The Lake Clinic - providing primary care to isolated floating villages on the Tonle Sap Lake, Cambodia.

CONTEXT: One of the most isolated areas in South-East Asia is the Tonle Sap Lake region in Cambodia. Scattered throughout the lake are remote fishing villages that are geographically isolated from the rest of the country. ISSUE: Receiving health care at a clinic or hospital often involves a full day of travel from the Tonle Sap Lake region, which is unaffordable for the vast majority of residents. INTERVENTION: The Lake Clinic (TLC) is a non-government organization established in 2007. In 2008, a ship was built that was designed for transport of a medical team and supplies to provide primary care to the fishing villages. Initially the project started with one team serving seven villages. TLC has since expanded to two full teams serving 19 villages. TLC provides adult and pediatric primary care, vaccinations, dental services, eyecare services, antenatal care and health education free of charge. From 2008 to 2012, there were a total of 13 160 pediatric visits and 17 722 adult visits. In addition to these services, 739 patients received dental care, 346 patients received eye care, there were 1239 antenatal visits, 116 family planning visits, and 1600 patients received health education. In total, 130 patients were referred to hospitals or health centers for a higher level of care. A total of 6627 immunizations were provided. The most common pediatric illness was upper respiratory infection (44.4%), and the most common adult illness observed was gastritis (20.6%). LESSONS LEARNED: Despite the challenges, TLC has been able to achieve a significant goal: to provide primary care medical services to a remote area of Cambodia where no medical services were previously available. TLC strives to strengthen healthcare delivery with the goal to provide the best possible care in the region. New partnerships have allowed laboratory capacity and a formalized hospital referral system for pediatric patients beginning in 2014. A new boat, which completed construction in December 2013 and is now fully operational, has allowed the TLC team to reach a greater number of patients more efficiently.

On the training and testing of entry-level commercial motor vehicle drivers.

This study examined the effectiveness of 3 different training types on commercial motor vehicle (CMV) drivers' skill levels. The training types included a conventional 8-week certified course, a conventional 8-week certified course with approximately 60% of driving time spent in a CMV driving simulator, and a Commercial Driver's License (CDL) test focused short course. Participants' scores on the Division of Motor Vehicles (DMV) road and range tests were assessed. In addition to their DMV scores, participants replicated DMV road and range driving tests in an instrumented vehicle and the CMV driving simulator. Results indicated no training group differences in DMV road tests. There were differences between training groups on DMV range tests and real truck and simulator versions of the DMV road and range tests; on these tests conventional- and simulator-trained participants generally scored higher than CDL-focused participants. However, all groups performed higher in the real truck than in the simulator for both road and range tests. These findings indicate the need for a minimum standard of entry-level CMV driver training as well as support of the use of a driving simulator for training entry-level drivers; however, testing using a simulator does not appear to be feasible with current technology.

Driver responses to differing urban work zone configurations.

This study reports the results of a simulator-based assessment of driver response to two different urban highway work zone configurations. One configuration represented an existing design which was contrasted with a second configuration that presented a reduced taper length prototype work zone design. Twenty-one drivers navigated the two different work zones in two different conditions, one with and one without a lead vehicle; in this case a bus. Measures of driver speed, braking, travel path, and collision frequency were recorded. Drivers navigated significantly closer to the boundary of the work area in the reduced taper length design. This proximity effect was moderated by the significant interaction between lead vehicle and taper length and such interactive effects were also observed for driver speed at the end of the work zone and the number of collisions observed within the work zone itself. These results suggest that reduced taper length poses an increase in risk to both drivers and work zone personnel, primarily when driver anticipation is reduced by foreshortened viewing distances. Increase in such risk is to a degree offset by the reduction of overall exposure to the work zone that a foreshortened taper creates. The benefits and limitations to a simulation-based approach to the assessment and prediction of driver behavior in different work zone configurations are also discussed.

Psychogenic mania and bereavement.

Early notions of mania invoked a combination of psychogenic and organic factors, but psychogenic mania has not endured as a concept. We present a 37-year-old woman with an acute manic episode precipitated by the prolonged death of her husband from cancer. To our knowledge this is the first published account of 'maniacal grief' in the absence of pre-existing affective disorder, and with clear causal relations. Mania was clearly induced by the bereavement and we argue that the loss represented more than a non-specific life event. This case supports a re-examination of mania as potentially a 'reactive' or psychogenic phenomenon.

"Spiritual starvation?": a case series concerning christianity and eating disorders.

