Extensively drug resistant tuberculosis in a HIV-infected patient in a UK hospital.

Tuberculosis (TB) is a major cause of mortality in the HIV-infected population, with growing concern about increasing incidence in extensively drug-resistant (XDR) TB worldwide. We describe the first published case of XDR TB and HIV co-infection in the UK. The case describes a patient newly diagnosed with smear-positive pulmonary TB and HIV. The isolate was found to be XDR TB, requiring use of third-line TB drugs alongside antiretroviral medication, causing multiple complications due to drug toxicity and interactions. After culture conversion was achieved directly observed treatment with close community support was organized for the patient. Despite these arrangements the patient required readmission for new-onset headaches after poor adherence to treatment. Investigations confirmed lymphocytic meningitis. The patient eventually deteriorated and died from acute cerebral infarction. This case highlights the complexity of managing drug-resistant TB in HIV-infected individuals, due to difficult adherence, drug toxicity and potential public health risks.

International spread of MDR TB from Tugela Ferry, South Africa.

We describe a death associated with multidrug-resistant tuberculosis and HIV infection outside Africa that can be linked to Tugela Ferry (KwaZulu-Natal, South Africa), the town most closely associated with the regional epidemic of drug-resistant tuberculosis. This case underscores the international relevance of this regional epidemic, particularly among health care workers.

Outcomes of a leadership intervention for a metropolitan fire department.

Poor leadership can contribute to job dissatisfaction and employees' "burnout." Perceived lack of leadership skills is also a source of stress for supervisors. This study evaluated the efficacy of a brief multicomponent leadership intervention provided for fire service supervisors in an urban fire department. Ratings by 51 line firefighters and 8 first-line supervisors documented improvements in their immediate supervisors' performance at 3 mo. postintervention. Self-reports by line firefighters also showed improvements in perceptions of their ability to attain career goals, which were sustained at 9 mo. postintervention. There were also improvements on certain stress related symptoms indices reported by the sample of firefighter supervisors at both the 3-mo. and 9-mo. follow-ups. No significant changes on any of these measures, obtained at comparable time points, were observed in a (nonequivalent) control sample of firefighters and their first-line supervisors in an "untreated" urban fire department.

Bioterrorism. Implications for the occupational and environmental health nurse.

1. Bioterrorism is the intentional release of a biological agent--bacterial, viral, or genetically altered--to instill fear or create chaos, massive casualities, illness, and death in humans, animals, or plants. 2. The threat of bioterrorism is real. Although every community is vulnerable, terrorists seek densely populated, highly visible targets. 3. Occupational and environmental health nurses must to be able to recognize and report signs and symptoms of an early bioweapons outbreak in their workplaces and communities. Only thorough preparedness and planning will result in effective mitigation and treatment. 4. The Bioterrorism Readiness Plan (at http://www.apic.org and http://www.CDC.gov/ncidod/hip) is a template for health care professionals to help plan a realistic response to bioterrorism. It serves as a tool for successful collaboration and communication among all disciplines and public health agencies for the best possible outcomes.

Ecological model of occupational stress. Application to urban firefighters.

1. Multiple individual and organizational barriers make it difficult for occupational health nurses and other providers to understand and handle stress in the workplace. 2. Recent research suggests adverse health effects resulting from occupational stress are more related to the context or conditions of work than workers' characteristics. 3. The ecological approach described in this article provides a means to examine the context in which stress occurs through an analysis of four levels of influence. The levels of influence include the microsystem, the organizational system, the peri-organizational system, and the extra-organizational system. 4. Through a careful analysis using this approach, an identification of the entire spectrum of factors contributing to the occurrence of workplace stressors can be identified, and more effective interventions addressing existing and potential problems related to occupational stress can be developed.

PTSD among bereaved parents following the violent deaths of their 12- to 28-year-old children: a longitudinal prospective analysis.

