What do consultant occupational physicians do in the National Health Service? An audit.

AIM: To assess the range of activities undertaken by National Health Service (NHS) consultant occupational physicians, and quantify the proportion of time spent on these so that appropriate guidance and a model job description may be developed by the Association of NHS Occupational Physicians (ANHOPS). METHODS: A questionnaire was developed and sent to all full time consultant occupational health physicians (as recorded on the ANHOPS database). RESULTS: Sixty-five questionnaires were sent out, of which 38 were returned (59%). Only 31(48%) of replies matched the entry criteria of being full-time NHS consultants returning fully completed questionnaires. An average of 18 h face-to-face clinical work (range = 0-36 h) over five sessions (range = 0-9 sessions) was found. Remaining time was predominantly spent on clinical administrative work although some consultants took on a variety of other managerial activities. CONCLUSIONS: Responding full-time NHS consultant OHPs found it difficult to quantify and categorize their workloads, particularly for non-clinical work. Their responsibilities vary widely. Of use for job planning purposes is the average commitment of clinical sessions (five).

Healthy workplace indicators: costing reasons for sickness absence within the UK National Health Service.

Sandwell Healthcare NHS Trust has been developing a tool for monitoring the reasons and costs of long-term sick leave (> 7 days). The data obtained from this process has been used to modify the type of occupational health and safety services provided for the Trust. Adoption of more standardized tools of this nature throughout the National Health Service (NHS) would help trusts to compare, and where appropriate enhance, the services provided by occupational health. Musculo-skeletal and mental health problems, account for the greatest costs arising from long-term sickness absence. It may therefore be prudent for NHS employers and their occupational health services to target their efforts on these particular problems.

Audit of immunization policy and practice of health care workers within National Health Service Trusts in England and Wales.

The purpose of this study was to identify the variation in occupational health immunization policies and practice within NHS Trusts throughout England and Wales. Questionnaires were sent to 440 NHS Trusts and 279 were returned (a response rate of 63%). The results were compared with current Department of Health Guidelines. They highlighted the fact that NHS Trusts do not adopt a consistent approach to immunization practice and that these policies often do not reflect Department of Health Guidance. Of those responding, 249 (89%) stated that they would like additional guidance on immunization practice within the NHS workplace. The production of updated, evidence-based guidelines for immunization practice, may help to ensure that a more consistent approach is taken throughout the NHS. This would benefit both the Trusts and their employees who at present may be confused by being given different advice when moving between Trusts.

Variation between experienced observers in the interpretation of accident and emergency radiographs.

Skill mix and role extension initiatives have highlighted the difficulty of establishing quality standards for the accuracy of plain film reporting. An acceptable performance might be one which is indistinguishable from that of a group of experienced consultant radiologists. In order to assess the feasibility of setting such a standard, the variation between experienced observers must first be established. This study examines the variation found between three observers with the three major types of plain film examination. 402 plain film examinations (205 skeletal, 100 chest and 97 abdominal) performed on accident and emergency patients were reported retrospectively and independently by three experienced radiologists. The clinical data supplied on the request cards were available to the readers. Each examination was categorized by each reader as being normal, as showing significant abnormality relevant to the current clinical problem, or as showing insignificant or irrelevant abnormality. Concordance between all three readers was found in 51%, 61% and 74% of abdominal, chest and skeletal radiographs, respectively. Weighted kappa values confirmed that the level of agreement between pairs of observers was higher with skeletal radiographs (kappa w = 0.76-0.77) than with chest (kappa w = 0.63-0.68), or abdominal (kappa w = 0.50-0.78) examinations. However, the frequency of major disagreements (at least one reader reporting "normal" and one reporting "relevant abnormality") was similar for abdominal (11%), chest (12%) and skeletal (10%) radiographs. When the reports were reclassified into only two groups--either significantly abnormal or not--pairs of observers disagreed on 9-10% of skeletal, 11-19% of chest and 8-18% of abdominal cases. The average incidence of errors per observer was estimated to be in the range 3-6%. The magnitude of interobserver variation in plain film reporting is considerable, and must be taken into account when designing assessment techniques and setting quality standards for this activity.

A comparison of iodixanol with iopamidol in aorto-femoral angiography.

This double-blind, randomized, parallel group clinical investigation in 140 consecutive patients undergoing aorto-femoral arteriography was carried out to compare iodixanol (Visipaque) 270 mgI ml-1 with iopamidol (Iopamiro) 300 mgI ml-1. The aims of the study were to compare adverse events and discomfort, clinical chemistry parameters in blood, haemodynamics and diagnostic information of the angiograms in the two groups. The main parameter for statistical analysis was the visual analogue scale (VAS) score for overall discomfort experienced by the patients during the examination. 134 patients, 69 and 65 receiving iodixanol and iopamidol, respectively, were examined according to the protocol and included in the evaluation. The two groups of patients were judged to be comparative. Statistically significant milder discomfort was felt with iodixanol than with iopamidol (p = 0.0001); mean VAS values 16 mm and 51 mm, respectively. Pain was reported far less frequently after iodixanol than after iopamidol (7.4% versus 50.8%) whereas sensation of warmth was less intense after iodixanol than after iopamidol. Four patients in the iodixanol group and two in the iopamidol group reported transient, non-serious adverse events. The difference was not statistically significant (p = 0.68). Systolic blood pressure was affected to a slightly greater degree after injection of iopamidol than after injection of iodixanol. Measurements of diastolic blood pressure, as well as clinical chemistry parameters in blood, revealed no changes of clinical importance, and all arteriograms performed were of diagnostic value. The conclusion is that iodixanol 270 mgI ml-1 is as efficacious as iopamidol 300 mgI ml-1, but produces less discomfort during arteriography. As such, iodixanol is a good alternative to iopamidol in aorto-femoral angiography.

