In the UK it is estimated that work-related stress is responsible for six million days of sick leave a year, with stress being linked to many minor and major illnesses.

FOR MOST PEOPLE, work is a significant and meaningful feature of life with the majority of us spending around 25% of our adult lives working. While work can provide us with structure, purpose, satisfaction, self-esteem and spending power, the workplace can also be a setting of stress and worry

What is work-related stress? Everyone is under some pressure in the workplace. Some external pressures can be a positive factor, helping us to be more productive. Some people actually thrive under shortterm added pressure, and our bodies are designed to meet these short-term demands. Hormones including adrenaline are released to prepare us for a “fight or flight” response to demanding situations. However, excessive and prolonged stress can take its toll, producing a range of physical and emotional health problems which have come to be grouped as “work-related stress”. There is no single cause of work-related stress. While stress can be triggered by sudden, unexpected pressures, it is often the result of a combination of stressful factors which accumulate over time. Some people can become so used to the symptoms of excessive stress that it goes unnoticed to their detriment. Most work-related stress is related to management of work, relationships at work, organisational set-up and whether you feel you have power and control in your work. The experience of stress is different for every person. Some people are affected more than others, so what is stressful for one person may not be stressful for another. It can depend on your personality type and on how you have learned to respond to pressure. Typical triggers of stress include:

• lack of control over work
• excessive time pressures
• excessive or inflexible working hours
• too much or too little work or responsibility
• confusion about duties and responsibilities
• lack of job variety and interest
• inadequate training and possibilities for learning new skills
• poor work/life balance
• difficult relationships at work
• lack of support and lack of contact with colleagues
• organisational confusion, restructuring, job change
• uncertainty over job prospects

Symptoms of work-related stress Work-related stress can manifest itself as physical and emotional health problems, and as altered ways of behaving at work and at home.

Physical symptoms:

• increased susceptibility to colds and other infections
• headaches
• muscular tension
• backache and neckache
• excessive tiredness
• difficulty sleeping
• digestive problems
• raised heart rate
• increased sweating
• lower sex drive
• skin rashes
• blurred vision
• emotional and behavioural changes
• wanting to cry much of the time
• feeling that you can’t cope
• short temperedness at work and at home
• feeling that you’ve achieved nothing at the end of the day
• eating when you’re not hungry
• losing your appetite
• smoking and drinking to get you through the day
• inability to plan, concentrate and ontrol work
• getting less work done
• poor relationships with colleagues or clients
• loss of motivation and commitment

Self-help It is impossible to escape pressure at work altogether, so it is important to learn how to manage stress. There are a number of ways in which you can reduce the negative impact of stress, most of which involve taking a good look at how you function within your work setting and beyond.

Changes at work If work-related stress is affecting you, it is important to deal with the problem as soon as possible. One of the most important factors in reducing stress levels is managing time effectively. Prioritise tasks, delegate where necessary and take care not to take on more than you can handle. Completing one task before going on to the next will help you to feel more in control of work, while varying tasks will help to keep you interested. Make time to relax at work by stretching and breathing deeply. This will help you to keep focused and prevent tired muscles. Simply ensuring you get outside for a walk during your lunch break can be helpful. It is helpful to identify which situations stress you most. Practise how you could behave differently in tricky situations Perhaps you need to be more assertive (see BUPA factsheet titled Improving assertiveness), or you need to learn to “take a step back” in tricky situations. It can seem hard to confront the causes of workplace stress and to ask for help. But sometimes, support and advice from your line manager or human resources department is necessary to help you deal with difficulties at work, whether it is to clarify your job role and responsibilities, or to deal with workplace bullying. If you find talking about your concerns difficult, it may help to make notes to bring along to the work interview with you. Make these clear and specific. Try to remember that it is in everybody’s interest that the workplace is as stress-free as possible.

Lifestyle changes Regular activities outside work will help you to meet new people, take your mind away from work worries and remind you that there is more to life than the office. Bring a sense of fun into your life by starting a creative hobby such as painting, or a new form of physical activity such as dancing or swimming. There is increasing evidence that regular physical activity helps to reduce stress levels. It provides valuable “time out” and can trigger brain chemicals that improve mood. A brisk daily walk is ideal, but the main thing is to choose an activity that you enjoy. Learning to relax can improve sleep and relieve stress-related physical pains such and stomach pains and headaches. Your GP surgery or the local library will have details of adult education classes where you can learn helpful techniques. Libraries loan books, tapes or computer-based packages. Confiding in trusted friends or relatives is a useful way to articulate worries and negative feelings. It can give a fresh perspective and help to make stressful situations more manageable. Avoid unhelpful responses to stress such as increased alcohol intake, smoking, and high caffeine intake. These all increase stress levels. Regular meals and a balanced, high-fibre diet will provide sustained levels of energy to keep you on an even keel. At the end of the day, reflect on what you’ve achieved rather than worrying about future work. Don’t be too hard on yourself and remember to take each day as it comes.

Seeking further help Some people need to seek further help for work related stress, as they may be depressed or have an anxiety disorder which needs treatment. Anyone concerned that they need help should visit their GP for advice. If you are diagnosed with depression, you may be prescribed a course of antidepressants. Other treatments can include a talking therapy such as counselling. There are also courses for stress management and lots of self help resources. Some workplaces may provide a confidential counselling service or telephone helpline. Libraries, social services and local health centres will have details of local courses.

Conclusion Stress is an inevitable but complex companion to our working lives. Without challenges and pressures, work would lack sparkle, but we all have the capacity to be overwhelmed by work-related stress, and to experience its exhausting effects. The aim should be to manage stress by becoming aware of our individual ways of responding to it, and through making effective changes to our working lifestyle.

Over-the-counter (OTC) drugs are medications available to consumers without a prescription. Millions of consumers each year use these formulations for the treatment of self-diagnosed conditions without physician intervention, because doing so has been deemed safe by regulatory bodies, such as the U.S. Food and Drug Administration (FDA), U.K.'s Committee on Safety of Medicines, and others. More than 80 therapeutic categories have been approved as OTC drugs and range from drugs that fight acne to medications that treat fever, allergy to weight control drugs. While, there is little risk associated with the use of these medications, severe adverse effects can result because of either improper use or drug interactions.

