resulting from exposure to prior therapies. CCS with underlying cancer predisposition syndromes are at additional genetic risk of SMN development. The McGill Interactive Pediatric OncoGenetic Guidelines (MIPOGG) tool identifies children with cancer at increased likelihood of having a cancer predisposition syndrome, guiding clinicians through a series of Yes or No questions that generate a recommendation for or against genetic evaluation. We evaluated MIPOGG's ability to predict SMN development in CCS. METHODS Using the provincial cancer registry (Ontario, Canada), and adopting a nested case-control approach, we identified CCS diagnosed and/or treated for a primary malignancy before age 18 years (1986-2015). CCS who developed an SMN (cases) were matched, by primary cancer and year of diagnosis, with CCS who did not develop an SMN (controls) over the same period (1:5 ratio). Potential predictors for SMN development (chemotherapy, radiation, and MIPOGG output) were applied retrospectively using clinical data pertaining to the first malignancy. Conditional logistic regression models estimated hazard ratios and 95% CIs associated with each covariate, alone and in combination, for SMN development. RESULTS Of 13,367 children with a primary cancer, 317 (2.4%) developed an SMN and were matched to 1,569 controls. A MIPOGG output recommending evaluation was significantly associated with SMN development (hazard ratio 1.53; 95% CI, 1.06 to 2.19) in a multivariable model that included primary cancer therapy exposures. MIPOGG was predictive of SMN development, showing value in nonhematologic malignancies and in CCS not exposed to radiation. CONCLUSION MIPOGG has additional value for SMN prediction beyond treatment exposures and may be beneficial in decision making for enhanced individualized SMN surveillance strategies for CCS.

ObjectiveTo explore impacts of the COVID-19 pandemic on patterns of sickness absence among staff employed by the National Health Service (NHS) in England.MethodsWe analysed prospectively collected, pseudonymised data on 959,356 employees who were continuously employed by NHS trusts during 1 January 2019 to 31 July 2020, comparing the frequency of new sickness absence in 2020 with that at corresponding times in 2019.ResultsAfter exclusion of episodes directly related to COVID-19, the overall incidence of sickness absence during the initial 10 weeks of the pandemic (March-May 2020) was more than 20% lower than in corresponding weeks of 2019, but trends for specific categories of illness varied. Marked increases were observed for asthma (122%), infectious diseases (283%) and mental illness (42.3%), while reductions were apparent for gastrointestinal problems (48.4%), genitourinary/gynaecological disorders (33.8%), eye problems (42.7%), injury and fracture (27.7%), back problems (19.6%), other musculoskeletal disorders (29.3%), disorders of ear, nose and throat (32.7%), cough/flu (24.5%) and cancer (24.1%). A doubling of new absences for pregnancy-related disorders during 18 May to 19 July of 2020 was limited to women with earlier COVID-19 sickness absence.ConclusionsVarious factors will have contributed to the large and divergent changes that were observed. The findings add to concerns regarding delays in diagnosis and treatment of cancers, and support a need to plan for a large backlog of treatment for many other diseases. Further research should explore the rise in absence for pregnancy-related disorders among women with earlier COVID-19 sickness absence.1. What is already known about this subject?Historically, rates of sickness absence among the NHS workforce in England have been relatively high but stable. Reports of a marked increase during the first wave of the COVID-19 pandemic have not distinguished between different categories of underlying illness.2. What are the new findings?During the first wave of COVID-19, incidence of sickness-absence changed markedly when compared to the previous year, with major increases for some categories of illness, and large declines for many others, including cancer.3. How might this impact on policy or clinical practice in the foreseeable future?The findings support a need to plan for effects from delayed diagnosis and treatment of cancer, and to manage a large backlog of treatment for many other diseases.

Right ventricular (RV) functional adaptation to afterload determines outcome in pulmonary hypertension (PH). RV afterload is determined by the dynamic interaction between pulmonary vascular resistance (PVR), characteristic impedance (Z(c)), and wave reflection. Pulmonary vascular impedance (PVZ) represents the most comprehensive measure of RV afterload; however, there is an unmet need for an easier bedside measurement of this complex variable. Although a recent study showed that Z(c) and wave reflection can be estimated from RV pressure waveform analysis and cardiac output, this has not been validated. Estimations of Z(c) and wave reflection coefficient (λ) were validated relative to conventional spectral analysis in an animal model. Z(c), λ, and the single-beat ratio of end-systolic to arterial elastance (E(es)/E(a)) to estimate RV-pulmonary arterial (PA) coupling were determined from right heart catheterization (RHC) data. The study included 30 pulmonary artery hypertension (PAH) and 40 heart failure with preserved ejection fraction (HFpEF) patients [20 combined pre- and postcapillary PH (Cpc-PH) and 20 isolated postcapillary PH, (Ipc-PH)]. Also included were 10 age- and sex-matched controls. There was good agreement with minimal bias between estimated and spectral analysis-derived Z(c) and λ. Z(c) in PAH and Cpc-PH groups exceeded that in the Ipc-PH group and controls. λ was increased in Ipc-PH (0.84 ± 0.02), Cpc-PH (0.87 ± 0.05), and PAH groups (0.85 ± 0.04) compared with controls (0.79 ± 0.03); all P values were

ObjectiveByssinosis remains a significant problem among textile workers in low/middle-income countries. Here we share our experience of using different prediction equations for assessing ‘chronic’ byssinosis according to the standard WHO classification using measurements of forced expiratory volume in 1 s (FEV1).MethodsWe enrolled 1910 workers in a randomised controlled trial of an intervention to improve the health of textile workers in Pakistan. We included in analyses the 1724 (90%) men who performed pre-bronchodilator spirometry tests of acceptable quality. We compared four different equations for deriving lung function percentage predicted values among those with symptoms-based byssinosis: the third US National Health and Nutrition Examination Survey (NHANES-III, with ‘North Indian and Pakistani’ conversion factor); the Global Lung Function Initiative (GLI, ‘other or mixed ethnicities’); a recent equation derived from survey of a western Indian population; and one based on an older and smaller survey of Karachi residents.Results58 men (3.4%) had symptoms-based byssinosis according to WHO criteria. Of these, the proportions with a reduced FEV1 (1/forced vital capacity (FVC) ratio (ConclusionAccurate measures of occupational disease frequency and distribution require approaches that are both standardised and meaningful. We should reconsider the WHO definition of ‘chronic’ byssinosis based on changes in FEV1, and instead use the FEV1/FVC.

Historically well-recognized occupational threats such as coal workers pneumoconiosis, silicosis, and asbestosis remain important and are very likely underestimated in measures of global disease burden. Studies of occupational exposure related to idiopathic pulmonary fibrosis, the most common interstitial lung disease, are limited but there is moderate evidence for metal, wood, and stone dust being significant contributors. Vigilance is required to identify causes, such as hypersensitivity pneumonitis due to microbial contamination of metalworking fluid (now responsible for greater than 50% of occupational hypersensitivity pneumonitis cases in the United Kingdom) in an everchanging workplace environment.

ObjectiveThe association between combat-related traumatic injury (CRTI) and cardiovascular risk is uncertain. This study aimed to investigate the association between CRTI and both metabolic syndrome (MetS) and arterial stiffness.MethodsThis was a prospective observational cohort study consisting of 579 male adult UK combat veterans (UK-Afghanistan War 2003–2014) with CRTI who were frequency-matched to 565 uninjured men by age, service, rank, regiment, deployment period and role-in-theatre. Measures included quantification of injury severity (New Injury Severity Score (NISS)), visceral fat area (dual-energy X-ray absorptiometry), arterial stiffness (heart rate-adjusted central augmentation index (cAIx) and pulse wave velocity (PWV)), fasting venous blood glucose, lipids and high-sensitivity C reactive protein (hs-CRP).ResultsOverall the participants were 34.1±5.4 years, with a mean (±SD) time from injury/deployment of 8.3±2.1 years. The prevalence of MetS (18.0% vs 11.8%; adjusted risk ratio 1.46, 95% CI 1.10 to 1.94, pConclusionsCRTI is associated with an increased prevalence of MetS and arterial stiffness, which are also influenced by age, injury severity, physical activity and SEC. The longitudinal impact of CRTI on clinical cardiovascular events needs further examination.

