The effect of shiftwork on driving to and from work

A questionnaire study was conducted to obtain information from shiftworkers on the levels of tiredness experienced on the drive to and from work at different times of the day. The results demonstrated that, compared to non-shiftworkers, shiftworkers were more tired on the drive between their home and the workplace and more at risk of falling asleep behind the wheel. The main factors contributing to this increased level of sleepiness and associated driving impairment were the length of the sleep period prior to work, the type of shift and the travelling time. There was some evidence to suggest that on working days shiftworkers were more likely to be involved in an accident than non-shiftworkers. However, there were insufficient data to determine whether accidents were correlated with driver sleepiness.

Work-related stress: a brief review

Work-related stress is a serious and growing problem in the UK and as such, is regarded as a significant health and safety issue. It is vital that this issue is addressed and that action is taken to address the problems that this may create both for individuals and the organisations in which individuals work. This paper reviews the concept of work-related stress showing how its deleterious impact may exert both direct and indirect effects on the workforce thus affecting both individual and organisational effectiveness. It also shows how individual and organisational factors may contribute to the development of occupational stress. However, since not all the stress which affects people at work is caused by the workplace, the home/work interface is also considered. The paper concludes by considering how work-related stress may be managed.

Reconstruction of the orbital floor after its removal for malignancy

Reconstruction of the orbital floor for malignant disease can be difficult. The tissue used should replace the floor itself and the orbital rim to ensure appropriate positioning of the globe and to avoid ectropion. The authors present a simple technique using temporalis muscle with attached coronoid process of the mandible that covers both these areas, and which is suitable for most defects in this area.

Human osteoclast cathepsin K is processed intracellularly prior to attachment and bone resorption

Cathepsin K is a member of the papain superfamily of cysteine proteases and has been proposed to play a pivotal role in osteoclast-mediated bone resorption. We have developed a sensitive cytochemical assay to localize and quantify osteoclast cathepsin K activity in sections of osteoclastoma and human bone. In tissue sections, osteoclasts that are distant from bone express high levels of cathepsin K messenger RNA (mRNA) and protein. However, the majority of the cathepsin K in these cells is in an inactive zymogen form, as assessed using both the cytochemical assay and specific immunostaining. In contrast, osteoclasts that are closer to bone contain high levels of immunoreactive mature cathepsin K that codistributes with enzyme activity in a polarized fashion toward the bone surface. Polarization of active enzyme was clearly evident in osteoclasts in the vicinity of bone. The osteoclasts apposed to the bone surface were almost exclusively expressing the mature form of cathepsin K. These cells showed intense enzyme activity, which was polarized at the ruffled border. These results suggest that the in vivo activation of cathepsin K occurs intracellularly, before secretion into the resorption lacunae and the onset of bone resorption. The processing of procathepsin K to mature cathepsin K occurs as the osteoclast approaches bone, suggesting that local factors may regulate this process.

Comparative effects of a genetically engineered insect virus and a growth-regulating insecticide on microbial communities in aquatic microcosms

The effects of a genetically engineered insect baculovirus on indigenous aquatic microbial communities were determined in closed, recirculating aquatic microcosms, and compared with the effects of a natural strain of the virus and of a growth-regulating insecticide, Dimilin. The recombinant virus was a nuclear polyhedrosis virus (NPV) of the spruce budworm (Choristoneura fumiferana (Cf)) with a lacZ marker gene inserted into the egt region of the CfNPV. The natural virus was Ireland strain CfNPV. Microbial measurement endpoints included decomposition activity (mass loss of organic material), respiration on two different substrates (O2 consumption), heterotrophic bacterial abundance (plate counts), and microbial community metabolic profiles (carbon source utilization patterns in Biolog GN microplates). Viral DNA of both the natural strain and the recombinant viruses, detected by polymerase chain reaction techniques, settled out of the microcosm water and accumulated on bottom substrates within 3 days of the microcosm inoculations. The viral DNA persisted in bottom substrates for the duration of the 21-day experimental period, although there was some evidence that the recombinant virus was less stable than the natural strain in particulate organic matter. No significant changes in microbial decomposition or respiration activity, bacterial abundance, or average metabolic responses were detected by a time trend analysis in microcosms inoculated with either the lacZ recombinant virus or the natural Ireland strain CfNPV. Significant effects on microbial decomposition and respiration activity were detected in microcosms treated with the growth-regulating insecticide at, and above, the expected environmental concentrations. Despite significant effects on microbial community functional attributes in Dimilin-treated microcosms, there were no detectable changes in community structure in terms of metabolic profiles or bacterial abundance.

