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Research Plus: April/May 2010

Hepatitis C meta-analysis

A meta-analysis found high rates of spontaneous clearance of hepatitis C virus in patients with acute infection. Anti-viral treatment should be delayed for 12 weeks to allow for this. Of the 22 studies meeting inclusion criteria, 16 were treatment studies (five randomised controlled trials). The clearance rate for untreated patients was 55.1%, and the average time from the onset of symptoms to spontaneous clearance was 9.7 weeks. For patients undergoing antiviral treatment – mostly peginterferon monotherapy or combination therapy – the overall sustained virological response rate (SVR = no detectable virus for six months after completing treatment) was 78%; significantly higher than the untreated rate. Viral clearance decreased if treatment was delayed: for treatment within 12 weeks of diagnosis, SVR = 82.5%; 66.9% for treatment at 12–24 weeks; and 62.5% for treatment beyond 24 weeks.

Influenza face masks

A critical review of research on the use of surgical masks to protect healthcare workers from pandemic influenza queries current World Health Organisation guidelines that recommend the use of standard surgical masks for all patient care, with the more efficient N95 respirators (equivalent to FFP2 masks in the UK) used for aerosol-generating procedures. The review examined 25 laboratory, and 21 human studies, but only six were of sufficient quality to evaluate their efficacy. A lack of high-quality research in healthcare settings led the review team, from the University of New South Wales, Australia, to conclude that the guidelines can neither be supported nor nullified at this stage.

Work-related MSDs

A systematic review that looked only at case–control or cohort studies confirms plausible causal relationships between various reported risk factors and work-related musculoskeletal disorders (MSDs). Sixty-three papers published between 1997 and 2008 were included, 51 of which were prospective cohort studies. There was reasonable evidence of a causal relationship between the development of work-related MSDs and high biomechanical and psychosocial demands, smoking, high body mass index and the presence of co-morbidities. Biomechanical risk factors include excessive repetition, awkward postures and heavy lifting.

Does OHS training work?

A systematic review was carried out to assess two fundamental questions: whether occupational health and safety (OHS) training has a beneficial effect on workers and employers; and whether higher engagement with training results in increased benefit. Twenty randomised controlled trials met initial inclusion criteria but only 14 were of sufficient quality for the evidence synthesis. There was strong evidence that OHS training was effective in changing targeted behaviours; small and inconsistent evidence that it had an effect on health; insufficient evidence on the effect of training on knowledge, attitudes and beliefs (though the existing evidence did show positive and large impacts); and insufficient evidence (too few studies) to conclude whether or not high-engagement training is more effective than medium- or low-engagement training.

Low back pain and exercise

Two systematic reviews examined the effect of exercise on low back pain (LBP). A Cochrane review looked at evidence for exercise as a means of preventing LBP recurrence1. It identified 13 papers reporting nine intervention studies. Four were post-treatment programmes intended to prevent LBP recurrence, while five covered exercise regimes that formed part of the treatment itself. There was moderate-quality evidence that post-treatment exercises can reduce the rate and number of LBP recurrences. Sickness absence duration (total days) was reduced by post-treatment exercises, but there was no effect on the rate of sickness absence (number of spells over time) – suggesting that exercise participants returned to work earlier from sick leave than those in ‘usual care’. There was conflicting evidence for the efficacy of the exercise treatment programmes on LBP recurrence.

The second study looked at the effect of exercise on work disability due to non-acute LBP2. It identified 23 studies meeting inclusion criteria, 20 suitable for meta-analysis. There was a significant long-term benefit of exercise compared with ‘usual care’ (work disability odds ratio = 0.66) but no significant improvement at short- or medium-term follow-up. Regimes involving more contact hours of exercise were no more effective than those of lower duration.

  1. Cochrane Database of Systematic Reviews 2010; 1: article no. CD006555. DOI: 10.1002/14651858.CD006555.pub2.
  2. Journal of Rehabilitation Medicine 2010; 42; 193–205.

Integrated care can reduce LBP disability

A programme of integrated care, directed at both the patient and the workplace, is beneficial for people with chronic low back pain (LBP), according to a randomised controlled trial carried out in the Netherlands. The multidisciplinary intervention was designed to restore occupational functioning and achieve lasting return to work in the patients’ own job or similar work. Patients were randomised either to ‘usual care’ or to a programme that combined participatory ergonomics with graded activity based on cognitive behavioural principles. Mean sickness absence duration was 88 days in the integrated care group, compared with 208 days in the usual care group (p = 0.003). Median sickness absence in the 12 months’ follow-up was 82 days in the intervention group, compared with 175 in the usual care group (p = 0.003). The authors acknowledge that a Hawthorne effect cannot be ruled out.

GPs do not follow LBP guidelines

A large-scale analysis of primary healthcare of patients with low back pain (LBP) found that GPs frequently did not follow international best-practice guidelines and that patient outcomes were often suboptimal. The study, carried out in Australia between 2005 and 2008, mapped 3,533 GP patient visits with a new episode of LBP. More than one-quarter (25.3%) of patients were referred for imaging, even though this is generally discouraged. Similarly, while it is generally recommended that initial care should focus on advice and simple analgesic medication (eg paracetamol), only 20% of patients received the former and 17% the latter. Where paracetamol was prescribed, only one-third of patients were given the correct dose. Doctors tended instead to prescribe non-steroidal anti-inflammatory drugs (37%) and opioids (20%). A comparison of referrals in the period 2001–2004 found that GP practice had not generally improved since the release of an Australian LBP guideline in 2004.

Exercise training to treat anxiety

A systematic review found ‘solid evidence to recommend exercise training to patients as a means for reducing anxiety symptoms with minimal risk of adverse events’. It included 40 papers published from 1995 to 2007. Exercise training significantly reduced anxiety scores among patients with chronic illness, and sessions lasting longer than 30 minutes had a greater impact than sessions of shorter duration. Programmes lasting three to 12 weeks produced significantly larger effects than those lasting more than 12 weeks – the authors suggest this may be due to better adherence to the training in the shorter programmes.

Controlling your working patterns

According to this Cochrane review, flexible working is generally beneficial for health and wellbeing, but only where individuals rather than employers have control over the working patterns. All 10 papers meeting inclusion criteria were controlled before-and-after studies rather than randomised controlled trials – thus limiting the evidence quality – and follow-up was restricted to 12 months, so longer-term effects on physical or mental health could not be evaluated. The authors’ ‘tentative’ conclusions were that flexible working interventions that increase worker control and choice – such as self-scheduling or gradual/partial retirement – were generally health enhancing, whereas workplace interventions ‘motivated or dictated by organisational interests, such as fixed-term contract and involuntary part-time employment’, had equivocal or negative effects on health.

Cancer risk in painters

A meta-analysis led by the International Agency for Research on Cancer found a causal association between occupation as a painter and cancer. The analysis included all cohort, record-linkage, and case–control studies published up to August 2009 – 47 in total – and resulted in a summary relative risk for lung cancer in painters of 1.35 after controlling for smoking. Risk increased with duration of employment. There was insufficient data to examine the effects of specific chemicals.

 

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