Decision-making in job attendance within health care--a qualitative study

BACKGROUND

Musculoskeletal complaints are considered a major cause of sickness absence, particularly in areas such as the health sector. However, little is known about the personal decision-making process for self-certified sickness absence.

AIMS

To explore female health care workers' thoughts and experiences about work attendance when experiencing musculoskeletal symptoms.

METHODS

A qualitative study using individual, semi-structured, in-depth interviews with eight female health care workers was performed. Questions were related to factors influencing the decision to attend work and decision-making when facing the dilemma of attending work when experiencing musculoskeletal symptoms. The data were analysed according to the systematic text condensation.

RESULTS

Subjects reported a high threshold before calling in sick. Self-certified sickness absence was not a strategy for coping with musculoskeletal symptoms as participants chose to be physically active and work part-time rather than taking sickness absence. Making decisions about attending work fostered conflicting norms, as women faced a dilemma between feeling guilt towards colleagues and patients and taking care of their own health.

CONCLUSIONS

The findings highlight the complexity of managing work when experiencing musculoskeletal symptoms, and the dilemmas faced by those affected. The importance of work environment factors and the fact that some women feel compelled to work part-time in order to prioritize their own health require further consideration.

Short incubation with methyl aminolevulinate for photodynamic therapy of actinic keratoses

BACKGROUND

Photodynamic therapy (PDT) using methyl aminolevulinate (MAL) is an effective first-line treatment for actinic keratoses. A reduced incubation period may have practical advantages.

OBJECTIVE

This study aims to evaluate the effect of incubation time (1 vs. 3 h), MAL concentration (160 mg/g vs. 80 mg/g) and lesion preparation in the setting of MAL-PDT for treatment of actinic keratosis (AK).

DESIGN

Open, randomized, parallel-group multicentre study.

SETTING

Outpatient dermatology clinics.

SUBJECTS

One hundred and twelve patients with 384 previously untreated AK. Most lesions (87%) were located on the face and scalp and were thin (55%) or moderately thick (34%).

METHODS

Lesions were debrided, and MAL cream (160 mg/g or 80 mg/g) was applied before illumination with red light (570-670 nm; light dose, 75 J/cm2). Patients were followed up at 2 and 3 months. Sixty patients (54%) were re-treated and assessed at 6 months.

MAIN OUTCOME

Complete lesion response rates 3 and 12 months after last treatment.

RESULTS

For lesions on the face/scalp, lesion complete response rates were 78% for thin AK and 74% for moderately thick AK lesions after 1 h vs. 96% and 87% after 3 h incubation with MAL 160 mg/g. Lesion recurrence rates at 12 months after two treatments were similar [19% (3 of 16) with 1 h vs. 17% (3 of 18) with 3 h 160 mg/kg MAL-PDT] and lower than for 80 mg/g MAL-PDT (44-45%).

CONCLUSION

MAL-PDT using a 1-h incubation may be sufficient for successful treatment of selected AK lesions.

Histopathologic and Immunohistochemical Characterization of Nipah Virus Infection in the Guinea Pig

Mortality rate in humans infected with Nipah virus (NiV) has been reported as high as 92%. Humans infected with NiV show a widespread multisystemic vasculitis with most severe clinical and pathologic manifestations in the brain, lungs, and spleen. The purpose of this study was to study pathologic and immunohistochemical findings in guinea pigs infected with NiV. Of 28 animals inoculated intraperitoneally, only 2 survived the infection, and most died between 4 and 8 days postinoculation (dpi). Viral antigen with minimal pathologic changes was first detected 2 dpi in lymph nodes and spleen. More severe changes were noted in these organs 4-8 dpi, where pathologic damage had a vasocentric distribution and viral antigen was abundant in vascular endothelium, tunica media, adventitia, as well as in macrophages lining sinuses. The urinary bladder, uterus, and ovaries were also affected with necrosis and acute inflammation. In these organs, immunohistochemical positive staining was intense in blood vessels, epithelial cells, and ovarian follicles. Approximately 50% of the animals that died or were euthanized in extremis had evidence of viral antigen and histopathologic changes in brain, especially involving meninges and ependymal cells, with lesser changes in the neural parenchyma. A unifying feature of the damage for all affected tissues was necrosis and inflammation of the vasculature, chiefly in arterioles, capillaries, and venules. Inoculation of guinea pigs intraperitoneally with NiV produces a disease with considerable resemblance to the disease in humans, but with reduced pulmonary involvement and marked infection of urinary bladder and the female reproductive tract.