Soft tissue sarcomas are a heterogenous group of neoplasms without well-validated biomarkers. Cancer-related inflammation is a known driver of tumor growth and progression. Recent studies have implicated a high circulating neutrophil-lymphocyte ratio as a surrogate marker for the inflammatory tumor microenvironment and a poor prognosticator in multiple solid tumors, including colorectal and pancreatic cancers. The impact of circulating neutrophil-lymphocyte ratio in soft tissue sarcomas has yet to be elucidated.We performed a retrospective analysis of patients undergoing curative resection for primary or recurrent extremity soft tissue sarcomas at academic centers within the US Sarcoma Collaborative. Neutrophil-lymphocyte ratio was calculated retrospectively in treatment-naïve patients using blood counts at or near diagnosis.A high neutrophil-lymphocyte ratio (≥4.5) was associated with worse survival on univariable analysis in patients with extremity soft tissue sarcomas (hazard ratio 2.07; 95% confidence interval, 1.54-2.8; P.001). On multivariable analysis, increasing age (hazard ratio 1.03; 95% confidence interval, 1.02-1.04; P.001), American Joint Committee on Cancer T3 (hazard ratio 1.89; 95% confidence interval, 1.16-3.09; P = .011), American Joint Committee on Cancer T4 (hazard ratio 2.36; 95% confidence interval, 1.42-3.92; P = .001), high tumor grade (hazard ratio 4.56; 95% confidence interval, 2.2-9.45; P.001), and radiotherapy (hazard ratio 0.58; 95% confidence interval, 0.41-0.82; P = .002) were independently predictive of overall survival, but a high neutrophil-lymphocyte ratio was not predictive of survival (hazard ratio 1.26; 95% confidence interval, 0.87-1.82; P = .22).Tumor inflammation as measured by high pretreatment neutrophil-lymphocyte ratio was not independently associated with overall survival in patients undergoing resection for extremity soft tissue sarcomas.

Objective:Despite the policy relevance of carer burden, limited research focuses on family carers’ experience of carer burden among different disease groups. This study aimed to examine differences in carer burden among family carers of people with and without dementia.Design:Secondary data analysis was conducted on a national cross-sectional dataset. Multivariable ordered logistic regression was used to analyze four levels of carer burden (low, mild, moderate, high). The main independent variable was dementia diagnosis, and controls included variables relating to the care recipient, family carer, and context of care.Setting:The original survey was funded by Irish Health Service Executive and undertaken by the National Centre for the Protection of Older People in Ireland.Participants:The original dataset consisted of 2,311 family carers of older people in Ireland. Approximately, one-fifth of this sample had a diagnosis of dementia.Measurements:Carer burden was measured using the standardized 22-item Zarit Burden Interview. Care-recipient dependency was measured using the Activities for Daily Living Scale. Sociodemographic details and information about the context of caring were collected using self-report scales.Results:In our model, dementia diagnosis and dependency level were significantly associated with carer burden. Family carer and context of care variables including gender, marital status, education, residence, co-residence, and perceived support showed significant relationships with carer burden. Our results highlighted significant differences in carer burden distribution; in particular, family carers of people with dementia were less likely to report low or mild carer burden (−6.95 ppts and −3.64 ppts, respectively) and more likely to report moderate or high carer burden (8.46 ppts and 2.13 ppts, respectively).Conclusion:Our findings suggest that family carers of people with dementia may experience additional challenges associated with caring. Therefore, family carers of people with dementia may require tailored social supports to maintain good health and well-being.

Allogeneic cancer vaccines are designed to induce antitumor immune responses with the goal of impacting tumor growth. Typical allogeneic cancer vaccines are produced by expansion of established cancer cell lines, transfection with vectors encoding immunostimulatory cytokines, and lethal irradiation. More than 100 clinical trials have investigated the clinical benefit of allogeneic cancer vaccines in various cancer types. Results show limited therapeutic benefit in clinical trials and currently there are no FDA-approved allogeneic cancer vaccines. We used recently developed bioinformatics tools including the pVACseq suite of software tools to analyze DNA/RNA-sequencing data from the The Cancer Genome Atlas to examine the repertoire of antigens presented by a typical allogeneic cancer vaccine, and to simulate allogeneic cancer vaccine clinical trials. Specifically, for each simulated clinical trial, we modeled the repertoire of antigens presented by allogeneic cancer vaccines consisting of three hypothetical cancer cell lines to 30 patients with the same cancer type. Simulations were repeated ten times for each cancer type. Each tumor sample in the vaccine and the vaccine recipient was subjected to human leukocyte antigen (HLA) typing, differential expression analyses for tumor-associated antigens (TAA), germline variant calling, and neoantigen prediction. These analyses provided a robust, quantitative comparison between potentially beneficial TAAs and neoantigens versus distracting antigens present in the allogeneic cancer vaccines. We observe that distracting antigens greatly outnumber shared TAAs and neoantigens, providing one potential explanation for the lack of observed responses to allogeneic cancer vaccines. This analysis provides additional rationale for the redirection of efforts toward a personalized cancer vaccine approach. Significance: A comprehensive examination of allogeneic cancer vaccine antigen repertoire using large-scale genomics datasets highlights the large number of distracting antigens and argues for more personalized approaches to immunotherapy that leverage recent strategies in tumor antigen identification.

Rationale Studies have suggested some asthma patients are at risk of severe COVID-19, but they have had limited data on asthma phenotype and have not considered if risks are specific to COVID-19. Objectives Determine the effect of asthma phenotype on three levels of COVID-19 outcomes. Compare hospitalisation rates to influenza and pneumonia. Methods Electronic medical records were used to identify asthma patients and match them to the general population. Patient-level data were linked to Public Health England SARS-CoV-2 test data, hospital, and mortality data. Asthma was phenotyped by medication, exacerbation history, and type-2 inflammation. The risk of each outcome, adjusted for major risk factors, was measured using Cox regression. Measurements and main results 434,348 asthma and 748,327 matched patients were included. All asthma patients had a significantly increased risk of a GP-diagnosis of COVID-19. Asthma with regular inhaled corticosteroid (ICS) use (HR=1.27, 95%CI=1.01-1.61), intermittent ICS + add-on asthma medication use (HR=2.00, 95%CI=1.43-2.79), regular ICS + add-on use (HR=1.63, 95 CI=1.37-1.94), or with frequent exacerbations (HR=1.82, 95% CI=1.34-2.47) was significantly associated with hospitalisation. These phenotypes were significantly associated with influenza and pneumonia hospitalisations. Only patients with regular ICS + add-on asthma therapy (HR=1.70, 95%CI=1.27-2.26) or frequent exacerbations (HR=1.66, 95%CI=1.03-2.68) had a significantly higher risk of ICU admission or death. Atopy and blood eosinophil count were not associated with severe COVID-19 outcomes. Conclusions More severe asthma was associated with more severe COVID-19 outcomes, but type-2 inflammation was not. The risk of COVID-19 hospitalisation appeared to be similar to the risk with influenza or pneumonia. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Importance Prompt recognition of a child with a cancer predisposition syndrome (CPS) has implications for cancer management, surveillance, genetic counseling, and cascade testing of relatives. Diagnosis of CPS requires practitioner expertise, access to genetic testing, and test result interpretation. This diagnostic process is not accessible in all institutions worldwide, leading to missed CPS diagnoses. Advances in electronic health technology can facilitate CPS risk assessment. Objective To evaluate the diagnostic accuracy of a CPS prediction tool (McGill Interactive Pediatric OncoGenetic Guidelines [MIPOGG]) in identifying children with cancer who have a low or high likelihood of having a CPS. Design, Setting, and Participants In this international, multicenter diagnostic accuracy study, 1071 pediatric (

