A review of occupationally-linked suicide for dentists.

BACKGROUND AND OBJECTIVES: Suicide rates among dentists and a perceived elevated risk for suicide have been debated in the academic literature. It has filtered into the public psyche that dentists have the highest suicide rate of any occupation. The present review seeks support for both protagonist and antagonist positions from multidisciplinary perspectives. Contemporary risk factors and strategies for intervention and the prevention of suicide in dentistry are explored. METHODS: An online database search for articles and reports, with selected target words, was conducted for peer reviewed publications on suicide in the dental profession, and for factors contributing to dentist suicide. Review guidelines from the American Psychological Association were used to clarify concepts, identify where most work was focussed, and to explore the superiority of any approach to the emotive topic over another. RESULTS: Findings suggest the dominant belief that dentists have an elevated risk of suicide may be historically, but not currently, accurate. Although dentists' suicide is trending down, diversity in methodology means no current consensus is possible. Factors found to be influencing dentists' suicide ranged from known occupational stressors, to toxins and substance abuse, and untreated mental health problems. CONCLUSION: The contemporary position in New Zealand shows dentists per sé are not more likely than other health professionals to commit suicide although they may have been in the past. Dentists should be aware of individual susceptibility to burnout and mental health problems. Future directions are outlined to address this including peer intervention, and programmes available for dentists to cope better with risks leading to suicide.

No role for tri-iodothyronine (T3) testing in the assessment of levothyroxine (T4) over-replacement in hypothyroid patients.

Tri-iodothyronine (T3) is a sensitive marker of endogenous hyperthyroidism. In levothyroxine (T4)-induced hyperthyroidism, there is no reason for T3 to be elevated, but this test is often requested in over-treated hypothyroid patients. This study investigated how informative T3 levels are in these patients. Our hypothesis is that T3 measurement would not add anything to the assessment of T4 over-replacement in primary hypothyroidism. Over a 15-week period, consecutive thyroid function test requests in patients on levothyroxine had T3 levels measured if thyroid-stimulating hormone (TSH) was below the reference range (RR; <0.27 miu/L) and free T4 was within or above the RR (12-22 pmol/L). Those with fully suppressed TSH (<0.02 mu/L) and high free T4 (>27 pmol/L) were defined as being over-replaced, while those with low, but measurable TSH and a normal free T4 were defined as unlikely to be over- replaced (control group). Receiver operating characteristic (ROC) curve analysis was used to assess the discriminant power of T3 to detect over-replacement. Of the 542 patients examined, 33 were included in the over-replaced group and 236 patients in the control group. A total of 273 patients were excluded for not fulfilling the criteria for either of these groups. In the over-replaced group, none had a raised T3. The most discriminant T3 level, using ROC curve analysis, was 1.6 nmol/L (RR=1.3-2.6 nmol/L), with a corresponding sensitivity and specificity of 58% and 71%, respectively (P=0.16). T3 levels bear little relation to thyroid status in patients on levothyroxine replacement, and normal levels can be seen in over-replaced patients. Measurement of T3 in this situation is of doubtful clinical value. WHAT'S ALREADY KNOWN ABOUT THIS TOPIC?: Thyroid function tests are the way that adequacy of levothyroxine replacement is determined. Where the test is available, T3 is often requested together with T4 and TSH by clinicians. The question is whether T3 measurement adds any further information. WHAT DOES THIS ARTICLE ADD?: The presented data supports the position that T3 measurement does not add anything to the interpretation of thyroid hormone levels in subjects with hypothyroidism on levothyroxine replacement therapy. Unnecessary testing could be avoided if this were more widely appreciated. In addition, over-replacement, with its attendant risks, would be more readily recognised and not wrongly excluded on the basis of a falsely reassuring normal T3 result.

Levels and patterns of daily physical activity and sedentary behavior measured objectively in older care home residents in the United Kingdom.

BACKGROUND: Physical activity is important for maintaining independence and quality of life in older people living in care homes. Little is known about patterns of physical activity or sedentary behavior in this population. METHODS: Thirty-three care home residents (82.6 ± 9.2 years) wore an ActiGraph GTX3 accelerometer for seven days, which provided minutes of sedentary behavior and low, light, and moderate-to-vigorous physical activity. Participants undertook the Mini-Mental State Examination and care staff reported activities of daily living (Barthel index) and functional ambulation classification (FAC) for each participant. RESULTS: Participants spent on average 79% of their day sedentary, 14% in low, 6% in light, and 1% in moderate-to-vigorous physical activity. Activity levels did not significantly differ between days or hours of the day (P > .05). CONCLUSION: Levels of physical activity were very low and time being sedentary was high. This study can inform physical activity and sedentary behavior interventions for care homes' residents.

