Identification of risk factors is a sensible precursor to designing interventions and seeing if they work as expected. It would seem obvious then that if a supposed risk factor turns out not to be valid then it should not feature in intervention studies or duty of care standards. Evidence from:  M.Hakkanen et al. Occupational and Environmental Medicine (2001) Vol.58 #2 p.129. Results show that the most significant risk factor for absence with diagnosable arm, neck and shoulder disorders is age: Age 30-40 Risk Ratio = 2.9 (95% confidence interval 1.2 to 7.1). High physical load was protective. The Radar report is available to subscribers: SK 1#2 5 Evidence from: G.A.M.Ariens et al. Occupational and Environmental Medicine (2001) Vol.58 #3 p.200. Among those sitting, neck pain (but not a diagnosis) was more likely if the neck was flexed by 20 degrees for more than 70% of the time. The Radar report is available to subscribers: SK 1#2 6 Evidence from: RSI conference 2nd March 2001. RSI was

Fibromyalgia (FM) is probably multi factorial in origin. Evidence from: A.Hakkinen et al. Annals of Rheumatic Disease (2001) Vol. 60 #1, p. 21. Muscle strength training works just as well for FM as for health people. This very small study shows that people with FM may have completely normal muscle health. If so, some other cause must be sought. The Radar report is available to subscribers: SK 1#2 2 Evidence from: R.Kwaitek et al. Arthritis and Rheumatism (Dec 2000) Vol. 43 #12. Small reductions in blood flow were detected in the thalamus of the Fibromyalgia cases. These were not sufficiently distinct to be diagnostic. The Radar report is available to subscribers: SK 1#2 3 Evidence from: V.Hadhazy et al. Journal of Rheumatology (2000) Vol.27 p.2911. Strenuous exercise improves quality of life for FM cases. But doesn’t cure FM. The suggestion is that there is no organic disease sufficient to negate the effects of fitness improvement. The Radar report is available to subscribers: SK

OSHA (USA) have published a framework and supporting tools for the prevention and management of work-related musculoskeletal disorders. The approach is essentially one of responding to significant symptoms by first deciding if they are significant and then, caused by work. the latter includes cases where the initial injury was not at work but where work could slow recovery or aggravate the injury. By responding to symptoms, the standard selects the most vulnerable rather than the average worker. Evidence from: OSHA Ergonomics Standard and supporting evidence review. SK 1#2 1 Evidence from: Occupational Health Review May/June 2001 p 3 Confirmation that the “Ergonomics Standard” which was accepted in the last few days of the Clinton administration, has now been revoked. The standard has been discussed in detail in a previous issue of The State of Knowledge journal Vol. 1#2. The argument against the standard seems to have revolved around the economic burden on business. It is not clear th

This review was created at the outset of the Radar project. The summary here covers diagnosis, causation, foreseeability, duty of care, prognosis, rehabilitation, mitigation, exposure variation. Evidence from: Andrew@reliabilityoxford.co.uk Early attempts to audit stress risk were conceptually flawed. The Radar report is available to subscribers: SK 1#1 3

This review was created at the outset of the Radar project. The summary here covers hazards, measurement of harm, foreseeability, legal regimes, remediation. Evidence from: Andrew@reliabilityoxford.co.uk The Radar report is available to subscribers: SK 1#1 2

This review was created at the outset of the Radar project. A summary of the findings for diagnosis, causation, foreseeability, duty of care, prognosis, rehabilitation. Evidence from: andrew@reliabilityoxford.co.uk The Radar report is available to subscribers: SK 1#1 1

Epidemiology may be used in evidence, helps justify the origin and certainty of expert opinion, helps in cross-examination. A relative risk among the exposed of 2.0 or higher is considered persuasive of causation in an individual. There are guidelines to help US judges to critique epidemiological evidence, no such guidelines exist in the UK. Evidence from: Reference Manual on Scientific Evidence. Federal Judicial Center…. 2000 2nd Edition. USA The Radar report is available to subscribers: 1#12 11

Seeking a diagnosis of asthma depends on how severe it is. This study avoided self selection by following a cohort for 22 years. It found that symptoms of asthma (not diagnosed) and atopy were predictive of adult asthma. The implied defence is that adult asthma was very likely to happen regardless of any specific negligent exposure. Evidence from: HL Rhodes et al. Journal of Allergy and Clinical Immunology. November (2001) Vol. 108 #5. p. 720. A longitudinal study of early life risk factors for adult asthma. Cases of adult onset asthma should regarded as having a potential environmental cause. However, increased severity of asthma in adult life may have an innocent explanation. Risk factors for adult asthma may be useful in deciding the degree to which other causes are investigated. This was a prospective cohort study of 100 babies, born to atopic parents. Bronchial hyperresponsiveness was measured at 11 and 22 yrs. Annual check-up in first 5 years. 73 were followed up at 5 years, 67 a