The Committee on Safety of Medicines, an independent committee of experts, advise the British government on safety, quality, and efficacy of medicines. The Committee recently advised that Simvastatin 10mg should be made available as OTC, without the need of prescription. The switch to OTC is good news for people on prescription Simvastatin as they can now lower their cholesterol without regular visits to the doctor and at reduced cost. The low strength of Simvastatin has been considered safe, however, lack of proper patient education can result in number of harmful side effects.

Statins such as Simvastatin work to lower blood cholesterol levels by reducing cholesterol production within the liver. Statins block the liver enzyme hydroxy-methylglutaryl-coenzyme A reductase (HMG-CoA reductase), which is responsible for making cholesterol. Therefore, scientifically, statins are HMG-CoA reductase inhibitors. The benefits of statins include decreasing a patient';s risk for congestive heart disease (CHD). It is estimated that approximately 14.8 million people use Stains worldwide and are credited for saving the lives of more than 16,000 -17,000 people per year. Moreover, in addition to cholesterol reduction, Statins have also been shown to reduce the risk of breast cancer. The low cost OTC statins are expected to extend benefits to more patients with risk of congestive heart disease.

The benefits of OTC Statins must be weighed against the potential side effects. Proper patient education is the key to success of OTC Statins. The patient might experience side effects, commonly termed as ';statin side effects';, by taking higher than recommended dose. These side effects can include headache, nausea, vomiting, constipation, diarrhea, headache, rash, muscle pain, and weakness. Taking other commonly available OTC medications can treat these conditions. However, combination of OTC medication with Statin may result in dangerous drug interactions. A commonly encountered side effect with the usage of Statin and pain relieving medications is Rhabdomylysis, which can result in damage to muscles. Though these OTC pain medications are often considered benign, they might result in dangerous drug interactions when used with Statins.

In addition to the side effects, the patients may not be aware that diet and lifestyle can impact CHD risk. Even while taking OTC Statins, the patient may be exposed to CHD risk because of patient';s diet and lifestyle.

Patient education is becoming crucial as prescription medications such as Simvastatin go OTC. The patient should be adequately educated and informed about the possible side effects and risks of the medications. Though OTC medications are deemed safe, lack of patient education can result in serious side effects.

Upcoming patent expirations in United States for Statins such as Zocor and Pravachol is expected to force companies to explore the opportunity of OTC Statins. While the switch allows companies to sustain their revenues, the FDA';s efforts to reduce healthcare cost will also be complemented. However, this is not a lucrative option for Statins with long patent expiry such as Lipitor and Crestor.

As more prescription medicines go OTC in global markets, weighing benefits with possible side effects will become of utmost priority. Patient education is expected to remain a key strategy for the success of OTC products. Initiative of European countries such as United Kingdom to make Simvastatin available as OTC is expected to be a trial that will be carefully watched by the world.

Autism is a disorder that affects the way a person communicates with other people. Most (but not all) people with autism also have a learning disability. There are a number of related disorders known as autistic spectrum disorders. These include Asperger’s syndrome, which involves fewer or less disabling autism symptoms. About autism and Asperger’s Around 9 in a 1000 children aged four to five are affected by an autism spectrum disorder (ASD). Autism is rarer, affecting about 1 in 5,000 children. It is four times more common in boys than girls. An ASD is any disorder where autistic symptoms are present. Autism is thought to be caused by an abnormality in the development of the brain that occurs before, during or soon after birth. The exact cause is unknown, but doctors think that there may be a genetic factor, but no pattern of inheritance. Symptoms Symptoms of autism first appear in children in their first three years. In severe cases, autistic behaviour may be noticed soon after birth. There are three main types of symptoms. Children with autism, rather than ASD, usually have some symptoms from all of the groups. Social difficulties Generally, this group of symptoms can be described as difficulty getting on with other people. Children with ASD may:

• rarely make full eye contact
• not seek affection in the usual way, and resist being cuddled or kissed
• be unable to play with their peers, and have difficulty making friends
• not understand other people’s emotions
• find it difficult to accept simple social rules, which can cause problems at school

Imagination

Behaviour

Intelligence and autism Around 70% of people with autism have an IQ below 70 (the average IQ of the population is 100). This is classed as a learning disability. Some people with autism have normal or high intelligence. Many people with Asperger’s have normal or above average intelligence and can lead independent lives. Diagnosis and assessment Autism is usually diagnosed in childhood, when a parent may raise concerns about their child with a GP or health visitor. The most common age for diagnosis is between three and four years, though some children may not be diagnosed until the age of 12. Mild autism spectrum disorders, such as Asperger’s syndrome, are often not noticed until the child starts school because many aspects of their development are normal. At school their poor social skills are more noticeable and challenging behaviour may arise. There is no specific test for autism. Tests may be carried out to exclude other conditions (eg blood and hearing tests). Diagnosis is then based on observation of communication, behaviour and development. A number of health professionals, as well as the parents or carers are involved. If autism is suspected, the child will be assessed to identify specific needs. He or she may see a child psychiatrist (doctor specialising in children’s mental health), paediatrician, speech therapist, psychologist, and an educational expert such as a specialist teacher or educational psychologist. Each child should have an appointed key worker, such as a health visitor or school nurse, who knows about the assessment process and acts as a contact for the parent or carer. Treatment Treatments include special education, behavioural training, social skills training and, in some cases, medicines. Special education All children with autism need special education. This may be in a special school, or if symptoms are less severe, in a mainstream school with additional individual help. In general, autistic children do better if classroom activities are very structured. Behavioural therapies These may be provided by a clinical psychologist and can help a family cope with any behavioural problems associated with autism. Similar methods may be used at school where the child can be taught better ways to express themselves. Medicines Sometimes medication is used to reduce specific symptoms. For example, some drugs can be used in the short term to help relieve agitation, obsessional or hyperactive behaviour. However, these can have side-effects if used for a long time. For example, drugs to reduce hyperactivity can increase repetitive and obsessional behaviour. Other treatments There are various approaches available to help with communication, such as music therapy and picture symbols. However, there is only limited evidence that these treatments are effective. Some people claim that a hormone called secretin can help with the symptoms of autism. However, again there is no scientific evidence for this and the sideeffects have not been investigated fully. Help for carers Parents and carers need information, help and support too. This should be provided by the health professionals involved in the child’s care, but further advice is available from charities such as the National Autistic Society (see Further information, below). Respite breaks give the parent or carer a chance to rest while somebody else looks after the child. They may be provided by social services. Some families are also entitled to welfare such as disability living allowance.