Squash.

Squash is a game which demands physical fitness: you should be fit to play squash, not play squash to get fit. GPs may expect to see eye injuries, tennis elbow, ankle injuries and Achilles tendon ruptures. A knowledge of the nature of the game can help in the management of the problem.

Hockey.

Hockey players as a whole do not suffer from the same degree of overuse injuries that many athletes experience. However, they do sustain a large number of contact injuries. A few minutes explanation as to the immediate treatment required may well reduce the number of times the player has to return to the surgery in the future.

Computerized tomography of the sacro-iliac joints in the diagnosis of sacro-iliitis.

The radiological confirmation of sacro-iliitis is essential for the early diagnosis of ankylosing spondylitis. Conventional radiography is too insensitive to detect early changes in these joints, and radionuclide scintigraphy is a non-specific, though highly sensitive, technique. This study describes a preliminary survey of the use of computed tomography (CT) of the sacro-iliac joints in the diagnosis of early sacro-iliitis. Patients were selected for study from a routine rheumatology clinic. Entry criteria included a clinical suspicion of sacro-iliitis and normal or equivocal findings on conventional radiography. Twenty-two patients were selected for study. Nine had normal plain films and normal CT; four had equivocal plain films with conclusive evidence of sacro-iliitis on CT; in two cases, conventional radiographs were normal but CT showed clear evidence of sacro-iliitis; two other patients had equivocal findings on straight X-ray examination but normal CT. Computerized tomography of the sacro-iliac joints can be useful in the early diagnosis of sacro-iliitis if conventional radiography is equivocal or normal. Further controlled studies are necessary to establish the sensitivity and specificity of the technique.

Skeletal trauma from chain-saw injuries.

Some of the radiologic features of chain-saw injuries are described. These occurred in an industrial logging community, where the use of such machines is common. The increasing availability of chain saws for domestic use makes it likely that accident and emergency departments will be seeing a wide variety of injuries following accidents with chain saws. The radiologic appearances include the chipping of bone, the breaching of joint cavities, and partial severing of tubular bones.

The diagnosis of acute gallbladder disease by technetium-99m-labelled HIDA hepatobiliary scanning.

A series of 105 patients with upper abdominal pain suggestive of biliary colic who had hepatobiliary scans within 48 h of admission to hospital is presented. Fifty of the 65 patients with abnormal scans had operative treatment and gallbladder pathology was found in every case. Fourteen of these patients had hepatobiliary scans which also showed delayed excretion of tracer into the duodenum, and of these, 12 were found to have common bile duct stones and one a stricture of the distal end of the common bile duct. Of the 40 patients who had normal scans, 7 were found to have gallstones on further investigation. In these patients abnormal hepatobiliary scans have shown a 100 per cent correlation with gallbladder disease. We suggest that this is the investigation of choice for the surgeon contemplating early cholecystectomy on patients with suspected acute gallbladder disease.

Soft tissue changes in early rheumatoid arthritis as seen on xeroradiography and non-screen radiographs.

Forty-seven patients with early or newly established rheumatoid arthritis were studied with non-screen radiography and xerography. Estimations of soft tissue swelling, bone erosion and cysts were made by two observers and the results compared between observers and the two types of imaging. The results indicate no significant advantage or disadvantage in xerographic imaging compared with non-screen radiographs in the identification of superficial soft tissue swelling and bone erosions. More cysts were, however, identified on the radiographs. In a previous anatomical study of the dissected hand, xerography showed definite advantages in the detection of certain features.

Sequential liver and biliary tract scanning with 131I labelled Rose Bengal.

131I labelled Rose Bengal is offered as an aid for estimating the functional state of the liver, gall bladder and patency of the biliary tree. When the tracer is injected intravenously, it is cleared from the blood by the polygonal cells of the liver, excreted into the bowel and discharged into the duodenum. The equipment used was a gamma camera and small digital image processing system with area of interest capability. The diagnostic criteria used were those of blood retention, maximum hepatic uptake, liver, gall bladder and biliary tree visualisation times and time of excretion into the duodenum. Preliminary results from the findings in 60 patients of whom 42 were jaundiced are presented to demonstrate the ability of the technique to disclose evidence indicating intra- or extrahepatic causes of jaudice. Of 33 patients with proven extrahepatic obstruction Rose Bengal scanning provided the correct evidence in 31 cases, the other two having intermittent obstruction by common bile duct stones. Of the 12 patients with proven diffuse parenchymal disease the technique disclosed the correct evidence in all cases. All four post-cholecystectomy patients with recurrence of symptoms showed good visualisation of the duct system and excretion into the bowel.