Purpose: FOLFIRINOX has demonstrated promising results for patients with pancreatic ductal adenocarcinoma (PDAC). Chemotherapy-induced immunogenic cell death can prime antitumor immune responses. We therefore performed high-dimensional profiling of immune cell subsets in peripheral blood to evaluate the impact of FOLFIRINOX on the immune system. Experimental Design: Peripheral blood mononuclear cells (PBMC) were obtained from treatment-naïve (n = 20) and FOLFIRINOX-treated patients (n = 19) with primary PDAC tumors at the time of resection. PBMCs were characterized by 36 markers using mass cytometry by time of flight (CyTOF). Results: Compared with treatment-naïve patients, FOLFIRINOX-treated patients showed distinct immune profiles, including significantly decreased inflammatory monocytes and regulatory T cells (Treg), increased Th1 cells, and decreased Th2 cells. Notably, both monocytes and Treg expressed high levels of immune suppression-associated CD39, and the total CD39+ cell population was significantly lower in FOLFIRINOX-treated patients compared with untreated patients. Cellular alterations observed in responders to FOLFIRINOX included a significantly decreased frequency of Treg, an increased frequency of total CD8 T cells, and an increased frequency of CD27−Tbet+ effector/effector memory subsets of CD4 and CD8 T cells. Conclusions: Our study reveals that neoadjuvant chemotherapy with FOLFIRINOX enhances effector T cells and downregulates suppressor cells. These data indicate that FOLFIRINOX neoadjuvant therapy may improve immune therapy and clinical outcome in patients with PDAC.

Aim or Purpose A multitude of studies investigated the beneficial effects of periodontitis therapy on general health. In contrast, the present trial aimed to investigate the effect of an oral health education program combined with routine dental treatment on serum biomarkers of systemic health in a community of low-socioeconomic background with general dental treatment needs. Materials and Methods Eligible participants (plaque index >50%, bleeding on probing >30%, active carious lesion) were randomised to a group that received dental treatment combined with an oral health education program (OHE+GDT) or a group that received general dental treatment only (GDT). Participants in both groups received routine dental treatment. In addition, participants in the OHE+GDT group received 180 min of health education and a full-mouth debridement. Serum levels of high-sensitivity C-reactive protein (hsCRP), lipid profiles, and HbA1c were measured at baseline and after 12 months. Results 295 participants (mean age, 45.4 ± 11 years) were analysed. Periodontal health significantly improved in both groups. However, no intergroup differences were detected (P=0.92 Generalised Estimating Equation (GEE)). A significant reduction of hsCRP levels at the follow-up assessment was observed in the OHE+GDT group, which was significantly different from the GDT group (P =0.01). Multivariate modelling indicated that baseline hsCRP levels, baseline body mass index, and higher consumption of vegetables (P = 0.021) predicted a reduction in hsCRP levels. Conclusions This study demonstrated that oral health education combined with routine dental treatment was associated with a significant reduction in hsCRP levels and hence suggests a beneficial effect on general health.

ObjectiveTo quantify occupational risks of COVID-19 among healthcare staff during the first wave (9 March 2020–31 July 2020) of the pandemic in England.MethodsWe used pseudonymised data on 902 813 individuals employed by 191 National Health Service trusts to explore demographic and occupational risk factors for sickness absence ascribed to COVID-19 (n=92 880). We estimated ORs by multivariable logistic regression.ResultsWith adjustment for employing trust, demographic characteristics and previous frequency of sickness absence, risk relative to administrative/clerical occupations was highest in ‘additional clinical services’ (care assistants and other occupations directly supporting those in clinical roles) (OR 2.31 (2.25 to 2.37)), registered nursing and midwifery professionals (OR 2.28 (2.23 to 2.34)) and allied health professionals (OR 1.94 (1.88 to 2.01)) and intermediate in doctors and dentists (OR 1.55 (1.50 to 1.61)). Differences in risk were higher after the employing trust had started to care for documented patients with COVID-19, and were reduced, but not eliminated, following additional adjustment for exposure to infected patients or materials, assessed by a job-exposure matrix. For prolonged COVID-19 sickness absence (episodes lasting >14 days), the variation in risk by staff group was somewhat greater.ConclusionsAfter allowance for possible bias and confounding by non-occupational exposures, we estimated that relative risks for COVID-19 among most patient-facing occupations were between 1.5 and 2.5. The highest risks were in those working in additional clinical services, nursing and midwifery and in allied health professions. Better protective measures for these staff groups should be a priority. COVID-19 may meet criteria for compensation as an occupational disease in some healthcare occupations.Trial registration numberISRCTN36352994.

BACKGROUND: Studies of patients admitted to hospital with COVID-19 have found varying mortality outcomes associated with underlying respiratory conditions and inhaled corticosteroid use. Using data from a national, multicentre, prospective cohort, we aimed to characterise people with COVID-19 admitted to hospital with underlying respiratory disease, assess the level of care received, measure in-hospital mortality, and examine the effect of inhaled corticosteroid use. METHODS: We analysed data from the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) WHO Clinical Characterisation Protocol UK (CCP-UK) study. All patients admitted to hospital with COVID-19 across England, Scotland, and Wales between Jan 17 and Aug 3, 2020, were eligible for inclusion in this analysis. Patients with asthma, chronic pulmonary disease, or both, were identified and stratified by age ( FINDINGS: 75 463 patients from 258 participating health-care facilities were included in this analysis: 860 patients younger than 16 years (74 [8·6%] with asthma), 8950 patients aged 16-49 years (1867 [20·9%] with asthma), and 65 653 patients aged 50 years and older (5918 [9·0%] with asthma, 10 266 [15·6%] with chronic pulmonary disease, and 2071 [3·2%] with both asthma and chronic pulmonary disease). Patients with asthma were significantly more likely than those without asthma to receive critical care (patients aged 16-49 years: adjusted odds ratio [OR] 1·20 [95% CI 1·05-1·37]; p=0·0080; patients aged ≥50 years: adjusted OR 1·17 [1·08-1·27]; p INTERPRETATION: Underlying respiratory conditions are common in patients admitted to hospital with COVID-19. Regardless of the severity of symptoms at admission and comorbidities, patients with asthma were more likely, and those with chronic pulmonary disease less likely, to receive critical care than patients without an underlying respiratory condition. In patients aged 16 years and older, severe asthma was associated with increased mortality compared to non-severe asthma. In patients aged 50 years and older, inhaled corticosteroid use in those with asthma was associated with lower mortality than in patients without an underlying respiratory condition; patients with chronic pulmonary disease had significantly increased mortality compared to those with no underlying respiratory condition, regardless of inhaled corticosteroid use. Our results suggest that the use of inhaled corticosteroids, within 2 weeks of admission, improves survival for patients aged 50 years and older with asthma, but not for those with chronic pulmonary disease. FUNDING: National Institute for Health Research, Medical Research Council, NIHR Health Protection Research Units in Emerging and Zoonotic Infections at the University of Liverpool and in Respiratory Infections at Imperial College London in partnership with Public Health England.