People with COPD can become increasingly disabled by frailty associated with muscle wasting. early opinions about this are presented in the report. It may be possible to intervene. Claims for COPD should include some element of anticipation of prolonged infirmity. Evidence from: MB Reid. American Journal of Respiratory and Critical Care Medicine. October (2001) Vol. 164 #7 p1101. Editorial on COPD and muscle wasting. Muscle loss commonly occurs in COPD. This is partly because of the effects chronic inflammation (Am. J. Resp. Crit. Care. Med. 2001 vol. 164#8 p1414) but partly because of metabolic imbalances. But are these cause or effect? The editor favours effect, possibly due to prolonged inactivity/deterioration. But according to Am. J. Resp. Crit. Care Med. 2001 Vol. 164#9 p 1712 muscle loss is selective, the diaphragm remains strong preferentially. This argues against a genetic cause of muscle wasting. It would also seem to argue against the distal effects of chronic inflammation.

There are many potential effects of an ageing demographic. Most should be slowly evolving as the demographic gradually changes. Knowledge based liability exposure can change very quickly, as new understandings develop.  In this report, the potential for mis attribution of causation is explored.  Evidence from: CE Ruse et al. Age and Ageing. November (2001) Vol. 30 #6 p 450. It will be increasingly important to assess gentic contributions to disease causation as the demographic ages. This would help prevent mistaking an increase in frequency of disease for evidence of an environmental cause. The Radar report is available to subscribers: 1#12 4

These draft guidelines cut through the unfounded professional attitudes to back pain including: bogus diagnoses, illegitimate statements about causation, alarmist prognoses, prognoses based on bio mechanical models and so on. Application of the guidelines should see greater accuracy of medical care and reductions in liability exposure, but only if they are used. Evidence from: N Bogduk. Draft- Evidence-Based Clinical Guidelines For The Management Of Acute Low Back Pain Table 6.1  of the draft guidelines is reproduced in the Radar report. It details which factors really do influence prognosis. The Radar report is available to subscribers: 1#12 1

Human exposure to SV 40 was not widespread but did occur by means of contaminated polio vaccine in the early 1960’s. For the present, links between SV40 and mesothelioma would appear to remain speculative. Evidence from: C Carroll-Pankhurst et al. British Journal of Cancer. November (2001) Vol.85 #9 p 1295. The Radar report is available to subscribers: 1#11 12

IARC classified crystalline silica as a probable carcinogen in 1987, however, significant doubts remain. This study suggests that silicosis is not a cause of lung cancer. By chance the study also finds that silica is associated with death from diseases of the urinary system (kidney disease). Evidence from: P Carta et al. Occupational and Environmental Medicine. December (2001) Vol.58 # 12 p 786. The Radar report is available to subscribers: 1#11 11  

Specialists often assume that osteoarthritis is caused by heavy labouring work. But is it? If it is then defences should be explored as should potential case load. Evidence from: A Lievense et al. Journal of Rheumatology. November (2001) Vol. 28 #11 p 2520. Systematic review of research findings linking work with osteo arthritis of the Hip. 16 articles were selected in out of 2,921 on the grounds of study quality. All retained studies found hip OA associated with heavy vs. light workload. 12 of these were statistically significant but none were high quality cohort studies. That is they were snaphots. So the authors suspect recall bias as a possible explanation for the association. 10 of the 16 studies showed a dose response relationship. Comment This review is of an acceptable quality. The association and dose-response relationships could both be explained by the availability and seeking of medical assistance: Hip OA cases are more likely to seek treatment because pain hinders work hen

Elective surgery is not usually within the scope of this database. However, the current debate about implants illustrates a more general problem of medicalising a sense of low well-being and finding an identifiable event to blame. Any defect in the implant or defective surgery could heighten such concerns, but wouldn’t necessarily make them any more valid. Besides medical liability, product liability could be in the frame. Evidence from: P Tugwell et al. Arthritis and Rheumatism. November (2001) Vol. 44 # 11. p 2477. Links between silicone implants and rheumatological disease have been promoted for many years. This research paper is a review of all the evidence for such an association. 1773 relevant articles using any sort of connective tissue disease (CTD) (including rheumatoid arthritis etc.) outcome as the variable of interest. NO association was found between a new syndrome or established diagnoses. Full report available: http://www.fjc.gov/breimlit/science/report.htm Comment

