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BackgroundLimited research suggests that non-occupational health doctors rarely discuss occupation with their patients. There is a gap in research regarding the attitudes and practices of doctors towards discussing patient occupation and return to work. The aim of this work was to explore the attitudes of ophthalmology doctors towards work as a clinical outcome and assess the need for occupational health training among participants (doctors).MethodsA cross-sectional survey among doctors working in ophthalmology in two London teaching hospitals. The survey focused on the attitudes of doctors towards 'work' as a clinical outcome, their practices of asking patients about occupation, their perceived level of competency in this area of clinical practice and the level of training doctors had received in this field. Descriptive data analysis was undertaken and results presented as frequencies and proportions.ResultsThe response rate was 30/72 (42%). Approximately a quarter (8/30;27%) of doctors 'always' discussed return to work during care planning whilst the majority (25/30;87%) of doctors agreed or strongly agreed that this should always be the case. Over half of the doctors had received no formal OH training on how to discuss or assess the impact of health on work and only 17/30 (57%) considered themselves competent in discussing these work outcomes with patients. Over half agreed that additional training would be useful, with the majority believing that it would be most useful at all stages of medical training.ConclusionWe found the majority of ophthalmology doctors regard 'return to work' as an important clinical outcome yet most do not routinely discuss work outcomes with patients to inform care planning. Majority of doctors lack training in how to discuss issues relating to work and would benefit from additional OH training.

Objective To explore the patterns of sickness absence in National Health Service (NHS) staff attributable to mental ill health during the first wave of the COVID-19 epidemic in March–July 2020.Design Case-referent analysis of a secondary dataset.Setting NHS Trusts in England.Participants Pseudonymised data on 959 356 employees who were continuously employed by NHS trusts during 1 January 2019 to 31 July 2020.Main outcome measures Trends in the burden of sickness absence due to mental ill health from 2019 to 2020 according to demographic, regional and occupational characteristics.Results Over the study period, 164 202 new sickness absence episodes for mental ill health were recorded in 12.5% (119 525) of the study sample. There was a spike of sickness absence for mental ill health in March–April 2020 (899 730 days lost) compared with 519 807 days in March–April 2019; the surge was driven by an increase in new episodes of long-term absence and had diminished by May/June 2020. The increase was greatest in those aged >60 years (227%) and among employees of Asian and Black ethnic origin (109%–136%). Among doctors and dentists, the number of days absent declined by 12.7%. The biggest increase was in London (122%) and the smallest in the East Midlands (43.7%); the variation between regions reflected the rates of COVID-19 sickness absence during the same period.Conclusion Although the COVID-19 epidemic led to an increase in sickness absence attributed to mental ill health in NHS staff, this had substantially declined by May/June 2020, corresponding with the decrease in pressures at work as the first wave of the epidemic subsided.

Background: The NHS is the biggest employer in the UK. Depression and anxiety are common reasons for sickness absence among staff. Evidence suggests that an intervention based on a case management model using a biopsychosocial approach could be cost-effective and lead to earlier return to work for staff with common mental health disorders. Objective: The objective was to assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of an early occupational health referral and case management intervention to facilitate the return to work of NHS staff on sick leave with any common mental health disorder (e.g. depression or anxiety). Design: A multicentre mixed-methods feasibility study with embedded process evaluation and economic analyses. The study comprised an updated systematic review, survey of care as usual, and development of an intervention in consultation with key stakeholders. Although this was not a randomised controlled trial, the study design comprised two arms where participants received either the intervention or care as usual. Participants: Participants were NHS staff on sick leave for 7 or more consecutive days but less than 90 consecutive days, with a common mental health disorder. Intervention: The intervention involved early referral to occupational health combined with standardised work-focused case management. Control/comparator: Participants in the control arm received care as usual. Primary outcome: The primary outcome was the feasibility and acceptability of the intervention, study processes (including methods of recruiting participants) and data collection tools to measure return to work, episodes of sickness absence, workability (a worker’s functional ability to perform their job), occupational functioning, symptomatology and cost-effectiveness proposed for use in a main trial. Results: Forty articles and two guidelines were included in an updated systematic review. A total of 49 of the 126 (39%) occupational health providers who were approached participated in a national survey of care as usual. Selected multidisciplinary stakeholders contributed to the development of the work-focused case management intervention (including a training workshop). Six NHS trusts (occupational health departments) agreed to take part in the study, although one trust withdrew prior to participant recruitment, citing staff shortages. At mixed intervention sites, participants were sequentially allocated to each arm, where possible. Approximately 1938 (3.9%) NHS staff from the participating sites were on sick leave with a common mental health disorder during the study period. Forty-two sick-listed NHS staff were screened for eligibility on receipt of occupational health management referrals. Twenty-four (57%) participants were consented: 11 (46%) received the case management intervention and 13 (54%) received care as usual. Follow-up data were collected from 11 out of 24 (46%) participants at 3 months and 10 out of 24 (42%) participants at 6 months. The case management intervention and case manager training were found to be acceptable and inexpensive to deliver. Possible contamination issues are likely in a future trial if participants are individually randomised at mixed intervention sites. Harms: No adverse events were reported. Limitations: The method of identification and recruitment of eligible sick-listed staff was ineffective in practice because uptake of referral to occupational health was low, but a new targeted method has been devised. Conclusion: All study questions were addressed. Difficulties raising organisational awareness of the study coupled with a lack of change in occupational health referral practices by line managers affected the identification and recruitment of participants. Strategies to overcome these barriers in a main trial were identified. The case management intervention was fit for purpose and acceptable to deliver in the NHS. Trial registration: Current Controlled Trials ISRCTN14621901. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 12. See the NIHR Journals Library website for further project information.

