Anorexia nervosa with bipolar disorder: A case report

Whether eating disorders cause or are the result of affective disorders is an unsettled question. The association between manic syndromes and eating disorders has been reported rarely. We describe a patient in whom anorexia nervosa developed shortly after the onset of rapid cycling manic—depressive disorder, and whose eating disorder and manic—depressive symptoms twice resolved simultaneously with lithium treatment. This case demonstrates that anorexia nervosa can occur in the context of manic—depressive disorder. This patient first developed depressive, then anorexic, and finally manic symptoms, rapidly alternating with depression. It is uncertain whether this patient's anorexia nervosa had a biological or a psychological basis. Response to lithium carbonate argues for the mobilization of an anorexic diathesis during a mood disorder. Appearance of the anorexia nervosa after initial depression could be seen also as an unsuccessful way to defend against major mood problems.     

Side Effects and toxicity of lithium

Although lithium remains the most specific treatment for bipolar affective disorder, it should be cautiously prescribed and used only when clinically indicated. The main indications for lithium are the manic phase of bipolar affective disorder and prophylaxis of both manic and depressive episodes. Lowering serum lithium levels will markedly reduce the incidence of side effects, and patients should be maintained at the lowest possible serum level. The serum level may be as low as 0.4 mEq/L and as high as 1.5 mEq/L, depending on the clinical response of the patient and the presence of side effects. The most controversial areas are the possibility of renal toxicity and the concomitant use of lithium with neuroleptics, especially haloperidol.     

INVITED REVIEW: EVALUATION OF LITHIUM TREATMENT IN ALCOHOLISM

In psychiatric practice, lithium prevents manic depressivesrecidivism. Lithium could also be useful in non-manic-depressiveconditions with a reduction of aggression and impulsivity. Fromthe observation that alcoholics often present mood swings andimpulsivity, several authors studied the effects of maintenancedoses of lithium on alcohol intake and the depressive symptomsof alcoholics. This article reviews all the published controlledand uncontrolled studies on the effects of lithium in chronicalcoholics. Wren, Kline and colleagues first demonstrated thatlithium treatment could significantly decrease the number ofdisabling alcoholic episodes and that its effect was independentof an effect on the depressive symptoms. These initial optimisticconclusions were not confirmed by later controlled studies involvinga larger number of patients. Most of the recent studies failedto demonstrate a significant effect of lithium on the depressivesymptoms of alcoholics. Thus, it is now established that lithiumis not an effective treatment of affective disorders in alcoholics.The latest published studies also suggest that lithium treatmentdoes not decrease alcohol intake or craving for alcohol in eitherdepressed or non-depressed alcoholics.     

奥氮平与碳酸锂治疗躁狂发作30例对照分析

目的评价奥氮平治疗躁狂症的疗效与耐受性。方法将符合《中国精神障碍分类与诊断标准（第3版）》（CCMD-3）中各型躁狂发作诊断标准的60例住院患者随机分为两组，每组30例，分别用奥氮平和碳酸锂治疗6周。以Bech—Rafaelsen躁狂量表（BRMS）评定疗效，以副反应量表（TESS）及相关辅助检查评价耐受性。结果治疗前后两组BRMS分值均有非常显著性差异，治疗有效率相当；组间比较显示，奥氮平治疗后第1周BRMS评分即显著下降，表明奥氮平较碳酸锂起效迅速。两组的不良反应均少且轻。结论奥氮平可作为心境稳定剂用于躁狂发作的治疗。     

奥氮平与碳酸锂治疗躁狂发作30例对照分析

目的评价奥氮平治疗躁狂症的疗效与耐受性。方法将符合《中国精神障碍分类与诊断标准(第3版)》(CCMD-3)中各型躁狂发作诊断标准的60例住院患者随机分为两组,每组30例,分别用奥氮平和碳酸锂治疗6周。以Bech-Rafaelsen躁狂量表(BRMS)评定疗效,以副反应量表(TESS)及相关辅助检查评价耐受性。结果治疗前后两组BRMS分值均有非常显著性差异,治疗有效率相当;组间比较显示,奥氮平治疗后第1周BRMS评分即显著下降,表明奥氮平较碳酸锂起效迅速。两组的不良反应均少且轻。结论奥氮平可作为心境稳定剂用于躁狂发作的治疗。     

