The interactions between pain, pain-related fear of movement and productivity.

BACKGROUND: Employees with physically heavy work have an increased risk of musculoskeletal disorders leading to reduced work ability. AIMS: To investigate if a high level of musculoskeletal pain or pain-related fear of movement was associated with low productivity among employees with physically heavy work and differing work ability levels. METHODS: The study was conducted at a Danish production site and employees with physically heavy work in the production line were included in the study. Work ability was assessed with the Work Ability Index (WAI), pain-related fear of movement with the Tampa Scale for Kinesiophobia and productivity and musculoskeletal pain by self-reported measures. Sickness absence records for construction of WAI were obtained from the workplace. RESULTS: There was a 77% response rate with 350 employees included in the final analysis. Among employees with only moderate work ability, there was neither an association between pain and productivity nor between pain-related fear of movement and productivity. For employees with good work ability, higher levels of pain and higher levels of pain-related fear of movement both raised the odds of low productivity significantly. CONCLUSIONS: Despite the fact that musculoskeletal pain increases the risk of reduced work ability significantly, musculoskeletal pain and pain-related fear of movement were associated with low productivity only among employees with good work ability.

Does muscle strength predict future musculoskeletal disorders and sickness absence?

BACKGROUND: High muscle strength is considered relevant for preventing musculoskeletal disorders and long-term sickness absence. However, prospective studies on the association between muscle strength and future musculoskeletal disorders and long-term sickness absence are few and show contrasting results. AIMS: To investigate the association between low muscle strength and future musculoskeletal disorders and long-term sickness absence. METHODS: Muscle strength in trunk flexion and extension, shoulder elevation and abduction as well as handgrip was recorded from a representative sample of Danish workers (n = 421) in 1995. Musculoskeletal disorders were reported 5 years later (in 2000). Information on long-term sickness absence was retrieved from a register of social transfer payments in the period 1996-2007. RESULTS: Regression analyses adjusted for age, gender, smoking, body mass index and physical work demands showed that workers with low muscle strength (the lowest quartile) of trunk extension and flexion, shoulder elevation and abduction and handgrip did not have a significantly increased risk for future musculoskeletal disorders or long term sickness absence compared with stronger workers. CONCLUSIONS: Low muscle strength does not seem to be a good predictor for musculoskeletal disorders and long-term sickness absence in the general working population.

Patients receiving a prescription for diamorphine (heroin) in the United Kingdom.

The United Kingdom is unusual internationally in that it is one of few countries able to prescribe diamorphine for the treatment of opiate dependence. Prescribing diamorphine has been part of the UK response to drug problems since the 1920s. Despite this, little is known about who receives diamorphine and how treatment is delivered. This study aims to describe the characteristics and treatment regimes of opiate-dependent drug users receiving a prescription for diamorphine in the United Kingdom in 2000, and report on their status in 2002. A retrospective case-note review was conducted in England and Wales. Two hundred and ten (72%; 210/292) patients' sets of case-notes were reviewed at 27 of the 42 (64%) drug clinics where diamorphine was prescribed by the doctor. Patients had been receiving a prescription for diamorphine for a median length of six years. The majority were unemployed white males, with a median age of 44 years. Illicit drug use and criminal activity, while low, had not been eliminated totally. The majority were prescribed ampoules and few had significant health problems. In some cases patients had been transferred to injectable diamorphine from injectable methadone to reduce injection related problems. There were wide variations in dose. The majority of patients had no serious drug, health or social problems. Diamorphine prescribing was a long-term commitment. The experience from the United Kingdom has been one of long-term prescribing with the aim of retaining patients in treatment and reducing the harms caused by illicit drug use. Prospective studies are needed to determine the long-term consequences of receiving a diamorphine prescription.

Detailed genetic and physical map of the 3p chromosome region surrounding the familial renal cell carcinoma chromosome translocation, t(3;8)(p14.2;q24.1).

