The research investigates whether or not physical trauma can aggravate or accelerate rheumatoid arthritis. Evidence from: AWAl-Allaf et al. Rheumatology. March (2001) Vol.40 #3 p 262. A high proportion of people with newly diagnosed RA could recall significant physical trauma in the 6 months preceding diagnosis. Rates of severe trauma are known. If a causal link is found, the number of RA cases could be estimated. The Radar report is available to subscribers: 1#5 4

Evidence from: TRDJ Radstake et al. Journal of Rheumatology. May (2001) Vol. 28 #5 p 962. A study of genetic anticipation among families with Rheumatoid Arthritis (RA) in Europe. Genetic anticipation describes a phenomenon where the age of onset of a genetically determined illness decreases with successive generations. The effect is that diseases that are normally associated with old age can manifest surprisingly early. The result of this may be that the illness is misdiagnosed or the symptoms are attributed to a cause, which is in fact innocent. The paper demonstrated that a small proportion (4%) of cases of RA had a parent with the same condition (28/683) and were diagnosed in advance of the age of diagnosis of the parent. Typically the anticipation was of the order of 16 years. Comment Although the proportion of cases with apparent genetic anticipation is small (4%) it may be worth keeping this possibility in mind when assessing cases of upper limb disorder.

This was a prospective study of new recruits with no previous pain in the preceding month. Ergonomic factors were independently observed as well as reported by questionnaire. Risk factors for new reports of pain lasting more than a day were identified. Evidence from: CM Pritchard (GJMacfarlane) Occupational and Environmental Medicine. June (2001) Vol.58 #6 p 374. Psychosocial factors were not predictive. The work reported here suggests that eliminating unbalanced and heavy lifting at work would improve, self-reported, employee comfort. A sense of what is meant by “heavy” can be gleaned from the detailed results. None of those reporting new pain had taken any time off work because of it. The Radar report is available to subscribers: 1#5 2

Genetic differences must be accounted for in studies of smoking risk of renal cell cancer. Innate risk of  cancer varies with the ability to metabolise environmental toxins, some of which may be carcinogenic. Evidence from: JC Semenza et al. American Journal of Epidemiology. May (2001) Vol. 153 #9. p 851. In this study there were clear differences of rsik between those with a high capacity to acetylate toxins and those with an impaired capacity, regardless of smoking history. Innate vulnerability is not a defence but may be used to discover and bolster causation arguments. The Radar report is available to subscribers: 1#5 1

Epidemiology provides data and tools with which to measure case load and to estimate liability exposure. Key concept = attributable risk; the basis of reliable probabilistic estimates of exposure. Evidence from: Andrew@reliabilityoxford.co.uk Attributable Risk If an exposure to a risk leads to an increased rate of ill health outcome, the absolute effect of exposure is measured by the difference between rate of occurrence in the exposed group (RE) and the rate occurrence in the unexposed group (RU). The difference in these rates, measures the rate attributable to exposure to the risk. Attributable risk rate = RE – RU Following from this; Attributable Fraction = (RE – RU )/ RU Which is the same as; Attributable Fraction = (RR-1)/RR where RR = relative risk, the result obtained from most epidemiological studies). For example, a RR of 2 gives an attributable fraction of 50%. For example, a RR of 3 gives an attributable fraction of 66%. It is quite possible for an individual to

Two studies of atopy (the innate risk of developing an allergy) and the effect of exposure to allergens. Given that people with a history of allergies are more likely to develop occupational allergy perhaps this should be used as a pre-placement screening enquiry?  Evidence from: BM Sympson et al. Clinical and Experimental Allergy. March (2001) Vol. 31 # 3 p 391. DH Garabrant et al. American Journal of Epidemiology. March (2001) Vol. 153 #6 p 515.   The Radar report is available to subscribers: 1#4 12

The study compared lung cancer risk in an occupational cohort with the relevant normal population in the USA. Workers were exposed to silica in sand dust. The potential effects of radon exposure were reduced to a minimum. Evidence from: K.Steenland et al. American Journal of Epidemiology. April (2001). Vol. 153 #7 p 695. The report provides exposure estimates and the strength of association between exposure and lung cancer. Dose response trends were looked for. Given the number of people exposed to silica dust at higher than the recommended level it would be possible to estimate the attributable case load. The Radar report is available to subscribers: 1#4 11