What is MRSA? MRSA stands for methicillin-resistant Staphylococcus aureus. The term is used to describe a number of strains of the bacteria, Staphylococcus aureus that are resistant to a number of antibiotics, including methicillin.

What is Staphylococcus aureus?

Staphylococcus aureus is a group of bacteria that live on the surface of people’s skin and inside the nose. It is normally harmless: most people who are carrying it are totally unaware that they have it. In fact, it is thought that up to 30% of the general UK population carries these bacteria in their nose or on their skin. This group of bacteria can be spread quite easily from person to person through contact.

Why is MRSA a concern?

Problems occur if Staphyloccocus aureus bacteria are able to enter the body through a cut or wound. Most healthy people have strong immune systems and are able to fight off a Staphylococcus aureus infection themselves and have only mild symptoms. However, people with weakened immune systems (for example due to other illnesses) or who have undergone surgery (for example heart surgery or hip replacement) can develop more serious problems. In more vulnerable people, Staphyloccocus aureus bacteria have been known to cause boils, abscesses, impetigo, septic wounds, heart-valve problems and toxic shock syndrome. In extreme cases, it can result in death. People with weakened immune systems who have been infected with Staphylococcus aureus require treatment with antibiotics to help clear the infection. The concern with MRSA strains of bacteria is that they are resistant to a number of the antibiotics that are normally used to treat Staphylococcus aureus infections.

How is MRSA treated?

Because MRSA is resistant to a number of different antibiotics, it is harder to treat than non-resistant bacteria. However, MRSA is not resistant to every antibiotic and most strains of MRSA can still be treated with vancomycin, teicoplanin and mupirocin. For people with weakened immune systems who have become infected with MRSA, the best treatments are with the antibiotics vancomycin or teicoplanin. These two antibiotics are given as injections or through an intravenous drip and so are only given to people in hospital. Certain groups of people are at a higher risk of infection with MRSA. For this reason, some healthy people are screened for MRSA by having a swab of their skin or inside of their nose taken. If these healthy people are found to be carrying MRSA on their skin or in their noses, they are normally treated with an antibiotic cream - mupirocin. This is applied to the affected areas of the body. This is done to reduce the chance of the bacteria entering the body through an open wound and the chance of other people catching MRSA.

Where does MRSA come from?

MRSA has appeared for three reasons: the widespread use of antibiotics, genetic selection and our dislike of tablets. Bacteria are constantly evolving because their genes are constantly changing. The result of this is that some of the bacteria will have more resistance to a certain antibiotic than others. So, when the weaker bacteria encounter that antibiotic, they are killed. But the more resistant ones will take longer to die. If these more resistant bacteria are not killed off, they will survive and multiply. Their “offspring” will have this resistance to the antibiotic and further changes to their genes will mean that some will be even more resistant to the antibiotic. Over time this combination of bacterial genetic change and our dislike of taking tablets has resulted in strains of Staphylococcus aureus that are resistant to many of today’s antibiotics. Normally these strains are resistant to just one or two antibiotics but, as in the case of MRSA, they can be resistant to more. This is why doctors encourage us to finish the whole course of antibiotics when we are prescribed them. The antibiotic will rapidly kill off the weaker bacteria and we will start to feel better. Many doctors believe that if we stop taking the antibiotic at this point, the stronger bacteria will survive and could produce more drug-resistant “offspring”. If the next person who is infected also fails to finish the whole course of the antibiotic, then even more resistant bacteria will result. For this reason, it is thought that this can all be avoided if we take the whole course of antibiotics in the first place: by taking all the tablets, all the bacteria (including the more resistant ones) should be killed off and no offspring can be produced.

Why is MRSA particularly important in hospitals?

MRSA is particularly important in hospitals for three reasons: 1) Hospitals contain a large number of people with weakened immune systems who could become infected with MRSA and develop unwanted symptoms 2) Many of the patients in a hospital have an intravenous drip or a catheter that creates a “wound” through which MRSA can enter the body 3) In some hospitals, people are in close proximity to each other, which increases the chances of MRSA infecting patients. However, in others patients stay in separate rooms, which helps to lower this risk hospitals offer many opportunities for Staphylococcus aureus bacteria to encounter a wide range of antibiotics and, through genetic change and survival, develop resistance to all of them.

What is done to protect people?

If a person is suspected of being infected with MRSA, a swab of the infected wound or a sample of blood or urine is taken. Any bacteria in the sample are grown in a laboratory and then identified. The results can take several days as it takes this long for the bacteria to grow. If a healthy person is found to be carrying MRSA, they are normally treated with an antibiotic cream - mupirocin. This is applied to the affected areas of the body. This is done to reduce the chance of other people catching MRSA. If a person with a weakened immune system is infected with MRSA, they are treated with either vancomycin or teicoplanin. At the moment, very few strains of MRSA are resistant to either of these two antibiotics. These two antibiotics are given as injections or through an intravenous drip and so are only given to people in hospital. In hospital, to prevent other patients becoming infected, people with MRSA are treated using “barrier nursing” techniques. This form of nursing means that the person may be placed in a separate room and they will be treated by doctors and nurses who will be wearing disposable gloves and aprons. To prevent other people from becoming infected with MRSA, the gloves and aprons will be disposed of and hands will be washed before the healthcare professionals treat another patient. It is worth mentioning that such measures are often used in hospitals and the use of gloves or aprons does not automatically mean that a person has MRSA.

