Harry S. Shannon

Disability resulting from occupational low back pain. Part II : What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins

This is the second of two papers that systematically review available scientific evidence on the causes of disability from occupational low back pain, and the effectiveness of interventions to prevent it after its onset (secondary prevention). This paper reviews the national history of how back pain and the risk factors for its extension into chronic disability, followed by a critical summary of intervention studies attempting to reduce the duration of this disability, and to evaluate the results.

Defining Obesity Cut Points in a Multiethnic Population

Background— Body mass index (BMI) is widely used to assess risk for cardiovascular disease and type 2 diabetes. Cut points for the classification of obesity (BMI >30 kg/m2) have been developed and validated among people of European descent. It is unknown whether these cut points are appropriate for non-European populations. We assessed the metabolic risk associated with BMI among South Asians, Chinese, Aboriginals, and Europeans. Methods and Results— We randomly sampled 1078 subjects from 4 ethnic groups (289 South Asians, 281 Chinese, 207 Aboriginals, and 301 Europeans) from 4 regions in Canada. Principal components factor analysis was used to derive underlying latent or “hidden” factors associated with 14 clinical and biochemical cardiometabolic markers. Ethnic-specific BMI cut points were derived for 3 cardiometabolic factors. Three primary latent factors emerged that accounted for 56% of the variation in markers of glucose metabolism, lipid metabolism, and blood pressure. For a given BMI, elevated levels of glucose- and lipid-related factors were more likely to be present in South Asians, Chinese, and Aboriginals compared with Europeans, and elevated levels of the blood pressure–related factor were more likely to be present among Chinese compared with Europeans. The cut point to define obesity, as defined by distribution of glucose and lipid factors, is lower by ≈6 kg/m2 among non-European groups compared with Europeans. Conclusions— Revisions may be warranted for BMI cut points to define obesity among South Asians, Chinese, and Aboriginals. Using these revised cut points would greatly increase the estimated burden of obesity-related metabolic disorders among non-European populations.

Readiness for organizational change: A longitudinal study of workplace, psychological and behavioural correlates

To examine factors influencing readiness for healthcare organizational change, 654 randomly selected hospital staff completed questionnaires measuring the logistical and occupational risks of change, ability to cope with change and to solve jobrelated problems, social support, measures of Karaseks (1979) active vs. passive job construct (job demand× decision latitude) and readiness for organizational change. Workers in active jobs (Karasek, 1979) which afforded higher decision latitude and control over challenging tasks reported a higher readiness for organizational change scores. Workers with an active approach to job problem-solving with higher job change self-efficacy scores reported a higher readiness for change. In hierarchical regression analyses, active jobs, an active job problem-solving style and job-change self-efficacy contributed independently to the prediction of readiness for organizational change. Time 1 readiness for organizational change scores and an active approach to job problem-solving were the best predictors of participation in redesign activities during a year-long re-engineering programme.

Screening for Intimate Partner Violence in Health Care Settings: A Randomized Trial

CONTEXT Whether intimate partner violence (IPV) screening reduces violence or improves health outcomes for women is unknown. OBJECTIVE To determine the effectiveness of IPV screening and communication of positive results to clinicians. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial conducted in 11 emergency departments, 12 family practices, and 3 obstetrics/gynecology clinics in Ontario, Canada, among 6743 English-speaking female patients aged 18 to 64 years who presented between July 2005 and December 2006, could be seen individually, and were well enough to participate. INTERVENTION Women in the screened group (n=3271) self-completed the Woman Abuse Screening Tool (WAST); if a woman screened positive, this information was given to her clinician before the health care visit. Subsequent discussions and/or referrals were at the discretion of the treating clinician. The nonscreened group (n=3472) self-completed the WAST and other measures after their visit. MAIN OUTCOME MEASURES Women disclosing past-year IPV were interviewed at baseline and every 6 months until 18 months regarding IPV reexposure and quality of life (primary outcomes), as well as several health outcomes and potential harms of screening. RESULTS Participant loss to follow-up was high: 43% (148/347) of screened women and 41% (148/360) of nonscreened women. At 18 months (n = 411), observed recurrence of IPV among screened vs nonscreened women was 46% vs 53% (modeled odds ratio, 0.82; 95% confidence interval, 0.32-2.12). Screened vs nonscreened women exhibited about a 0.2-SD greater improvement in quality-of-life scores (modeled score difference at 18 months, 3.74; 95% confidence interval, 0.47-7.00). When multiple imputation was used to account for sample loss, differences between groups were reduced and quality-of-life differences were no longer significant. Screened women reported no harms of screening. CONCLUSIONS Although sample attrition urges cautious interpretation, the results of this trial do not provide sufficient evidence to support IPV screening in health care settings. Evaluation of services for women after identification of IPV remains a priority. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00182468.