Prospective study of breast cancer risk for mutation negative women from BRCA1 or BRCA2 mutation positive families.

Published studies have reached contradictory conclusions regarding breast cancer risk for women from families segregating a BRCA1 or BRCA2 mutation who do not carry the family-specific mutation. Accurate estimation of breast cancer risk is crucial for appropriate counselling regarding risk management. The aim of this study is to prospectively assess whether breast cancer risk for mutation negative women from families segregating BRCA1 or BRCA2 mutations is greater than for women in the general population. Eligible women were 722 first-, second- and third-degree relatives of a BRCA1 or BRCA2 mutation carrier from 224 mutation positive (128 BRCA1, 96 BRCA2) families, had no personal cancer history at baseline, and had been tested and found not to carry the family-specific mutation. Self-reported family history of cancer, preventive interventions and verified cancer diagnoses were collected at baseline, and every 3 years thereafter. Median follow-up was 6.1 years (range 0.1-12.4 years). Time at risk of breast cancer was censored at cancer diagnosis or risk-reducing surgery. Standardised incidence ratios (SIR) were estimated by comparing observed to population incidences of invasive breast cancer using Australian Cancer Incidence and Mortality Books. Six cases of invasive breast cancer were observed. The estimated SIRs were 1.14 (95% CI: 0.51-2.53) overall (n = 722), 1.29 (95% CI: 0.58-2.88) when restricted to first- and second-degree relatives of an affected mutation carrier (n = 442) and 0.48 (95% CI: 0.12-1.93) when restricted to those with no family history of breast cancer in the non-mutation carrying parental lineage (n = 424). There was no evidence that mutation negative women from families segregating BRCA1 or BRCA2 mutations are at increased risk of breast cancer. Despite this being the largest prospective cohort to assess this issue, moderately increased breast cancer risk (2-fold) cannot be ruled out.

Field intensive care--weaning and extubation.

Injury following ballistic trauma is the most prevalent indication for providing organ system support within an ICU in the field. Following damage control surgery, postoperative ventilatory support may be required, but multiple factors may influence the indications for and duration of invasive mechanical ventilation. Ballistic trauma and surgery may trigger the systemic inflammatory response syndrome (SIRS) and are important causative factors in the development of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). However, their pathophysiological effect on the respiratory system is unpredictable and variable. Invasive mechanical ventilation is associated with numerous complications and the return to spontaneous ventilation has many physiological benefits. Following trauma, shorter periods of ICU sedation-amnesia and a protocol for early weaning and extubation, may minimize complications and have a beneficial effect on their psychological recovery. In the presence of stable respiratory function, appropriate analgesia and favourable operational and transfer criteria, we believe that the prompt restoration of spontaneous ventilation and early tracheal extubation should be a clinical objective for casualties within the field ICU.

Operational anaesthesia for the management of traumatic brain injury.

The primary brain insult that occurs at the time of head injury, is determined by the degree of neuronal damage or death and so cannot be influenced by further treatment. The focus of immediate and ongoing care from the point of wounding to intensive care management at Role 4 should be to reduce or prevent any secondary brain injury. The interventions and triage decisions must be reassessed at every stage of the process, but should focus on appropriate airway management, maintenance of oxygenation and carbon dioxide levels and maintenance of adequate cerebral perfusion pressure. Early identification of raised intracranial pressure and appropriate surgical intervention are imperative. Concurrent injuries must also be managed appropriately. Attention to detail at every stage of the evacuation chain should allow the head-injured patient the best chance of recovery.

Who benefits from Intensive Care in the field?

The limited capacity and resources of a Field Hospital Intensive Care Unit may necessitate the triage or prioritisation of critically ill patients requiring admission. The use of critical care resources by members of the local population in certain Areas of Operation, who can not be discharged or transferred to equivalent care in their local health service, impacts significantly on bed occupancy. Therefore available resources must be distributed efficiently and equitably with decisions guided by the principles of advocacy for the patient. Patients must be admitted only on the concept of potential benefit and reasonable chance of recovery, which would not be available elsewhere. Discriminating between seriously ill patients before admission and decision making regarding withdrawal of care is very difficult. Senior clinicians working regularly in a critical care setting demonstrate a better level of discrimination in assessing outcome of seriously ill patients and are best placed to make decisions regarding admission, continuation and withdrawal of treatment.