This study examined the prevalence of posttraumatic stress disorder (PTSD) among parents bereaved by the violent deaths of their 12- to 28-year-old children. A community-based sample of 171 bereaved mothers and 90 fathers was recruited by a review of Medical Examiner records and followed for 2 years. Four important findings emerged: Both parents' gender and children's causes of death significantly affected the prevalence of PTSD symptoms. Twice as many mothers and fathers whose children were murdered met PTSD caseness (full diagnostic) criteria compared with accident and suicide bereavement. Symptoms in the reexperiencing domain were the most commonly reported. PTSD symptoms persisted over time, with 21% of the mothers and 14% of the fathers who provided longitudinal data still meeting caseness criteria 2 years after the deaths. Parents who met caseness criteria for PTSD, compared with those who did not, were significantly different on multiple study variables. Both theoretical and clinical implications for the findings are discussed.

Coping responses and posttraumatic stress symptomatology in urban fire service personnel.

Emergency workers, including urban fire fighters and paramedics, must cope with a variety of duty-related stressors including traumatic incident exposures. Little is known about coping responses of emergency workers or whether their coping responses predict future mental health outcomes. The previously formulated Coping Responses of Rescue Workers Inventory (CRRWI) underwent a principal components analysis employing a sample (N = 220) of urban fire fighters and paramedics. Six empirically and theoretically distinct CRRWI components were identified which were relatively stable over a 6-month period. Scores on one of the CRRWI scales, but neither years of service nor their past half year's traumatic incident exposures, predicted future changes in self-reports of posttraumatic stress symptomatology.

Exposure to traumatic incidents and prevalence of posttraumatic stress symptomatology in urban firefighters in two countries.

Urban firefighters are at risk for posttraumatic stress disorder (PTSD) due in part to their exposure to duty-related trauma. This study compared duty-related trauma exposures and the prevalences of posttraumatic stress in U.S. and Canadian firefighters. Both samples reported relatively numerous and frequent posttrauma symptoms, and the rates of self-reported PTSD prevalence did not differ significantly. However, analysis of departmental records for respondents' previous year on duty revealed significant differences in both frequencies and categories of traumatic incident exposures. Some of the vulnerability and moderating risk factors associated with PTSD caseness differed between the U.S. and Canadian samples. Potential explanations for the observed differences in risk factors for PTSD in these 2 firefighter samples are considered.

Parents' health, health care utilization, and health behaviors following the violent deaths of their 12- to 28-year-old children: a prospective longitudinal analysis.

Health status, health care utilization, and health behaviors of parents bereaved by the violent deaths of their adolescent and young adult children were examined 4, 12, and 24 months later. Participants were 261 bereaved parents (171 mothers, 90 fathers). About 20% of the parents reported "poor" physical health during the early bereavement period compared with 16% of Americans the same age. Over time, mothers' health improved whereas fathers' health deteriorated. Fathers in poor health compared with fathers in good health are 15 times more likely to report emotional distress and 4.6 times more likely to report trauma symptoms. Mothers in poor health compared with mothers in good health are 11 times more likely to report emotional distress and 3 times more likely to report trauma symptoms. Mothers' reports of physician visits and medication use were higher than fathers', however, mothers' rates for both decreased significantly over time whereas fathers' rates remained constant. Over 70% of the mothers and nearly 60% of the fathers practiced 2 or more health protective behaviors over time--a finding significantly associated with fewer stress-related illnesses, days absent from work, and non-productivity at work. Implications for the findings are discussed.

Exposure to duty-related incident stressors in urban firefighters and paramedics.

Little is known about the variables that might be associated with posttraumatic stress symptomatology in high-risk occupational groups such as professional firefighters and paramedics. A sample of 173 urban professional firefighter/EMT's and firefighter/paramedics rated and ranked the stressfulness of 33 actual and/or potential duty-related incident stressors. They also reported whether they had experienced each of these incident stressors within the past 6 months and, if they had, to recall on how many occasions within the past 6 months. A principal components analysis of their rescaled incident stressor ratings yielded five components: Catastrophic Injury to Self or Co-worker, Gruesome Victim Incidents, Render Aid to Seriously Injured, Vulnerable Victims, Minor Injury to Self and Death & Dying Exposure.