[Mystery of mydriatic pupils]

The authors describe the case of a 27-year-old man who was examined on account of vertigo and blurred vision. In the objective case-history there was mild confusion, in the physical examination broad symmetrical mydriasis dominated. Later other similar patients were found. Atropine intoxication was proved. The source of the alkaloid was poppy seed contaminated with seeds of henbane (Hyoscyamus niger), in bakery goods served in the works canteen.

Characterization of the in vitro and in vivo activity of monoclonal antibodies to human IL-18

IL-18 is a cytokine with potent IFN-gamma inducing activities as well as an important mediator of Th1 polarized immune responses. In this study we demonstrated that IL-18 induces the concentration-dependent production of the proinflammatory mediators IFN-gamma, IL-6, and GM-CSF, but not the anti-inflammatory cytokine, IL-10 from peripheral blood lymphocytes in the presence of mitogen. Three neutralizing IL-18 monoclonal antibodies (MAbs) were investigated, one of which (2C10) inhibited IL-18 bioactivity with an IC50 of 0.1 nM and had a K(D) of 3.9 x 10(-11) M. A NOD/SCID mouse model engrafted with human peripheral blood lymphocytes was developed to test the in vivo efficacy of this MAb. The IFN-gamma production induced by LPS administration was inhibited approximately 90% by prior dosing of MAb 2C10. The therapeutic utility of a high-affinity IL-18 MAb may be of benefit in Th1-driven autoimmune diseases such as rheumatoid arthritis and Crohn's Disease, where elevated levels of IL-18 have been observed.

Nutritional screening and older adults

Nutrition is rarely included in the screening programmes of older people. However, nutritional screening of this population is important to distinguish between deterioration in their health status due to the physical decline of ageing and that due to nutritional deficiency.

Mycobacterial disease of the parotid gland

Mycobacterial disease is an unusual but important condition that should be considered in the differential diagnosis of a discrete parotid gland swelling or mass. The management of this condition involves exclusion of neoplastic disease and combined medical and surgical therapy. We present 5 cases of mycobacterial involvement of the parotid gland and discuss issues surrounding the diagnosis and treatment options.

Social perceptions of cancer and their impacts: implications for nursing practice arising from the literature

Social perceptions of cancer and their impacts: implications for nursing practice arising from the literature At the millennium cancer still holds a special mystique and is imbued with socio-cultural meanings, which extend far beyond the rational, scientific and biological facts of the disease. Excessive fear and dread may cause family and friends to display avoidance or overprotective behaviours to the ill person, who may subsequently perceive dissatisfaction with social support. Drawing on a literature review this paper explores the impact of cancer on social relationships. Interpersonal strain in relationship is often explained in the stigmatization of the illness and this concept is explored through contemporary social theorizing. These findings have direct implications for nursing practice where the goal of care is to enhance the support relationship.

Panic disorder in hospitalized cancer patients

Cancer is commonly complicated by psychiatric comorbidity, particularly depression. However, the effects of panic on cancer treatment and cancer patients' quality of life are not well understood. To examine more closely the occurrence of panic attacks and panic disorder in cancer patients, we retrospectively reviewed charts of 106 consecutive psychosomatic consultations of inpatients with cancer at a regional cancer center. Approximately one-fifth of the patient sample presented with panic attacks or panic disorder at the time of the consultation. We present four case examples to demonstrate the potential effect of panic on cancer patients, including requests for cancer treatment discontinuation. We report resolution of panic with benzodiazepine and selective serotonin reuptake inhibitors.

Complementary therapy: complement or threat to modern medicine?

Some believe that medicine has lost its holistic perspective as a result of which many people now seek help from 'alternative' practitioners who seem able to devote time to their patients and listen to their concerns. Such practitioners also treat the 'whole person' rather than only their symptoms, a feature which seems to be valued by patients. The use of complementary therapies is, therefore, increasing world-wide. This paper explores this increase, questioning whether this truly reflects dissatisfaction with 'traditional' (allopathic) medicine or rather represents an increased satisfaction with 'alternative' therapies. It also investigates the use of such therapies in mainstream medicine revealing considerable variation in attitudes towards and use of such therapies in current medical practice questioning whether this should be seen as a threat to modern medicine or their use may enhance patient well-being and quality of life.