Extensive studies of loss of heterozygosity of 3p markers in renal cell carcinomas (RCCs) have established that there are at least three regions critical in kidney tumorigenesis, one most likely coincident with the von Hippel-Lindau gene at 3p25.3, one in 3p21 which may also be critical in small cell lung carcinomas, and one in 3p13-p14.2, a region which includes the 3p chromosome translocation break of familial RCC with the t(3;8)(p14.2;q24.1) translocation. A panel of rodent-human hybrids carrying portions of 3p, including a hybrid carrying the derivative 8 (der(8)(8pter-->8q24.1::3p14.2-->3pter)) from the RCC family, have been characterized using 3p anchor probes and cytogenetic methods. This 3p panel was then used to map a large number of genetically mapped probes into seven physical intervals between 3p12 and 3pter defined by the hybrid panel. Markers have been physically, and some genetically, placed relative to the t(3;8) break, such that positional cloning of the break is feasible.

A novel transcriptional unit of the tre oncogene widely expressed in human cancer cells.

Tre is a recombinant gene isolated from NIH3T3 cells transfected with human Ewing's sarcoma DNA. It is composed of three major genetic elements derived, 5' to 3', from human chromosomes 5, 18 and 17. We report here on transcripts from the 3' domain of tre. The transcripts were cloned from a cDNA library of cytoplasmic poly(A)+ RNA from tre-transfected NIH3T3 tumor cells. The complete cDNA sequence, 8201 nucleotides, possessed an unusually long non-coding region and a translatable region with two open reading frames. In one cDNA clone, the presence of two insertions suggested the possibility of alternative splicing. The sequence mapped to the centromere-proximal region of 17q. Transfection-tumorigenicity assays with the open reading frames subcloned into expression vectors were positive for the reading frame adjacent to the 5' non-coding region and negative for the second, downstream, reading frame and the possible alternatively spliced versions of both reading frames. Analysis of the 786 amino acid sequence deduced from the 5' reading frame predicted a highly hydrophilic protein with two charge clusters suggesting nucleic acid-binding properties. When used as probe, the cloned sequence detected RNA transcripts in a wide variety of human cancer cells regardless of their lineage of origin from different tissues, but not in human cells from normal tissue.

A randomised controlled intervention study on prevention of work related skin problems among gut cleaners in swine slaughterhouses.

AIMS: To evaluate the effect of an intervention to reduce work related skin problems in gut cleaning departments in Danish swine slaughterhouses. The intervention consisted of an evidence based prevention programme and a documented method for implementation. METHODS: Randomised controlled intervention study with a one year follow up. The intervention included educational activities and evidence based recommendations. The effect of the intervention was evaluated by telephone interviews using a standardised questionnaire based on the Nordic Occupational Skin Questionnaire (NOSQ-2002) with modified and additional questions on exposure, preventive measures, information, and discussions on prevention of skin problems, etc. RESULTS: A total of 644 (87.5%) responded at the baseline interview and 622 (71.6%) at the one year follow up interview. A total of 495 participated in both interviews (67.3%). In the intervention departments the frequency of eczema on hands or forearms within the past three months at follow up was reduced significantly from 56.2% at baseline to 41.0% at follow up, while a slight non-significant increase was observed in the comparison departments (from 45.9% to 50.2%). The intervention activities resulted in more frequent use of protective gloves in general and the use of cotton gloves worn underneath rubber and plastic gloves. At follow up three times as many in the intervention departments used the recommended high fat skin care products introduced as part of the intervention activities. At follow up, discussion of skin problems was increased in the intervention group while no changes were observed in the comparison group. CONCLUSIONS: A significant 27% relative reduction of occupational eczema in a high risk group was feasible through implementation of an evidence based prevention programme.

Decisions for and against resuscitation in an acute geriatric medicine unit serving the frail elderly.