BackgroundVentilator-associated pneumonia (VAP) is an important diagnosis in critical care. VAP research is complicated by the lack of agreed diagnostic criteria and reference standard test criteria. Our aim was to review which reference standard tests are used to evaluate novel index tests for suspected VAP.MethodsWe conducted a comprehensive search using electronic databases and hand reference checks. The Cochrane Library, MEDLINE, CINHAL, EMBASE, and web of science were searched from 2008 until November 2018. All terms related to VAP diagnostics in the intensive treatment unit were used to conduct the search. We adopted a checklist from the critical appraisal skills programme checklist for diagnostic studies to assess the quality of the included studies.ResultsWe identified 2441 records, of which 178 were selected for full-text review. Following methodological examination and quality assessment, 44 studies were included in narrative data synthesis. Thirty-two (72.7%) studies utilised a sole microbiological reference standard; the remaining 12 studies utilised a composite reference standard, nine of which included a mandatory microbiological criterion. Histopathological criteria were optional in four studies but mandatory in none.ConclusionsNearly all reference standards for VAP used in diagnostic test research required some microbiological confirmation of infection, with BAL culture being the most common reference standard used.

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 disease...

ObjectivesWe aimed to investigate whether there has been a geographic shift in the distribution of mesothelioma deaths in Great Britain given the decline of shipbuilding and progressive exposure regulation.MethodsWe calculated age-adjusted mesothelioma mortality rates and estimated rate ratios for areas with and without a dockyard. We compared spatial autocorrelation statistics (Moran’s I) for age-adjusted rates at local authority district level for 2002–2008 and 2009–2015. We measured the mean distance of the deceased’s postcode to the nearest dockyard at district level and calculated the association of average distance to dockyard and district mesothelioma mortality using simple linear regression for men, for 2002–2008 and 2009–2015.ResultsDistrict age-adjusted male mortality rates fell during 2002–2015 for 80 of 348 districts (23%), rose for 267 (77%) and were unchanged for one district; having one or more dockyards in a district was associated with rates falling (OR=2.43, 95% CI 1.22 to 4.82, p=0.02). The mortality rate ratio for men in districts with a dockyard, compared with those without a dockyard was 1.41 (95% CI 1.35 to 1.48, pConclusionFor most districts age-adjusted mesothelioma mortality rates increased through 2002–2015 but the relative contribution from districts with a dockyard fell. Dockyards remain strongly spatially associated with mesothelioma mortality but the strength of this association appears to be falling and mesothelioma deaths are becoming more dispersed.

BACKGROUND: Postoperative wound complications are challenging in patients with localized extremity soft-tissue sarcomas. Various factors have been associated with wound complications, but there is no individualized predictive model to allow providers to counsel their patients and thus offer methods to mitigate the risk of complications and implement appropriate measures. QUESTIONS/PURPOSES: We used data from multiple centers to ask: (1) What risk factors are associated with postoperative wound complications in patients with localized soft-tissue sarcomas of the extremity? (2) Can we create a predictive nomogram that will assess the risk of wound complications in individual patients after resection for soft-tissue sarcoma? METHODS: From 2000 to 2016, 1669 patients undergoing limb-salvage resection for a localized primary or recurrent extremity soft-tissue sarcoma with at least 120 days of follow-up at eight participating United States Sarcoma Collaborative institutions were identified. Wound complications included superficial wounds with or without drainage, deep wounds with drainage because of dehiscence, and intentional opening of the wound within 120 days postoperatively. Sixteen variables were selected a priori by clinicians and statisticians as potential risk factors for wound complications. A univariate analysis was performed using Fisher’s exact tests for categorical predictors, and Wilcoxon’s rank-sum tests were used for continuous predictors. A multiple logistic regression analysis was used to train the prediction model that was used to create the nomogram. The prediction performance of the datasets was evaluated using a receiver operating curve, area under the curve, and calibration plot. RESULTS: After controlling for potential confounding factors such as comorbidities, functional status, albumin level, and chemotherapy use, we found that increasing age (odds ratio 1.02; 95% confidence interval, 1.00-1.03; p = 0.008), BMI (OR 1.05; 95% CI, 1.02-1.09; p = 0.004), lower-extremity location (OR 6; 95% CI, 2.87-12.69; p < 0.001), and neoadjuvant radiation (OR 2; 95% CI, 1.47-3.16; p < 0.001) were associated with postoperative wound complications (area under the curve 69.2% [range 62.8%-75.6%]). CONCLUSIONS: We found that age, BMI, tumor location, and timing of radiation are associated with the risk of wound complications. Based on these factors, a validated nomogram has been established that can provide an individualized prediction of wound complications in patients with a resected soft-tissue sarcoma of the extremity. This may allow for proactive management with nutrition and surgical techniques, and help determine the delivery of radiation in patients with a high risk of having these complications. LEVEL OF EVIDENCE: Level III, therapeutic study.

Background Day care is an important service for some people with dementia and their carers. In Ireland, day care services for people with dementia are delivered by a mix of dementia specific day-care centres and generic centres that cater for people with dementia to various degrees. In this paper we map the geographic variation in the supply of day care services for people with dementia relative to potential need. Methods Using a national HSE survey of day care centres, we estimate the current supply of day care services for people with dementia in both generic and dementia specific centres by combining a number of qualitative and quantitative measures. To identify the variation in supply, we map day care provision at local and regional levels to the number of people with dementia in the area. To consider geographic accessibility, we map and analyse the population living outside the catchment area of the day care centres. Results There is significant variation across the country in the existing capacity of day care centres to cater for people with dementia. The number of places per 100 persons with dementia varies from 9 to 16 across the Community Health Organisation areas. We show that 20 per cent of people with dementia are not living within a 15km radius of a day care centre that caters for people with dementia. Conclusion Day care has a place in the menu of service for people with dementia living in the community. As the number of people with dementia grows, investment in day care centres needs to be targeted to areas of greatest need. In many parts of the country, the current day care centres have limited capacity to provide a service for people with dementia that live in their catchment area. There is considerable geographical inequity in day care provision for people with dementia across the country.

Background: Non-invasive ventilation (NIV) for respiratory failure and airway clearance is an established intervention in cystic fibrosis (CF), but its therapeutic benefit on lung function and survival remains under-investigated. Methods: Using data from the UK CF Registry between 2007 and 2015, we explored the patterns of NIV use, and assessed changes in mean percent predicted FEV1 (ppFEV1) prior to and after NIV use, and the survival of patients on NIV. Results: Among 11,079 patients, 1107 had at least one record of NIV treatment. Incidence and prevalence of NIV was lower in children and followed non-linear temporal patterns. Adjusting for other risk factors, ppFEV1 rose by 0.70 (95%CI: -0.83, 2.24) after first NIV use in children. In adults with a low ppFEV1 (

Competent communication practices among healthcare providers are a key factor in maintaining patient safety during transfers of patient care. Research shows that the majority of errors in p...