What can be done to keep antibiotic resistance under control?

In the wider world, there is now concern that antibiotic resistance could continue to develop to the point where some bacteria are resistant to all antibiotics. To stop this from happening, the medical profession has taken a number of steps: 1. Reducing its levels of antibiotic prescribing by no longer prescribing antibiotics for viral infections. For example, many coughs and colds are caused by viruses and antibiotics will have no effect whatsoever. In the past, antibiotics were prescribed to help prevent co-infection with bacteria, however this only served to increase antibiotic resistance and has been stopped. 2. Encouraging patients to finish their whole course of antibiotics, regardless of whether they feel better earlier or not. This measure is particularly important in preventing resistant bacteria from surviving and multiplying. 3. Using infection control measures in hospitals, including handwashing between patients, to minimise the chances of bacteria being passed from one patient to another. Further information External resources: Health Protection Agency: MRSA information for patients NHS Direct: MRSA information Centers for Disease Control: MRSA factsheet For consumer-friendly and reliable health information on over 200 conditions, treatments and living healthily, visit BUPA's website at: www.bupa.co.uk

 By Curt Herberts, Research Analyst, Frost & Sullivan, North America

While gene therapy has been on the scientific horizon for a few decades, only in the last couple of years has it really taken successful strides in climbing the ominous oncology clinical trial ladder. Despite some serious setbacks, involving the death of one patient and the development of leukaemia in another three, gene therapy has continued to make progress and now has a New Drug Application (NDA) under review at the FDA, and many more in clinical trials. Within the next two to seven years, gene therapy could break the activation energy to finally make it the next big thing in cancer treatment regimes.

IN THE PAST, cancer treatment has involved a mélange of different choices including surgery, radiation, chemotherapy, hormonal therapy, and biologic therapy. However, new discoveries have led to promising technologies within the realms of anti-angiogenesis, monoclonal antibodies, vaccines, and gene therapy. Gene therapy is defined as an “approach to preventing and/or treating disease by replacing, removing or introducing genes or otherwise manipulating genetic material.” Researchers and drug companies alike see this technology as a potential effective therapy to treat different diseases in areas such as: haemophilia, cystic fibrosis, cancer, cardiovascular, pulmonary, neurological, and infectious disease. Gene therapy is applicable across so many different disease states because of its ability to target specific molecular targets on particular cell types within the body. This allows the therapy to directly affect the site of disease, while eliminating extraneous side effects associated with forms of systemic therapy. Currently, there are a number of different techniques to deliver desired gene therapy regimens into specific targeted cells within the body. Some of them include viral vectors, liposomal vectors, ex vivo cell transfection, artificial chromosomes, matrix vectors, genetically engineered cells, gene activators, naked DNA, bacterial vectors, chemical and physical methods, regulation of gene expression, and gene repair.

It has yet to be decided which of these techniques will prove most effective in delivering a specific treatment to the desired location within the body. Many biotechnology and pharmaceutical companies have found significant barriers to commercialisation when trying to develop a gene therapy product. The main problem resides in designing a delivery system that will deliver sufficient quantities of therapeutic DNA into a large enough number of cells, and then express the desired proteins at high enough levels to have a therapeutic effect on the disease. In addition, difficulties lie in the costs and risks associated with clinical trials, financial and logistical difficulties inherent in moving beyond basic research to large-scale manufacture and marketing, as well as research in the sector has generally been taking a much longer time to market than the already lengthy average of seven years for most pharmaceutical drugs. Currently, there are twenty-two new gene therapy candidates in clinical trials for multiple cancer indications. Currently, one of the most promising gene therapies in multiple clinical trials is the Adenoviral p53. Adenoviruses can infect and multiply in cells in which the p53 tumour suppressor gene has been inactivated. Luckily, cancer cells are the only type of cells in the body with an inactivated p53 gene, and about 50 percent of malignant head and neck tumours are composed of cells with the inactivated p53 gene. Therefore, when the adenovirus gets into a cancer cell with an inactivated p53 gene, it replicates, and then lyses (kills) the cancer cell thereby releasing more virus particles to infect neighbouring cancer tissue. With the p53 adenovirus gene therapy in clinical trials for multiple oncology indications, it looks as if it might be the first big leap into the actual application of gene therapy for curing cancer. Many companies such as Introgen/Aventis, Matrix Pharmaceuticals, Schering Plough, and Transgene are currently testing different applications of the p53 tumour suppressor Adenovirus on oncology patients. Phase III trials will hopefully prove whether or not this potential therapeutic will be able to clinically work better than existing therapies and thereby gain a substantial percentage of the skyrocketing cancer market.

Background Frost & Sullivan, an international consultancy firm, has been supporting clients’ growth for over four decades. Our market expertise covers a broad spectrum of industries, while our portfolio of advisory competencies include strategic consultancy, market intelligence and management training. Our mission is to work with our clients’ management teams to deliver market insights and to create value and drive growth through innovative approaches. Frost & Sullivan’s network of more than 500 consultants, industry experts, corporate trainers and support staff, spans the globe with 19 offices worldwide.

Leukaemia is a type of cancer which affects the blood cells. In the UK, leukaemia is the 12th most common cancer in adults, affecting more men than women. It is the most common cancer in children.

Cancer The building blocks of the body are cells, which normally repair and reproduce in a controlled process. With cancer, this process goes wrong and cells divide and grow in an uncontrolled way. The body is made up of many different types of cells, such as skin, nerve, muscle and blood cells. With leukaemia, it is white blood cells that are affected.