This was a study of multiple chemical sensitivity (MCS) and chronic fatigue syndrome (CFS) in war veterans (Gulf1, Bosnia). Evidence from: S.Reid et al. (Simon Wessely) American Journal of Epidemiology. March (2001) Vol. 153 #6 p604. The Radar report is available to subscribers: 1#4 10

The paper reports an estimate of the normal incidence of hypospadias (a male genital malformation observed at birth). Evidence from: HEVirtanen et al. APMIS Feb. (2001) Vol. 109, #2 p 96. Changes in incidence would alert researchers to look for an environmental cause.. In Finland, there has been no change of incidence between 1970 and 1999. This paper provides a useful baseline against which to assess any change. The Radar report is available to subscribers: 1#4 9

Pain hypersensitivity could explain disability where tissue damage is absent. This preliminary study provides tentative clues about this phenomenon and its potential prognostic power. MWerneke et al. Spine. April (2001) Vol. 26 #7 p 758 A proposed new method for predicting chronicity of low back pain following an acute attack. The authors propose that centralisation of pain within weeks of the acute attack may indicate a better outcome. Centralisation phenomenon is where the pain migrates from the distal or peripheral to the proximal or central. The authors conclude that the negative assessment of centralisation in the first few weeks is a useful predictor of continuing (long-term) pain and disability. However, the study was either not well designed or poorly reported. Comment A semi objective test would be very useful in selecting back pain cases that ought to be managed more closely. The method proposed here is not validated by this study, but it is likely (given the desire to find a

The study examined the outcomes of lumbar fusion surgery in Worker’s Compensation supported patients. Evidence from: MScott et al. Spine. April (2001) Vol. 26 #7 p 738 Improved quality of life was detectable in half of cases that had the surgery. Litigation was a strong but imprecise predictor of post-operative disability. The Radar report is available to subscribers: 1#4 7

The study focussed on a specific identifiable source of emf exposure at 16.7 Hz: electrified railways. Evidence from: JSchuz et al. British Journal of Cancer. Mar (2001) Vol.84 #5 p 697. 16.7 Hz is one third of mains frequency in the UK. Contributing exposures at this frequency are likely to be very small. The Radar report is available to subscribers: 1#4 6

This research explored the association between occupational exposure to emfs and health outcomes as measured by cause of death. Employees worked for a power generation company. Evidence from: JMHarrington et al. Occupational and Environmental Medicine. May (2001) Vol.58 #5 p 307. Some exposures were well above those typically seen in the domestic setting. Overall, those who worked at this company had a reduced mortality rate compared with the equivalent average population. The Radar report is available to subscribers: 1#4 5

The research suggests that people with RA are much more vulnerable to hip fracture and would benefit from a higher standard of the duty of care. Evidence from: TM Huusko et al. Annals of Rheumatic Diseases May (2001) Vol. 60 #5 It is possible that the cause is related to greater use of steroids. This could then be relevant for asthmatics. The Radar report is available to subscribers: 1#4 4

Reflex sympathetic dystrophy can be a devastating condition. This report provides data for reserving and cost benefit calculation of mitigation measures. Evidence from: A Zyluk. Journal of Hand Surgery. April (2001) Vol. 26B #2 p 151 A study of outcomes, following treatment for Reflex Sympathetic Dystrophy. 146 cases were assessed for functional capacity and pain, both before treatment and again at 11 months after treatment. Diagnosis was confirmed in the presence of diffuse pain and at least three of: swelling, discolouration, abnormal skin temp, limited ROM. 64% of cases were described as having a good outcome. Of these only a third were completely free of pain, but 100% had full range of motion restored and 80% had some reduction in grip strength compared to normal values. Comment Of the 46% with poor outcomes it is not known how many were misdiagnosed. Patient attitudes were not recorded. Some loss of comfort can be expected a year after treatment even for good outcomes. However it

Does surgery have a useful role in mitigating carpal tunnel syndrome? Evidence from: AJ Rege et al. Journal of Hand Surgery. April (2001) Vol. 26B #2 p 148 A study of the effectiveness of carpal tunnel release in the restoration of normal life. Prospective study on 96 release patients compared with healthy normal controls. Quality of life assessment by Nottingham Health Profile, before, and 4 months after, surgery. Only 58% of the initial cohort completed the study. Completers were mainly between 30 and 60 yr. old. The authors conclude that outcome (quality of life) after surgery was not dependent on physical parameters but was associated with attitude before surgery. They question the value of surgery for people with a grumbling, dissatisfied view of life. Comment Patient satisfaction and return to normal life after carpal tunnel release was once (30 years ago) regarded as a given. Non-organic factors now provide an increasing challenge to surgeons and, to those who pay for surgery.