Background: Although strategies have been developed to minimise the risk of occupational hand dermatitis in nurses, their clinical effectiveness and cost-effectiveness remain unclear. Objectives: The Skin Care Intervention in Nurses trial tested the hypothesis that a behaviour change package intervention, coupled with provision of hand moisturisers, could reduce the point prevalence of hand dermatitis when compared with standard care among nurses working in the NHS. The secondary aim was to assess the impact of the intervention on participants’ beliefs and behaviour regarding hand care, and the cost-effectiveness of the intervention in comparison with normal care. Design: Cluster randomised controlled trial. Setting: Thirty-five NHS hospital trusts/health boards/universities. Participants: First-year student nurses with a history of atopic tendency, and full-time intensive care unit nurses. Intervention: Sites were randomly allocated to be ‘intervention plus’ or ‘intervention light’. Participants at ‘intervention plus’ sites received access to a bespoke online behaviour change package intervention, coupled with personal supplies of moisturising cream (student nurses) and optimal availability of moisturising cream (intensive care unit nurses). Nurses at ‘intervention light’ sites received usual care, including a dermatitis prevention leaflet. Main outcome measure: The difference between intervention plus and intervention light sites in the change of point prevalence of visible hand dermatitis was measured from images taken at baseline and at follow-up. Randomisation: Fourteen sites were randomised to the intervention plus arm, and 21 sites were randomised to the intervention light arm. Blinding: The participants, trial statistician, methodologist and the dermatologists interpreting the hand photographs were blinded to intervention assignment. Numbers analysed: An intention-to-treat analysis was conducted on data from 845 student nurses and 1111 intensive care unit nurses. Results: The intention-to-treat analysis showed no evidence that the risk of developing dermatitis was greater in the intervention light group than in the intervention plus group (student nurses: odds ratio 1.25, 95% confidence interval 0.59 to 2.69; intensive care unit nurses: odds ratio 1.41, 95% confidence interval 0.81 to 2.44). Both groups had high levels of baseline beliefs about the benefits of using hand moisturisers before, during and after work. The frequency of use of hand moisturisers before, during and after shifts was significantly higher in the intensive care unit nurses in the intervention plus arm at follow-up than in the comparator group nurses. For student nurses, the intervention plus group mean costs were £2 lower than those for the comparator and 0.00002 more quality-adjusted life-years were gained. For intensive care unit nurses, costs were £4 higher and 0.0016 fewer quality-adjusted life-years were gained. Harms: No adverse events were reported. Limitations: Only 44.5% of participants in the intervention plus arm accessed the behaviour change package. Conclusion: The intervention did not result in a statistically significant decrease in the prevalence of hand dermatitis in the intervention plus group. Future work: Participants had a high level of baseline beliefs about the importance of using hand moisturisers before, during and after work. Future research should focus on how workplace culture can be changed in order for that knowledge to be actioned. Trial registration: Current Controlled Trials ISRCTN53303171. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 58. See the NIHR Journals Library website for further project information.