Social support and network conflict in firefighters and paramedics.

The relationship(s) between self-rated social support network conflict (both at work and off-work) and self-report measures of occupational stressors, job satisfaction, and health outcomes were examined in samples of currently employed professional firefighters (n = 1,730) and paramedics (n = 253). In both samples, perceived social support and network conflict at work were more strongly correlated with job satisfaction and work morale, as well as a measure of their appraised occupational stressors, than with their comparable home (off-work) satisfaction/conflict ratings. The path analysis generated suggested that, with only one exception, social support and relational conflict in the combined respondent sample could be conceptualized as direct sources of stress influencing the respondents' appraisal of their occupational stressors. The path model further suggested that firefighter/paramedics' appraisal of their occupational stressors mediated the network variables' influences on self-reported job dissatisfaction and stress symptom health outcome measures.

Firefighters and paramedics: years of service, job aspirations, and burnout.

1. Data were collected from an anonymous mail survey of over 2,000 paramedics and firefighters to determine the relationships among years of service and four occupational outcomes, including burnout. 2. Paramedics had poorer outcomes than firefighters. Job title, not percent of emergency service runs per se, significantly differentiated the groups with respect to burnout and job aspiration variables. 3. After adjusting for age, years of service correlated negatively with three measures of job aspirations: job satisfaction, work related morale, and career goal attainment in both groups. 4. If signs and symptoms of burnout occur throughout the worker's life cycle rather than with increasing years of experience, the findings have implications for both prevention and intervention strategies.

Gender differences in fire fighter job stressors and symptoms of stress.

This study described gender differences in fire fighter appraisal of job stressors and symptoms of stress. A sample of 670 male and 41 female fire fighters responded to an anonymous mail survey consisting of three standardized and investigator-developed questionnaires. Male and female fire fighter respondents were more similar than different on both job stressor and symptoms of stress measures. Five job stressors were ranked the most "bothersome" by both males and females during the last 10 shifts worked. These were: sleep disturbance, wage/benefit concerns, job skill concerns, substandard equipment, and safety concerns. Of these five job stress factors, only one gender difference was noted. Female fire fighters reported significantly higher scores than males on job skill concerns. Job discrimination reported by female respondents was significantly higher than for males (t = 3.51, p < .0001) even though it was not ranked among the five most stressful factors. Partial correlations computed between job stressors and symptoms of stress, while controlling for the number of years as a fire fighter, were of moderately high magnitude for both genders and similar to simple correlations computed. These results suggest that the number of years of service did not account for gender differences reported.

Sources of occupational stress among firefighter/EMTs and firefighter/paramedics and correlations with job-related outcomes.

INTRODUCTION/OBJECTIVE: This paper reports the results of an initial effort to develop and test a measure of the various sources of job-related stress in firefighter and paramedic emergency service workers. METHODS: A 57-item paper and pencil measure of occupational stressors in firefighter/Emergency Medical Technicians (EMTs) and firefighter/paramedics was developed and administered by anonymous mail survey. RESULTS: More than 2,000 (50% rate of return) emergency service workers completed and returned the surveys. The responses of 1,730 firefighter/EMTs and 253 firefighter/paramedics were very similar in terms of the degree to which job stressors were bothersome. A factor analysis of replies yielded 14 statistically independent "Occupational Stressor" factors which together accounted for 66.3% of the instrument's variance. These Sources of Occupational Stress (SOOS) factor scale scores essentially did not correlate with a measure of the social desirability test-taking bias. Finally, SOOS factors were identified that correlated with job satisfaction and work-related morale of the respondents. Conflict with administration was the job stressor factor that most strongly correlated with reports of low job satisfaction and poor work morale in both study groups. CONCLUSION: The findings suggest that firefighter and paramedic job stress is very complicated and multi-faceted. Based on this preliminary investigation, the SOOS instrument appears to have adequate reliability and concurrent validity.

