Nerys Williams

Occupational Asthma. An assessment of diagnostic agreement between physicians.

Objectives: To investigate the levels of agreement between expert respiratory physicians when making a diagnosis of occupational asthma. Methods: 19 cases of possible occupational asthma were identified as part of a larger national observational cohort. A case summary for each case was then circulated to 12 physicians, asking for a percentage likelihood, from the supplied information, that this case represented occupational asthma. The resulting probabilities were then compared between physicians using Spearman’s rank correlation and Cohen’s κ coefficients. Results: Agreement between the 12 physicians for all 19 cases was generally good as assessed by Spearman’s rank correlation. For all 66 physician–physician interactions, 45 were found to correlate significantly at the 5% level. The agreement assessed by κ analysis was more variable, with a median κ value of 0.26, (range –0.2 to +0.76), although 7 of the physicians agreed significantly (p<0.05) with ⩾5 of their colleagues. Only in one case did the responses for probability of occupational asthma all exceed the “on balance” 50% threshold, although 12 of the 19 cases had an interquartile range of probabilities not including 50%, implying “on balance” agreement. The median probability values for each physician (all assessing the identical 19 cases) varied from 20% to 70%. Factors associated with a high probability rating were the presence of a positive serial peak expiratory flow Occupation Asthma SYStem (OASYS)-2 chart, and both the presence of bronchial hyper-reactivity and significant change in reactivity between periods of work and rest. Conclusions: Despite the importance of the diagnosis of occupational asthma and reasonable physician agreement, certain variations in diagnostic assessment were seen between UK expert centres when assessing paper cases of possible occupational asthma. Although this may in part reflect the absence of a normal clinical consultation, a more unified national approach to these patients is required.

Teaching of occupational medicine to undergraduates in UK schools of medicine.

Objectives  To assess any recent change in the commitment to teaching of occupational medicine in UK undergraduate medical curricula.

Work Rules: Insights from Inside Google That Will Transform How You Live and Lead

The three main authors are academics with chairs of physical medicine and rehabilitation within North America. Of a total of 214 contributors only three were from Europe. The aim of the book is to cover a variety of medical conditions any specialist or GP could encounter in his or her medical practice. There is an emphasis on chronic medical conditions requiring rehabilitation from the practitioners’ perspectives in an ambulatory setting. The concept is to complement existing texts of rehabilitation medicine and provide an efficient and useful reference tool in the office setting. The 162 chapters are divided into three parts covering musculoskeletal, pain and rehabilitation of chronic medical conditions. Chapters are well organized to a set pattern including synonyms, ICD coding, definitions, symptoms, physical examination (findings), functional limitations, diagnostic studies, treatment (initial, rehabilitation, procedures including surgery), potential disease complications, potential treatment complications and references. Although standing alone each chapter follows in logical order with respect of anatomical or related conditions. The entire book is very readable and although orientated to world rather than purely UK medicine deals succinctly with most important issues. The text is scientifically correct and is superbly illustrated with extremely clear radiological images. The tables showing details of physical examination manoeuvres are particularly helpful. The book is comprehensive except for the provision of an index rather than just chapter headings in the hard copy version and details specifically about cognitive testing, cold injuries and skin conditions other than systemic lupus erythematosus. Some medical complications of physical medicine and rehabilitation are better dealt with by Cardenas and Hooton in their focused manual on the subject. This edition covers new topics such as labral tears (shoulder and hip) and conditions associated with cancer and its treatment. The book serves well as a useful and economic reference source for its wide intended audience. As an occupational physician, it represents at present a helpful source of specialized reference material. Unless rehab services in the UK become more accessible, the book is likely to become a standard aid in dealing with multidisciplinary teams treating severely injured employees.

The Mood Disorder Questionnaire

Question 1 comprises 13 items enquiring about whether the patient feels they have been their usual self, specifically about their levels of energy, of self confidence and irritability to name a few items. Question 2 enquires if several of the items in Question 1 have occurred at the same time. Question 3 asks about how much of a problem the symptoms have been in work/social life/relationships.

Every cloud has a silver lining … even a failed private practice

Born in Scotland to an English father and an Irish mother, this man was educated at a Jesuit school before entering Stonyhurst College. His poor finances led him to seek a respectable job. He studied medicine and spent some time in general practice in Aston near Birmingham. While still young he published several short stories. He was not, however, an indoor type. During his studies, he spent time as a ship’s doctor firstly on a Greenland whaler and then on a voyage up the West African coast. He prepared a paper, published in the Lancet, on the diagnosis of leucocythaemia. He then returned to university and completed his doctorate on ‘vasomotor changes in tabes dorsalis’. Having graduated, he joined a practice in Plymouth. But things did not work out and he left to set up his own practice in Portsmouth. He was not successful and had few patients. He used one of his medical teachers at the university, Professor Joseph Bell, to form the basis of his most famous character in short stories. He had worked as ward assistant for Professor Bell and this enabled him to see the man at close quarters. Bell took delight in observing people and said that the walk of a sailor was different than that of a soldier. He was expert at detecting differences in accents and studied the hands to see if there were any calluses or marks which could indicate their job. Bell said ‘all careful teachers have first to show the student how to recognise accurately the case. Recognition depends on accurate and rapid appreciation of small points in which the diseased state differs from the healthy.’ Thus, this eminent professor spent time and effort on determining patients’ occupations and insisted his students did the same. From Portsmouth our subject went to Vienna to study ophthalmology. That was also a fiasco and he returned to private practice in Wimpole Street. The same lack of patients occurred again. In his autobiography, he reported that no patients crossed his doorstep. But fate was about to strike. He suffered influenza and was at death’s door. He emerged realizing that he could not combine medical and literary careers and so opted for the latter. His success as a writer of plays and stories was phenomenal but he managed to see military service and it was for this that he was knighted, helped by the fact that the Monarch was a fan. He drove fast cars, spent his life playing golf, flying hot air balloons and airplanes and was into bodybuilding. Who knows what might have happened if his private practice had been successful. We might have been deprived of Sherlock Holmes and Dr Watson and Arthur Conan Doyle may never have become the household name he is today. Nerys Williams R. HOUSE ET AL.: UPPER EXTREMITY DISABILITY IN HAVS 173

Obesity Prevention and Public Health

Although recognised clinically for some time as an important condition that increases risk of ill-health in affected individuals, it is only recently that obesity has been recognised as a population-wide problem that requires preventive action. Disturbingly the epidemic is not confined to developed countries, with many developing countries and those in transition affected. This book draws together the existing literature and expertise with a view to helping set the agenda for public health action. The book is divided into three sections.