About leukaemiaWhite blood cells are produced by the bone marrow, the soft spongy centre of bones. They then pass from the bone marrow into the blood stream and lymph system. White blood cells are involved in various functions of the immune system (the body’s defence system), which protects the body from infections. In leukaemia, some blood cells do not grow properly, but remain within the bone marrow and continue to reproduce in an uncontrolled way. These cells fill up the bone marrow and prevent it from making healthy white blood cells. This means the body is less able to fight off infections. The bone marrow is also able to make other types of blood cells, such as red blood cells and platelets. Problems can result from a reduction in number of these cells. For example, a lack of red blood cells leads to anaemia, which can result in breathlessness and fatigue. A lack of platelets can lead to problems with the blood-clotting system, resulting in bruising. Leukaemia is the most common cancer in children, but cancer is generally rare in children, and leukaemia affects nine times as many adults as children.

Types of leukaemiaThere are many types of leukaemia, named depending on the type of white blood cell affected, and how quickly the disease develops. Only the common types are discussed here. The two main types of leukaemia are acute and chronic. Acute leukaemia tends to affect younger people. The symptoms develop rapidly, and it can quite quickly become life-threatening if not treated. The most common form affects white blood cells called lymphocytes. This is called acute lymphocytic leukaemia (ALL). Chronic leukaemia tends to affect older people. The disease gets worse slowly and has a more prolonged progression. With chronic leukaemia, the white blood cells are almost fully grown and normal when they enter the blood stream. They can function, but not as well as they should do. One type of leukaemia called chronic myeloid leukaemia (CML) affects a particular type of white blood cells called myeloid cells. It has two phases, a chronic phase that may last several years, during which symptoms develop slowly, followed by a more aggressive phase (accelerated phase), where symptoms become rapidly worse.

What causes leukaemia?The cause of most cases of leukaemia is not known, although there are some risk factors that increase the chance of developing the disease. These include:

• a weakened immune system - this may be a result of drugs that suppress the immune system (such as those used for organ transplants), high doses of radiation (such as in radiotherapy for another cancer), or diseases that affect the immune system (such as HIV)
• age - chronic leukaemias are more common over the age of 40
• smoking
• certain genetic conditions, such as Down’s syndrome
• previous chemotherapy for another cancer
• other blood disorders, such as aplastic anaemia, a rare condition where the bone marrow fails to produce blood cells correctly
• contact with a chemical called benzene, one of the chemicals in petrol and a solvent used in the rubber and plastics industry

Symptoms of leukaemia The symptoms of leukaemia vary greatly, depending on the exact type of disease and how advanced it is. Few or no symptoms may occur in the early stages, especially in people with chronic leukaemia. Many symptoms are vague, such as fever, headaches, weight loss and night sweats.

• tiredness, breathlessness and pale skin (due to anaemia, a reduction in number of red cells in the blood)
• frequent infections that do not get better (due to reduction in white blood cells, which fight infection)
• abnormal bleeding from gums and cuts (due to a reduction in platelets which are important for normal blood clotting)
• increased bruising (due to platelet reduction)
• heavier periods in women (due to platelet reduction)
• nosebleeds (due to platelet reduction)
• abdominal pain, due to an enlarged spleen or liver
• swollen lymph glands (glands in the neck, groin and under the arms)
• bone pain, due to the pressure of cell build-up
• swollen gums, and occasionally, swollen testicles

DiagnosisLeukaemia can be diagnosed from a blood test to measure the number of blood cells and look for any abnormal cells. People with suspected leukaemia are referred to a specialist doctor, usually a haematologist (an expert in the treatment of blood disorders). Other tests are often performed to investigate the type of leukaemia and how far it has progressed. These include blood tests, X-rays, CT scans, removal of bone marrow for microscopic analysis and genetic analysis of the abnormal cells. These tests are all very important because they help guide the treatment. Diagnosis, investigation, treatment and follow-up for people with leukaemia usually takes place at specialist centres, in hospitals.

TreatmentThe effectiveness of treatment for leukaemia depends on the type and stage of the disease. Acute leukaemia often goes into remission (the symptoms go away; the disease is under control but not necessarily cured). However, many people with acute leukaemia have a relapse (the disease returns). Chronic leukaemias develop more slowly than the acute types, but respond less well to chemotherapy and are rarely cured.

Acute leukaemiaAcute leukaemia is treated with chemotherapy to destroy the abnormal cancer cells. Mixtures of drugs are given into a vein in a series of treatment courses. Medicines are available which reduce the side-effects of chemotherapy such as nausea. Hair may fall out during treatment but it re-grows once the chemotherapy has stopped. Some people may be able to use “cold caps” which cool the scalp and help prevent hair loss. If the leukaemia returns (relapses), intensive treatment may be given. This involves a bone marrow or a stem cell transplant. Bone marrow or stem cell transplants allow much higher doses of chemotherapy to be given. Before transplantation, very high doses of chemotherapy and sometimes radiotherapy are given to destroy all the bone marrow, both abnormal and normal. This improves the chance of completely curing the leukaemia. Then normal bone marrow cells, donated from a close relative or carefully removed from the person’s own bone marrow, are infused into the bloodstream with a drip. Stem cell transplant involves transplanting stem cells (the most basic type of cell, from which all types of blood cells develop), rather than bone marrow cells. Stem cells can be harvested (collected) from a leukaemia patient’s own blood or from a donor. New alternatives, which are currently experimental, include harvesting stem cells from umbilical cord blood or placentas of new born babies.

Chronic leukaemiaTreatment for chronic leukaemia depends on its type and stage. Often treatment is not started unless there are symptoms. In the early stage, treatment aims to control symptoms by reducing the number of abnormal cells in the blood. Biological therapy may be an option for certain types of leukaemia, such as chronic myeloid leukaemia (CML). This involves treatment with natural substances (such as a protein called interferon alfa that helps the immune system fight leukaemia). As the condition becomes more advanced, treatment may consist of mild chemotherapy, blood transfusion and antibiotics for infections. Some evidence indicates that in chronic myeloid leukaemia, bone marrow transplantation can prolong life if performed during its chronic phase. Another available treatment is monoclonal antibodies. Antibodies are proteins that are produced by certain cells in response to infection. They usually attach themselves to bacteria or viruses and help to destroy them. A type of specifically manufactured monoclonal antibody that recognises and selectively destroys leukaemia cells can be infused into the body. An example is alemtuzumab (MabCampath), which is used to treat chronic lymphocytic leukaemia (CLL). For consumer-friendly and reliable health information on over 200 conditions, treatments and living healthily, visit BUPA's website at: www.bupa.co.uk

In the US alone, influenza (the flu) is responsible for killing 20,000 people and hospitalising a further 100,000 people each year. Over the past three years, it has been said that flu has generally maintained a relatively low profile in the Western World. This winter, however, the flu has hit back in a ferocious way with Asia so far bearing the brunt of this avian flu (H5N1) outbreak. At the time of writing, the likes of Cambodia, China, Indonesia, Japan, Laos, Pakistan, South Korea, Taiwan and Vietnam have all been affected. With the death toll currently standing at 19 – and rising – all avenues which could assist in the containment of this viral infection are being explored.