Survival and complications after insertion of self-expandable metal stents for malignant oesophageal stenosis

OBJECTIVE

To report on survival and complications after insertion of self-expandable stents in patients with malignant oesophageal stenosis.

MATERIAL AND METHODS

Data were gathered retrospectively from the medical records of 92 consecutive patients in the period 1994-2003. The study comprised 68 men and 24 women (median age 72 years, range 46-93 years) with stenosis from cancer of the oesophagus (n=61), the gastric cardia (n=26) and the lung (n=5), located mainly above (n=4) or below (n=62) the carina, or at the gastro-oesophageal junction (n=26). One uncovered stent and six different covered stents were used.

RESULTS

Median and mean survival times after stenting (n=92) were 83 (range 4-1102) and 125 days, respectively. Thirty-day mortality was 19% (n=17), and 7% (n=6) survived more than one year. Survival was neither significantly influenced by division of the patients into diagnostic subgroups nor by comparison of the three most frequently used stents. One, two, three and four stents were received by 76, 11, 4 and 1 patient(s), respectively. There was no stent-related mortality, and complications were bleeding 1 (1%), stent migration 7 (8%), recurrent stenosis 8 (9%) from both tumour overgrowth (n=8) and tumour ingrowth (n=2) when using uncovered stents. Thirteen (14%) patients were re-stented because of recurrent stenosis (n=8) including fistula formation to the left main bronchus (n=2) and stent migration (n=5).

CONCLUSIONS

Use of self-expandable stents in patients with inoperable malignant oesophageal stenosis carried few complications and resulted in relatively long survival in comparison with similar studies.

Frequent musculoskeletal symptoms and reduced health-related quality of life among industrial workers

The high percentage of musculoskeletal symptoms (MSS) found in studies of general populations and various occupational groups underlines the need to distinguish between severely and mildly affected individuals. To investigate associations between MSS and quality of life, we examined the frequency of MSS on a five-point scale, health-related quality of life (SF-36) and sickness absence among 5654 workers in the aluminium industry. High frequencies of MSS from all body parts were related to lower scores on the SF-36 and increased sickness absence. This relationship was strongest for MSS from the lower back. Workers who reported low back MSS 'very often' had a mean role--physical score equivalent to that of the 15th percentile of the general population. These results show that workers who reported MSS often or very often were severely affected, and this scale can therefore be used to distinguish individuals at high risk for reduced health-related quality of life and sickness absence.

Influenza A virus infection complicated by fatal myocarditis

Influenza virus typically causes a febrile respiratory illness, but it can present with a variety of other clinical manifestations. We report a fatal case of myocarditis associated with influenza A infection. A previously healthy 11-year-old girl had malaise and fever for approximately 1 week before a sudden, witnessed fatal collapse at home. Autopsy revealed a pericardial effusion, a mixed lymphocytic and neutrophilic myocarditis, a mild lymphocytic interstitial pneumonia, focal bronchial/bronchiolar mucosal necrosis, and histologic changes consistent with asthma. Infection with influenza A (H3N2) was confirmed by virus isolation from a postmortem nasopharyngeal swab. Attempts to isolate virus from heart and lung tissue were unsuccessful. Immunohistochemical tests directed against influenza A antigens and in situ hybridization for influenza A genetic material demonstrated positive staining in bronchial epithelial cells, whereas heart sections were negative. Sudden death is a rare complication of influenza and may be caused by myocarditis. Forensic pathologists should be aware that postmortem nasopharyngeal swabs for viral culture and immunohistochemical or in situ hybridization procedures on lung tissue might be necessary to achieve a diagnosis. Because neither culturable virus nor influenza viral antigen could be identified in heart tissue, the pathogenesis of influenza myocarditis in this case is unlikely to be the result of direct infection of myocardium by the virus. The risk factors for developing myocarditis during an influenza infection are unknown.