If the standard biomechanical model of causation doesn’t have any practical utility, why is it so popular? It may be that no credible alternative has been proposed, but that doesn’t mean a defectice model should be adhered to. Defective models lead to defective assumptions and defective claims handling. Evidence from: R Ferrari. Spine. October (2001) Vol. 26 #19 p 2063. An editorial on the subject of research into whiplash neck injury. There is consensus that direction of vehicle impact is not prognostic of acute or chronic problems or litigation status. So if direction doesn’t matter, protection in vehicle is irrelevant. So why continue to focus research into protection from just one direction? The best treatments take no account of detailed pathology, so why study it any more? Good treatments such as nonspecific exercise regimens and general advice do not require deep understanding of pathology. Identification of an acute lesion would not explain why some develop ch

Short term effects of exposure are well-known and usually reversible. This study sought an association between cumulative exposure and signs of peripheral nerve symptoms (PNS). Evidence from: A Pilkington et al. Occupational and Environmental Medicine. November (2001) Vol.58 # 11 p 702. Short term effects were observed as expected. The Radar report is available to subscribers: 1#10 17

If shift work increased the intensity of heart disease risk factors by some non-volitional mechanism then there would be a good case for controlling shift work in a way which counteracts that mechanism. But first, is there a significant effect on risk factors? Evidence from: B Karlsson et al. Occupational and Environmental Medicine. November (2001) Vol.58 # 11 p 747. A study of known risk factors for heart disease and their association with shift work. 27,485 Swedish workers took part. Blood and build were analysed. Obesity was found to be more prevalent among all ages of women shift workers, but only two age groups of men. Increased triglycerides (>1.7 mmol/l) were found for two groups of shift working women but not men. Impaired glucose tolerance was found among 60-year old women shift workers. Comment The authors conclude that shift work presents an increased risk of heart disease. However, risk factors for disease are not indicators that disease will necessarily occur. Strengths

Asthma diagnosis rates in children increased very significantly in the past 20 years. The search for environmental cause has been intense. But how big could the environmental proportion of new cases be? Evidence from: G Koeppen-Schomerus et al. Archives of Diseases in Childhood. November (2001), Vol. 85 #5 p 398. In 1999 Genetics accounted for 70% of asthma diagnoses. It would be interesting and useful to know if the same proportion was still found now. If an environmental cause of asthma diagnosis inflation is found then the maximum proportion would be 30% of cases. The Radar report is available to subscribers: 1#10 13

If injury can be a cause of MS then why not a virus which causes nerve inflammation? The study sought associations between exposure to 21 different pathogens and risk of MS using discordant twin pairs. Evidence from: M Bergkvist et al. Acta Neurologica Scandinavica. November (2001) Vol.104 #5 p 262. The lack of any detectable effect from any of these pathogens suggests that if a pathogen is responsible it wasn’t one of these and, that neuro inflammation is not a prime cause either. The Radar report is available to subscribers: 1#10 12  

The International Agency for Research on Cancer (IARC) has published a monograph on low frequency emfs. They conclude that exposure is possibly carcinogenic to humans. The opinion arises from consistent evidence of detectable risk of leukaemia in children exposed to more then 0.4 micro Tesla time weighted average. Evidence from: IARC monographs series. In our view, this does not represent a date of knowledge on generic causation. A number of objections to the IARC conclusion are acknowledged by IARC and expert opinion more widely. The Radar report is available to subscribers: 1#10 11

There is some consensus that the risk of lung cancer posed by asbestos dust exposure is usually of the order RR = 5, that from smoking, RR= 10 and from the combination, RR = 50. This review paper suggests an alternative view, that the asbestos related risk is actually reduced by co-smoking. Evidence from: FD Liddell. Ann Occup Hyg. Jul (2001) Vol. 45(5) p 341-56. The author introduces the term: relative asbestos effect, to account for the competition between smoke and asbestos to be the first to actually cause the cancer. The Radar report is available to subscribers: 1#10 10

Noise induced hearing loss is still an issue. This reform of duty of care standards will bring more people within the claimant population. Poor understanding in the courts risks providing compensation for trivial harm. Given that exposure measurement is also subject to considerable uncertainty, a Duty to ensure exposure (with hearing protection) is less than 85 dB(A) would seem to be in accord with the requirements of civil liability (for the 50 year old male manual worker). That is, exposure below this value would not be shown to have on the balance of probabilities, contributed to measured HTLs. Evidence from: andrew@reliabilityoxford.co.uk A full description of the noise Directive its strengths and weaknesses. The Radar report is available to subscribers: 1#10 1

This was an 8 year longitudinal study of those in pain. Pain is commonplace and usually meaningless but what if it was indicative of risk of cancer? Evidence from: GJ Macfarlane et al. BMJ. (2001) #7314 p 662. The report includes estimates of the prevalence of pain and the statistical association between pain and cancer outcomes. It would appear that the pain being described by people before they died had no direct link with the cancer that killed them. The Radar report is available to subscribers: 1#9 12