Work-related stress and occupational therapy

Occupational stress and burnout have been studied extensively in the human services. It has been suggested that healthcare professionals in particular are at risk of stress owing to the caring nature of their work. Articles related to occupational therapy and work-related stress were reviewed in regard to practice in Australia, Canada, the United Kingdom, the United States and Sweden. Although the empirical literature is relatively weak for occupational therapy, it has been argued that occupational therapists in health care share risk factors with other healthcare professionals. These risk factors include repeated exposure to distress and difficult behaviour, prolonged interventions and uncertain outcome. Issues such as professional status, staffing issues and the nature of the profession have been identified as additional risk factors for occupational therapists. However, empirical studies that enable burnout rates of occupational therapists to be compared with those of related occupational groups suggest that this may not be the case. Occupational therapists may in fact be protected from some stress and burnout factors. Further research is recommended to clarify the nature of stress experienced by occupational therapists and to identify both risk and protective factors characteristic of the profession. Copyright © 2001 Whurr Publishers Ltd.

Adult Growth Hormone Deficiency. What does the newest hormone replacement therapy do?

All patients with known pituitary or hypothalamic disease, or surgery or radiation treatment to the area could have growth hormone deficiency. Growth hormone deficiency in adults is an approved indication for recombinant growth hormone treatment in Australia. Diagnosis currently requires measurement of growth hormone response to insulin hypoglycaemia. Many patients have dramatic improvements in body composition, functional capacity and psychological wellbeing following recombinant human growth hormone replacement. (author abstract)

Stem cells in the aetiopathogenesis and therapy of rheumatic disease

Animal models of autoimmune disease and case reports of patients with these diseases who have been involved in bone marrow transplants have provided important data implicating the haemopoietic stem cell in rheumatic disease pathogenesis. Animal and human examples exist for both cure and transfer of rheumatoid arthritis, systemic lupus erythematosus (SLE) and other organ-specific diseases using allogeneic haemopoietic stem cell transplantation. This would suggest that the stem cell in these diseases is abnormal and could be cured by replacement of a normal stem cell although more in vitro data are required in this area. Given the morbidity and increased mortality in some patients with severe autoimmune diseases and the increasing safety of autologous haemopoietic stem cell transplantation (HSCT), pilot studies have been conducted using HSCT in rheumatic diseases. It is still unclear whether an autologous graft will cure these diseases but significant remissions have been obtained which have provided important data for the design of randomized trials of HSCT versus more conventional therapy. Several trials are now open to accrual under the auspices of the European Bone Marrow Transplant Group/European League Against Rheumatism (EBMT/EULAR) registry. Future clinical and laboratory research will need to document the abnormalities of the stem cell of a rheumatic patient because new therapies based on gene therapy or stem cell differentiation could be apllied to these diseases. With increasing safety of allogeneic HSCT it is not unreasonable to predict cure of some rheumatic diseases in the near future.

Can anticonvulsant drug therapy 'cure' epilepsy?

There is now evidence to show that, as time passes, epilepsy, even if untreated, tends to undergo spontaneous remission in a significant proportion of patients. The question therefore arises as to whether anticonvulsant drug therapy increases this chance of the patient with epilepsy ultimately entering a terminal remission which continues after the treatment is withdrawn, Le. whether anticonvulsant drug therapy itself may sometimes cure epilepsy. There are no well-designed studies available in the literature that provide a clear answer to this question. However, data from a number of investigations carried out for other purposes can be used to see whether contemporary anticonvulsant drug therapy is associated with higher rates of expected untreated terminal remission than those that apply for never-treated patients with epilepsy, or for those whose anticonvulsant treatment has probably been inadequate for various social or historical reasons. Despite the admitted uncertainties inherent in drawing conclusions from such material, there appears to be a reasonably consistent tendency for contemporary anticonvulsant drug treatment to be associated with a greater chance of achieving probable cure of epilepsy. Therefore it would appear premature to take the view that contemporary anticonvulsant drug therapy does no more than suppress epileptic seizures until epilepsy remits spontaneously, or fails to remit, with the passing of time.

Premenstrual syndrome: The condition, the therapy and the pharmacist.

The following aspects of premenstrual syndrome are discussed: classification, common symptoms, aetiology, pharmacological treatment, other therapies, role of the pharmacist. (non-author abstract)

Early Australian experience with infliximab, a chimeric antibody against tumour necrosis factor-alpha, in the treatment of Crohn's disease: is its efficacy augmented by steroid-sparing immunosuppressive therapy?