Effects of high-dose inhaled corticosteroids on bone metabolism in prepubertal children with asthma

We studied the effect of inhaled corticosteroids on the increase in bone mineral content in prepubertal children with asthma. Forty-eight asthmatic, prepubertal children receiving either inhaled beclomethasone dipropionate or budesonide were evaluated. Nine children of similar age not receiving inhaled steroids served as controls. The average age of corticosteroid-treated children was 7.8 +/- 2.4 years, and of control children, 8.4 +/- 2.1 years (NS). The average dose of inhaled corticosteroids in the treated children was 0.67 +/- 0.48 mg/m(2)/day, and they were followed over a 9-20-month period. Total bone mineral content (TBMC) was measured at baseline and after 9-20 months. A derived value for 12 months' TBMC was calculated, assuming that changes in TBMC were linear with the passage of time. The change in TBMC over a 12-month period was 264 +/- 68 mg for the corticosteroid-treated children and 330 +/- 84 mg for control children (P < 0.025). In a multiple regression analysis in which adjustments were made for the effects of age, height, and weight, the change in TBMC in corticosteroid-treated children was inversely related to the inhaled steroid dose/m(2)/day (P = 0.016). The increase in the lumbar vertebral bone mineral density in control children was also significantly greater than in the corticosteroid-treated children (P < 0.025). We conclude that inhaled steroids, at an average dose of 0.67 mg/m(2)/day, when used in the treatment of asthma reduce the acquisition of bone mineral in prepubertal children.

Ibuprofen versus other non-steroidal anti-inflammatory drugs: use in general practice and patient perception

OBJECTIVE

To investigate whether ibuprofen was as well-regarded by patients as other non-steroidal anti-inflammatory drugs (NSAIDs).

DESIGN

Questionnaire sent to 1137 consecutive recipients of an NSAID prescription from 21 doctors in six general practices with computerized records. Patient responses were subsequently linked to data held on the practice records.

SETTING

General practices in and around Nottingham, selected to reflect local variations in number of partners, list size, geographical location, deprivation, prescribing burden and prescribing rate.

SUBJECTS

Unselected patients receiving NSAIDs prescribed for all indications for use.

MAIN OUTCOME MEASURES

Effectiveness of ibuprofen and other NSAIDs, possible drug related adverse events, patients' overall satisfaction with ibuprofen and other NSAIDs, factors associated with choice of ibuprofen, drug costs of ibuprofen and other NSAIDs.

RESULTS

The main NSAIDs used were ibuprofen, diclofenac and naproxen. Ibuprofen use ranged from 1.0% of prescriptions in one practice to 69.1% in another. Although ibuprofen was generally prescribed in low doses, it was perceived by patients as being as effective as the other NSAIDs used, even after allowing for severity of the pre-treatment condition. Overall, 50.5% of patients rated their NSAID the best treatment they had received for their condition with no differences between individual drugs.

CONCLUSIONS

Ibuprofen is as highly regarded as other NSAIDs when used in similar circumstances. Switching patients to ibuprofen may be a realistic way of reducing financial and medical costs associated with NSAIDs.

Pharmacoepidemiology of non-steroidal anti-inflammatory drug use in Nottingham general practices

AIM

To investigate the pharmacoepidemiology of NSAID usage in Nottingham general practices.

DESIGN

Questionnaire sent to 1137 consecutive recipients of an NSAID prescription from 21 doctors in six general practices with computerized records. Patient responses were subsequently linked to data held on the practice records.

SETTING

General practices in and around Nottingham, selected to reflect local variations in number of partners, list size, geographical location, deprivation, prescribing burden and prescribing rate.

SUBJECTS

Unselected patients receiving NSAIDs prescribed for all indications.

MAIN OUTCOME MEASURES

Indication for treatment, differences in prescribing to different age groups, compliance and overall scheme drug exposure, drug effectiveness and tolerability, possible drug-related adverse events, patients' overall satisfaction with treatment and estimated costs of care.

RESULTS

NSAIDs were used for a wide range of conditions and only a small number of patients had rheumatoid arthritis. The main drugs used were ibuprofen, diclofenac and naproxen. Patients making short-term use of NSAIDs had low compliance if they experienced adverse drug effects, whilst conversely in long-term users, those with high compliance reported more adverse drug effects. Calculated compliance did not vary with age although older patients (over 65 years) claimed in their questionnaires to be more compliant than younger patients. Half the patients reported good or complete symptom relief. Half of those questions (and two thirds of those with good or complete symptom relief) rated their NSAID as the best treatment they had received for their current condition. The frequency of gastrointestinal adverse events was higher in the young and the old, which correlated with the use of anti-ulcer drugs, and increased with the total number of medications used.

CONCLUSIONS

NSAIDs are used for a wide-range of conditions. They give symptom relief to, and are perceived as effective by, most patients taking them.

Treatment of male sexual dysfunction

Male sexual dysfunction is a prevalent condition in the population, is a major health problem and has previously been both under diagnosed and under treated. There are now a number of treatments available that are safe and easy to use which provide an effective solution for most presenting patients. Oral drugs have recently become the first-line option for many men with about 60-70% of new presentations achieving success. Those who fail a trial of oral treatments have a number of other options available, which are able to provide erections sufficient for intercourse in many of the oral drug failures. All these options, their indications, side-effects and complications are outlined in this chapter.