Prevalence of musculoskeletal symptoms among aluminium workers

The aim of this study was to determine the prevalence of musculoskeletal symptoms (MSS) in workers in the aluminium industry, and to test the relationship with work by using the duration of employment as a measure of exposure. A total of 5654 workers (92%) answered a questionnaire. Operators, who were more exposed to physically demanding work, showed a greater incidence of MSS than did office workers. Among operators, the duration of employment was significantly correlated with MSS in nine out of ten areas of the body, when adjusted by multiple regression analyses for age, gender, height, weight, smoking and physical activity. Among office workers this relationship was weaker and was significant only for neck and lower back areas. The higher prevalence of MSS among operators and the association between their duration of employment and MSS suggests that a higher risk of MSS is related to the working environment.

Immunohistochemical and in situ hybridization studies of influenza A virus infection in human lungs

Influenza viruses are responsible for acute febrile respiratory disease. When deaths occur, definitive diagnosis requires viral isolation because no characteristic viral inclusions are seen. We examined the distribution of influenza A virus in tissues from 8 patients with fatal infection using 2 immunohistochemical assays (monoclonal antibodies to nucleoprotein [NP] and hemagglutinin [HA]) and 2 in situ hybridization (ISH) assays (digoxigenin-labeled probes that hybridized to HA and NP genes). Five patients had prominent bronchitis; by immunohistochemical assay, influenza A staining was present focally in the epithelium of larger bronchi (intact and detached necrotic cells) and in rare interstitial cells. The anti-NP antibody stained primarily cell nuclei, and the anti-HA antibody stained mainly the cytoplasm. In 4 of these cases, nucleic acids (ISH) were identified in the same areas. Three patients had lymphohistiocytic alveolitis and showed no immunohistochemical or ISH staining. Both techniques were useful for detection of influenza virus antigens and nucleic acids in formalin-fixed paraffin-embedded tissues and can enable further understanding of fatal influenza A virus infections in humans.

Depletion of lymphocytes and diminished cytokine production in mice infected with a highly virulent influenza A (H5N1) virus isolated from humans

Previously, we observed that several virulent influenza A (H5N1) viruses which caused severe or fatal disease in humans were also lethal in BALB/c mice following dissemination of the virus to solid organs, including the brain. In contrast, one particular human H5N1 virus was nonlethal in mice and showed no evidence of systemic spread. To compare H5N1 viruses of varying pathogenicity for their ability to alter the mammalian immune system, mice were infected with either influenza A/Hong Kong/483/97 (HK/483) (lethal) or A/Hong Kong/486/97 (HK/486) (nonlethal) virus and monitored for lymphocyte depletion in the blood, lungs, and lymphoid tissue. Intranasal infection with HK/483 resulted in a significant decrease in the total number of circulating leukocytes evident as early as day 2 postinfection. Differential blood counts demonstrated up to an 80% drop in lymphocytes by day 4 postinfection. In contrast, nonlethal HK/486-infected mice displayed only a transient drop of lymphocytes during the infectious period. Analysis of lung and lymphoid tissue from HK/483-infected mice demonstrated a reduction in the number of CD4(+) and CD8(+) T cells and reduced synthesis of the cytokines interleukin-1beta and gamma interferon and the chemokine macrophage inflammatory protein compared with HK/486-infected mice. In contrast, the cytokine and chemokine levels were increased in the brains of mice infected with HK/483 but not HK/486. Evidence of apoptosis in the spleen and lung of HK/483-infected mice was detected in situ, suggesting a mechanism for lymphocyte destruction. These results suggest that destructive effects on the immune system may be one factor that contributes to the pathogenesis of H5N1 viruses in mammalian hosts.

Pathogenesis of and immunity to avian influenza A H5 viruses

In 1997 in Hong Kong, 18 human cases of respiratory illness were caused by an avian influenza A H5N1 virus. Although avian influenza viruses had not previously been known to cause respiratory illness in humans, the H5N1 viruses caused severe illness and death, primarily in individuals aged > 12 years. The introduction of H5N1 viruses into humans raised concerns about the potential of these viruses to cause a pandemic. We have used the BALB/c mouse to better understand the pathogenesis of and immunity to the H5N1 viruses in a mammalian model. Previously, we demonstrated that H5N1 viruses isolated from humans replicated efficiently in the lungs of mice without prior adaptation to this host. Two general phenotypes of pathogenicity of H5N1 viruses, based on high and low lethality for mice, were observed. We now demonstrate that in addition to a lethal outcome, H5N1 viruses with a high pathogenicity phenotype exhibit additional features that include rapid and uncontrolled replication in the lungs of infected mice, dissemination and replication of the virus in other organs, and depletion of peripheral blood leukocytes. The BALB/c mouse model was also used to better understand the parameters of protective immunity to the H5N1 viruses. Prior infection with H5N1 viruses of low pathogenicity or an antigenically related non-pathogenic H5N3 virus protected mice from death by infection with a highly pathogenic HK/483 virus. Serum hemagglutination-inhibition antibody titers of 40 or greater were associated with protection of mice from death. Immunization of mice with baculovirus-expressed recombinant H5 hemagglutinin protein or a previously defined HS-specific synthetic peptide induced MHC class II restricted CTL activity. Mice that had CTL activity but no serum hemagglutination-inhibition antibody were not protected from a lethal challenge with H5N1 virus. These results suggest that antibody is required for protection of mice against lethal challenge with H5N1 viruses of the high pathogenicity phenotype.