MORE OFTEN THAN NOT it is the very young, elderly or immuno-compromised who are the most susceptible to this illness. Furthermore, this viral respiratory infection tends to be seasonal, first appearing in early winter and lasting through to early spring. The common flu patient normally suffers from a severe bout of chills, congestion, coughs. exhaustion, fever, headaches, muscle pains and a sore throat. However, this latest outbreak of highly pathogenic avian influenza (HPAI) A H5N1 has proved to be fatal.

Urgency calls for the rapid test?Some experts suggest that rapid tests should play a part in the containment procedures of this current flu outbreak. The latest generation of rapid tests is considered to be of a high level of sensitivity and may be used to rule out the presence of an influenza infection in suspected cases who are showing some of the worrying symptoms. These easyto- use tests, widely available on the internet and costing around $10 - $15 per test, are capable of giving an almost immediate response. Crucially, at the point of care (POC). However, these tests may still be too expensive for widespread use in developing countries. In affected areas, both the local population and relief workers could benefit from employing these tests. Indeed, checking a chicken farmer or a bird shop owner in rural Asia for infection would necessitate a rapid response. Otherwise, awaiting laboratory confirmation could result in the person falling into an even more critical state. In addition to ensuring faster patient management, faster results would curb the prescription of antibiotics in inappropriate cases and reduce the build-up of antibiotic resistance.

Bonus for the rapid flu test market?Before this outbreak, sales for rapid influenza tests were traditionally limited to the winter and spring months. Whilst the media attention given to this serious outbreak has undoubtedly afforded the influenza POC test industry some unexpected exposure, this may just represent another blip in the longterm growth of this market. Following the multiple discoveries of anthrax in letters a few years ago in the US, there was an upsurge in the demand for rapid flu tests. Since anthrax and flu symptoms are highly similar, rapid flu tests were used to ease the concern of worried people. By confirming the person did have the flu, these tests were coincidentally able to rule out the more dreaded anthrax infection. Since 2001, the market for rapid influenza tests has settled down again. In 2003, the US market was estimated at less than $10 million by Frost & Sullivan, whereby rapid flu tests accounted for approximately a fifth of all respiratory rapid tests sold in the US. In Europe, the demand for rapid flu tests remains minimal, principally due to a lack of awareness and a continued reliance on laboratory analysis.

Increased uptake of tests?Through a combination of mass culling of chickens and ducks, banning the import of poultry meat and eggs, improved personal hygiene and thorough cooking, this avian flu has, thus far, been restricted to Asia. Although current efforts are focused on preventing a pandemic, and not on diagnostics, the rapid flu test may yet have a greater role to play before this outbreak is finally contained.

Background Frost & Sullivan, an international consultancy firm, has been supporting clients’ growth for over four decades. Our market expertise covers a broad spectrum of industries, while our portfolio of advisory competencies include strategic consultancy, market intelligence and management training. Our mission is to work with our clients’ management teams to deliver market insights and to create value and drive growth through innovative approaches. Frost & Sullivan’s network of more than 500 consultants, industry experts, corporate trainers and support staff, spans the globe with 19 offices worldwide.

Media contact: Katja Feick, Public Relations Manager, Healthcare Practice katja.feick@frost.com T: +44 (0) 20 7915 7856 http://frost.com http://pharma.frost.com

This month, in the fourth of this new series of factsheets designed to broaden your clinical knowledge we look at epilepsy.

AROUND 2% OF THE POPULATION suffers from epilepsy, which untreated can cause seizures, or fits. Epilepsy usually starts between the ages of three months and the teens. Around 60 per cent of children with epilepsy grow out of it, but for most other people, it can be controlled with medication.

What is epilepsy? Epilepsy is characterised by seizures, sometimes called fits or convulsions. These occur when some of the nerve cells in the brain become overactive, and fire off uncontrolled random signals. Some people have one seizure and then never have another again. But people who experience repeated seizures – whether once a year, or several times a day – have epilepsy. The cause of epilepsy is not known, but it’s generally thought to be the result of a chemical imbalance in the brain. People can be more at risk if they have had a stroke, head injury, meningitis or if they have a history of drug or alcohol abuse. Epilepsy sometimes runs in families, and can be the result of a brain injury at birth or a brain tumour. In most cases, though, it is not known why some people get epilepsy and others don’t.

SeizuresThe main symptom of epilepsy is repeated seizures. Most people have no other symptoms, and live perfectly normal lives. Seizures may come on without warning, although they can be triggered by flashing lights. They are sometimes preceded by an “aura”, which may be a strange smell, taste or feeling. There are different kinds of seizures. Some people experience just a fleeting loss of awareness. Others lose consciousness and suffer stiffening or jerking movements in their body. Seizures can last just a few seconds, or may go on for some minutes, and can be barely noticeable or quite traumatic. Types of epilepsy There are several different types of epilepsy, each with different symptoms.

Primary generalised epilepsyIn this kind of epilepsy, also known as grand mal epilepsy, nerve cells in both sides of the brain become overactive at the same time. Seizures usually last for about five minutes, and can be alarming. In a grand mal seizure, people are likely to experience some or all of the following:

Absence seizuresAbsence seizures, also called petit mal epilepsy, is not as alarming as grand mal. There may be a loss of consciousness, or more often just a loss of awareness, but this kind of seizure doesn’t involve falling down or experiencing involuntary jerking movements. In fact, people may just look as if they are daydreaming. This kind of seizure is most common in children aged between five and nine. Most grow out of them by the time they are 13. For more information, see the BUPA factsheet, Epilepsy in children.