Overview of the relationship between organizational and workplace factors and injury rates

Abstract This paper summarizes data from ten studies examining the relationship between organizational and workplace factors and injury rates. The studies were identified from a systematic literature search, as well as from other sources, and were included if they reported comparisons among at least 20 workplaces. Factors that were examined in at least two studies were identified. Their relationship with injury rates was determined. It was not possible to make quantitative comparisons between studies. We looked for ‘consistency’ or ‘contradiction’ in the relationships. Among the variables ‘consistency’ associated with lower injury rates were: empowerment of the workforce (in general matters); delegation of safety activities; and an active role (in health and safety) of top management. Among the ‘contradictory’ variables were the level and use of discipline for safety violations; and several others that were contradictory only in subgroups of the same study. We discuss the limitations of synthesizing results from the diverse studies.

Effect of lung function and mode of inhalation on penetration of aerosol into the human lung.

The method using radioactive tracer particles has been applied to study the effect of the mode of inhalation of aerosols on the depth of deposition in the lungs of 50 patients with airways obstruction. The findings show that the penetration of particles is directly related to: (1) volume inspired per breath (VI); (2) forced expiratory volume in one second (FEV1); and inversely related to (3) flow rate during inhalation (V). In mathematical terms, alveolar deposition (%) = 40-3 (VI)+10-98 (FEV1)--0-75 (V)+40-4; for this regression F = 4-41 and P less than 0-01.

A case control study of carcinoma of the ovary.

There is increased concern over the apparent rise in incidence of patients with carcinoma of the ovary, particularly in older women. In an attempt to identify aetiological factors 300 women with cancer of the ovary diagnosed at laparatomy were studied. A questionnaire was administered to these women (Group A) and to two control groups matched by age. The first control group (Group B) comprised patients in a gynaecological ward and the second (Group C) comprised were shown in the obstetric history of the three groups. Fewer of the women in Group A had married and fewer had ever been pregnant and the family size was smaller. Significantly fewer of them recollected an attack of mumps, measles, or rubella. In all, only 81 of the whole series of 900 had used oral contraceptives, 19 of Group A and 31 in each of the control groups, a statistically significant deficiency. These findings support those of other investigations and suggest lines of further inquiry.

Upper limb work-related musculoskeletal disorders among newspaper employees: Cross-sectional survey results

At a metropolitan newspaper office in Canada with extensive video display terminal (VDT) use, researchers carried out a survey (n = 1,007, 84% response) to establish baseline prevalence of work-related musculoskeletal disorders (WMSDs) and to identify demographic, postural, task, and psychosocial factors associated with WMSD symptoms. One-fifth of the respondents reported moderate or worse upper limb pain recurring at least monthly or lasting more than a week over the previous year. Logistic regression showed that employees who faced frequent deadlines and high psychological demands (fast work pace and conflicting demands), had low skill discretion and social support, spent more time keyboarding, or who had their screen in a non-optimal position were more likely to report moderate to severe symptoms. Women reported significantly higher levels of symptoms than men.

The impact of re-engineering and other cost reduction strategies on the staff of a large teaching hospital: a longitudinal study.

OBJECTIVES To examine changes over time in the hospital staffs perceptions of how rapid organizational change, caused by fiscal constraints imposed by governments, affects them, their work environment, and the quality of care and services that they provide. METHODS A random sample of hospital employees (n = 900) of a large Ontario teaching hospital participated in a longitudinal study which involved surveys at 3 measurement periods over a 2-year period. The questionnaire used in this study included scales reflecting work environment, emotional distress, personal resources, spillover from work to home and vice versa, and perceptions regarding patient care and the hospital as an employer. RESULTS Significant increases in depression, anxiety, emotional exhaustion, and job insecurity were seen among employees, particularly during the first year of the change process. By the end of the second year, employees reported deterioration in team work, increased unclarity of role, and increased use of distraction to cope. Job demands increased throughout the period whereas little change occurred in the employees job influence or decision latitude. Overall, the work environment was negatively affected. Although patient care was unaffected in the first year, a significant decline in perceptions of patient care, attention to quality improvement, and overall quality of care were later seen. CONCLUSIONS This study raises questions about whether hospital re-engineering and mergers will be able to achieve the cost reductions sought without sacrificing quality of work life. Along with the rapid change, there was increase in emotional distress among staff and a deterioration in their relationship with their employer.

Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data

BACKGROUND WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability. METHODS We analysed information about availability and costs of cardiovascular disease medicines (aspirin, β blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry. FINDINGS Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India. The four cardiovascular disease medicines were potentially unaffordable for 0·14% of households in high-income countries (14 of 9934 households), 25% of upper middle-income countries (6299 of 24,776), 33% of lower middle-income countries (13,253 of 40,023), 60% of low-income countries (excluding India; 1976 of 3312), and 59% households in India (9939 of 16,874). In low-income and middle-income countries, patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available (odds ratio [OR] 0·16, 95% CI 0·04-0·57). In communities in which all four medicines were available, patients were less likely to use medicines if the household potentially could not afford them (0·16, 0·04-0·55). INTERPRETATION Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries, which have very low use of these medicines. Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHOs targets of 50% use of key medicines by 2025. FUNDING Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.