The effect of oral dexamethasone on duration of analgesia after upper limb surgery under infraclavicular brachial plexus block: a randomised controlled trial

The effects of oral dexamethasone on peripheral nerve blocks have not been investigated. We randomly allocated adults scheduled for forearm or hand surgery to oral placebo (n = 61), dexamethasone 12 mg (n = 61) or dexamethasone 24 mg (n = 57) about 45 min before lateral infraclavicular block. Mean (SD) time until first pain after block were: 841 (327) min; 1171 (318) min; and 1256 (395) min, respectively. Mean (98.3%CI) differences in time until first postoperative pain for dexamethasone 24 mg vs. placebo and vs. dexamethasone 12 mg were: 412 (248-577) min, p < 0.001; and 85 (-78 to 249) min, p = 0.21, respectively. Mean (98.3%CI) difference in time until first postoperative pain for dexamethasone 12 mg vs. placebo was 330 (186-474) min, p < 0.001. Both 24 mg and 12 mg of oral dexamethasone increased the time until first postoperative pain compared with placebo in patients having upper limb surgery under infraclavicular brachial plexus block.

Origin-Independent Dynamic Polarizability Density from Coupled Cluster Response Theory

The calculation of the origin-independent density of the dynamic electric dipole polarizability, previously presented for uncorrelated and density functional theory (DFT)-based methods, has been developed and implemented at the coupled cluster singles and doubles (CCSD) level of theory. A pointwise analysis of polarizability densities calculated for a number of molecules at Hartree-Fock (HF) and CCSD clearly shows that the electron correlation effect is much larger than one would argue considering the integrated dipole electric polarizability alone. Large error compensations occur during the integration process, which hide fairly large deviations mainly located in the internuclear regions. The same is observed when calculated CCSD and B3LYP polarizability densities are compared, with the remarkable feature that positive/negative deviations between CCSD and HF reverse sign, becoming negative/positive when comparing CCSD to B3LYP.

Number of musculoskeletal pain sites leads to increased long-term healthcare contacts and healthcare related costs - a Danish population-based cohort study

BACKGROUND

People with musculoskeletal pain seek more healthcare than the general population, however little is known about the long-term effect on healthcare use. The aim of this study was to examine the consequences of number of musculoskeletal pain sites on long-term care-seeking and healthcare-related costs and explore how health anxiety influences this relationship.

METHODS

We conducted a Danish population-based longitudinal cohort study of 4883 participants combining self-reported survey data from 2008 with ten-year follow-up data from national health registers. Using a causal inference framework, we examined associations between number of pain sites (range 0-7)/level of health anxiety (high/low level) and face-to-face healthcare contacts/healthcare-related costs. Data were analyzed using negative binomial regression with generalized estimating equations. Regression models were adjusted for sex, age, duration of pain, level of education, comorbidity, personality traits, risk of depression, marital status, physical job exposure, and previous healthcare utilization.

RESULTS

For each additional pain site general healthcare contacts (Incidence Rate Ratio (IRR): 1.04 (95% CI: 1.03-1.05)), healthcare-related costs (IRR: 1.06 (95% CI: 1.03-1.08) and musculoskeletal healthcare contacts (IRR: 1.11 (95% CI:1.09-1.14) increased. Those with high levels of health anxiety at baseline had a slightly higher number of general healthcare contacts (IRR 1.06 (1.01-1.11), independent of number of pain sites. However, level of anxiety did not influence the effect of number of pain sites on any healthcare use or cost outcomes.

CONCLUSIONS

We found evidence for a causal association between increasing number of pain sites and greater healthcare use and cost, and high levels of health anxiety did not increase the strength of this association. This suggests that number of pain sites could be a potential target for biopsychosocial interventions in order to reduce the need for future care-seeking.

Sensory distribution of the lateral femoral cutaneous nerve block - a randomised, blinded trial

BACKGROUND

The lateral femoral cutaneous nerve (LFCN) block may be used for post-operative pain management in patients undergoing total hip arthroplasty. The aim of this trial was to investigate the sensory coverage of the posterior and the lateral incision lines and the involvement of the femoral nerve after an LFCN block.

METHODS

The study was a randomised, blinded trial in 20 healthy volunteers. All subjects received a bilateral LFCN block randomised to 8 ml ropivacaine on the right side and 8 ml isotonic saline on the left side, or vice versa. An orthopaedic surgeon depicted the incision lines (invisible to the investigators) prior to block performance. The distribution of the blocked area and the coverage of the incision lines were assessed with temperature discrimination and pinprick test before unblinding the incision lines. Pain during tonic heat stimulation and involvement of the femoral nerve by measuring quadriceps strength were assessed.

RESULTS

The mean difference in block coverage of the posterior (primary outcome) and the lateral incision lines tested with temperature discrimination were 5.8% (95% CI: -2.2 to 14.0%, P = 0.146) and 18.9% (95% CI: 6.5-31.4%, P = 0.005), respectively, comparing the active with the placebo side. A varying anatomic distribution area was observed. No clinically significant differences for experimental pain and quadriceps muscle strength were found. The block failure rate was 15%.

CONCLUSION

An LFCN block consisting of 8 ml 0.75% ropivacaine had limited coverage of the posterior and lateral incision lines.

A Systematic Review of the Clinimetric Properties of the 6-Item Version of the Hamilton Depression Rating Scale (HAM-D6)

BACKGROUND

In a study aimed at identifying the items carrying information regarding the global severity of depression, the 6-item Hamilton Depression Rating Scale (HAM-D6) was derived from the original 17-item version of the scale (HAM-D17). Since then, the HAM-D6 has been used in a wide range of clinical studies. We now provide a systematic review of the clinimetric properties of HAM-D6 in comparison with those of HAM-D17 and the Montgomery Asberg Depression Rating Scale (MADRS).

METHODS

We conducted a systematic search of the literature in PubMed, PsycInfo, and EMBASE databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Studies reporting data on the clinimetric validity of the HAM-D6 and either the HAM-D17 or MADRS in non-psychotic unipolar or bipolar depression were included in the synthesis.