OBJECTIVES: The “Surgery for Abdomino-thoracic ViolencE (SAVE)” animate lab engages surgical residents in the management of complex penetrating injuries. We hypothesized that residents will improve their understanding of the management of trauma patients and will perform skills that they have not previously performed in training. DESIGN: Pre- and post-lab assessments were reviewed from surgical residents participating in the SAVE lab over two years (2017-2018). Residents of varying levels were grouped and reviewed “real-life” trauma scenarios with supplemental imaging. Seniors were tasked with creating injuries while juniors performed as primary surgeons under supervision. Each successive scenario increased in difficulty, from hollow viscus injury and solid organ disruption, to great vessel and cardiac injuries with the goal to “SAVE” the patient. Assessments included a pre- and post-lab multiple-choice questionnaire of trauma management knowledge and a survey of completed technical skills. SETTING: Academic General Surgery residency program PARTICIPANTS: General, Vascular, Urology, and Plastic Surgery PGY1-5 residents RESULTS: 119 residents participated in the SAVE lab in 2017 and 2018. PGY1-PGY4 residents showed significant improvement in knowledge of trauma management on matched pre- and post-lab assessments. The most significant improvement was seen in the PGY1 and PGY2 residents, with scores increasing by 21% (p

Rationale Asthma is heterogeneous and knowledge on exacerbation patterns is lacking. Previous studies have had a relatively short follow-up or focused on severe disease. Objectives Describe exacerbation patterns over a prolonged follow-up in a population including patients of all disease severity. Methods We used electronic healthcare records to identify asthma patients aged 18-55 years and their exacerbations, 2007-2015. A cohort with ≥7-years of data was used to describe exacerbation patterns by asthma severity defined by medication use. Effect estimates for risk factors were calculated for sporadic (single year of exacerbations) and recurrent (>1 year) exacerbation patterns, using logistic regression. In a nested case-control design, the association between a history of exacerbations, spanning 5-years, and a future exacerbation was examined. Measurements and Main Results 51,462 patients were eligible for the 7-year cohort; 64% had no exacerbations. Of those who exacerbated, 51% did so only once; exacerbation frequency increased with disease severity. Only 370 patients (0.7%) were characterised by a frequent-exacerbator phenotype (yearly exacerbations), of whom 58% had mild/moderate asthma. Exacerbation risk factors were not uniquely associated with a particular exacerbation pattern. A past exacerbation increased the risk of a future exacerbation more than all other factors, although this effect dissipated over 5-years. Conclusions During 7-years of follow-up, exacerbations occur in around one-third of patients. Of those who exacerbate, half do not do so again; the timing of future exacerbations is largely unpredictable. Just 2% exhibit a frequent-exacerbator phenotype. Past exacerbation patterns are the most informative risk factor for predicting future exacerbations.

This paper reports on a collaborative project between educational industry and research partners, in Queensland, Australia with the aim of developing instruments to gather new information about beginning teacher workforce issues. The investigation stimulates deeper insight into beginning teachers’ (n = 504) and school leaders’ (n = 306) perceptions of specific factors influencing beginning teacher attrition and retention and beginning teacher workforce stability. The convergent mixed-method study includes demographic data and information derived from Likert scales and open questions and is underpinned by context-conscious understanding development theory . The initial scale validation and justification involves confirmatory factor analysis and reliability analysis. The findings offer a new lens to develop an in-depth, multi-layered understanding of beginning teacher workforce issues to inform future research and policy decisions.

The postoperative outcomes of elderly patients undergoing resection of retroperitoneal sarcomas (RPS) have not been widely studied.Patients undergoing surgical resection for primary or recurrent RPS between 2000 and 2015 at participating US Sarcoma Collaborative institutions were identified. Patient demographics, perioperative morbidity, mortality, length of stay, discharge to home, disease-specific survival, and disease-free survival were compared between elderly (≥70 y, n = 171) and nonelderly (70 y, n = 494) patients.There was no difference in perioperative morbidity (total and major complications elderly versus nonelderly: 39% versus 35%; P = 0.401 and 18% versus 17%; P = 0.646, respectively) or mortality between elderly and nonelderly patients with each group experiencing a 1% 30-d mortality rate. Length of stay and 30-d readmission rates were similar (elderly versus nonelderly; 7 d interquartile range [IQR: 5-9] versus 6 d [IQR: 4-9], P = 0.528 and 11% versus 12%, P = 0.667). Elderly patients were more likely to be discharged to a skilled nursing or rehabilitation facility (elderly versus nonelderly; 19% versus 7%, P 0.001). There was no difference in 3-y disease-free survival between the elderly and nonelderly patients (41% versus 43%, P = 0.65); however, elderly patients had a lower 3-y disease-specific survival (60% versus 76%, P 0.001). In elderly patients, the presence of multiple comorbidities and high-grade tumors were most predictive of outcomes.Advanced age was not associated with an increased risk of perioperative morbidity and mortality following resection of RPS in this multi-institutional review. Although short-term oncologic outcomes were similar in both groups, the risk of death after sarcoma recurrence was higher in elderly patients and may be related to comorbidity burden and tumor histology.

ObjectiveTo quantify occupational risks of Covid-19 among healthcare staff during the first wave of the pandemic in EnglandMethodsUsing pseudonymised data on 902,813 individuals continuously employed by 191 National Health Service trusts during 1.1.19 to 31.7.20, we explored demographic and occupational risk factors for sickness absence ascribed to Covid-19 during 9.3.20 to 31.7.20 (n = 92,880). We estimated odds ratios (ORs) by multivariable logistic regression.ResultsWith adjustment for employing trust, demographic characteristics, and previous frequency of sickness absence, risk relative to administrative/clerical occupations was highest in additional clinical services (including care assistants) (OR 2.31 [2.25-2.37]), registered nursing and midwifery professionals (OR 2.28 [2.23-2.34]) and allied health professionals (OR 1.94 [1.88-2.01]), and intermediate in doctors and dentists (OR 1.55 [1.50-1.61]). Differences in risk were higher after the employing trust had started to care for documented Covid-19 patients, and were reduced, but not eliminated, following additional adjustment for exposure to infected patients or materials, assessed by a job-exposure matrix. For prolonged Covid-19 sickness absence (episodes lasting >14 days), the variation in risk by staff group was somewhat greater.ConclusionsAfter allowance for possible bias and confounding by non-occupational exposures, we estimated that relative risks for Covid-19 among most patient-facing occupations were between 1.5 and 2.5. The highest risks were in those working in additional clinical services, nursing and midwifery and in allied health professions. Better protective measures for these staff groups should be a priority. Covid-19 may meet criteria for compensation as an occupational disease in some healthcare occupations.Key messagesWhat is already known about this subject?Healthcare workers and other keyworkers (workers whose job was considered essential to societal functioning) had a higher likelihood of testing positive for COVID-19 than other workers during the first lockdown in England. Amongst healthcare workers, those working in inpatient settings had the highest rate of infection.What are the new findings?Between March and July 2000, the overall risk of COVID-19 sickness absence in National Health Service staff in England was lower at older ages, higher in non-white staff, and (in comparison with administrative and clerical staff) more than doubled in registered nurses and among workers such as healthcare assistants providing support to health professionals. Risk in health care scientists was little different from that in administrative and clerical occupationsHow might this impact on policy or clinical practice in the foreseeable future?Our results suggest that the risk reduction strategies that were in place for healthcare scientists were effective. However, the protection for nursing and supporting health professionals was insufficient. In the event of a further ‘wave’ of infections resulting in high hospital admissions, attention should be paid to ensuring that risk reduction strategies for nurses and supporting health professionals are improved.

This report addresses the extent to which there may be scope for preventive programmes for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and, if so, what economic benefits may accrue from the implementation of such programmes. We consider the economic case for prevention programmes, whether there is scope for preventive programmes for ME/CFS, and what are the health and economic benefits to be derived from the implementation of such programmes. We conclude that there is little scope for primary prevention programmes, given that ME/CFS is attributable to a combination of host and environmental risk factors, with host factors appearing to be most prominent, and that there are few identified modifiable risk factors that could be the focus of such programmes. The exception is in the use of agricultural chemicals, particularly organophosphates, where there is scope for intervention, and where Europe-wide programmes of health education to encourage safe use would be beneficial. There is a need for more research on risk factors for ME/CFS to establish a basis for the development of primary prevention programmes, particularly in respect of occupational risk factors. Secondary prevention offers the greatest scope for intervention, to minimise diagnostic delays associated with prolonged illness, increased severity, and increased costs.

