Shift work and cardiovascular risk

@HealthMed It is well-known that shift workers have increased risk factors for serious heart disease, for example as reported in Knuttson's 1986 Lancet paper on papermill workers. They are more likely to smoke and tend to have higher blood pressure, cholesterol and weight and be more likely to have diabetes than  workers whose work pattern is confined to the daytime. They are also more likely to have insomnia, itself an independent risk factor for cardiovascular disease. Clinical pharmacologist Daniel Hackem from Ontario and his colleagues from Norway, Sweden and the USA had now raised further public and health professional interest in this disease link in a paper published in the British Medical Journal.

They looked at 34 previous studies of over 2 million shiftworkers. Together, there were over 17,000 heart events, over 6000 heart attacks and almost 2000 strokes. They concluded that stroke risk was around 5% higher and coronary event risk 24% higher in the shift-workers. Surprisingly, despite their large dataset, the researchers found no associated increase in mortality.

They take care to point out, as with any other observational study, that this is not necessarily a cause and effect relationship. People who take on shift work may be different in some unconnected way that puts up risk of vascular disease. Lower socio-economic status is an obvious important confounder. The work itself may be more stressful, at the same time as their being fewer other staff members in support 'out of hours'. Shift workers may also take more caffeine to try to stay alert during often long shifts.

Nonetheless there are several key messages reinforced by this report.

Shift-workers are more likely to have an excess of a wide range of cardiovascular risk factors. They  should therefore be encouraged to seek regular medical advice and their employers to raise awareness of these health risks and to support their staff in seeking regular medical advice. Shift-workers should also be supported in ensuring a healthy lifestyle despite the constraints on exercise and diet of unsocial hours of work.

Clinical pharmacologists and other health professionals should make sure to take a good occupational health history, including identifying whether a patient does shift work. They should make sure particular  care is taken to identify and reduce severity of cardiovascular risk factors in shift workers, supported by effective regular advice on healthy lifestyle. And where drug treament is indicated, prescribing treatment targets should be adjusted to take account of the increased cardiovascular risk to be prevented.

Employers should also make sure that patterns of shift work follow international guidance regarding avoiding abrupt shift changes, maximum shift duration and ensuring sufficient staff are working 'out of hours' to ensure that work is done both safely for employers' outcomes as well as their workers' health.

Assessing prescribing skills

@HealthMed Doctors and other prescribers internationally find prescribing challenging. To get this right at times of high pressure, including in the emergency medicine setting, it is vital that basic skills are as well developed as possible. Add to that the need for care in calculation, avoiding the distracting effects of multi-tasking, challenges in medicines reconciliation, and risks inherent in shift-working and other complex work patterns. And electronic prescribing systems alone are not a sufficient safeguard. For example, reporting from the USA indicates that error rates may increase following the move from paper to electronic prescribing. The complex range of skills needed for safe and effective prescribing includes sound core knowledge of basic mechanisms of drug action, drug use in the clinical setting, and the impact of patient genetics, age, gender, lifestyle, the disease to be treated as well as co-existing medical conditions and the impact of other drugs and remedies. Many of these principles are easier to put into practice by adopting a personalized approach to therapeutics, with the aim of prescribing the right drug or drugs at the right dose to the right patient for the right disease and at the right time.

To help to increase focus on early training in essential prescribing principles and practice, in the United Kingdom the British Pharmacological Society and the Medical Schools Council supported by a national team of experts, to develop a Prescribing Skills Assessment that will eventually allow all students to rehearse and demonstrate competencies relevant to safe and effective initiation, monitoring, review and, when needed change in route, dose, duration or type of medicines alone and in combination in clinical practice, along with skills in communicating key points about medicines to patients, their carers and to relevant health professional colleagues.

See related blogs on
- Improving prevention of serious adverse drug reactions 
- Personalized medicine for better drug discovery

Stress and recovery in junior doctors

@HealthMed This blog is the start of a series of occasional notes highlighting articles of note published in the Postgraduate Medical Journal, the Fellowship of Postgraduate Medicine's first journal, launched in 1925, with the continued aim of educating doctors and other health professionals.
In the September 2011 issue, Dr Elke Ochsmann and colleagues from Aachen in north-west Germany report on a study of almost 1500 junior doctors. The authors report that 'Overtime work seems to be the important work related factor concerning junior doctors' level of strain'.
They add that for recovery from work-related stress 'performance feedback from colleagues seems to be a major resource'.
The conclude that the 'findings have implications regarding work time regulations and the necessity of leadership skill development training' in developing a better support system for junior doctors.

See the article for further information.

Taboo tablets - beta-blockers and professional string players

The following blog arose from contributing to an article in The Strad by Catherine Nelson on drugs and occupational stress amongst professional musicians.

As clinical pharmacologist and amateur violinist gives me two perspectives on performance or audition anxiety: this is due to the triggering of an extra release of
 adrenaline – and other fight-or-flight response hormones – which in turn can cause
 string players to feel anxious and suffer a shaking bowing arm. Beta-blockers can stop 
unwanted reactions to these hormones, such as an increased heart 
rate, and thus lessen detrimental effects of stress on the musician’s performance.


I had heard of a violinist who was so anxious and stiff during an audition that the bow simply flew out of his hands. Many professional musicians are worried by the stress of performance, and beta-blockers may help some players control the debilitating physical symptoms of this stress.
It is of course extremely important that musicians, for whom medical treatment of occupational stress may be indicated, work
 with a medical practitioner to ensure, if a beta-blocker appears worth a trial, that they take the right dose, provided it has been checked that this would be medically safe to do so. I am particularly concerned about anecdotal evidence of players sharing medicines - which may not be the right medicine, or a possible cause of severe and rapid onset harmful effects. People are increasingly turning to the internet to
 obtain drugs. At best these pills may be out of date – at worse 
they may be contaminated. Taking them without getting advice from a
 doctor can be very dangerous.
Beta-blockers slow the heart, helping to make people feel calmer, but they also make your heartbeat less forceful than it should be,
 so that even fit people may feel tired and short of breath, and some people may be tipped into heart failure. Players with certain pre-existing medical conditions may suffer worse adverse reactions. These
 drugs also make the airways less open, so are dangerous in asthma.
 Other side effects include sleep disturbance, weight gain and stomach upset, including increased stool frequency and urgency. There 
are also reports of people suffering depression while taking
 beta-blockers, though it may be that people with heightened anxiety are 
more prone to suffering depression. It is therefore better to avoid medicines if possible.
The message for beta-blockers should be that if they are worth a trial on medical grounds, to try a low
 dose under the advice of a medical practitioner; the dose may then be carefully increased if needed. If medically indicated, it is also very important always to 
try beta-blockers first under rehearsal conditions, as being made too relaxed or having unwanted effects could be harmful when performance really matters.

The implications of the broader issue of anecdotal widespread use of beta-blockers raise important occupational health and ethical concerns which deserve to be discussed nationally and internationally, both by the music profession and relevant medical organisations.

See The Strad for more on the article.