Survey of occupational health problems in an operational military environment

16 Armoured Field Ambulance provided primary and secondary medicalcare to British troops in Bosnia from April to October 1996.Patients presenting at both levels were reviewed and categorizedinto occupational illness, non-occupational disease and non-occupationalinjury. The results show that occupational illness was a smallbut significant component of primary care (8%) with non-occupationalinjury accounting for < 1%. In secondary care, the more seriousnature of the occupational disease seen is shown in that itaccounted for 38% of all admissions and 44% of the 149 patientswho had to be evacuated from theatre for further treatment. Non-occupational injury represented 8% of admissions and 13%of evacuations.     

Pharmacotherapy in bipolar disorder]

In the treatment of manic depressive disorders a distinction is made between acute treatment (combating the mania and the depression) and the maintenance treatment (prevention of subsequent episodes). In both forms of therapy the mood stabilizers are crucial: lithium carbonate, the anticonvulsants carbamazepine and valproic acid. The efficacy of lithium carbonate has been demonstrated in the acute treatment of mania and depression as well as in the maintenance treatment. Carbamazepine may be regarded as a good alternative, especially for the acute treatment of mania and for the maintenance treatment. Valproic acid so far has only be demonstrated to be efficacious in the acute treatment of mania. Monotherapy with a mood stabilizer is a first option, but its insufficient efficacy in many patients nevertheless necessitates a combined treatment, with two or even three mood stabilizers or with a mood stabilizer and other psychoactive agents. In the acute treatment of mania, antipsychotics are indicated in case of a severe or psychotic mania and benzodiazepines in severe disorders of sleep or restlessness. Antidepressants have a role as comedication in the acute treatment of the bipolar depression.     

Communication between an occupational physician and other medical practitioners--an audit

Four hundred and seventy-two consecutive referral episodes relatingto 386 patients attending the Occupational Health Departmentof a general teaching hospital were analyzed to evaluate thefrequency, content and effect on management of communicationsbetween the occupational physician and other doctors. In all,250 episodes (53%) were associated with such a communication.The likelihood of a communication was strongly influenced byreason for referral, particularly in respect of long or shortterm sickness absence; univariate odds ratios (OR)=10.58, 95%Cl=8.13–27.08) and 2.65, 95% Cl=1.55–4.60) respectively;a medical diagnosis of psychiatric illness (OR=3.17, 95% Cl=1.69–5.97));and by number of consultations. Communication was also morelikely when the occupational outcome was ill health retirement,rehabilitation in work or modified work. Ninety-eight per centof specific requests for information or an opinion eliciteda reply. Information received from other doctors influencedthe occupational health physician's management in 52 referralepisodes (20%). Specific action by GPs as a result of communicationwas documented in 54 and by specialists in 37 episodes. Theimportance of communication between occupational health physicianand other doctors in the occupational health process is confirmed.     

Risk factors for first-ever low back pain among workers in their first employment

BACKGROUND: Low back pain has been estimated to be the most costly ailment of people of working age. Both work characteristics and individual factors have been identified as risk factors. The first interaction between work characteristics and individual factors occurs when workers start in their first job. AIMS: To investigate work-related risk factors for first-ever low back pain in young workers in their first employment. METHODS: A cross-sectional analysis was performed on 278 young workers in their first employment and without a history of low back pain prior to working. Work-related physical factors, psychosocial work characteristics, individual variables and first-ever low back pain were queried by means of a questionnaire. RESULTS: About half of the workers who developed low back pain after job start did so in the first year of employment. An increased risk was observed for (i) long periods of seated work [relative risk (RR) = 3.2, 95% confidence interval (CI) = 1.6-6.4]; (ii) more than 12 flexion or rotation movements of the trunk per hour (RR = 3.0, 95%CI = 1.4-6.4); and (iii) more than 3 years seniority in a job involving lifting more than 25 kg at least once an hour (RR = 3.7, 95%CI = 1.4-9.4). As to psychosocial work characteristics, first-ever low back pain was associated with a combination of low psychological job demands and low supervisor support. CONCLUSION: Work-related physical factors and psychosocial work characteristics should be considered as risk factors for first-ever low back pain. First-ever episodes of low back pain are common in the first year of employment. This may reflect a lack of work experience or training.     