Recent studies indicate continuing controversy over the appropriateness of intensive care in various clinical settings, particularly for very young and very old patients. We studied decisions regarding cardiopulmonary resuscitation (CPR) and the associated clinical course in an acute geriatric unit serving the frail elderly. Despite multiple acute and chronic conditions, advanced age, and functional impairment, patients overwhelmingly preferred CPR. The patients with do-not-resuscitate (DNR) orders were more functionally dependent, more acutely and chronically ill, and less likely to participate in the decision regarding CPR. The majority of DNR orders were made by surrogates, while the majority of CPR directives were made by the patients themselves. Other forms of acute and supportive care, such as parenteral antibiotics, artificial feeding, and transfusions were not withheld from the DNR patients unless a separate decision to limit a specific treatment was undertaken following consultation between the attending physician and the patient or family. Acuity of illness greater than two SDs above the unit mean and the presence of a surrogate decision maker predicted the majority of DNR orders. Length of stay averaged 28 days for all unit patients, 24 days for patients choosing CPR, and 46 days for patients with DNR orders. The four patients who were resuscitated but died stayed an average of 25 days, while the two survivors of resuscitation stayed 20 and 53 days, respectively. The findings indicate that patients and their families considered appropriate clinical criteria including severity of illness when making their decisions about CPR. Nevertheless, the majority chose to be resuscitated in the event of an arrest. Further studies are needed to explore medical decision making by elderly inpatients and their surrogates and to describe the associated clinical course.

Expression of Fc gamma RII and CD4 receptors by normal human megakaryocytes.

We studied human megakaryocytes to determine if they both expressed and synthesized Fc gamma and CD4 membrane receptors. The strategy employed relied on demonstration of receptor protein and mRNA in megakaryocytes present in freshly made marrow smears, or in megakaryocytes isolated from aspirated normal bone marrow by counterflow centrifugal elutriation. Protein was detected immunochemically, whereas mRNA was detected either by in situ hybridization, or by reverse transcription, polymerase chain reaction (RT-PCR). Using these methods CD4 and Fc gamma RII protein and mRNA were detected in most megakaryocytes. Fc gamma RI and Fc gamma RIII protein was not detected in these cells. Megakaryocytes were also cultured with recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) to determine the effect of this growth factor on Fc gamma RII expression. As has been noted in cells of the monocyte-macrophage lineage, exposure to rhGM-CSF resulted in a significant increase in the level of megakaryocyte Fc gamma RII mRNA and protein. These observations are significant because they provide a physiologic basis for known viral trophism displayed by megakaryocytes. They are also of interest because they suggest that alternative portals exist for entry of human immunodeficiency virus (HIV-1) into megakaryocytes and that such infection may play a role in acquired immunodeficiency syndrome (AIDS)-related thrombocytopenia.

Hypertension during extracorporeal membrane oxygenation: cause, effect, and management.

The major complication of extracorporeal membrane oxygenation (ECMO) for the treatment of neonatal respiratory failure is bleeding related to heparinization. Systolic hypertension has emerged as another serious side effect in our experience. Thirty-eight of the first 41 newborns we treated with ECMO developed a systolic blood pressure greater than 90 mm Hg. The mean hypertension index (HI blood = hours greater than 90/hr on ECMO) was 0.17 +/- 0.16. Possible biochemical mediators were assayed in 17 patients. Plasma renin activity (PRA), aldosterone, epinephrine, norepinephrine, prostaglandin E2, thromboxane, and antidiuretic hormone were elevated. Angiotensin-converting enzyme (ACE) and prostacyclin were not elevated. Eighteen patients (44%) had intracranial hemorrhage (ICH), and 11 patients (27%) had clinically significant ICH. The HI was significantly (p less than 0.005) lower in those patients without ICH (0.11 +/- 0.01) than in those patients with ICH (0.25 +/- 0.04). PRA at hour 12, day 2, and day 3 was significantly higher (p less than 0.05) in patients experiencing ICH (62 +/- 42; 93 +/- 15; 73 +/- 30 ng/ml/hr) than in those without ICH (27 +/- 25; 14 +/- 8; 12 +/- 4 ng/ml/hr). An aggressive approach to medical management evolved that included hydralazine, nitroglycerine, and captopril, which protected against ICH. Two of 23 patients (9%) treated with the protocol sufferred clinically significant ICH, whereas nine of 18 patients (50%) treated before implementation of the protocol experienced ICH. The ACE inhibitor captopril was most effective in the control of hypertension. We conclude that systolic hypertension is common during neonatal ECMO, is associated with ICH, and is related to a high PRA. Aggressive management of hypertension during ECMO can reduce the incidence of ICH, and captopril is an important component of this aggressive medical management.

Cytogenetic findings in primary uveal melanoma.