Juvenile myoclonic epilepsy During a juvenile myoclonic epileptic seizure, the hands, arms or whole body will start jerking, but the person doesn’t lose consciousness or awareness. This type of epilepsy usually develops in late childhood. It tends to run in families.

Temporal lobe epilepsy Temporal lobe epilepsy has quite different symptoms. They include:

DiagnosisTo diagnose epilepsy, a doctor will need a detailed description of the seizures – family members or friends can often help with this. The doctor may then arrange for some tests. These can include an EEG (electroencephalogram), a brain scan – either CT (computerised tomography) or MRI (magnetic resonance imaging) and blood and urine tests.

TreatmentThere is no cure for epilepsy, but drug treatment can control the seizures in around 70 per cent of people. These drugs sometimes have side-effects, though, such as drowsiness or a rash. If someone who has had epilepsy doesn’t have a seizure for two years, their doctor may suggest they come off the medication (or reduce the dose). Some children with particular forms of epilepsy are recommended a “ketogenic” diet – one high in fat and low in carbohydrates. Brain surgery may be appropriate for some people with severe and disabling epilepsy that is not improved after trying several different anti-epileptic drugs over three to five years.

Managing epilepsyPeople with epilepsy may need to avoid certain activities or jobs where it could be dangerous to have a seizure – most obviously, things like flying a plane, but also, for example, operating certain machinery, riding a bicycle in busy traffic, or swimming alone. People who are diagnosed with epilepsy cannot drive until their doctor confirms that their seizures are under control – usually no less than a year since their last seizure. If a child has epilepsy, it is important to ensure he or she doesn’t get too tired. And older children and adults may benefit from relaxation and anti-stress exercises. It’s also a good idea for someone with epilepsy to carry a card, necklace or bracelet which says that they have epilepsy. Family, friends, teachers and colleagues should be told what to do in the event of a seizure.

ince its launch in March 1998 Viagra has revolutionised the erectile dysfunction (ED) market. A blockbuster drug since its inception, the blue diamond-shaped pill had been the only name in town for over five years. But with GlaxoSmithKline (GSK) and Bayer introducing Levitra to the U.S. market and Cialis from Eli Lilly and ICOS just receiving FDA approval, will they cannibalise Viagra’s sales or expand the ED market? Erectile dysfunction is the repeated inability to get or keep an erection firm enough for sexual intercourse. The successful introduction of Viagra, the first phosphodiesterase (PDE) inhibitor, by Pfizer resulted in a substantial increase in men willing to acknowledge ED and seek treatment from their doctors. Viagra is safe and well tolerated, but it does not seem to work in all men. In addition, only 10 percent of the patient population suffering from ED uses Viagra. This huge untreated ED population represents a significant opportunity for the newer players. Levitra and Cialis, the second generation of PDE agents, will provide men with additional options for the treatment of ED.

New Kids on the Block

Cialis and Levitra possess several traits that make them better than Viagra. Cialis is known as “the weekend pill” because it can last as long as 36 hours compared to four hours for Viagra. This long lasting effect is the focus of its marketing campaign. It is also the only pill that can sustain efficacy after a meal. Viagra must be taken on an empty stomach. Men can take a pill on Friday and expect a weekend of enjoyment, providing flexibility that Viagra cannot offer. Levitra is the choice for those that are more spontaneous because it takes the least time to work because it has the highest specificity. It works within 16 minutes while Viagra takes 30 minutes to an hour. Cialis and Levitra offer men with various comorbidities treatment options. Men with enlarged prostates can take Cialis with Flomax, while Levitra works better in diabetes patients suffering from impotence.

Viagra Still King

Viagra is one of the most recognisable brands in the pharmaceutical industry and synonymous with erectile dysfunction. GSK/Bayer and Lilly ICOS will find it extremely challenging to win a marketing battle against Pfizer. Viagra also has a good track record and established clinical data backing it up, unlike its two new rivals. A strong brand goes a long way towards preserving revenues and many doctors and patients have fierce loyalty to products that have served them well in the past. There has been no U.S. clinical trial data published directly comparing the use of either Cialis or Levitra with Viagra. Despite the long lasting effect of Cialis and fast onset of Levitra, they are not that different from Viagra. All three drugs are PDE-5 inhibitors that work on the same enzyme. All three drugs have 70 percent effectiveness. They have side effects such as headaches, upset stomachs, nasal stuffiness and nitrate contraindications in common. The cost of therapy is not significantly different. Viagra is currently the first-line treatment for ED and this does not look to change for the foreseeable future.

Room for Everyone

The advances Cialis and Levitra make will not come at the expense of Viagra but from expanding the market since they can reach parts of the patient population for which Viagra is not a viable option. The potential of the ED market is in its size. As the population continues to age the potential market will only grow in size. These new products entering the market with extensive promotional and sales campaigns behind them will only amplify awareness and discussion concerning ED, making it much easier for patients to consult their doctors. The launch of the two new drugs in Europe has expanded the market. Erectile dysfunction is highly prevalent and a vastly underserved market. Getting men to seek medical help is the biggest challenge. If GSK/Bayer and Lilly ICOS succeed in bringing more men to their doctors’ offices they both can eventually achieve blockbuster status.

Background

Frost & Sullivan, an international consultancy firm, has been supporting clients’ growth for over four decades. Our market expertise covers a broad spectrum of industries, while our portfolio of advisory competencies include strategic consultancy, market intelligence and management training. Our mission is to work with our clients’ management teams to deliver market insights and to create value and drive growth through innovative approaches. Frost & Sullivan’s network of more than 500 consultants, industry experts, corporate trainers and support staff, spans the globe with 19 offices worldwide.