RationaleAsbestos is posited to cause otherwise ‘idiopathic’ pulmonary fibrosis (IPF); establishing this has important diagnostic and therapeutic implications.ObjectivesTo determine the association between occupational asbestos exposure and IPF; to investigate interaction with MUC5B rs35705950 genotype.MethodsMulti-centre, incident case-control study. Cases (n=494) were men diagnosed with IPF at 21 United Kingdom hospitals. Controls (n=466) were age-matched men who attended a hospital clinic in the same period. Asbestos exposure was measured using a validated job exposure matrix and a source-receptor model. The primary outcome was the association between asbestos exposure and IPF, estimated using logistic regression adjusted for age, smoking and centre. Interaction with MUC5B rs3570950 was investigated using a genetic dominant model.Measurements and Main Results327 (66%) cases and 293 (63%) controls ever had a high or medium asbestos exposure risk job; 8% of both cases and controls, had cumulative exposure estimates ≥ 25 fibre.ml−1.years. Occupational asbestos exposure was not associated with IPF, adjusted OR 1.1(95%CI 0.8-1.4; p=0.6) and there was no gene-environment interaction (p=0.2). Ever smoking was associated with IPF, OR 1.4 (95%CI 1-1.9; p=0.04). When stratifying for genotype there was significant interaction between smoking and work in an exposed job (pMUC5B rs3570950.ConclusionsOccupational asbestos exposure alone, or through interaction with MUC5B rs35705950 genotype, was not associated with IPF. However, exposure to asbestos and smoking interact to increase IPF risk in carriers of the minor allele of MUC5B rs3570950.Clinical trial registered with www.clinicaltrials.gov (NCT03211507).

Background and Objectives: We have conducted a survey of academic and clinical experts who are participants in the European ME/CFS Research Network (EUROMENE) to elicit perceptions of general practitioner (GP) knowledge and understanding of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and suggestions as to how this could be improved. Materials and Methods: A questionnaire was sent to all national representatives and members of the EUROMENE Core Group and Management Committee. Survey responses were collated and then summarized based on the numbers and percentages of respondents selecting each response option, while weighted average responses were calculated for questions with numerical value response options. Free text responses were analysed using thematic analysis. Results: Overall there were 23 responses to the survey from participants across 19 different European countries, with a 95% country-level response rate. Serious concerns were expressed about GPs’ knowledge and understanding of ME/CFS, and, it was felt, about 60% of patients with ME/CFS went undiagnosed as a result. The vast majority of GPs were perceived to lack confidence in either diagnosing or managing the condition. Disbelief, and misleading illness attributions, were perceived to be widespread, and the unavailability of specialist centres to which GPs could refer patients and seek advice and support was frequently commented upon. There was widespread support for more training on ME/CFS at both undergraduate and postgraduate levels. Conclusion: The results of this survey are consistent with the existing scientific literature. ME/CFS experts report that lack of knowledge and understanding of ME/CFS among GPs is a major cause of missed and delayed diagnoses, which renders problematic attempts to determine the incidence and prevalence of the disease, and to measure its economic impact. It also contributes to the burden of disease through mismanagement in its early stages.

Disease spectrum in pediatric sarcoma differs substantially from adults. We report a cohort of very young children with non-rhabdomyosarcoma soft tissue sarcoma (NRSTS) detailing their molecular features, treatment, and outcome.We report features of consecutive children (age2 years) with NRSTS (2000-2017). Archival pathological material was re-reviewed, with additional molecular techniques applied where indicated.Twenty-nine patients (16 females, 55%) were identified (median age 6 months; range 0-23). Most common diagnoses included infantile fibrosarcoma (IFS, n = 14, 48%), malignant rhabdoid tumor (MRT, n = 4, 14%), and undifferentiated sarcoma (n = 4, 14%). Twenty-seven of 29 (93%) had tumor molecular characterization to confirm diagnosis. Clinical presentation included a swelling/mass (n = 23, 79%). Disease extent was localized (n = 20, 69%), locoregional (n = 6, 21%), or metastatic (n = 3, 10%). Seventeen of 29 (59%) who underwent surgery achieved complete resection (R0). Other treatments included conventional chemotherapy (n = 26, 90%), molecularly targeted therapies (n = 3, 10%), and radiation (n = 5, 17%). At last follow-up (median 3 years; range 0.3-16.4), 23 (79%) were alive, disease-free and six (21%) had died of disease. All patients with IFS were alive and all those with MRT died. A cancer predisposition syndrome (CPS) was confirmed in three of 10 (30%) genetically tested patients.We recommend tumor molecular characterization in all young patients including evaluation for CPS to optimize treatment options and prognostication.

Introduction and Objectives It has been estimated that 15% of the population burden of chronic obstructive pulmonary disease population is attributable to occupational factors. Most of the evidence comes from studies conducted in high-income countries (HICs). Our aim was to examine the relationship between occupational exposures and respiratory health in both HICs and Low- and middle-income countries (LMICs) participating in the multinational, population-based, cross-sectional BOLD study. Methods We analysed data from 28,823 adults aged ≥40 years who completed respiratory and occupational questionnaires and had acceptable and repeatable post-bronchodilator spirometry measurements. Occupational exposures comprised three categories (organic dust; inorganic dust; fume) and 11 high-risk occupations (farming; flour, feed or grain milling; cotton or jute processing; hard-rock mining; coal mining; sandblasting; working with asbestos; chemical or plastics manufacturing; foundry or steel milling; welding; and firefighting). The associations of respiratory symptoms and lung function with occupational exposures were estimated using multivariable regression models adjusted for potential confounders for each BOLD site and then pooled using meta-analysis. Sensitivity analyses by sex, national gross national income and smoking status were also performed. Results We found that people working in any of three categories of occupational exposures and the 11 high-risk occupations under consideration were more likely to report respiratory symptoms than those who do not work in any of those occupations. Overall, we found no consistent associations between the occupational exposure categories and high-risk occupations and measures of lung function. Nevertheless, in sensitivity analyses, men in HICs exposed to organic dusts in the workplace for at least 20 years (median) had significantly decreased FEV1/FVC (β=-0.34%; 95% CI -0.42% to -0.27%) and decreased FVC (β=-0.18L; 95% CI -0.32L to -0.04L). Men in LMICs exposed to fumes for at least 11 years had significantly decreased FEV1/FVC (β=-0.29%; 95% CI -0.41% to -0.16%). Conclusions In a large global study, we found respiratory symptoms to be associated with 11 high-risk occupations. The associations between occupational exposures and lung function varied by gross national income groups; more research is needed to understand these differences. Meanwhile, preventive measures and respiratory health surveillance should be enhanced among exposed workers.

Introduction and Objectives A cigarette smoking – idiopathic pulmonary fibrosis (IPF) association has been observed in several case-control studies. However, it is not known whether smoking causes IPF or if the observed association arises as a result of confounding (for example many studies have used population controls and may be vulnerable to selection bias). Mendelian randomization can offer an opportunity to investigate causality between cigarette smoking and IPF. Methods Genetic instruments for lifetime smoking score[1] (taking into account smoking duration and heaviness) were obtained from a genome-wide association study (GWAS) performed in UK Biobank (462,690 individuals, European ancestry). We used variants that were significantly associated with smoking at p Results 118 variants were used as instruments. In the main analysis, the odds ratio per standard deviation increase in lifetime smoking score was 0.6 (95%CI 0.4–1, p=0.07). Similar results were obtained in statistical sensitivity analyses. Conclusions This Mendelian randomization analysis does not provide evidence to support the notion that smoking causes IPF. It may be that confounding is responsible for the association in observational studies. Clearly, there is a strong case for stopping smoking for other reasons. References Wootton RE, Richmond RC, Stuijfzand BG, Lawn RB, Sallis HM, Taylor GM, Hemani G, Jones HJ, Zammit S, Smith GD, Munafo MR. Evidence for causal effects of lifetime smoking on risk for depression and schizophrenia: a Mendelian randomisation study. Psychological Medicine 2019 Nov 6:1–9. Allen RJ, Guillen-Guio B, Oldham JM, Ma SF, Dressen A, Paynton ML, Kraven LM, Obeidat ME, Li X, Ng M, Braybrooke R. Genome-wide association study of susceptibility to idiopathic pulmonary fibrosis. American Journal of Respiratory and Critical Care Medicine 2020 Mar 1;201(5):564–74.