RESULTS

The search identified 681 unique records, of which 51 articles met the inclusion criteria. According to the published literature, HAM-D6 has proven to be superior to both HAM-D17 and MADRS in terms of scalability (each item contains unique information regarding syndrome severity), transferability (scalability is constant over time and irrespective of sex, age, and depressive subtypes), and responsiveness (sensitivity to change in severity during treatment).

CONCLUSIONS

According to the published literature, the clinimetric properties of HAM-D6 are superior to those of both the HAM-D17 and MADRS. Since the validity of HAM-D6 has been demonstrated in both research and clinical practice, using the scale more consistently would facilitate translation of results from one setting to the other.

Sleep and delirium in unsedated patients in the intensive care unit

BACKGROUND

Sleep deprivation and delirium are major problems in the ICU. We aimed to assess the sleep quality by polysomnography (PSG) in relation to delirium in mechanically ventilated non-sedated ICU patients.

METHODS

Interpretation of 24-h PSG and clinical sleep assessment in 14 patients. Delirium assessment was done using the confusion assessment method for the intensive care unit (CAM-ICU).

RESULTS

Of four patients who were delirium free, only one had identifiable sleep on PSG. Sleep was disrupted with loss of circadian rhythm, and diminished REM sleep. In the remaining three patients the PSGs were atypical, meaning that no sleep signs were found, and sleep could not be quantified from the PSGs. Clinical total sleep time (ClinTST) ranged from 2.0-13.1 h in patients without delirium. Six patients with delirium all had atypical PSGs, so sleep could not be quantified. Short periods of REM sleep were found. ClinTST was median 8.5 h (range 0.4-13.8 h). EEG reactivity and wakefulness was found in all but one PSG. Four patients were CAM-ICU "unassessable" (unresponsive to voice). PSGs were atypical without reactivity or wakefulness, even though clinical wakefulness was documented. ClinTST was median 18.3 h (range 3.7-19.8 h). Paroxystic EEG activity was found in this subgroup.

CONCLUSIONS

The objective signs of sleep were absent in all but one PSG, so even though patients were not sedated, sleep could not be quantified. Even in patients without delirium, sleep could only be quantified in one of four patients. Paroxystic activity is frequent in unsedated patients, unresponsive to voice, but the implication is unknown.

The experience of demanding work environments in younger workers

BACKGROUND

Investigating whether certain individual or background characteristics are associated with an increased risk of experiencing an excessively demanding work environment in younger workers may help to reduce future inequality in health and maximize their labour market participation.

AIMS

To describe the work environment of Danish 20- to 21-year olds and to investigate the influence of family socioeconomic background and individual characteristics at age 14-15 on later experience of physical and psychosocial work environments.

METHODS

We obtained information on subjects' school performance, vulnerability, health and parental socioeconomic status from registers and a questionnaire completed in 2004. A questionnaire concerning eight measures of subjects' psychosocial and physical work environment in 2010 was used to determine the outcomes of interest.

RESULTS

The study population consisted of 679 younger workers aged 20-21. The psychosocial work environment was in general good but younger workers experienced more demanding physical work than the general working population. Overall, individual as well as family factors had a limited impact on their assessment of the work environment. Low self-esteem at age 14-15 was associated with experiencing high demands and lack of trust and fairness at work, whereas low parental socioeconomic status was associated with a demanding physical work environment.

CONCLUSIONS

This study showed a social gradient in experiencing a demanding physical work environment at age 20-21. The psychosocial work environment experienced by younger workers was generally good, but vulnerable young people may need special attention to protect them from or prepare them for psychosocially demanding jobs later in life.

Sleep in the Intensive Care Unit measured by polysomnography

BACKGROUND

Sleep deprivation has deleterious effects on most organ systems. Patients in the Intensive care unit (ICU) report sleep deprivation as the second worst experience during their stay only superseded by pain. The aim of the review is to provide the clinician with knowledge of the optimal sleep-friendly care and environment.

METHODS

Pubmed was systematically searched. Studies regarding polysomnography in ICU populations or healthy volunteers exposed to ICU conditions were included.

RESULTS

Thirty-eight studies were identified. The patients were qualitatively but not necessarily quantitatively sleep deprived with loss of circadian rhythm and extreme sleep fragmentation. Sedation, care interventions, noise, disease and mechanical ventilation are the most contributing factors to sleep deprivation.

CONCLUSION

Sedation should be kept at a minimum and interrupted once daily. Care interventions should be clustered and noise reduced and/or masked with earplugs. NAVA, proportional assist+ or assist-control ventilation should be preferred to pressure support ventilation and adjusted to allow smaller tidal volumes, thus avoiding central apnoeas.

The norepinephrine transporter gene is a candidate gene for panic disorder

Panic disorder (PD) is an anxiety disorder characterized by recurrent panic attacks with a lifetime prevalence of 4.7%. Genetic factors are known to contribute to the development of the disorder. Several lines of evidence point towards a major role of the norepinephrine system in the pathogenesis of PD. The SLC6A2 gene is located on chromosome 16q12.2 and encodes the norepinephrine transporter (NET), responsible for the reuptake of norepinephrine into presynaptic nerve terminals. The aim of the present study was to analyze genetic variants located within the NET gene for association with PD. The case-control sample consisted of 449 patients with PD and 279 ethnically matched controls. All cases fulfilled the ICD-10 diagnostic criteria for PD. Genotyping was performed using the Sequenom platform (Sequenom, Inc, San Diego, USA). To test for allelic and haplotypic association, the PLINK software was used, and COMBASSOC was applied to test for gene-wise association. After quality control 29 single nucleotide polymorphisms (SNPs) spanning the gene-region were successfully analyzed. Seven SNPs located within the 5' end of the gene were significantly associated with PD. Furthermore, the NET gene showed overall evidence for association with the disease (P = 0.000035). In conclusion, the present study indicates that NET could be a susceptibility gene for PD.

Sick at work--a risk factor for long-term sickness absence at a later date?

BACKGROUND

Little is known about the long-term consequences of sickness presence (ie, going to work despite ill-health), although one study suggests an association with coronary heart disease. This study examined the effect of sickness presence on future long-term sickness absence.