We analyzed cytogenetic abnormalities in 10 cases of primary uveal melanoma. Clonal chromosomal abnormalities were present in nine cases. Chromosome 6 was most commonly affected (seven cases) and included gain of material from 6 and/or loss of material from 6q. Trisomy of chromosome 8 or gain in material from 8q, mostly in the form of an i(8q) resulting in three to five copies of the 8q segment was seen in six cases. Monosomy of chromosome 3 and rearrangements of chromosome 9 were less frequent and were altered in three cases each. Clinical, histopathologic, and cytogenetic abnormalities are correlated.

Functional magnetic resonance imaging of the acute effect of intravenous heroin administration on visual activation in long-term heroin addicts: results from a feasibility study.

This preliminary report is the first demonstration of the acute effects of diacetylmorphine (heroin) administration on functional activation in the human brain using functional magnetic resonance imaging (fMRI). Four opiate addicts who received regular prescriptions for heroin, underwent fMRI using a visual activation paradigm before and after a dose of 30 mg heroin. All four showed a decrease after the heroin dose in the extent of significant activation. This method shows promise for sequential scanning to determine brain activity in response to different drugs and routes of drug administration.

Neural responses associated with cue evoked emotional states and heroin in opiate addicts.

Ten male opiate addicts, who were current heroin injectors, underwent positron emission tomographic (PET) scanning during exposure to a sequence of six alternating drug related and neutral video cues, on two occasions. After the second scan, each subject received heroin or placebo using a randomised single-blind procedure. This design allowed the investigation of patterns of brain activity during a range of self-reported cue evoked emotional states, both in the presence and absence of heroin. Self-reports of 'urge to use' correlated strongly with increased regional blood flow (rCBF) in the inferior frontal and orbitofrontal cortex target regions of the mesolimbic dopaminergic system, implicated in conditioning and reward. 'Urge to use' was also associated with highly significant increased rCBF in the right pre-cuneus, an area associated with episodic memory retrieval, and in the left insula, implicated in the processing of the emotional components of stimuli. Self-reports of feeling 'high' correlated with rCBF activation in the hippocampus, an area relevant to the acquisition of stimulus-associated reinforcement.

Communicating the diagnosis of lung cancer.

In order to assess their reaction to the information given, 50 patients underwent a semi-structured interview with a social worker within 1 week of having been told the diagnosis of lung cancer. There were 32 men and 18 women with a mean age of 63 (range 38-82) years. Thirty-eight (76%) belonged to Registrar General social class IV or V, and 45 (90%) had left school at the age of 15 years. Two patients were unaware of the diagnosis despite having been told that they had lung cancer. Two patients would have preferred not to have been told the diagnosis and two were unsure, while 46 (92%) felt that telling them the diagnosis truthfully had been correct. No patient felt that they had been given too much information, but 13 (26%) indicated a lack of information about prognosis. Despite being told 'bad news', 31 (62%) felt more reassured after their interview with the doctor, 5 (10%) felt less reassured, and 14 (28%) were uncertain. Twenty-one (42%) patients were experiencing a sense of guilt or regret at having smoked. Many patients had concerns about specific symptoms which they expected to suffer. In general, patients wanted to be told their diagnosis truthfully and required a high level of information. Many patients felt reassured by the discussion of such details.

Biomechanical evaluation of five different occipito-atlanto-axial fixation techniques.