Mortality and cancer incidence in Ontario glass fiber workers

BACKGROUND: In a previous cohort study of glass fiber manufacturing, we found a significant increase in lung cancer. This study extends the follow-up period. METHODS: We conducted a historical prospective study of 2557 men employed in producing glass wool. We obtained work histories, causes and dates of death, and date and site of cancer diagnoses. We computed standardized mortality and incidence ratios (SMR, SIR). RESULTS: The overall SMR for lung cancer was 163 (95% CI = 118-221). The SMR did not vary consistently by duration of employment and time since first employment. However, plant workers with >20 years' employment and >40 years since first exposure had an SMR for lung cancer of 282 (95% CI = 113-582). The SMR dropped with later date of first exposure, but the trend was non-significant. There was an unexpected overall increase in kidney cancer incidence. DISCUSSION: The increase in lung cancer is greater than in other cohorts of glass fiber workers. Since exposure data are lacking from the early years of the plant, we cannot state if the excess was due to glass fibers, other work exposures or other reasons.     

Prevalence and patterns of major depressive disorder in the United States labor force

BACKGROUND AND AIMS OF THE STUDY: In this paper, we identify the 12-month and lifetime prevalence of major depressive disorder in and out of the labor force, and among the employed and unemployed. We examine whether prevalence by labor force and employment status varies by gender and over the life cycle. Finally, we examine whether people can "recover" from depression with time by identifying patterns of labor force participation and employment as time since most recent episode passes. METHODS: We examine data collected as part of the National Comorbidity Survey, a survey representative of the population of the United States designed to identify the prevalence of major mental illnesses. The National Comorbidity Study identified cases of major depression via the Composite International Diagnostic Interview. Using these data, we estimate univariate and bivariate frequency distributions of major depressive disorder. We also estimate a set of multivariate models to identify the effect of a variety of dimensions of major depression on the propensity to participate in the labor force, and be employed if participating. RESULTS: Lifetime and 12-month prevalence rates of depression are similar in and out of the labor force. Within the labor force, however, depression is strongly associated with unemployment. The negative relationship between depressive disorder and employment is particularly strong for middle age workers. Depression and the number of depressive episodes have a differing pattern of effects on labor market outcomes for men and women. We find evidence that labor force participation and employment rates for people with a history of depression increase significantly over time in the absence of additional depressive episodes. DISCUSSION: Labor market status represents an important dimension along which prevalence of major depression varies. The relationship between depression and employment status is particularly strong for middle aged persons, but becomes weaker as time passes since the last depressive episode. Continued exploration of the association between work (or lack of work) and depression may ultimately help in the prediction, treatment and assessment of the illness. IMPLICASIONS FOR PRACTICE AND POLICY: These results present a basic set of facts about the relationship between major depressive disorder and labor market outcomes. We have not, however, attempted to sort out the complexities of this relationship here. These complexities arise at almost every turn. For instance, the high level of prevalence of depression among the unemployed may be due to the possibility that the stresses associated with unemployment trigger depressive episodes or to the possibility that workers who are depressed are more likely to be fired or quit. IMPLICATIONS FOR FURTHER RESEARCH: Our continuing research attempts to address these problems. Understanding when and how depression affects labor market outcomes and when and how labor market outcomes affect depression is an important endeavor for those interested in treating the disease and understanding its consequences.     

The treatment of cyanide poisoning

Cyanide has gained historical notoriety as a poison used with intent to cause fatality. Its occurrence in industry is confined to a small number of uses in a relatively narrow range of industries, including the manufacture of Perspex and nylon and in electroplating. With proper controls in these settings, episodes of poisoning are extremely rare. However, because of the potential for a fatal outcome, procedures for the treatment of acute poisoning are essential. Antidotes include methaemoglobin generators, direct binding agents and sulphur donors, but there is a lack of international consensus about the treatment of choice. This article reviews the mechanisms and treatment of cyanide intoxication and emphasizes the importance of having agreed local procedures for the emergency treatment of poisoning.     