AN ENLARGED PROSTATE – known as benign prostatic hyperplasia or BPH – is caused by an overgrowth of prostate cells. This enlargement constricts the urethra so the flow of urine is reduced, making it increasingly difficult to empty the bladder.

The prostate gland

The prostate is a gland about the size of a walnut that is only present in men. It is located just below the bladder and surrounds the urethra, the tube through which urine flows from the bladder and out through the penis. Please see the diagram, below.

One of the main functions of the prostate is to produce an important liquefying component of semen, which allows the sperm to move freely. The gland is divided into three zones, peripheral, transitional and central. With BPH, it is the central part where overgrowth of cells takes place.

BPH is very common, affecting about one third of men over 50. Although it is not prostate cancer, the symptoms of BPH are similar to those of prostate cancer so you should see your doctor if you start to experience problems passing urine.

Symptoms

• hesitancy (difficulty in starting to pass urine

• a weak stream

• the need to strain to pass urine

• the feeling that your bladder isn’t empty after urination

• the need to pass urine urgently

• frequent trips to the toilet, including having to get up several times in the night

• feeling a burning sensation or pain when passing urine

Diagnosis

Your doctor will ask you questions about your symptoms and your general health. You may be asked to fill in a urination questionnaire to help work out the severity of your symptoms.

A digital rectal examination (DRE) will be performed to examine the size and consistency of your prostate by inserting a finger into the rectum. Although this can be uncomfortable, it is not painful. Many men find the prospect of a DRE embarrassing, but should bear in mind that it’s a simple procedure, performed routinely by GPs.

Your doctor will also feel your abdomen to find out if the bladder is distended. A distended bladder may indicate that you are not completely emptying it (chronic urinary retention, which is painless).

Other tests will be carried out to make sure that your urinary problems are due to BPH and not other conditions. A urine test will be done to check for infection or blood. Blood tests, including a prostate specific antigen (PSA) test may be carried out. This measures the amount of an enzyme produced by the prostate. High levels of the enzyme can indicate prostate cancer. Other blood tests include one to assess your kidney function and another for blood sugar to check for diabetes. Both of these problems can cause urinary symptoms.

Other tests

Less common tests may include: urine flow tests; ultrasound to measure urine left in the bladder and to check for bladder stones; urodynamic measurements using a catheter inserted into the bladder to measure the pressure of urine there; and transrectal ultrasonography (TRUS) where an ultrasound probe is passed into the rectum to give a view of the prostate.

A biopsy (samples of the prostate) may be collected using a needle to check for cancerous cells.

Treatment

The mainstays of treatment for BPH are drugs and surgery. However, as any treatment can have unwanted effects, some men with mild symptoms opt for “watchful waiting”, where no treatment is undertaken. Instead the situation is monitored closely with routine check-ups. If symptoms deteriorate, it is then possible to opt for treatment.

Drug treatment There are two main classes of drugs that are prescribed for BPH: alpha-blockers and 5-alpha-reductase inhibitors.

Alpha-blockers

Work by relaxing the muscles at the neck of the bladder and in the prostate. In this way they reduce the pressure on the urethra and so help increase the flow of urine. They do not cure BPH but help to alleviate some of the symptoms.

Around 60% of men find symptoms improve significantly within the first 2-3 weeks of treatment with an alpha-blocker. There are several different alpha blockers. Currently, these are doxazosin (Cardura), terazosin (Hytrin), tamsulosin (Flomax), alfuzosin (Xatral) and prazosin (Hypovase). They can also be used to treat high blood pressure. The most common side-effects of alpha-blockers are tiredness, dizziness and headaches.

5-alpha-reductase inhibitors

These drugs work by inhibiting the production of a hormone called DHT, which contributes to prostate enlargement. Finasteride (Proscar) is the most commonly used drug of this type for BPH. Unlike alpha blockers, 5-alpha- reductase inhibitors are able to reverse BPH to some extent and so may delay your need for surgery.

Plant extracts

A number of plant extracts are popularly used to alleviate BPH, although formal evidence that they are effective is often scanty. However, there is some scientific evidence that an extract of saw palmetto (called Serenoa repens) can be beneficial. If you decide to try a plant remedy, it’s always best to discuss this first with your doctor or pharmacist as interactions with conventional medicines are possible.

Surgery

There are three main surgical options for BPH:

TURP

Transurethral resection of the prostate (TURP) is the most common operation for BPH. The procedure is usually done under a general anaesthetic. A long thin instrument called a resectoscope is passed into the urethra. With a light source and lens on the end it acts as a telescope, allowing the surgeon to view the prostate either directly or on a video monitor. A precisely controlled electric current, applied by a loop of wire at the end of the resectoscope, is used to shave off sections of the enlarged prostate. See the separate BUPA fact sheet on TURP for further details.

TURP is an effective procedure with over 90% of men reporting an improvement after the operation. However, as with any surgical procedure there is a risk of side-effects and complications. A common side-effect of this procedure is retrograde ejaculation - where semen passes into the bladder during orgasm instead of out of the penis. This is sometimes called a “dry orgasm”. Retrograde ejaculation is usually not a problem, although it may reduce fertility. Complications of the operation can include urinary incontinence or damage to the urethra, resulting in a “stricture” that can itself cause difficulty passing urine.

TUIP

Transurethral incision of the prostate (TUIP) may be appropriate for men who have a less enlarged prostate. It is a quicker operation than a TURP and involves removing less tissue. It is performed under general or spinal anaesthetic. As with a TURP an instrument is passed up through the penis, but instead of removing a portion of the prostate, small cuts are made in the neck of the bladder and the prostate. This reduces the obstruction of the flow of urine.

Open prostatectomy

Open prostatectomy is only recommended for men whose prostate is very large. It is a major operation and carried out under a general anaesthetic. An incision is made in the lower abdomen in order to remove the central part of the prostate.

Other treatments

Laser therapy (using a laser probe to cut away prostate tissue) and transurethral microwave thermotherapy (using heat to remove some of the prostate tissue via a probe) are becoming more common in the treatment of BPH.

This is a BUPA health factsheet for more details please go to www.bupa.co.uk