STUDY DESIGN: The stabilizing effects of five different occipitocervical fixations were compared. OBJECTIVES: To evaluate the construct stability provided by five different occipito-atlanto-axial fixation techniques. SUMMARY OF BACKGROUND DATA: Few studies have addressed occipitocervical reconstruction stability and no studies to data have investigated anterior-posterior translational stiffness. METHODS: A total of 21 human cadaveric spines were used. After testing intact spines (CO-C2), a type II dens fracture was created and five different reconstructions were performed: 1) occipital and sublaminar wiring/rectangular rod, 2) occipital screws and C2 lamina claw hooks/rod, 3) occipital screws, foramen magnum screws, and C1-C2 transarticular screws/rod, 4) occipital screws and C1-C2 transarticular screws/Y-plate, and 5) occipital screws and C2 pedicle screws/rod. Biomechanical testing parameters included axial rotation, flexion/extension, lateral bending, and anterior-posterior translation. RESULTS: Pedicle screw fixation demonstrated the highest stiffness among the five reconstructions (P < 0.05). The two types of transarticular screw methods provided greater stability than hook or wiring reconstructions (P < 0.05). The C2 claw hook technique resulted in greater stability than sublaminar wiring fixation in anterior-posterior translation (P < 0.05). However, the wiring procedure did not significantly increase the stiffness levels beyond the intact condition under anterior-posterior translation and lateral bending (P > 0.05). DISCUSSION: C2 transpedicular and C1-C2 transarticular screws significantly increased the stabilizing effect compared to sublaminar wiring and lamina hooks. The improved stability afforded by C2 pedicular and C1-C2 transarticular screws offer many potential advantages including a high rate of bony union, early ambulation, and easy nursing care. CONCLUSION: Occipitocervical reconstruction techniques using C1-C2 transarticular screws or C2 pedicle screws offer biomechanical advantages compared to sublaminar wiring or lamina hooks. Pedicle screw fixation exhibited the highest construct stiffness among the five reconstructions.

Cost analysis in the management of esophageal coins: endoscopy versus bougienage.

PURPOSE: The aim of this study was to compare the safety, efficiency, and overall cost effectiveness of esophageal bougienage versus endoscopy in the retrieval of ingested coins. METHODS: Retrospective review of patients treated for esophageal coin ingestion at Children's Hospital of Wisconsin over a 1-year period using bougienage or endoscopic retrieval was conducted. (inclusion criterion) RESULTS: Twenty-seven patients were evaluated over the 1-year study period. Two patients spontaneously passed the coins before arrival and needed no further treatment. Twelve patients met criteria for bougienage, and this treatment was successful in 10 of the 12 patients. Mean length of hospital stay was 2.15 hours, and the mean cost was $546. Thirteen patients were treated successfully with endoscopy. The mean length of hospital stay was 22.7 hours, and the mean cost was $5,230. There were no complications in any of the 25 patients. CONCLUSIONS: Bougienage is equally safe, more efficient, and much less expensive than endoscopy for treatment of esophageal coins in properly selected patients. Nearly half of the patients were excluded from bougienage because of delayed presentation alone. Education of parents and physicians regarding symptoms of coin ingestion would allow primary treatment with bougienage in the majority of cases.

Experience with renal failure during extracorporeal membrane oxygenation: treatment with continuous hemofiltration.

We use extracorporeal membrane oxygenation (ECMO) to treat respiratory and cardiac failure in children who are unresponsive to standard ventilator and pharmacologic management. All patients have cardiac and abdominal ultrasonography prior to ECMO to identify major structural anomalies and anatomically normal kidneys. Despite this, oliguric renal failure is seen in a number of patients. Acute renal failure (ARF) developed in two of the first 20 patients we placed on ECMO and both of these patients died. Six of the last 27 patients (22%) also developed ARF and were treated with continuous hemofiltration (CH) placed in-line with the extracorporeal circuit. The technique of CH removes plasma water and dissolved solutes while retaining proteins and cellular components of the intravascular space. The duration of CH ranged from 9 to 112 hours (mean 57.5 hours). Indications for CH were hypervolemia, hyperkalemia, and azotemia. The mean serum potassium prior to CH was 5.6 (range 4.3 to 7.0) compared with 4.5 after filtration. We filtered 5 to 10 mL/kg/h and replaced it with crystalloid chosen on the basis of serum and filtrate electrolytes. These six patients had a 33% mean weight gain prior to CH. We were able to remove as much as 2,200 g in the most edematous patient with significant improvement in cardiopulmonary status. Four of the patients on CH died of their primary pulmonary or cardiac disease without specific problems related to ARF. The other two patients were successfully weaned from ECMO, extubated, and have not needed further therapy for renal failure. We conclude that CH is useful in managing the complications of oliguric renal failure during ECMO.

Hemorrhagic complications during extracorporeal membrane oxygenation: prevention and treatment.