Abstract Background Allocating national resources to regions based on need is a key policy issue in most health systems. Many systems utilise proxy measures of need as the basis for allocation formulae. Increasingly these are underpinned by complex statistical methods to separate need from supplier induced utilisation. Assessment of need is then used to allocate existing global budgets to geographic areas. Many low and middle income countries are beginning to use formula methods for funding however these attempts are often hampered by a lack of information on utilisation, relative needs and whether the budgets allocated bear any relationship to cost. An alternative is to develop bottom-up estimates of the cost of providing for local need. This method is viable where public funding is focused on a relatively small number of targeted services. We describe a bottom-up approach to developing a formula for the allocation of resources. The method is illustrated in the context of the state minimum service package mandated to be provided by the Indonesian public health system. Methods A standardised costing methodology was developed that is sensitive to the main expected drivers of local cost variation including demographic structure, epidemiology and location. Essential package costing is often undertaken at a country level. It is less usual to utilise the methods across different parts of a country in a way that takes account of variation in population needs and location. Costing was based on best clinical practice in Indonesia and province specific data on distribution and costs of facilities. The resulting model was used to estimate essential package costs in a representative district in each province of the country. Findings Substantial differences in the costs of providing basic services ranging from USD 15 in urban Yogyakarta to USD 48 in sparsely populated North Maluku. These costs are driven largely by the structure of the population, particularly numbers of births, infants and children and also key diseases with high cost/prevalence and variation, most notably the level of malnutrition. The approach to resource allocation was implemented using existing data sources and permitted the rapid construction of a needs based formula that is highly specific to the package mandated across the country. Refinement could focus more on resources required to finance demand side costs and expansion of the service package to include priority non-communicable services.

A Rhodococcus erythropolis strain was isolated from soil on the basis of its ability to use acetaminophen as the sole source of both carbon and energy for growth. When grown in a complex medium containing an anilide inducer compound, the bacterium exhibited aryl acylamidase (EC 3.5.1.13) activity. This activity was not subject to carbon or nitrogen repression by the growth medium constituents as the enzyme was present throughout the exponential growth phase. The anilide was converted to the corresponding aniline, which was not further degraded. The enzyme was partially purified by a variety of methods including a batch ion exchange procedure, column ion exchange chromatography and hydrophobic interaction chromatography. The enzyme had a maximum activity at around pH 8.0 and had a Km for acetaminophen of 0.11 mM. Electrochemical assays of aryl acylamidase activity are described. The enzyme is suitable for use as a reagent in the clinical diagnostic measurement of acetaminophen.

Thirty-two patients older than 60 years underwent surgical treatment for lumbar disc herniation over a 10-year period. Other causes of low-back pain and sciatica were investigated, and bony nerve root entrapment syndromes were not included. Sciatica was a predominant symptom and was present in all patients, with 81% showing positive nerve root tension signs. Motor deficit was found in more than half of the cases. A sequestrated disc was present in 50%. The follow-up ranged from 1 to 10 years with an average of 50 months. Eighty-seven percent of the patients had excellent or good results. There were no poor results and no one required reoperation. Lumbar disc herniation in the elderly is not a common problem, but surgery yields a high rate of satisfactory results if a proper investigation and correct diagnosis is obtained.

The Roger Anderson external fixator was used in the treatment of unstable fractures of the distal radius in 52 patients, and the results evaluated after a follow-up averaging 58 months. The indications for its use were failure to maintain adequate closed reduction using plaster, and instability of the fracture as determined by the initial radiographs. Our radiological criteria for instability included dorsal angulation of more than 20 degrees, fractures involving the joint, radial shortening of more than 10 mm, and severe dorsal comminution. Using the Lucas modification of the Sarmiento demerit point-rating system, we found that 46 patients (89%) had good or excellent results and six (11%) were classified as fair. There were no poor results. Seven patients (14%) developed complications. None of these affected the long-term results except in one elderly woman where the pins loosened and had to be removed.

We evaluated the results of 85 patients having L4-L5 disc excision (52 having disc excision alone, and 33 having disc excision and fusion) using the Smiley-Webster scale at an average follow-up of 7.3 years. Both groups (fusion and nonfusion) were comparable except that the nonfusion group had a significantly higher percentage of patients with a history of chronic back pain and degenerative changes on their initial radiographs. The fusion group had significantly better results compared with the nonfusion group (85% satisfactory results versus 39% satisfactory results). The most common cause of unsatisfactory results in the fusion group was pseudarthrosis (two) while progressive degenerative disc disease (18) and recurrent disc prolapse (eight) were the most common cause of unsatisfactory results in the nonfusion group. The overall reoperation rate was 9.4% (13.5% in the nonfusion group, and 3% in the fusion group.

We reviewed the cases of 60 children with acute osteomyelitis with an average follow-up of 34 months. All patients were treated initially with high-dose intravenous (i.v.) antibiotics. Eight patients did not respond to this treatment within 48 h and had surgical drainage. The remaining 52 patients were divided into two subgroups: (a) 35 patients received i.v. antibiotics for an average of 21 days; (b) 17 patients received i.v. antibiotics for an average of 8 days followed by 4 weeks of oral therapy with monitoring of serum bactericidal levels. The incidence of chronic infection (12% for the operatively treated group and 4% for the nonoperatively treated group) depended more on the time interval between the presentation of symptoms and the onset of treatment than it did on the route of antibiotic administration.