Dental gold alloys and contact hypersensitivity

A total of 172 patients referred to the Norwegian National Adverse Reaction Group were patch-tested with a dental series. Of these, 25% showed a positive reaction to gold sodium thiosulfate or potassium dicyanoaurate. There was a statistically significant correlation (p=0.0019) between the presence of dental gold and a positive patch test to gold. There was a statistically significant correlation between ear piercing and a positive patch test to gold (p=0.04). In most cases, we did not find clinical correlates to positive patch tests to gold. 2 patients with objective and subjective oral/perioral and general symptoms are described as case reports. Their symptoms disappeared when gold restorations were removed. We conclude that there is an overrepresentation of gold allergies among those with dental restorations containing gold.

[Occupational skin problems among dental personnel]

Occupational dermatological problems are common among dental health personnel. We conducted a questionnaire survey to investigate the frequency of occupational dermatological problems among dental health personnel in Hordaland county, Norway. 333 of 394 employees (85%) answered the questionnaire. 148 of 333 respondents (44%) reported skin complaints. The proportion of respondents with skin complaints was lower among those with more than 20 years experience in dental health care. Hands were almost always involved. Use of gloves were reported to be the main cause of skin problems, especially the use of powdered gloves. Other frequently reported causes were soaps and methacrylates. Skin complaints from methacrylates occurred more often among employees wearing gloves most past of the working day. 3% of the respondents reported test-proven rubber allergy and 1% a methacrylate allergy. Our study confirm that occupational dermatological problems among dental health personnel are frequent. Irritant reactions are probably much more common than allergy. The most important allergens causing allergic contact dermatitis are rubber and methacrylates. Dental personnel should use non-powdered non-latex gloves and use non-touch techniques while handling methacrylates.

In vitro lymphocyte reactivity to gold compounds in the diagnosis of contact hypersensitivity

The use of the lymphocyte transformation test (LTT) in the diagnosis of contact hypersensitivity to gold was studied in 8 patients who had positive patch tests to gold salts, and in 8 control subjects who were negative to such patch tests. Gold sodium thiosulfate and gold chloride were added to cultures of lymphocytes, which were labeled by 3H-thymidine after 96 h. The lymphocyte stimulation index was calculated as the beta-counts in stimulated cultures divided by those in control cultures. The index was statistically significantly higher for the patient group (p=0.005-0.04) than for the control group. Levels of interferon-gamma (IFN-gamma) were determined for the supernatants of the lymphocyte cultures. An index IFN-gamma, which is defined as the level of IFN-gamma in stimulated cultures divided by that in control cultures, was statistically significantly higher for the patient group (p=0.01-0.006). The LTT stimulation index showed specificity and sensitivity between 67 and 80%, the respective values for Index IFN-gamma being between 73 and 100% when the patch test was used as a reference method. Evaluation of lymphocyte reactivity might be of future interest in the diagnosis of allergic reactions to gold if the sensitivity and specificity can be improved.