Hemorrhage related to systemic heparinization is the major complication of extracorporeal membrane oxygenation (ECMO). Intracranial hemorrhage (ICH) is the most devastating complication. ICH developed in 13 of our 25 ECMO patients (52%). Six died, six survived with normal neurologic function, and one is severely impaired. In nine of 13 patients (69%) ECMO was discontinued when serial cranial ultrasounds showed progressive ICH. Seizures developed in six infants while receiving ECMO, and ICH developed in all. There is a correlation between hypertension and ICH. A hypertension index (hours systolic BP greater than 90/hours receiving ECMO) was 0.1 +/- 0.12 for infants without ICH and 0.37 +/- 0.28 for infants with ICH (P less than .05). ICH developed in 79% of the patients with an index greater than 0.1. Twenty neck explorations were required in the first 20 patients for incisional bleeding (mean blood loss, 21.9 +/- 18.0 mL/kg/d). We now use fibrin glue following cannulation and have done only one neck exploration in the last five patients (mean blood loss, 2.8 +/- 2.2 mL/kg/d, P less than .05). Endobronchial bleeding has responded to phenylephrine lavage and increased positive end-expiratory pressure. We have controlled pleural space bleeding with topical thrombin. None of the hemorrhagic complications encountered correlate with the activated clotting time or the amount of heparin used. There is an increased risk of hemorrhage associated with platelet counts less than 100,000/microL for 75% of a day (P less than .05) so that aggressive platelet transfusion remains important in preventing hemorrhagic complications during ECMO.

Prescription of diamorphine, dipipanone and cocaine in England and Wales.

The vast majority of substitute prescribing to opiate addicts in England and Wales is of oral methadone. The prescription of diamorphine, dipipanone and cocaine to addicts is allowed subject to the 1971 Misuse of Drugs Act. Prescription of these drugs has aroused international interest and controversy in the United Kingdom although research is scanty. This report is a description of the current attitudes about, and practice of, prescribing diamorphine, dipipanone and cocaine by medical practitioners in the addiction field in England and Wales. A questionnaire was devised and sent to drug services in England and Wales which provided a prescribing service. Among respondents who reported that they currently hold a licence for heroin, dipipanone or cocaine, the number of patients treated by each doctor varied widely; from a handful of patients to 100 heroin patients. Dosage currently used ranged from a minimum of 10 mg to a maximum of 1000 mg daily for heroin. Doses of dipipanone were lower. More respondents thought that heroin and dipipanone were clinically justified in some situations than thought that they should never be prescribed, while the opinions were reversed in the case of cocaine.

AIDS in the elderly: a case and its implications.

Although acquired immunodeficiency syndrome (AIDS) remains relatively uncommon in the elderly, there are serious and unique implications associated with the diagnosis of AIDS in this age group. The most common mode of transmission is transfusion. With the growing number of elderly, an increase in AIDS in the elderly will occur despite improved screening methods. Dementia is a serious morbidity associated with AIDS in the elderly, which presents considerable diagnostic and ethical dilemmas. A case is presented which illustrates the geriatric multidisciplinary team approach to the care of a 90-year-old man with AIDS.

Skin cancer attitudes: a cross-national comparison.

A questionnaire concerning attitudes towards skin cancer, sun exposure and general environmental issues was administered to 132 holiday-makers on a beach in south-west England and (in translation) to 142 visitors to another beach in north-west Italy. Following the Janis & Mann (1977) classification of strategies for coping with decision conflicts, subscales were derived measuring tendencies to 'avoid' thinking about environmental issues, to 'bolster' prior attitudes (by playing down the seriousness of the risk of skin cancer while attending to the pleasures of sunbathing), and to be 'vigilant' concerning risk information and the need for specific protective behaviour (e.g. sunscreen use). The British scored higher than the Italians, and women higher than men, on vigilance, but there were no gender or nationality differences on the other subscales considered as a whole. Responses were also related to the covariates of age and self-reported vulnerability to sunburn. Those who showed less concern with environmental issues also tended to play down the risks of skin cancer and be less vigilant with regard to self-protection. It is suggested that health promotion should address both cultural norms concerning exposure to the sun and people's intuitive notions about their relative personal vulnerability.