Background: Tumour necrosis factor-alpha (TNF-alpha) plays an important role in the pathology of Crohn's disease. Infliximab, a chimeric antibody against TNF-alpha, has been shown in controlled clinical trials to be effective in two-thirds of patients with refractory or fistulating Crohn's disease. The factors that determine a clinical response in some patients but not others are unknown. Aims: To document the early Australian experience with infliximab treatment for Crohn's disease and to identify factors that may determine a beneficial clinical response. Methods: Gastroenterologists known to have used infliximab for Crohn's disease according to a compassionate use protocol were asked to complete a spreadsheet that included demographic information, Crohn's disease site, severity, other medical or surgical treatments and a global clinical assessment of Crohn's disease outcome, judged by participating physicians as complete and sustained (remission for the duration of the study), complete but unsustained (remission at 4 weeks but not for the whole study) or partial clinical improvement (sustained or unsustained). Results: Fifty-seven patients were able to be evaluated, with a median follow-up time of 16.4 (4-70) weeks, including 23 patients with fistulae. There were 21 adverse events, including four serious events. Fifty-one patients (89%) had a positive clinical response for a median duration (range) of 11 (2-70) weeks. Thirty patients (52%) had a remission at 4 weeks, 10 of whom had remission for longer than 12 weeks. Forty-two per cent of fistulae closed. Sustained remission (P = 0.065), remission at 4 weeks (P = 0.033) and a positive clinical response of any sort (P = 0.004) were more likely in patients on immunosuppressive therapy, despite there being more smelters in this group. Conclusion: This review of the first Australian experience with infliximab corroborates the reported speed and efficacy of this treatment for Crohn's disease. The excellent response appears enhanced by the concomitant use of conventional steroid-sparing immunosuppressive therapy.

Pharmacokinetics of ciprofloxacin in ICU patients on continuous veno-venous haemodiafiltration

Objectives: To investigate the pharmacokinetics of intravenous ciprofloxacin 200 mg every 8 h in critically ill patients on continuous veno-venous haemodiafiltration (CVVHDF), one form of continuous renal replacement therapy (CRRT). Design and setting: Open, prospective clinical study in a multidisciplinary, intensive care unit in a university-affiliated tertiary referral hospital. Patients: Sis critically ill patients with acute renal failure on CVVHDF. Interventions: Timed blood and ultrafiltrate samples were collected to allow pharmacokinetics and clearances to be calculated of initial and subsequent doses of 200 mg intravenous ciprofloxacin. CVVHD was performed with 1 l/h of dialysate and 2 l/h of predilution filtration solution, producing 3 lih of dialysis effluent. The blood was pumped at 200 ml/min using a Gambro BMM-10 blood pump through a Hospal AN69HF haemofilter,. Measurements and results: Ten pharmacokinetic profiles were measured. The CVVHDF displayed a urea clearance of 42 +/- 3 ml/min, and removed ciprofloxacin with a clearance of 37 +/- 7 ml/min. This rate was 2-2.5 greater than previously published for ciprofloxacin in other forms of CRRT. On average the CVVHDF was responsible for clearing a fifth of all ciprofloxacin eliminated (21 +/- 10%). The total body clearance of ciprofloxacin was 12.2 +/- 4.3 l/h. The trough concentration following the initial dose was 0.7 +/- 0.3 mg/l. The area under the plasma concentration time curves over a 24-h period ranged from 21 to 55 mg .h l(-1). Conclusions: Intravenous ciprofloxacin 600 mg/day in critically ill patients using this form of CRRT produced adequate plasma levels for many resistant microbes found in intensive care units.

Outpatient cognitive behavioural therapy programme for alcohol dependence impact of naltrexone use on outcome

Objective: Cognitive-behavioural therapy (CBT) has been effectively used in the treatment of alcohol dependence. Clinical studies report that the anticraving drug naltrexone, is a useful adjunct to treatment. Currently, few data are available on the impact of adding this medication to programmes in more typical, outpatient, and rehabilitation settings. The objective of this study was to examine the impact on outcome of adding naltrexone to an established outpatient alcohol rehabilitation program which employed CBT. Method: Fifty patients participated in an established 12-week, outpatient, 'contract'-based alcohol abstinence programme which employed CBT. They also received naltrexone 50 mg orally daily (CBT + naltrexone). Outcomes were compared with 50 historical, matched controls, all of whom participated in the same programme without an anticraving medication (CBT alone). All patients met DSM-IV criteria for alcohol dependence. Results: Programme attendance across the eight treatment sessions was lower in the CBT alone group (p < 0.001). Relapse to alcohol use occurred sooner and more frequently in the CBT alone group (p < 0.001). Rehabilitation programme completion at 12 weeks was 88% (CBT + naltrexone) compared with 36% for (CBT alone) (p < 0.001). Alcohol abstinence at 12 weeks was 76% (CBT + naltrexone) compared with 18% (CBT alone) (p < 0.001). Conclusion: When employing the same outpatient rehabilitation programme and comparing outcomes using matched historical controls, the addition of naltrexone substantially improves programme attendance, programme completion and reported alcohol abstinence. In a typical outpatient programme, naltrexone addition was associated with significantly improved programme participation, better outcomes and was well tolerated.