BACKGROUND: The outcomes of deep vein thrombosis (DVT) in children with May-Thurner Syndrome (MTS) remain unclear. OBJECTIVES: This systematic review and patient-level meta-analysis aims to describe the outcomes of children with MTS presenting with DVT. METHODS: A systematic review of the published literature was performed. Data related to patients

Encefalomielitis miàlgica/síndrome de fatiga crònica; Cura; Diagnòstic Myalgic encephalomyelitis/chronic fatigue syndrome; Care; Diagnosis Encefalomielitis miálgica/síndrome de fatiga crónica; Cuidado; Diagnóstico Designed by a group of ME/CFS researchers and health professionals, the European Network on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (EUROMENE) has received funding from the European Cooperation in Science and Technology (COST)—COST action 15111—from 2016 to 2020. The main goal of the Cost Action was to assess the existing knowledge and experience on health care delivery for people with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) in European countries, and to enhance coordinated research and health care provision in this field. We report our findings and make recommendations for clinical diagnosis, health services and care for people with ME/CFS in Europe, as prepared by the group of clinicians and researchers from 22 countries and 55 European health professionals and researchers, who have been informed by people with ME/CFS. This research received no external funding. EUROMENE receives funding for networking activities from the COST programme (COST Action 15111), via the COST Association.

While periodontal disease is associated with many risk factors, socioeconomically disadvantaged communities experience the highest disease burden. The aim of this study was to evaluate the effectiveness of a personalized oral health education program, in combination with routine dental treatment, in participants from a low socioeconomic community. We used a randomized, controlled, examiner-blinded clinical trial. A total of 579 participants (aged 18&ndash, 60 years) were randomly grouped: the intervention group (n = 292) received a personalized oral health education program in combination with routine dental care and the control group (n = 287) received routine dental care. All participants were assessed for improvement in oral health care behaviors, dental plaque, and periodontal status at baseline, 12 months, and 24 months. We found a significant drop (p &lt, 0.001) in the plaque indices, Periodontal Probing Depths (PPD) and Bleeding on Probing (BOP) between baseline and the 12-month follow-up for both groups. For BOP, the number of sites positive was significantly different between baseline and the 24-month follow-up (p = 0.037). No differences were found between the two groups for any evaluated clinical outcome. The personalized oral health education program used in the current study did not appear to add significant improvement to clinical outcomes of periodontal health compared with routine restorative dental care per se.

Introduction Firefighters work in a ‘safety critical role’ and undergo comprehensive pre-employment screening. Applicants with a history of asthma (often made in childhood) are regularly referred to our specialist occupational lung disease service for additional assessment including measurement of non-specific bronchial hyper-responsiveness (NSBHR). No studies have reported the impact of a pre-existing asthma diagnosis on future employment as a firefighter; most have studied current firefighters1 or others in safety critical roles.2 We sought to identify factors associated with a positive NSBHR test amongst UK firefighter applicants, and to link these to symptoms and employment status around one year later. Methods We reviewed case notes for all firefighter applicants referred between 2005–2019; we defined NSBHR as a fall in FEV1 of at least 20% (provocation concentration (PC)20) following inhalation of Results Clinical data were available on 120 applicants of whom 19 (16%) had a positive NSBHR test (see table 1). Follow-up data were available on 116 applicants. Those with a positive NSBHR test (n=17; 14.7%) were less likely to be accepted into the fire service than those with a negative test (76.5% vs 95.0% respectively, p=0.026). However, of the 4 with a positive NSBHR and not accepted by the fire service, only 2 were due to asthma. Of the 90 serving firefighters at follow-up, only 2 (2.2%) reported any recent trouble with asthma. Conclusions NSBHR is associated with atopy and a lower FEV1 but it was not otherwise possible to predict NSBHR. Although many applicants had a history of asthma and 16% a positive NSBHR result, encouragingly, only two individuals’ applications were rejected due to their asthma; individuals with a history of asthma should not be deterred from applying to become a firefighter. Specialist assessment may be useful in determining evidence of asthma amongst firefighter applicants prior to recruitment. References Miedinger D. Chest, 2007;131:1760–1767. Miedinger D. Clinical & Experimental Allergy, 2010;40:224–231.

Background Health information technology (HIT) is known to reduce prescribing errors but may also cause new types of technology-generated errors (TGE) related to data entry, duplicate prescribing, and prescriber alert fatigue. It is unclear which component behaviour change techniques (BCTs) contribute to the effectiveness of prescribing HIT implementations and optimisation. This study aimed to (i) quantitatively assess the HIT that reduces prescribing errors in hospitals and (ii) identify the BCTs associated with effective interventions. Methods Articles were identified using CINAHL, EMBASE, MEDLINE, and Web of Science to May 2020. Eligible studies compared prescribing HIT with paper-order entry and examined prescribing error rates. Studies were excluded if prescribing error rates could not be extracted, if HIT use was non-compulsory or designed for one class of medication. The Newcastle-Ottawa scale was used to assess study quality. The review was reported in accordance with the PRISMA and SWiM guidelines. Odds ratios (OR) with 95% confidence intervals (CI) were calculated across the studies. Descriptive statistics were used to summarise effect estimates. Two researchers examined studies for BCTs using a validated taxonomy. Effectiveness ratios (ER) were used to determine the potential impact of individual BCTs. Results Thirty-five studies of variable risk of bias and limited intervention reporting were included. TGE were identified in 31 studies. Compared with paper-order entry, prescribing HIT of varying sophistication was associated with decreased rates of prescribing errors (median OR 0.24, IQR 0.03–0.57). Ten BCTs were present in at least two successful interventions and may be effective components of prescribing HIT implementation and optimisation including prescriber involvement in system design, clinical colleagues as trainers, modification of HIT in response to feedback, direct observation of prescriber workflow, monitoring of electronic orders to detect errors, and system alerts that prompt the prescriber. Conclusions Prescribing HIT is associated with a reduction in prescribing errors in a variety of hospital settings. Poor reporting of intervention delivery and content limited the BCT analysis. More detailed reporting may have identified additional effective intervention components. Effective BCTs may be considered in the design and development of prescribing HIT and in the reporting and evaluation of future studies in this area.

BackgroundThe 4-m gait speed (4MGS) test is a simple physical performance measure and surrogate marker of frailty that is associated with adverse outcomes in older adults. We aimed to assess the ability of 4MGS to predict prognosis in patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).Methods213 participants hospitalised with AECOPD (52% male, mean age 72 years and mean forced expiratory volume in 1 s (FEV1) 35% predicted) were enrolled. 4MGS and baseline demographics were recorded at hospital discharge. All-cause readmission and mortality were collected for 1 year after discharge and multivariable Cox proportional hazards regressions were performed. Kaplan–Meier and competing risks analyses were conducted comparing time to all-cause readmission and mortality between 4MGS quartiles.Results111 participants (52%) were readmitted and 35 (16%) died during the follow-up period. 4MGS was associated with all-cause readmission, with an adjusted subdistribution hazard ratio of 0.868 (95% CI 0.797–0.945; p=0.001) per 0.1 m·s−1 increase in gait speed, and with all-cause mortality, with an adjusted subdistribution hazard ratio of 0.747 (95% CI 0.622–0.898; p=0.002) per 0.1 m·s−1 increase in gait speed. Readmission and mortality models incorporating 4MGS had higher discrimination than age or FEV1 % pred alone, with areas under the receiver operator characteristic curves of 0.73 and 0.80, respectively. Kaplan–Meier and competing risks curves demonstrated that those in slower gait speed quartiles had reduced time to readmission and mortality (log-rank, both pConclusions4MGS provides a simple means of identifying at-risk patients with COPD at hospital discharge. This provides valuable information to plan post-discharge care and support.