A mouse model for the evaluation of pathogenesis and immunity to influenza A (H5N1) viruses isolated from humans

During 1997 in Hong Kong, 18 human cases of respiratory illness, including 6 fatalities, were caused by highly pathogenic avian influenza A (H5N1) viruses. Since H5 viruses had previously been isolated only from avian species, the outbreak raised questions about the ability of these viruses to cause severe disease and death in humans. To better understand the pathogenesis and immunity to these viruses, we have used the BALB/c mouse model. Four H5N1 viruses replicated equally well in the lungs of mice without prior adaptation but differed in lethality for mice. H5N1 viruses that were highly lethal for mice were detected in multiple organs, including the brain. This is the first demonstration of an influenza A virus that replicates systemically in a mammalian species and is neurotropic without prior adaptation. The mouse model was also used to evaluate a strategy of vaccination against the highly pathogenic avian H5N1 viruses, using an inactivated vaccine prepared from nonpathogenic A/Duck/Singapore-Q/F119-3/97 (H5N3) virus that was antigenically related to the human H5N1 viruses. Mice administered vaccine intramuscularly, with or without alum, were completely protected from lethal challenge with H5N1 virus. Protection from infection was also observed in 70% of animals administered vaccine alone and 100% of mice administered vaccine with alum. The protective effect of vaccination correlated with the level of virus-specific serum antibody. These results suggests a strategy of vaccine preparedness for rapid intervention in future influenza pandemics that uses antigenically related nonpathogenic viruses as vaccine candidates.

Clobetasol propionate followed by calcipotriol is superior to calcipotriol alone in topical treatment of psoriasis

BACKGROUND

Although potent, topical corticosteroids offer effective and rapid healing of psoriatic lesions. Their long term use is limited because of the risk of side effects. Calcipotriol is safe for long-term treatment, but its initial efficacy is lower than with topical corticosteroids.

OBJECTIVES

To investigate whether 2 weeks of treatment with clobetasol propionate 0.05% ointment bd followed by 4 weeks of treatment with calcipotriol 50 microg/g bd would offer therapeutic advantages over 6 weeks of continuous treatment with calcipotriol.

METHODS

Forty-nine patients with moderate to severe plaque psoriasis were recruited from five centres in Norway. In a randomised, double-blind, right- versus left-side comparison, ointments were applied to two symmetrically-located areas.

RESULTS

Two weeks of treatment with clobetasol propionate produced a significantly greater decrease in total symptom score (combined scores of erythema, induration and scaling) than calcipotriol treatment (P < 0.0001). This improvement on the clobetasol propionate-treated side of the body was maintained throughout a subsequent 4-week treatment period when calcipotriol was applied to both sides of the body (P < 0.0001). The superiority of the clobetasol propionate followed by calcipotriol treatment was maintained during a 4-week, treatment-free, observation period. Treatments were well tolerated with no rebound effect.

CONCLUSIONS

Clobetasol propionate ointment bd for 2 weeks followed by treatment with calcipotriol ointment bd for 4 weeks was superior to calcipotriol ointment alone in the treatment of plaque psoriasis.

[Musculoskeletal problems among dental health personnel. A survey of the public dental health services in Hordaland]

A questionnaire concerning musculoskeletal discomfort was satisfactory completed by 329 (76%) of the employees in the Public Dental Services of Hordaland county during the winter of 1990. 81% of the respondents had experienced some sort of musculoskeletal discomfort during the last 12 months. Shoulder discomfort was reported by 45%. Neck discomfort had been experienced by 47%, and low back pain by 49%. The occurrence of other local discomfort was: hands/wrists 21%, upper part of the back 20%, hips 18%, knees 14%, elbows 12%, and ankles 10%. The dental personnel's experience of musculoskeletal discomfort did not differ from that found in the general Norwegian population. The respondents attributed by far the major part of the discomfort to their work. Only when localisation was considered were any occupational or gender-specific differences found. Neck discomfort increased with increasing age. Ergonomic equipment helped to alleviate discomfort in the shoulder. Perceived work load was positively associated with shoulder discomfort. Participation in sport activities showed negative association with discomfort in the lower hack.

Serum levels of vitamin D metabolites in isotretinoin-treated acne patients

Serum levels of vitamin D metabolites were determined in 11 patients treated for cystic acne with a four-month course of isotretinoin (Roaccutane). The levels were measured before treatment and after two months of medication. We found a significant fall in the level of 1,25-dihydroxyvitamin D (p less than 0.01) and a significant increase in the molar ratio of 24, 25-dihydroxyvitamin D to 25-hydroxyvitamin D (p less than 0.05). No significant changes were found for the vitamin D metabolites 25-hydroxyvitamin D or 24,25-dihydroxy-vitamin D, for serum calcium, phosphorus, alkaline phosphatase or parathyroid hormone. Our data indicate early changes in the metabolism of vitamin D in patients on retinoid treatment.