Intracarotid chemotherapy with etoposide and cisplatin for malignant brain tumors.

Chemotherapy for tumors of the central nervous system has a limited efficacy presumably because of restricted blood-brain barrier permeability. The advantage of regional intra-arterial administration of anticancer drugs is an increased uptake during the first passage of the drugs through tumor capillaries. Twenty patients with high-grade astrocytomas (HGA) and 28 patients with metastatic brain tumors (MBT) received intracarotid/intravertebral infusion of etoposide and cisplatin. Eight patients with HGA who underwent incomplete resection responded to chemotherapy alone. Four additional patients had complete resection of the tumor. Median survival time of the group (responders and nonresponders) has been 14 months. Twelve patients with MBT responded to chemotherapy alone (six had complete response [CR], and six had partial response [PR]) with a median survival time of 7 months. Intra-arterial chemotherapy (IAC) appears to be effective with acceptable toxicities. Accrual of additional patients is required before a final conclusion can be reached.

Self-reported symptoms of stress with temporomandibular disorders: comparisons to healthy men and women.

Replies on a self-report measure of symptoms of stress obtained from men and women patient samples with diagnosed temporomandibular disorders were compared with similar replies on this test obtained from healthy men and women. On most (six of 10) of the symptoms of stress subscales, the temporomandibular disorder patients' scores were elevated relative to the symptoms of stress averages of the healthy nonpatient samples. There were several statistically significant group differences. There were no statistically significant gender differences nor any gender group interactions. These data are seen as essentially supporting and extending prior studies, which have indicated that, on the average, temporomandibular disorder patients report more psychologic and somatic symptoms. Furthermore, current findings indicate that male temporomandibular disorder patients and female temporomandibular disorder patients report more numerous and/or frequent somatic, psychologic, and behavioral symptoms of stress compared with their healthy counterparts.

Response to symptoms in healthy, low utilizers of the health care system.

From the literature, it is clear that a small proportion of people account for an inordinately high number of health care visits. Conversely, there exists a group of individuals who rarely seek professional medical intervention and, yet, who remain healthy. This study examines a sample of adults who have not received remedial treatment for any symptom in the previous year, who consider themselves as healthy and who pass a comprehensive physical examination. A gender and age balanced group of healthy low utilizers was administered the Symptom Response Questionnaire, an instrument designed to elicit response tendencies to thirteen standardized symptoms. There were significant differences between age groups in response to symptoms with the older individuals more likely to seek professional help. There were few gender differences within the healthy sample. This sample of healthy low-utilizers was not without symptoms, reporting an average of 20 symptoms occurring in the previous week as measured by the SCL-90. A clinical headache group was also administered the SRQ to provide information about their response tendencies to symptoms. This preliminary study suggests that response to illness may be significantly influenced by age and patient status and that reported gender differences in health care utilization may need to be examined more carefully. It is proposed that behavior patterns of healthy, low utilizers may have direct implications for intervention with high utilizers of the health care system.

The case for peripheral persistence: effects of target and background luminance on a partial-report task.

The effects of varying target and background luminances were examined on a partial-report task of iconic memory. Experiment 1 demonstrated that with a dim preexposure and postexposure field, varying target luminance has a marked effect on performance. Increased luminance results in significantly longer iconic storage. In Experiment 2 performance on the task was determined as the background luminance was systematically increased. It was found that not only is the duration of iconic storage reduced by increasing background luminance but changes in target luminance have progressively less of an effect as background luminance increases. These results are discussed in terms of the known response properties of cone and rod photoreceptors and their potential contribution to iconic memory. Finally, possible reasons for discrepancies with other iconic memory studies are detailed.