Relative impact of CD4+CD25+ regulatory T cells and tacrolimus on inhibition of T-cell proliferation in patients with atopic dermatitis.

BACKGROUND: It has been established recently that CD4+CD25+ regulatory T cells (Tregs) play an important role in controlling various immune responses. Immunosuppressive drugs are often used to treat immune dysregulation but are frequently associated with undesirable side-effects. OBJECTIVES: We examined the suppressive capacity of circulating Tregs in patients with atopic dermatitis (AD). Combined effects of Tregs and tacrolimus on the inhibition of T-cell proliferation in vitro were also assessed. METHODS: CD4+CD25+ and CD4+CD25- T cells were isolated from peripheral blood mononuclear cells using immunomagnetic beads. CD4+CD25- T cells were stimulated with purified protein derivative (PPD) or house dust mite allergen (Der p1) for 6 or 7 days, respectively. A dose range of tacrolimus and CD4+CD25+ T cells were added separately, or together. Proliferation was measured by (3)H-thymidine incorporation. RESULTS: CD4+CD25+ T cells from normal controls and patients with AD are anergic and inhibit the proliferation of CD4+CD25- T cells in response to PPD and Der p1 in vitro in a dose-dependent manner. Addition of tacrolimus and Tregs together showed significantly stronger inhibition of proliferation than either on their own. This was true for both antigens and both in normal controls and in patients with AD. CONCLUSIONS: CD4+CD25+ T cells in patients with AD have normal suppressive activity compared with healthy controls. Tregs and tacrolimus have additive effects on the inhibition of proliferation in response to PPD and Der p1.

The immunomodulatory effects of regulatory T cells: implications for immune regulation in the skin.

Regulatory T cells are thought to have a critical role in the suppression of immune responses. In addition to the prevention of the development of autoimmunity, they are also thought to have a role in the prevention of allergic responses to environmental allergens, immune responses to tumours and the development of memory responses to chronic infections. They have been isolated within the skin and have been shown to express surface markers that enable skin-specific migration, suggesting that regulatory T cells have a functional role in the skin. There is accumulating evidence to suggest that regulatory T cells may be involved in numerous skin disorders and may also be modified by various therapeutic agents used to treat these disorders. We review the evidence for the presence of this T-cell subset in humans, the suppressive effects of regulatory T cells, and their role in the skin.

Changes in triceps surae muscle architecture with sarcopenia.

AIM: To investigate whether sarcopenia was evenly distributed among the three components of the triceps surae (TS) muscle group. METHODS: Muscle volume (VOL), fibre fascicle length (Lf), pennation angle (theta) and physiological cross-sectional area (PCSA = VOL/Lf) were measured in vivo for the lateral (GL) and medial (GM) heads of the gastrocnemius muscles and for the soleus muscle (SOL), in 15 young males (YM, aged 25.3 +/- 4.5 years) and 12 elderly males (EM aged 73.8 +/- 4.4 years). RESULTS: In the EM, VOL of all three muscles was significantly smaller than in the YM; differences were: 27% for the GL (P < 0.01), 29% for the GM (P < 0.01) and 17% for the SOL (P < 0.05). In total, TS VOL was 22% smaller in EM than in YM (P < 0.01). In the EM, values of theta were significantly smaller than in the YM; by 15-18% for the GL, GM and SOL (P < 0.05). In the EM, Lf of the GM was 16% smaller than in the YM (P < 0.01); no significant differences were found in the other muscles. PCSA of the GL and GM were both found to be smaller in EM by 19% (P < 0.01) and 14.5% (P < 0.05), respectively. No difference was observed in the SOL PCSA between YM and EM. Interestingly, probably because of the prevalent contribution of the SOL to PCSA distribution of each muscle to the TS PCSA, the relative TS PCSA was not different between YM and EM. Furthermore, the Lf/muscle length ratio did not differ between YM and EM. CONCLUSION: The present study shows that the relative PCSA composition of the TS is maintained with ageing and that the PCSA is scaled down harmonically with the decrease in muscle volume and fascicle length. Such observation suggests that the relative contribution of the components of the TS muscle to the total force developed by this muscle group is maintained with ageing.