METHODS

Information from a random sample of 11 838 members of the Danish core workforce was collected from questionnaires, containing questions about work, family and attitudes towards sickness absence. Information on prospective sickness absence spells of at least 2 weeks was derived from an official register during a follow-up period of 1.5 years.

RESULTS

Sickness presence is associated with long-term sickness absence of at least 2 weeks' duration as well as with spells lasting at least 2 months. Participants who had gone to work ill more than six times in the year prior to baseline had a 74% higher risk of becoming sick-listed for more than 2 months, even when controlling for a wide range of potential confounders as well as baseline health status and previous long-term sickness absence. The association was consistent for most subgroups of employees reporting various symptoms, but either disappeared or became insignificant when analysing subgroups of employees with specific chronic diseases.

CONCLUSIONS

Going to work ill repeatedly is associated with long-term sickness absence at a later date. For this reason, researchers and policy-makers should consider this phenomenon more carefully when planning future studies of sickness absence or when laying out new policies.

Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4–8‐years' follow‐up in a prospective, randomized study

OBJECTIVES

To compare the prognosis of subacromial impingement (SAI) stage II treated conservatively or with subacromial decompression.

METHODS

A follow-up study after 4-8 years in a randomized controlled trial (RCT) with 90 adult cases with SAI treated in a Danish hospital from 1996 to 2000 with graded physiotherapy and exercises or arthroscopic subacromial decompression. Outcomes were proportion of time per year with income transfers (indexed 0-1), including total transfers (marginalization), sick leave and disability pension obtained from the registry at the Ministry of Work. Self-reported function, working capability, employment status and global improvement were obtained by questionnaire in September 2004. The main outcomes are given as differences in development from baseline.

RESULTS

Seventy-nine (88%) responded to the questionnaire and registry data were obtained from 81. After 1 year the marginalization index increased by 0.45 [95% confidence interval (CI) 0.35-0.56] for surgery and 0.25 (0.16-0.34) for physiotherapy. Cases undergoing surgery also tended to have more sick payments during the first year, but the difference was not significant. Four years after inclusion, changes in indices did not differ between treatment groups. Self-reported outcomes after 4-8 years did not differ between treatment groups.

CONCLUSION

The results of surgical decompression were equal to those of conservative treatment, and the surgery group had more income transferrals during the first year of follow-up.

Determination of chlormequat in pig serum and sow milk by LC–MS/MS

Chlormequat is a plant growth regulator widely used on cereals, and there is general concern that it may impair human fertility. A LC-MS/MS method for the analysis of chlormequat in milk and serum was developed and validated in connection with an investigation on the effect of chlormequat on pig reproduction. Validation of the method was based on recovery tests at three spiking levels, determined as double determinations and repeated at least four times. Samples were extracted with methanol-water-acetic acid, centrifuged, filtrated and determined by LC-MS/MS. The mean recoveries were in the range 80-110%, and the LOD was 0.2 ng/g for serum and 0.3 ng/g for milk. The values for repeatability and reproducibility were within 2/3 of the limits given by the Horwitz equation. Samples of pig serum (59) and sow milk (27) were analyzed using the method. Chlormequat was determined in four milk samples in the range of 0.4 ng/g to 1.2 ng/g and in all serum samples in the range of 0.2 ng/g-4.0 ng/g.

Computer mouse use predicts acute pain but not prolonged or chronic pain in the neck and shoulder

BACKGROUND

Computer use may have an adverse effect on musculoskeletal outcomes. This study assessed the risk of neck and shoulder pain associated with objectively recorded professional computer use.

METHODS

A computer programme was used to collect data on mouse and keyboard usage and weekly reports of neck and shoulder pain among 2146 technical assistants. Questionnaires were also completed at baseline and at 12 months. The three outcome measures were: (1) acute pain (measured as weekly pain); (2) prolonged pain (no or minor pain in the neck and shoulder region over four consecutive weeks followed by three consecutive weeks with a high pain score); and (3) chronic pain (reported pain or discomfort lasting more than 30 days and "quite a lot of trouble" during the past 12 months).

RESULTS

Risk for acute neck pain and shoulder pain increased linearly by 4% and 10%, respectively, for each quartile increase in weekly mouse usage time. Mouse and keyboard usage time did not predict the onset of prolonged or chronic pain in the neck or shoulder. Women had higher risks for neck and shoulder pain. Number of keystrokes and mouse clicks, length of the average activity period, and micro-pauses did not influence reports of acute or prolonged pain. A few psychosocial factors predicted the risk of prolonged pain.

CONCLUSIONS

Most computer workers have no or minor neck and shoulder pain, few experience prolonged pain, and even fewer, chronic neck and shoulder pain. Moreover, there seems to be no relationship between computer use and prolonged and chronic neck and shoulder pain.

Survey of pesticide residues in table grapes: Determination of processing factors, intake and risk assessment

The differences in residue pattern between Italy and South Africa, the main exporters of table grapes to the Danish market, were investigated. The results showed no major differences with respect to the number of samples with residues, with residues being found in 54-78% of the samples. Exceedances of the European Union maximum residue limit (MRL) were found in five samples from Italy. A number of samples were rinsed to study the possible reduction of residues. For copper, iprodione, procymidone and dithiocarbamates a significant effect of rinsing was found (20-49% reduction of residues). However, no significant effect was found for organophosphorus pesticides and pyrethroids, whereas the number of samples with residues of benzilates, phenylamids and triazoles was insufficient to demonstrate any significant effects. An intake calculation showed that the average intake from Italian grapes was 3.9 microg day(-1) for pesticides and 21 microg day(-1) for copper. Correspondingly, the intakes from South African grapes were 2.6 and 5.7 microg day(-1), respectively. When the total exposure of pesticides from grapes were related to acceptable daily intake, expressed as the sum of Hazard Quotients, the exposure were approximately 0.5% for Italian samples and 1% for South African samples.

Risk factors for hand-wrist disorders in repetitive work

OBJECTIVES

To identify the risk of hand-wrist disorders related to repetitive movements, use of hand force and wrist position in repetitive monotonous work.