Absenteeism and mortality of workers exposed to electromagnetic fields in the French Electricity Company

The objective of this study was to describe the health status of electricity workers exposed to electromagnetic fields during their job. Two groups of exposed workers were studied from 1978 to 1993: the live line workers (n = 121) and the substation workers (n = 232.7) of the French Electricity Company (EDF). A control group was randomly selected from all the company non-management male employees; one control for each exposed subject was matched for the first year of employment. Absenteeism indices and mortality rates were computed and compared in the exposed and control groups. The absence rates were 1.98% in the substation workers and 2.5% in the control group (p < 0.001) and 2.7% in the live-line workers and 2.8% in the control group (NS). No effect of the length of exposure was found. However the medical causes of sickness absence were different: exposed employees had less psychiatric and respiratory diseases but more accidents at work than their control group. Relative risks of accidents at work were 1.2 95% confidence interval (CI) = 1.08-1.33[ for substation workers and 3.22 (CI = 1.78-5.88) for live line workers. EDF electromagnetic field exposed workers seemed not to be affected by any specific health problems except for an excess of accidents at work.     

Health care workers' exposure to blood-borne pathogens in Lebanon

Background Accidental exposure to blood-borne pathogens (BBPs)is a risk for health care workers (HCWs). Aim To study the pattern of occupational exposure to blood andbody fluids (BBFs) at a tertiary care hospital. Methods This study reports a 17-year experience (1985–2001)of ongoing surveillance of HCW exposure to BBFs at a 420-bedacademic tertiary care hospital. Results A total of 1590 BBF exposure-related accidents werereported to the Infection Control Office. The trend showed adecrease in these exposures over the years with an average ±standard error of 96 ± 8.6 incidents per year. In thelast 6 years, the average rate of BBF exposures was 0.57 per100 admissions per year (average of needlestick injuries alonewas 0.46 per 100 admissions). For 2001, the rates of exposurewere found to be 13% for house officers, 9% for medical student,8% for attending physicians, 5% for nurses, 4% for housekeeping,4% for technicians and 2% for auxiliary services employees.The reason for the incident, when stated, was attributed toa procedural intervention (29%), improper disposal of sharps(18%), to recapping (11%) and to other causes (5%). Conclusions The current study in Lebanon showed that exposureof HCWs to BBPs remains a problem. This can be projected toother hospitals in the country and raises the need to implementinfection control standards more efficiently. Similar studiesshould be done prospectively on a yearly basis to study ratesand identify high-risk groups.     

Low back pain interventions at the workplace: a systematic literature review

OBJECTIVE: To assess the effect of controlled workplace interventions on low back pain (LBP) through a review of controlled studies. The rising costs of employees with LBP have resulted in an abundance of offers to society and organizations of interventions to prevent and/or treat the problem. Little is known of the effect of the different interventions. METHODS: A systematic literature search based on the inclusion criteria: controlled trial, work setting and assessment of at least one of the four main outcome measures: sick leave; costs; new episodes of LBP; and pain. Effect of the interventions was reported for the four main outcome measures. RESULTS: Thirty-one publications from 28 interventions were found to comply with the inclusion criteria. Exercise interventions to prevent LBP among employees and interventions to treat employees with LBP have documented an effect on sick leave, costs and new episodes of LBP. Multidisciplinary interventions have documented an effect on the level of pain. CONCLUSIONS: The results show that there is good reason to be careful when considering interventions aiming to prevent LBP among employees. Of all the workplace interventions only exercise and the comprehensive multidisciplinary and treatment interventions have a documented effect on LBP. There is a need for studies employing good methodology.     

Workplace exposures and employment patterns in adult onset asthmatics and diabetics

BACKGROUND: Little is known about the impact of working conditions on employment decisions after the onset of chronic diseases in adult life. AIMS: To determine the effects of job characteristics on employment in patients attending asthma and diabetes clinics. METHODS: Patients aged 16-60 years were interviewed when attending outpatient clinics or undergoing day case surgery. The asthmatics (n=165) and diabetics (n=283) were taking regular prescribed medication for their condition, and were in paid employment at the time of diagnosis. Job titles at diagnosis were rated for exposures with the potential to cause or aggravate asthma or diabetes, and median ratings were used to assess the impact of exposures on the probability of changing the job held at diagnosis. RESULTS: Exposure to irritants or sensitizers at the time of diagnosis was more likely in asthmatics than in the comparison group (odds ratio = 7.09; 95% CI 3.12-16.17); physical activity was unrelated to diagnosis. At interview, on average 8.5 years after diagnosis, more asthmatics were unemployed (44%; mean age 47 years) than diabetics (31%; mean age 49 years) with ill-health being the most common reason given. No relation was found between exposure in the job held at diagnosis and subsequent job change. CONCLUSIONS: No evidence was found that changing jobs was used as a strategy to find more tolerable working conditions. The high proportion of unemployment due to ill-health among adult onset asthmatics deserves further investigation.     