Flattening the b(6)h(6)(2-) octahedron Ab initio prediction of a new family of planar all-boron aromatic molecules.

The structural chemistry of boron is dominated by 3D structures (polyhedra), while in carbon structural chemistry the planar aromatic structures are more abundant. In this Communication we present results of ab initio calculations showing that the polyhedral boranes can be flattened into planar aromatic structures similar to their carbon analogues. We predicted that a B6H62- octahedron (in Li2B6H6), a B5H52- trigonal bipyramid (in Li2B5H5), a B7H72- pentagonal bipyramid (in Li2B7H7), and a B10H84- bioctahedron with a joint edge (in Li4B10H8) can be reduced to a planar aromatic B6H66- hexagon (in Li6B6H6), to a planar pentagon B5H56- (in Li6B5H5), to a planar heptagon B7H76- (in Li6B7H7), and to a naphthalene-like B10H810- (in Li10B10H8). Ab initio prediction of these new planar aromatic boranes shows that a large new family of planar aromatic all-boron molecules is possible.

All-metal antiaromatic molecule: rectangular Al4(4-) in the Li3Al4(-) anion.

We report the experimental and theoretical characterization of antiaromaticity in an all-metal system, Li3Al4(-), which we produced by laser vaporization and studied with the use of photoelectron spectroscopy and ab initio calculations. The most stable structure of Li3Al4(-) found theoretically contained a rectangular Al4(4-) tetraanion stabilized by the three Li+ ions in a capped octahedral arrangement. Molecular orbital analyses reveal that the rectangular Al4(4-) tetraanion has four pi electrons, consistent with the 4n Hückel rule for antiaromaticity.

The diurnal rhythm in isometric muscular performance differs with eumenorrheic menstrual cycle phase.

The aim of this study was to examine the effect of the interaction of circamensal and diurnal rhythms in temperature upon the production of maximal voluntary muscle force. Ten eumenorrheic females (mean age: 24 +/- 3 yr mean body mass: 58.4 +/- 6.9 kg) participated in the experiment at both 06:00 and 18:00h at the mid-point of both the follicular and luteal phases of the menstrual cycle. Subjects performed tasks of maximal isometric lifting strength (MILS) at knee height, and endurance time (t) for lifting 45% of MILS, upon an isometric lift dynamometer. Body temperature was elevated at 18:00h and in the luteal phase by 0.52 +/- 0.4 and 0.26 +/- 0.35 degrees C, respectively. The amplitude of the diurnal variation in temperature was blunted by 0.3 degrees C within the luteal phase. Maximal isometric performance was elevated by 8% at 18:00h in the luteal phase of the cycle (p < 0.05 interaction for MILS) but unaffected by time of day in the follicular phase. Endurance time was unaffected by time or phase (p > 0.05). It should be noted that the classic diurnal rhythm in maximal voluntary isometric muscle force may not be evident in all phases of the female menstrual cycle.

Technical note: repeatability of measurement in determining stature in sitting and standing postures.

The aim of this study was to determine the effect of sitting and standing postures on the repeatability of a stadiometer designed to detect small variations in spinal length. Two groups of ten healthy subjects, with no previous or known history of back problems, participated in this study. One group was measured in the standing posture, while the other group was measured in a sitting posture. All subjects gave informed consent to participate in this study. Subjects had a set of landmarks defining the spinal contour marked on their backs and then stood in the stadiometer for three series of ten measurements to be performed. At the end of each measurement, the subjects were requested to move away from and then be repositioned in the stadiometer. Subjects improved the repeatability across the measurement series. At the end of the second measurement series, all subjects presented mean standard deviations of 0.43 +/- 0.08 mm (range 0.30-0.50 mm) in the standing posture. In the sitting posture, deviations of less than 0.05 mm were obtained only at the end of the third measurement series (0.48 +/- 0.08 mm; range 0.34-0.62 mm), suggesting that this posture required three measurement series before repeatable measurements could be assured rather than two in the standing posture.

Putting the 'tele' into health-care effectively.