METHODS

Using questionnaires and physical examinations, the prevalence and incidence of hand-wrist pain and possible extensor tendonitis (wrist pain and palpation tenderness) were determined in 3123 employees in 19 industrial settings. With the use of questionnaires and video recordings of homogenous work tasks number of wrist movements, hand force requirements and wrist position were analysed as risk factors for hand-wrist disorders, controlling for potential personal and psychosocial confounders. All participants were re-examined three times during a follow-up period of three years.

RESULTS

Force but not repetition and position was related to hand-wrist pain and possible tendonitis in the baseline analyses showing an exposure-response pattern. Odds ratios for the risk of hand pain was 1.7 (95% CI 1.3 to 2.2) and for possible tendonitis 1.9 (95% CI 1.1 to 3.3). There was no significant interaction between the ergonomic factors. In the follow-up analyses force remained a risk factor for hand pain (OR 1.4, 95% CI 1.1 to 1.8) and for possible tendonitis (OR 2.9, 95% CI 1.3 to 6.8). Repetition was also a risk factor for the onset of hand-wrist pain (OR 1.6, 95% CI 1.2 to 2.3).

CONCLUSIONS

Increasing levels of force were associated with prevalent and incident hand-wrist pain and possible extensor tendonitis. The results for repetition were less consistent. Working with the hand in a non-neutral position could not be identified as a risk factor.

Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up

OBJECTIVES

To compare the effect of graded physiotherapeutic training of the rotator cuff versus arthroscopic subacromial decompression in patients with subacromial impingement.

METHODS

Randomised controlled trial with 12 months' follow up in a hospital setting. Ninety consecutive patients aged 18 to 55 years were enrolled. Symptom duration was between six months and three years. All fulfilled a set of diagnostic criteria for rotator cuff disease, including a positive impingement sign. Patients were randomised either to arthroscopic subacromial decompression, or to physiotherapy with exercises aiming at strengthening the stabilisers and decompressors of the shoulder. Outcome was shoulder function as measured by the Constant score and a pain and dysfunction score. "Intention to treat" analysis was used, with comparison of means and control of confounding variables by general equation estimation analysis.

RESULTS

Of 90 patients enrolled, 84 completed follow up (41 in the surgery group, 43 in the training group). The mean Constant score at baseline was 34.8 in the training group and 33.7 in the surgery group. After 12 months the mean scores improved to 57.0 and 52.7, respectively, the difference being non-significant. No group differences in mean pain and dysfunction score improvement were found.

CONCLUSIONS

Surgical treatment of rotator cuff syndrome with subacromial impingement was not superior to physiotherapy with training. Further studies are needed to qualify treatment choice decisions, and it is recommended that samples are stratified according to disability level.

Understanding work related musculoskeletal pain: does repetitive work cause stress symptoms?

BACKGROUND

Pain in the neck and upper extremity is reported with high frequency in repetitive work. Mechanical overload of soft tissues seems a plausible mechanism, but psychological factors have received considerable attention during the past decade. If psychological factors are important for development of regional pain in repetitive work, stress symptoms would likely be on the causal path.

AIMS

To examine whether objective measures of repetitive monotonous work are related to occurrence and development of stress symptoms.

METHODS

In 1994-95, 2033 unskilled workers with continuous repetitive work and 813 workers with varied work were enrolled. Measures of repetitiveness and force requirements were quantified using video observations to obtain individual exposure estimates. Stress symptoms were recorded at baseline and after approximately one, two, and three years by the Setterlind Stress Profile Inventory.

RESULTS

Repetitive work, task cycle time, and quantified measures of repetitive upper extremity movements including force requirements were not related to occurrence of stress symptoms at baseline or development of stress symptoms during three years of follow up.

CONCLUSIONS

The findings do not indicate that repetitive work is associated with stress symptoms, but small effects cannot be ruled out. Thus the results question the importance of mental stress mechanisms in the causation of regional pain related to repetitive work. However, the findings should be interpreted with caution because the stress inventory has not been validated against a gold standard.

Tingling/numbness in the hands of computer users: neurophysiological findings from the NUDATA study

OBJECTIVES

To investigate whether tingling/numbness of the hands and fingers among computer users is associated with elevated vibration threshold as a sign of early nerve compression.

METHODS

Within the Danish NUDATA study, vibratory sensory testing with monitoring of the digital vibration threshold at seven frequencies on the second and fifth fingers of both hands was performed on 20 cases with unilateral tingling/numbness in the hands and fingers, and 20 gender- and age-matched controls. Both cases and controls were identified from questionnaire information about tingling/numbness at least once a week or daily within the last 3 months. Participants with more than slight muscular pain or disorders of the neck and upper extremities, excessive alcohol consumption, previous injuries of the upper extremities, or concurrent medical diseases were excluded. The two groups had a similar amount of work with mouse, keyboard, and computer.

RESULTS

Seven of the 20 cases (35%) had elevated vibration thresholds, compared with 3 of the 20 controls (15%); this difference was not statistically significant (chi2=2.13, P=0.14). Compared with controls, cases had increased perception threshold for all frequencies, but the difference was statistically significant for only 2 out of 14 measurements. Comparison between left and right hand threshold values within the case group did not show any significant difference at any frequency.

CONCLUSIONS

The results indicate that tingling/numbness of the hands and fingers among computer users cannot be explained by nerve compression.

Does computer use pose an occupational hazard for forearm pain; from the NUDATA study

AIMS

To determine the occurrence of pain conditions and disorders in the forearm and to evaluate risk factors for forearm pain in a cohort of computer workers.

METHODS

A total of 6943 participants with a wide range of computer use and work tasks were studied. At baseline and at one year follow up participants completed a questionnaire. Participants with relevant forearm symptoms were offered a clinical examination. Symptom cases and clinical cases were defined on the basis of self reported pain score and palpation tenderness in the muscles of the forearm.

RESULTS

The seven days prevalence of moderate to severe forearm pain was 4.3%. Sixteen of 296 symptom cases met criteria for being a clinical forearm case, and 12 had signs of potential nerve entrapment. One year incidence of reported symptom cases was 1.3%; no subjects developed new signs of nerve entrapment. Increased risk of new forearm pain was associated with use of a mouse device for more than 30 hours per week, and with keyboard use more than 15 hours per week. High job demands and time pressure at baseline were risk factors for onset of forearm pain; women had a twofold increased risk of developing forearm pain. Self reported ergonomic workplace factors at baseline did not predict future forearm pain.