This report of a public meeting involving officials, academics and campaigners. Evidence from: HSC/DETR At-work Road Safety Conference. The Barbican, London. 5th April 2001. Campaigners are intent on blurring the distinction between Motor and EL insurance when the driver or passengers are “at work”. The Radar report is available to subscribers: 1#4 1

Evidence from: Andrew@reliabilityoxford.co.uk Bias is a term that is commonly referred to in epidemiological studies. It is a technical term and does not imply a partisan desire for or attempt to produce a particular outcome. Bias is simply any factor that can distort the outcome of epidemiological work from its true value. There are a number of types of bias to consider: • failure to record or identify factors (confounders) that could result in the same effect or prevent the effect of the causal hypothesis under study. • inappropriate selection of study population. • diagnostic and exposure measurement techniques can be under or over sensitive, under or over specific and plain wrong. • measurements may be systematically biased. For example, an observer may improve in the accuracy of his observations with practice. If more cases than controls are observed at the beginning of the study, the results could be biased. Bias is particularly likely in studies that rely on exposure memory and/

The research explores how well the validity questionnaire can distinguish between those who intend to deceive and those who do not. Evidence from: BE McGuire et al. Journal of Clinical Psychology Mar (2001) Vol.57 #3 P401 A key issue in the design of validity questionnaires is whether they will work for specific claimant groups. This is especially pertinent when the illness itself is subjective. The Radar report is available to subscribers: 1#3 10

This editorial suggests a strong case for a specific identifiable cause of vCJD in Queeniborough. Evidence from: H Ashraf. Lancet March (2001) Vol. 357 #9620 p. 937. Five cases of confirmed new-variant CJD have occurred in a geographically small area in Leicestershire. The cases were included in a case control study which established a relative risk of 15 if you purchased and consumed beef from at least one of two butchers who, as standard practice, removed cow brains. Statistical significance was not recorded. Comment Clustering of cases will occur by chance, but the existence of a plausible link between cases reduces the credibility of this alternative explanation. The plausible link is founded on the memory of food purchasing and consumption habits over 20-year period. Victims and controls in the study were not equivalent. 9% of butchers (UK) practiced brain removal during the 80’s (no information available for the early nineties when exposure probably peaked). Slaughtering practice

Many insurers and HSE have been advised by Professor Tom Cox on the subject of stress at work. He has been a leading light behind the development of insight, guidance and standards in this field. He is soon to retire from his main post in Nottingham, but will be following two new ones! http://proftcox.wordpress.com/      

Evidence from: Thorax. April (2001) Vol.56 #4 p.251. A statement made by the British Thoracic Society covering diagnosis, cause and treatment for mesothelioma. The briefest highlights are reported here. Causation: • 1 in 10,000 cases are truly spontaneous. • Erionite also causes it. • Simian (SV(40)) virus has been proposed but not strongly supported. • Most cases are caused by asbestos. • In subjects heavily exposed to asbestos early in life more than 10% may die of mesothelioma. Relative Risk: Blue and brown asbestos are the most potent. Levels in well-maintained buildings are a small risk. Latency: From first exposure, to death has a mean of 41 years, rarely less than 15 years. Prognosis: Survival 8 – 14 months from diagnosis. Diagnosis: Occupational history is a key factor in diagnosis. The statement also includes advice on making an insurance claim for pleural mesothelioma! Comment Many of these views are well supported by published evidence.

Evidence from: DJ Hendrick. Clinical and Experimental Allergy Vol. 31 Jan (2001) p.1. An editorial on occupational asthma. The author notes that 11% of incident cases of occupational asthma are in fact reactive airways dysfunction syndrome I.e. no allergen involved. Triggered by irritants and viruses. Comment An important distinction, and one which is increasingly suspected for childhood asthma.

This academic paper seeks evidence for an occupational cause of Cryptogenic Fibrosing Alveolitis (a disease which is similar in some respects to asbestosis). Evidence from: JC McDonald et al. Chest Feb (2001) Vol. 119 #2 p. 428. Significant risks were found in coal miners an electrical/electronics workers. The Radar report is available to subscribers: 1#3 5