Although the introduction of new technologies has been successful and become accepted practice in many areas of industry, traditional methods have tended to prevail in health-care. Telemedicine has been adopted by enthusiasts who recognize the potential benefits of a 'global health service'. However, the more widespread introduction of telemedicine requires considerable organizational change in the way health-care is delivered. More evaluation is required of clinical outcomes, organizational effects, benefits to health-care providers and users, and quality assurance.

The need to ensure that the globalization of information and telematics does not destabilize health-care worldwide.

Modern telecommunication transcends institutional, organizational and cultural boundaries. In the context of health-care, this means that information, enquiries, demands and service provision can be routed anywhere, free of institutional or natural control. The Internet makes information available to anyone regardless of its quality, source or intention. Organizationally initiated applications such as telemedicine are usually intended to reinforce local systems, but their very design and intention indicate a potential rapidly to transcend inherited but electronically ineffectual boundaries. The consequences of such uncontrolled globalization of health-care activities will range from beneficial empowerment and quality improvement, to detrimental effects such as overloading of experts, and undermining of stable health-care systems. The major unplanned societal re-engineering effects in a paper-based culture are likely to be significant and global institutions need to respond by creating positive global frameworks and policies.

Estrogen variation and resting left ventricular structure and function in young healthy females.

PURPOSE: A potential confounding factor in the interpretation of left ventricular (LV) structural and functional data in female subjects could be menstrual phase or contraceptive use upon assessment. To date no study has addressed this issue. METHODS: Seventeen eumenorrheic (EU; mean +/- SD age = 21 +/- 3 yr) and 14 combined-oral contraceptive pill-using (COC: mean +/- SD age = 21 +/- 3 yr) females volunteered to participate. The EU had stable menstrual cycles and the COC had all been using the same pill preparation for a minimum of 6 months. Echocardiographic examinations occurred during the mid-follicular phase and mid-luteal phases in the EU and during mid-consumption and mid-end of withdrawal in the COC. LV structure and function were assessed using M-mode and pulsed-wave Doppler echocardiography. Data were compared via Student t-tests and limits of agreement (LoA) were calculated. RESULTS: Structure and function did not significantly differ between phases of the menstrual cycle or between consumption and withdrawal of oral contraception (P > 0.05). However, there was considerable variance in the LoA between variables. Smaller LoA were reported for those variables directly measured from echocardiograms compared with those from derived data. For example, in a measured variable such as LV internal dimension in diastole, the LoA data represented a variation of +/- 0.4 mm (+/- 1%) between phases. Conversely, data for LV mass, a derived variable, reported LoA values of +/- 15 g (10%) between phases. The LoA were consistent between EU and COC. Variation in both measured and derived variables were within, or close to, accepted limits of measurement or biological error. CONCLUSION: It would seem that in studies assessing LV structure and function in women the influence of menstrual phase or oral contraceptive use is of minor significance.

Manual handling performance: the effects of menstrual cycle phase.

Physiological and subjective responses to physical performance have been shown to interrelate with fluctuations in the female hormonal environment throughout the menstrual cycle. The aim of this study was to examine whether these fluctuations affect the strenuous performance required in manual handling. Seventeen eumenorrheic females performed lifting tasks in five phases of their menstrual cycle. These tasks were maximal isometric lifting strength (MILS) and an endurance lift at 45% MILS (t), at both knee and waist height; and the selection of a maximal acceptable load (MAL) to lift six times per min, for 10 min, in both the sagittal and asymmetric planes. Heart rate response (HR) and rating of perceived exertion (RPE) were recorded throughout each of the lifting tasks. MILS, t and the chosen MAL were unaffected by menstrual phase over both heights and planes of lift (p > 0.05). HR to the isometric endurance lift was greater following ovulation than prior to ovulation by approximately 7 beats.min-1 (p < 0.05). This was true when the data were analysed at 50, 80 and 100% of the time to volitional fatigue, and by an area under the curve procedure. HR to the dynamic lifting tasks was also elevated by approximately 7 beats.min-1 following ovulation. This difference was non-significant due to the low power of the analysis. Re-analysis of the data by re-sampling 1000 matched comparisons produced significant phase variations (p < 0.05). The RPE for all of the lifting tasks was independent of menstrual phase (p > 0.05). The impact of the eumenorrheic menstrual cycle on lifting capability was negligible in the present study. However, the results of this study indicate that all further investigations utilizing HR data to produce recommendations for health and safety in manual handling tasks must control for menstrual cycle phase in female populations.