CONCLUSION

Intensive use of a mouse device, and to a lesser extent keyboard usage, were the main risk factors for forearm pain. The occurrence of clinical disorders was low, suggesting that computer use is not commonly associated with any severe occupational hazard to the forearm.

Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice

OBJECTIVES

To determine whether minimal intervention by occupational specialists involving information about the disorder, encouragement to stay active and instruction in graded self-performed exercises could enhance the prognosis of lateral epicondylitis compared with the treatment usually given in general practice, to quantify workplace factors associated with the prognosis, and to consider treatments given in general practice.

METHODS

A randomized controlled trial was performed in a cohort of 266 consecutive new cases of lateral epicondylitis diagnosed in general practice. Workplace factors were assessed with questionnaires at the time of inclusion, and patients completed follow-ups at 3, 6 and 12 months. Status at 1 yr was assessed as overall improvement and pain reduction compared with the time of diagnosis. General practitioners (GPs) registered the treatments given for both cases and controls during follow-up. Numbers of contacts with GPs and physiotherapists were obtained from the National Health Insurance registry. Prognostic factors were analysed by multiple logistic regression analysis.

RESULTS

After 1 yr, 83% of cases showed improvement in the condition, but the intervention was found to have had no advantage. Poor overall improvement was associated with employment in manual jobs [odds ratio (OR) 3.0, 95% confidence interval (CI) 1.0-8.7], a high level of physical strain at work (OR 8.5, CI 1.0-74.7) and a high level of pain at baseline (OR 2.3, CI 1.0-5.3). Pain reduction less than 50% was associated with manual jobs (OR 2.3, CI 1.1-5.1), high physical strain at work (OR 3.6, CI 1.0-12.9), high baseline distress (OR 1.9, CI 1.0-4.0) and tennis elbow on the dominant side (OR 3.1, CI 1.4-6.8). The intervention group received less treatment and fewer treatment modalities, but the intervention was not followed by a reduction in the number of visits to GPs and physiotherapist clinics during 12 months of follow-up.

CONCLUSIONS

Poor prognosis at 1 yr of follow-up for lateral epicondylitis was related to manual work and high baseline pain, whilst no relation was found between the type of medical treatment given/chosen and prognosis. This may have implications for the future management of lateral epicondylitis in terms of a greater focus on interaction with the workplace regarding job modification to reduce physical demands during recovery.

Prognosis of shoulder tendonitis in repetitive work: a follow up study in a cohort of Danish industrial and service workers

BACKGROUND

The physical and psychosocial work environment is expected to modify recovery from shoulder disorders, but knowledge is limited.

METHODS

In a follow up study of musculoskeletal disorders in industrial and service workers, 113 employees were identified with a history of shoulder pain combined with clinical signs of shoulder tendonitis. The workers had yearly re-examinations up to three times. Quantitative estimates of duration, repetitiveness, and forcefulness of current tasks were obtained from video recordings. Perception of job demands, decision latitude, and social support was recorded by a job content questionnaire. Recovery of shoulder tendonitis was analysed by Kaplan-Meier survival technique and by logistic regression on exposure variables and individual characteristics in models, allowing for time varying exposures.

RESULTS

Some 50% of workers recovered within 10 months (95% CI 6 to 14 months). Higher age was strongly related to slow recovery, while physical job exposures were not. Perception of demands, control, and social support at the time when the shoulder disorder was diagnosed, were associated with delayed recovery, but these psychosocial factors did not predict slow recovery in incident cases identified during follow up.

CONCLUSION

The median duration of shoulder tendonitis in a cross sectional sample of industrial and service workers was in the order of 10 months. This estimate is most likely biased towards too high a value. Recovery was strongly reduced in higher age. Physical workplace exposures and perceived psychosocial job characteristics during the period preceding diagnosis seem not to be important prognostic factors.

Risk factors in the onset of neck/shoulder pain in a prospective study of workers in industrial and service companies

AIMS

To quantify the relative contribution of work related physical factors, psychosocial workplace factors, and individual factors and aspects of somatisation to the onset of neck/shoulder pain.

METHODS

Four year prospective cohort study of workers from industrial and service companies in Denmark. Participants were 3123 workers, previously enrolled in a cross sectional study, where objective measurement of physical workplace factors was used. Eligible participants were followed on three subsequent occasions with approximately one year intervals. Outcomes of interest were: new onset of neck/shoulder pain (symptom cases); and neck/shoulder pain with pressure tenderness in the muscles of the neck/shoulder region (clinical cases).

RESULTS

During follow up, 636 (14.1%) participants reported neck/shoulder pain of new onset; among these, 82 (1.7%) also had clinical signs of substantial muscle tenderness. High shoulder repetition was related to being a future symptom case, and a future clinical case. Repetition was strongly intercorrelated with other physical measures. High job demands were associated with future status as a symptom case, and as a clinical case. A high level of distress predicted subsequent neck/shoulder pain, and neck/shoulder pain with pressure tenderness.

CONCLUSIONS

High levels of distress, and physical and psychosocial workplace factors are predictors of onset of pain in the neck and/or shoulders, particularly pain with pressure tenderness in the muscles.

Results from the monitoring of pesticide residues in fruit and vegetables on the Danish market, 2000-01

To check compliance with the maximum residue levels in foods and to monitor the residue levels to enable an evaluation of the exposure of the Danish population to pesticides, a monitoring programme for pesticides residues in fruit and vegetables was performed. Sampling plans were designed based on previous findings and on consumption data. Samples (n = 4404) of mainly fresh conventionally and organically grown fruit and vegetables were collected at wholesalers and importers and at food processing companies. Of the samples, 3% were frozen products and 5% organically grown. Of the samples, 34% were of Danish origin, with 66% from other countries. Two accredited laboratories performed analyses of the samples using capillary gas chromatography, liquid chromatography and a spectrophotometric method. Reporting levels were set at the lowest calibration level or at the limit of determination. Residues were found in 60% of the samples of fruit but in only 18% of the vegetable samples. Residues above the maximum residue levels were found in 6% of all samples of fruit and in 2% of the vegetable samples.

Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study

AIMS

To assess the importance of physical and psychosocial risk factors for lateral epicondylitis (tennis elbow).

METHODS

Case-referent study of 267 new cases of tennis elbow and 388 referents from the background population enrolled from general practices in Ringkjoebing County, Denmark.

RESULTS

Manual job tasks were associated with tennis elbow (odds ratio (OR) 3.1, 95% confidence interval (CI) 1.9 to 5.1). The self reported physical risk factors "posture" and "forceful work" were related to tennis elbow. Among women, work involving performing repeated movements of the arms was related to tennis elbow (OR 3.7, CI 1.7 to 8.3). Among men, work with precision demanding movements was related to tennis elbow (OR 5.2, CI 1.5 to 17.9). Among both males and females, the results for work with hand held vibrating tools were inconsistent, partly because of few exposed subjects. A physical strain index was established based on posture, repetition, and force. The adjusted ORs for tennis elbow at low, medium, and high strain were 1.4 (CI 0.8 to 2.7), 2.0 (CI 1.1 to 3.7), and 4.4 (CI 2.3 to 8.7). Low social support at work, adjusted for physical strain, was a risk factor among women (OR 2.4, CI 1.3 to 4.6).

CONCLUSION

Results indicate that being a new case of tennis elbow is associated with non-neutral postures of hands and arms, use of heavy hand held tools, and high physical strain measured as a combination of forceful work, non-neutral posture of hands and arms, and repetition. Furthermore, tennis elbow among women was associated with low social support at work. The results for precision demanding movements and for vibration were less consistent.

Implantable cardioverter defibrillator in a 4-month-old infant with cardiac arrest associated with a vascular heart tumor

A previously healthy male infant was resuscitated after spontaneous ventricular fibrillation at 9 weeks of age. Echocardiography revealed three tumors in the left ventricle not amenable to complete resection. Despite treatment with antiarrhythmic agents the ventricular arrhythmias continued. When the child was 4 months old and weighed 7 kg an ICD system was implanted using epicardial sense-pacing leads and a superior vena caval lead as a subcutaneous defibrillator coil placed posterior on the left thorax. Shocks were delivered between the subcutaneous coil lead and the intraabdominally placed ICD can. This ICD array system has not been reported previously.

Results from the monitoring of pesticide residues in fruit and vegetables on the Danish market, 1998-99

The objective of the Danish pesticide monitoring programme for fruit and vegetables was to check for compliance with the maximum residue levels in foods and to monitor the residue levels to assess the pesticide exposure of the Danish population. Sampling plans were designed based on previous findings and on food consumption data. Approximately 60% of the samples were selected on the basis of positive findings in samples from the previous 5 years. The remaining samples reflected the pattern of food consumption in Denmark. In addition, a rolling programme is maintained for commodities with a low consumption and no detected residues. Within each commodity, the sampling was randon. Samples (n = 4150) of mainly fresh, conventionally grown fruit and vegetables were taken throughout the chain of suppliers including food-processing companies. Of the samples, 300 were frozen products and 2% were organically grown. Of the samples, 35% were of Danish origin, with 65% originating from other countries. Three accredited laboratories performed analyses of the samples using capillary gas chromatography, liquid chromatography and spectrophotometric methods. Results were registered online into a central database. Residues were found in 54% of the samples of fruit but only in 13% of the vegetables. Residues above the MRL were found in 4% of all samples of fruit and in 1% of vegetables.

Assessment of work postures and movements using a video-based observation method and direct technical measurements

The aim was to study postures and movements during repetitive work using video-based observations and direct technical measurements (inclinometers and goniometers). A total of 21 healthy women from a poultry processing plant volunteered. Neck flexion > 20 degrees was registered during 92% of the recorded time with the observation method, while the corresponding value measured with the inclinometer was 65%. Different reference positions and different measured variables apparently contributed to the differences between the methods. Mean wrist position was measured to be 0 degrees in flexion-extension and 19 degrees in ulnar deviation. Differences between the methods in the registered hand positions were small. The number of repetitive movements/minute and mean power frequency (MPF) of the electrogoniometer data was significantly related, showing both variables to be relevant measures of repetitiveness. In conclusion, the observation method and the technical measurements supplemented each other well. A reduction in class categories was suggested for future observation methods.

Lactoferrin and cyclic lactoferricin inhibit the entry of human cytomegalovirus into human fibroblasts

Lactoferrin is mainly produced by polymorphonuclear leukocytes and has been demonstrated in mammalian milk and external secretions. Lactoferrin is an iron-binding, multifunctional protein and may play an important role in immune regulation and in defense mechanisms against bacteria, fungi and viruses. Lactoferricin is a potent antimicrobial peptide generated from the N-terminal part of lactoferrin by pepsin cleavage. We demonstrate that lactoferrins from different species and its N-terminal peptide lactoferricin (particularly the cyclic form) inhibit expression of early and late antigens, as well as production of infectious viral progeny during human cytomegalovirus (HCMV) infection in vitro. Iron-saturated lactoferrin did not affect HCMV antigen expression. Heparin had the same effects as iron-depleted lactoferrin. Yet, mixtures of lactoferrin and heparin did not inhibit HCMV multiplication i.e. lactoferrin and heparin seemed to mutually block each other's antiviral activities. HCMV-infected cells exposed to lactoferrin and cyclic lactoferricin contained less intracellular virus than unexposed cells. The antiviral activity of cyclic lactoferricin was more than seven-fold weaker than that of the maternal molecule. Lactoferrin and cyclic lactoferricin prevented HCMV entrance into the host cell.

Physical exposure assessment in monotonous repetitive work--the PRIM study

OBJECTIVES

A program called the Project on Research and Intervention in Monotonous Work (PRIM) was initiated in 1994 as a prospective cohort study of work-related musculoskeletal disorders. The group-based exposure assessment strategy, focusing on task-related exposure and used to obtain baseline measures of physical exposures, is reported in this paper.