The 'value case' for investment in occupational health.

This paper introduces the problems facing occupational health departments in the current environment created by new legislation and changes in social attitudes. The problems of establishing the true costs and benefits of service provision are discussed. The paper also explains the employment of the 'value principle' in organizations and postulates its use in order to establish the appropriate position of occupational health in corporate thinking. A practical system is suggested, based on a four-step process of strategic planning, issues development, option establishment and plan implementation, which can be used to evaluate and justify investment in services. The problems of future risk are addressed. The paper concludes with the priority of establishing the strategic importance of occupational health services alongside other personnel issues and expresses the possibility of using the same principles outside the business world.     

Diagnosis and treatment of bipolar disorder in children

In general, bipolar disorder with its classical presentation of regularly recurring manic and depressive episodes can be well diagnosed in adults and adolescents. However, bipolar disorder in children is a controversial issue, difficult to diagnose and to distinguish from other illnesses that frequently occur in childhood. In the US, where the diagnosis of'bipolar disorder' is made relatively often in children, not only its classical presentation but also chronic mood dysregulation and even other mood symptoms may lead to the diagnosis of bipolar disorder. The preferred view is the British one, whereby bipolar disorder is only diagnosed in children if they present with clear manic episodes and euphoric mood. Treatment of bipolar disorder in children consists of pharmacotherapy and of psychoeducation aimed at lifestyle adjustments, including reduction of stress, a stable sleep pattern, and adjustments at school.     

Health surveillance in milling, baking and other food manufacturing operations--five years' experience.

The objective of this study was to describe the incidence of allergic respiratory disease and its outcome in terms of symptoms and jobs, across different flour-using industries. It uses the findings of a health surveillance programme in a large food organization over a five-year period. The population under surveillance consisted of 3,450 employees with exposure to ingredient dusts, of whom 400 were in flour milling, 1,650 in bread baking, 550 in cake baking and 850 in other flour-using operations. A total of 66 employees with either asthma or rhinitis symptoms attributable to sensitization to allergens in the workplace were identified. The majority of these (48/66) had become symptomatic prior to the commencement of the health surveillance programme in 1993. The incidence rates (per million employees per year) for those who developed symptoms between 1993 and 1997 were 550 for flour milling, 1,940 for bread baking, 0 for cake baking and 235 for other flour-using operations. The agent believed to be responsible for symptoms was most commonly grain dust in flour millers and fungal amylase in bread bakers. Wheat flour appeared to have a weaker sensitizing potential than these other two substances. In terms of outcome, at follow-up 18% of symptomatically sensitized employees had left the company. Two of the ex-employees retired through ill health due to occupational asthma. Of those still in employment, 63% described an improvement in symptoms, 32% were unchanged and 4% were worse than when first diagnosed. Over half the cases still in employment were continuing to work in the same job as at the time of diagnosis.     

Are tribunals given appropriate and sufficient evidence for disability claims?

BACKGROUND: Occupational physicians are sometimes surprised at the decisions made by employment tribunals. AIM: To assess employment tribunal judgements on disability discrimination in order to determine whether the evidence placed before the tribunal was appropriate and sufficient. METHOD: Qualitative review of recorded tribunal judgements for an 18-month period between 1 January 2005 and 31 June 2006. RESULTS: Of a total of 2497 cases, 2271 (91%) were withdrawn or settled before going to tribunal. Of the remaining 226 cases, 38 were default judgements. In total, 188 cases were actually heard and only 65 judgements were recorded. Of these, 50 (2% of all cases) were full hearings. In 18 full hearings, there was input from an occupational physician, and the tribunal view was that there was discrimination in six cases, four where the advice had been ignored. Only four cases had input from a consultant occupational physician; in three cases, the finding was that discrimination had not taken place and in the fourth, the advice from the consultant was ignored by the management.