Aetiology of Papillon LeFevre Syndrome

Papillon LeFevre Syndrome, or PLS, was first described over 70 years ago. It is characterised by severe periodontal disease, typically leading to loss of teeth by adolescence, combined with palmoplantar hyperkeratosis. The fact that it is associated with consanguinity in particular ethnic groups suggests that genotype may contribute to the aetiology of this syndrome. Microbiological studies have been hampered by the rareness of the condition which makes prospective studies virtually impossible to perform. Numerous studies on small groups of patients, sometimes single cases, together suggest an association of recognised periodontal pathogens with PLS. Actinobacillus actinomycetemcomitans has been especially linked to PLS and raised levels of antibody to A.a. have been measured in some PLS patients, though not others. Porphyromonas gingivalis and Prevotella intermedia have also been detected in plaque samples from PLS, using monoclonal antibodies. Many other species have also been associated with PLS following culture and identification, as well as use of probes. Treatment has been attempted by eradication of periodontal pathogens so that teeth can erupt into a 'safe' environment. Successful treatment has needed intensive treatment and monitoring and good oral hygiene as well as thorough antibiotic therapy of patient, family members and even pets. Recently a Cathepsin C genotype has been strongly linked to PLS. However, this gene cannot account for all features of PLS and we can speculate that additional genes must be involved. It is concluded that PLS results from a combination of host and bacterial factors, including recessive human gene(s) associated with consanguinity, specific periodontal pathogens and lack of thorough oral hygiene. It is also believed that the human genetic component may merit examination as a 'host factor' in other bacterial infections. (C) 2001 Academic Press.

Combination therapy with tacrolimus and anti-thymocyte globulin for the treatment of steroid-resistant acute graft-versus-host disease developing during cyclosporine prophylaxis

We report our experience with the combination of anti-thymocyte globulin (ATGAM) and tacrolimus in the treatment of 20 patients with steroid refractory and dependent acute graft-versus-host disease (GVHD) transplanted between August 1996 and February 2000. All patients received cyclosporine-based GVHD prophylaxis. Thirteen patients developed a maximum of grade TV, five grade III and two grade II acute GVHD, with 15 patients being refractory to steroids and five dependent on steroids. Patients were treated with ATGAM (15 mg/kg for 5 d) and tacrolimus (0.025-0.1 mg/kg/d) in addition to continuation of their high-dose steroids and cessation of their cyclosporine. Within 28 d of treatment, we observed eight complete responses (CR), six partial responses (PR) and six with no response. Overall response (CR + PR) was predicted by GVHD severity. Infectious complications occurred in 80% of patients. The median survival was 86.5 d (range, 21-1081 d) with 35% of patients remaining alive, Survival following combination therapy was significantly more likely in men (P < 0.001), skin-only GVHD (P = 0.027), less severe GVHD (P = 0.048), and in responders to tacrolimus and ATGAM (P< 0.001). In conclusion, concurrent introduction of ATGAM and tacrolimus is a promising therapeutic combination for GVHD refractory to steroids and cyclosporine.

Lipid-lowering therapy following major cardiac events: progress and deficits

Objective: To assess hospital prescribing of lipid-lowering agents in a tertiary hospital, and examine continuation of, or changes to, such therapy in the 6-18 months following discharge. Design: Retrospective data extraction from the hospital records of patients admitted from October 1998 to April 1999. These patients and their general practitioners were then contacted to obtain information about ongoing management after discharge. Setting: Tertiary public hospital and community. Participants: 352 patients admitted to hospital with acute myocardial infarction or unstable angina, and their GPs. Main outcome measures: Percentage of eligible patients discharged on lipid-lowering therapy and percentage of patients continuing or starting such therapy 6-18 months after discharge. Results: 10% of inpatients with acute coronary syndromes did not have lipid-level estimations performed or arranged during admission. Documentation of lipid levels in discharge summaries was poor. Eighteen per cent of patients with a total serum cholesterol level greater than 5.5 mmol/L did not receive a discharge prescription for a cholesterol-lowering agent. Compliance with treatment on follow-up was 88% in the group discharged on treatment. However, at follow-up, 70% of patients discharged without therapy had not been commenced on lipid-lowering treatment by their GPs. Conclusions: Prescribing of lipid-lowering therapy for secondary prevention following acute coronary syndromes remains suboptimal. Commencing treatment in hospital is likely to result in continuing therapy in the community. Better communication of lipid-level results, treatment and treatment aims between hospitals and GPs might encourage optimal treatment practices.