METHODS

Monotonous, repetitive worktasks were evaluated at 19 factories. Tasks with an estimated similarity in physical exposure were aggregated before 103 exposure groups were formed. Subjects from the exposure groups were randomly sampled for measurements, and task-related exposure levels were quantified by 43 single exposure items using a real-time video-based observation method that allowed computerized estimates of repetitiveness, body postures, force, and velocity. In combination with questionnaire-based data on task distribution, the duration of exposure was calculated at the individual level.

RESULTS

The video-based observational method and the large number of exposure variables enabled the establishment of detailed quantitative exposure profiles in 103 task-based exposure groups. However, methodological problems associated with the use of grouped exposure assessment were revealed. Despite efforts to optimize group homogeneity, the within-group variance was larger than the between-group variance for several shoulder postural variables.

CONCLUSIONS

A task-based exposure-assessment strategy can be successful in solving some of the main problems associated with the assessment of physical workplace exposures. The large within-group variance in exposure to nonneutral shoulder postures may eventually require individual assessment or the inclusion of groups with maximal contrast in exposure or both.

Association between plasma testosterone and work-related neck and shoulder disorders among female workers

OBJECTIVES

The aims were to study the association between anabolic hormone testosterone in plasma and the presence of musculoskeletal disorders among female workers and to study the association between changes in testosterone and changes in musculoskeletal complaints.

METHODS

In a cross-sectional design 145 women from 2 different industries filled out questionnaires about current musculoskeletal complaints, participated in a clinical examination of the neck and upper extremities, and gave a blood sample for the analysis of free testosterone in plasma. Individual characteristics, psychosocial job factors, and stress reactions were evaluated by questionnaires. In a follow-up study a subgroup of 73 sewing machine operators from the cross-sectional study was reexamined after 1 year.

RESULTS

The group of women with clinically verified neck or shoulder disorders had significantly lower plasma testosterone than the women with no disorders. Furthermore, the testosterone level showed a negative association with age and a positive association with smoking and body mass index. Changes in pain status or clinically diagnosed musculoskeletal disorders were not associated with changes in testosterone levels. However, this finding may well be due to a strong plant influence in that marked changes in testosterone levels were observed for 2 of the 3 participating plants.

CONCLUSIONS

There is some indication of an association between musculoskeletal disorders in the neck and shoulders and a low level of free plasma testosterone. The study failed to clarify the associations found between changes in testosterone and changes in musculoskeletal complaints over time.

Musculoskeletal disorders of the neck and shoulders in female sewing machine operators: prevalence, incidence, and prognosis

OBJECTIVES

To assess the occurrence and persistence of two restrictively defined neck-shoulder disorders among sewing machine operators. To assess factors associated with the development of neck-shoulder disorder and prognostic factors for remaining a case, when disorders were already present.

METHODS

In an initial group of 243 sewing machine operators, 178 were followed up for 2 years. At baseline and at 1 and 2 years follow up the participants underwent a clinical examination of the neck and arms and filled in a questionnaire about current musculoskeletal complaints. Clinical criteria for two main neck-shoulder disorders were defined: rotator cuff tendinitis and myofascial pain syndrome. A baseline control group consisted of 357 women with varied non-repetitive work.

RESULTS

At baseline the overall prevalence of myofascial pain syndrome and rotator cuff tendinitis was 15.2% and 5.8% among sewing machine operators compared with 9.0% and 2.2%, respectively, among controls. The presence of the disorders was strongly associated with a self perception of poor general health. Although myofascial pain syndrome showed a U shaped association with years as a sewing machine operator, rotator cuff tendinitis was absent among the newest recruits and present among 15% of the women with more than 20 years as a sewing machine operator. Besides years as a sewing machine operator, the risk of having a neck-shoulder disorder at baseline was significantly associated with high stress (prevalence ratio (PR)=2.54; 95% confidence interval (95% CI) 1.28 to 5.05) when adjusted for age, body mass index, smoking, living alone with children, job strain, and social support from colleagues and supervisors. Only one of 13 participants with rotator cuff tendinitis at baseline recovered during follow up. Myofascial pain syndrome showed a much more fluctuating tendency. Low social support (RR 3.72; 95% CI 1.22 to 11.30) and smoking (RR 3.93; 95% CI 1.33 to 11.58) were associated with the development of neck-shoulder disorders, which was also associated with neck-shoulder pain score and living alone with children.

CONCLUSION

Rotator cuff tendinitis showed a higher degree of persistence than myofascial pain syndrome. Both disorders highly influenced the perception of general health. Women who lived alone with children, were smokers, or experienced low support from colleagues and supervisors had a higher risk of contracting a neck-shoulder disorder.

Is supraspinatus pathology as defined by magnetic resonance imaging associated with clinical sign of shoulder impingement?

To examine the association between supraspinatus pathology and clinical sign of impingement, 42 workers with and 31 age-matched workers without signs of subacromial impingement had their shoulder examined by magnetic resonance imaging. All subjects were selected from an epidemiologic study evaluating the risk of shoulder impingement syndrome in relation to ergonomic exposure. Physical examination was conducted according to the same protocol and included assessment of shoulder function. Magnetic resonance images were evaluated in a blinded manner with regard to clinical status and age. Twenty-two (55%) subjects in the impingement group and 16 (52%) subjects in the control group had a pathologic supraspinatus tendon (odds ratio 1.13 [95% confidence interval 0.45 to 2.88]). The prevalence of supraspinatus pathology increased from 32% in the youngest to 48% in the middle and 72% in the oldest age group. The results of this study indicate that supraspinatus pathology is related to age rather than to clinical sign of impingement.

Shoulder impingement syndrome in relation to shoulder intensive work

OBJECTIVES

To analyse the risk of shoulder impingement syndrome relative to shoulder intensive work.