Background: Serial peak flow monitoring is commonly used to diagnose occupational asthma (OA). Methods: A laboratory animal (LA) worker presented with work-related dyspnoea triggered by talking, dust and modest exertion. It was also present, to a lesser extent, away from work. She recorded her peak flow (PF) ≥4 times a day on consecutive days for 4 weeks. The values were plotted using specialist software. Results: Spirometry was normal (FEV1 2.98 (105%) and FVC 3.41 (106%)). PF plot showed striking work-related variability (fig 1); OASYS score was 3.91 and ABC score was 95 indicating >90% probability of OA. Serum specific IgE and skin prick tests to LA allergens were negative. There was no exposure to other respiratory sensitisers. Respiratory physiotherapy assessment identified breathing pattern disorder (Nijmegen Questionnaire score 46/64). We explained she did not have OA; her symptoms were managed with physiotherapy and she continued working in her existing role. Conclusions: Whilst serial PF monitoring remains an important tool in diagnosing OA, it is not 100% specific; results must be interpreted alongside the clinical history and, if available, immunology tests. PF measurements can be inaccurate in patients with abnormal breathing pattern and inducible laryngeal obstruction. Clinicians should be aware that such conditions may cause false positive results to avoid misdiagnosis of OA with potentially serious consequences.

Background: Respiratory exposure to aluminium dust can cause aluminosis, a rare but well described ILD with upper lobe fibrosis and peripheral emphysema. ILD associated with aluminium welding has rarely been reported; there are three case reports of probable aluminosis and one of “pulmonary granulomatosis” from the USA and one of desquamative interstitial pneumonia from the UK all presenting from 1978-1991. Methods: We report three recent cases from the UK of ILD in male aluminium welders, two of whom worked for the same company. Results: Conclusions: Little is reported about the constituents, and respiratory effects, of aluminium welding fumes. The number of people exposed to aluminium fumes is unknown but the reporting of associated ILD is extremely rare. We report three recent cases of ILD in aluminium welders, two of whom were from the same company, suggesting that a causal link is plausible and that, in these cases, the exposures may have been particularly high. Further work is underway to determine if other co-workers may be affected.

Background: In South Africa, the increased consumption of sugary drinks has been associated with increased obesity rates. Mass media campaigns can play a crucial role in improving knowledge, shifting attitudes, and building support for government action on reducing sugary drink consumption. No study to date has evaluated the effectiveness of mass media campaigns on the health harms of sugary drinks in South Africa. Objective: The purpose of this study was to evaluate the impact of a mass media campaign on knowledge and attitudes around sugary drinks and on public support for a proposed tax on sugary drinks in South Africa. Methods: The &ldquo, Are You Drinking Yourself Sick?&rdquo, campaign aired in South Africa from October 2016 to June 2017 to shift attitudes toward sugary drinks, build personal risk perceptions of the health harms of consuming sugary drinks, and build public support for a proposed tax on sugary drinks. Campaign impact was measured in representative cross-sectional household surveys of adults ages 18 to 56. The surveys were conducted just prior to the launch of the campaign (N = 1000), from October 7 to 10, 2016, and immediately following its conclusion (N = 1000), from July 12 to 21, 2017. Campaign impact was assessed by comparing changes from the pre-campaign to the post-campaign period on key outcome indicators. In addition, the effect of campaign awareness was analyzed in logistic regression analysis of the post-campaign data. Results: The campaign was recalled by 55% of survey respondents, and 78% of campaign-aware respondents said that the campaign&rsquo, s main message was &ldquo, drinking sugary drinks can make you sick.&rdquo, There were significant changes from the pre- to the post-campaign period in knowledge that sugary drink consumption can lead to obesity and related health problems and that sugary drinks contribute toward the obesity problem in South Africa. Campaign awareness was also significantly associated with increases in knowledge about the harms of sugary drinks, and in particular, on government action, including the proposed tax on sugary drinks. Discussion: Media campaigns are an effective intervention for obesity prevention. In addition to improving knowledge and shifting attitudes, media campaigns can effectively build public support for strong government action and therefore must be a component of a comprehensive obesity prevention approach.

Background Day care is an important service for many people with dementia and their carers. In Ireland, day care services for people with dementia are delivered by a mix of dementia-specific day care centres as well as generic day care centres that cater for people with dementia to various degrees. In this paper we examine the geographic distribution of day care services for people with dementia relative to potential need. Methods Using a national survey of day care centres, we estimate the current availability of day care services for people with dementia in the country. We use geographic information systems (GIS) to map day care provision at regional and sub-regional levels and compare this to the estimated number of people with dementia in local areas. Results There is significant variation across the country in the existing capacity of day care centres to cater for people with dementia. The number of places per 100 persons with dementia in the community varies from 14.2 to 21.3 across Community Health Organisation areas. We also show that 18% of people with dementia do not live within 15kms of their nearest day care centre. Conclusion Currently, day care centres, in many parts of the country, have limited capacity to provide a service for people with dementia who live in their catchment area. As the number of people with dementia increases, investment in day care centres should be targeted to areas where need is greatest. Our GIS approach provides valuable evidence that can help inform decisions on future resource allocation and service provision in relation to day care.

An Electronic Health Record (EHR) has been introduced to four Irish maternity units, with further implementations planned. Previous studies indicate that healthcare professionals are concerned that EHRs may increase time spent on documentation and medication-related tasks.To determine the impact of an EHR on task time distribution in a Neonatal Intensive Care Unit (NICU).A pre-post, time and motion study. An electronic data collection tool was used to collate time spent on direct care, professional communication, reviewing charts, documentation, and medication-related tasks. Interruptions and contact with the patient zone were quantified. Statistical significance was assessed using two-sample proportion tests, two-sample t-tests, and two-sample Wilcoxon rank-sum tests. A Bonferroni correction set significance at p ≤ 0.0025.63 doctors and nurses participated, with 169.23 h of data collected. There were no significant changes to nurses' task time distribution. The proportion of time spent by doctors on professional communication increased from 15.4% to 26.0% (p 0.001). Significant increases to median task times were seen for both doctors and nurses. Interruptions to tasks decreased post-implementation (p 0.001), as did frequency of contact with the patient zone (p 0.001).The EHR did not redistribute time towards documentation and medication-related tasks. A reduction in interruptions to tasks may streamline workflow. Decreased contact with the patient zone may improve patient safety through reduced potential for pathogen transmission.

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.

Exposures at work can give rise to different phenotypes of “work-related asthma.” The focus of this review is on the diagnosis and management of sensitizer-induced occupational asthma (OA) caused by either a high- or low-molecular-weight agent encountered in the workplace. The diagnosis of OA remains a challenge for the clinician because there is no simple test with a sufficiently high level of accuracy. Instead, the diagnostic process combines different procedures in a stepwise manner. These procedures include a detailed clinical history, immunologic testing, measurement of lung function parameters and airway inflammatory markers, as well as various methods that relate changes in these functional and inflammatory indices to workplace exposure. Their diagnostic performances, alone and in combination, are critically reviewed and summarized into evidence-based key messages. A working diagnostic algorithm is proposed that can be adapted to the suspected agent, purpose of diagnosis, and available resources. Current information on the management options of OA is summarized to provide pragmatic guidance to clinicians who have to advise their patients with OA.

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p