METHODS

A cross sectional study of a historical cohort of 1591 workers employed between 1986 and 1993 at a slaughterhouse or a chemical factory. Workers not doing tasks in slaughtering or meat processing constituted the reference group. Intensity of shoulder work in meat processing tasks was assessed by video based observations. Information on shoulder disorders was collected by questionnaire and by physical examinations. Impingement syndrome was diagnosed when shoulder symptoms had been present for at least 3 months during the past year and there were signs of subacromial impingement in the corresponding shoulder at physical examination. Shoulder function was assessed at the same occasion with the Constant scoring technique. Prevalence of shoulder impingement syndrome was analysed according to job title and cumulative exposure.

RESULTS

Prevalence ratio for shoulder impingement syndrome was 5.27 (95% confidence interval (95% CI), 2.09 to 12.26) among currently working and 7.90 (95% CI, 2.94 to 21.18) among former slaughterhouse workers. Transformed model based prevalence ratios according to years in slaughterhouse work showed an overall association between cumulative exposure and risk for shoulder impingement syndrome.

CONCLUSIONS

This study supports the hypothesis that shoulder intensive work is a risk factor for impingement syndrome of the shoulder. Despite the historical cohort design healthy worker selection may have influenced the exposure-response relation found.

[Occupational medicine in general practice. A study of the extent and nature of occupational injuries in the county of Ringkjøbing]

The purpose of this investigation was to estimate the occurrence and type of work-related incidents in primary health care in the county of Ringkoebing, Denmark, with 270,000 inhabitants. Symptom-related general practitioner (GP)-consultations among 17-66 year-old residents were registered among 114 GP's during four days over one year. In each occasion the GP evaluated the question of work-relatedness versus none-work-relatedness. Of 3017 registered consultations, 479 were work-related (15.9%). There were 376 disease cases and 103 injury cases. Musculoskeletal diseases constituted the dominating diagnostic category, as well as being the category with the highest proportion of work-relatedness, corresponding to 35% of all musculoskeletal consultations. Notification as a work injury case was performed for 19% of all work-related cases. This investigation represents the hitherto most extensive Danish material of the distribution of work-related incidents within the broad spectrum of the GP's practice.

Occurrence of carpal tunnel syndrome among slaughterhouse workers

OBJECTIVES

The aim of this study was to examine the risk of carpal tunnel syndrome (CTS) among workers with daily occupational exposure to high-force and high-velocity manual work.

METHODS

The study was carried out retrospectively among a cohort of 1591 workers employed at a slaughterhouse or at a chemical factory; 1141 persons (71.7%) participated. Workers not doing tasks in slaughtering or meat processing constituted the reference group. Exposure assessments were made for 46 different tasks in slaughtering and meat processing from video-based observations at the workplace. CTS was diagnosed if there were current symptoms typical of CTS in combination with positive neurophysiological signs of CTS or if the subject had previously been operated on for CTS.

RESULTS

Altogether 1.6% of the reference group, 5.1% of the nondeboning slaughterhouse workers [prevalence ratio (PR) 3.23, 95% confidence interval (95% CI) 1.3-7.99] and 7.8% of the deboning slaughterhouse workers (PR 4.91, 95% CI 2.03-11.81) had CTS. Increased risk estimates persisted after adjustment for other potential risk factors by logistic regression. The prevalence of CTS in the dominant hand was equally increased in both groups of slaughterhouse workers (but only statistically significant for the workers in deboning tasks), while the prevalence of CTS in the nondominant hand was significantly increased only among the slaughterhouse workers in deboning tasks.

CONCLUSIONS

This study supports the hypothesis that daily high-velocity and high-force manual work is a risk factor for CTS.

Musculoskeletal disorders of the neck and upper limb among sewing machine operators: a clinical investigation

One hundred and seven women participated in a clinical study of an age-stratified random sample of sewing machine operators compared to a group of auxiliary nurses and home helpers. Four groups, according to years of being a sewing machine operator, consisted of: (controls) 25; (0-7 years) 21; (8-15 years) 25; and (more than 15 years) 36. The numbers of the main clinical diagnoses in the four groups were: cervicobrachial fibromyalgia (myofascial pain syndrome) 2, 4, 11, 24; cervical syndrome 0, 1, 3, 10; and rotator cuff syndrome 1, 1, 6, 11. The observed exposure-response relationship between clinical outcomes and years as a sewing machine operator was maintained when adjusting for current exposure to musculoskeletal strain and other potential confounders. Muscle palpation proved to be a reproducible examination with kappa values around 0.70.

Prevalence of persistent neck and upper limb pain in a historical cohort of sewing machine operators

Four hundred and twenty-four sewing machine operators from a historical cohort of garment industry workers answered questionnaires concerning musculoskeletal symptoms and job exposure. They were compared with 781 women from the general population of the region and an internal control group of 89 women from the garment industry. The risk for persistent neck and shoulder complaints increased with years of being a sewing machine operator: (up to seven years, eight to fifteen years, and more than fifteen years: prevalence proportion ratio 1.8, 3.5 and 4.4 [neck] and 1.5, 4 and 6.8 [shoulder] compared with the controls [n = 781]). The exposure-response relationships remained when adjusted for potential confounders, of which age, current shoulder-neck exposure, and child bearing were the most contributing. The study revealed that work for more than eight years as a sewing machine operator probably has a cumulative deleterious effect on the neck and shoulders.

[The rotator cuff syndrome--a frequent disease caused by loading]

The rotator cuff syndrome is defined as a cronical pain syndrome, originating from the rotator cuff with characteristic pain and referred pain. Disorders evolving from the rotator cuff and the rotator muscles comprise between 70 og 90% of the shoulder disorders. The rotator cuff syndrome may be of occupational origin, particularly in heavy work with tasks at or above shoulder level, e.g. shipyard welders and plate workers. Biomecanically surveys show that continuous blood flow in the rotator muscles ceases at about 30 degrees of flexion or abduction of the upper arm. Electromyographic examinations have shown high muscle tension in the same muscles in assembly plant employees. High prevalences of shoulder pain have been shown in these groups and it is considered that the workers are actually suffering from disorders in the rotator cuff and its muscles. The rotator cuff syndrome is on the list of occupational disorders in the Danish Workers' Compensation Act but, in the authors' experience knowledge on etiology, examination and treatment is insufficient. Diagnostic criteria are proposed with the object of improving clinical practice and medical insurance declarations.