METHOD: We describe the cases of four patients with eating disorders in whom complex interactions occurred among religious faith, pathogenesis of the eating disorder, and clinical management. RESULTS: In some of the cases, religious beliefs seemed to provide a containment of maladaptive behaviors, partly through prayer and through a sense of belonging to the religious community. In other cases, it proved difficult to separate the concept of a punitive God from the illness process. DISCUSSION: The cases are discussed with reference to a limited empirical literature. Similarities are noted between some religious institutions and eating disorder treatment regimes. This paper explores management issues, including the use of pastoral counseling and the ethics of addressing religious beliefs in therapy. We note the benefits of a rapprochement between psychiatry and religion.

Season of birth and bulimia nervosa.

OBJECTIVE: Previous studies suggest season of birth variation in eating disorders akin to those of psychoses. We studied season of birth variation in bulimia nervosa. METHOD: Season of birth variation in 935 patients was examined after adjustment for population trends. Variation was also examined for subgroups by age and previous anorexia nervosa. RESULTS: Season of birth did not differ significantly from population norms among bulimics (p >.30), contrasting with studies of other eating disorders. With a history of anorexia nervosa (n = 227), peak season of birth was in March (p <.05). This is consistent with previous studies and also with seasonal birth variation for psychoses. DISCUSSION: Overall, we find no evidence of season of birth variation in bulimia nervosa, and suggest any positive findings be treated with caution. We discuss a number of confounding influences and argue that one explanation remains shared trait vulnerability between anorexia nervosa and psychoses.

Blood-letting in anorexia nervosa: a case study.

BACKGROUND: Deliberate blood-letting has been characterized as an alternative to purging behavior in bulimia. METHOD: We describe a female healthcare worker with an 8-year history of restrictive anorexia nervosa, who initially presented with anemia, using blood-letting, cold baths, and starvation to control her mental state. RESULTS: In contrast with the previous cases of bulimia, the aim of blood-letting in this case of anorexia nervosa was to achieve anemia. She compared the psychic correlates of anemia to emaciation, rather than to deliberate self-harm or purging. DISCUSSION: We note that mainstream 19th century psychiatry prescribed "baths, blood-letting and diet" as a treatment of "madness."

Use of leucotomy for intractable anorexia nervosa: a long-term follow-up study.

OBJECTIVE: We studied the long-term outcomes of intractable anorexia nervosa treated with leukotomy and specialized psychotherapy over 20 years ago. METHOD: All traceable subjects were interviewed using the Eating Disorders Examination (EDE) and the Structured Clinical Interview for DSM-III-R (SCID). They also completed questionnaires. Detailed histories were taken. RESULTS: Four of five female subjects were traced. Their cases had been severe, with failure of previous intensive psychotherapy and now with high risk of death from terminal inanition. One patient had committed suicide, whereas the others enjoyed a reasonable quality of life. Persistent core psychopathology was evident, but patients had not succumbed to weight loss. All suffered depression and anxiety-related disorders, but endorsed their treatment, which had allowed sustained weight gain by release of appetitive behavior, provision of a license to change, and alleviation of phobic anxiety, allowing psychotherapeutic engagement. DISCUSSION: We argue that these outcomes are relatively favorable and would not have been possible without this latter engagement in specialist psychotherapy to address burgeoning panic at unavoidable weight gain.

Application of the powers of compulsory admission to psychiatric hospital by general practitioners, social workers and psychiatrists.

Ways of extending or consolidating the powers of compulsory admission under the Mental Health Act 1983 have been discussed by the government and other organizations, including the Royal College of Psychiatrists. However there is little data on how existing legislation is applied. The authors examined the differential application of the Act between GPs, psychiatrists and social workers by means of an anonymous, confidential questionnaire. Fourteen case vignettes were interpreted by 20 social workers, 19 GPs and 28 Section 12 approved psychiatrists, who were asked to decide if they would detain the patient under the Act. Responses were analysed between and within the three groups. There was general agreement between groups on situations involving 'danger to self' and 'danger to others', but social workers were less likely to detain on health grounds and GPs tended to use the Act unpredictably, in areas not covered by the Act. The authors conclude that the Act may not be used to its fullest extent due to differences in interpretation or in knowledge, which may arise from differential constructs of mental illness and training. A national study of knowledge of mental health law is suggested.

Sexual harassment of psychiatric trainees: experiences and attitudes.

A survey was carried out of psychiatric trainees' work-related experiences of unwanted sexual contact. A structured postal questionnaire was administered to 100 psychiatric trainees from senior house officer to specialist registrar level in a large psychiatric rotation. There was an 85% response rate; 86% (73) of the sample had experienced unwanted sexual contact, with 47% (40) experiencing deliberate touching, leaning over or cornering, and 18% (15) receiving letters, telephone calls or material of a sexual nature. Three-quarters (64) of respondents had experienced unwanted sexual contact from patients and 64% (54) from staff. Experiences and attitudes did not generally differ by gender, grade or training experience. Four out of 48 female respondents described stalking by patients. Of the 39 respondents who had reported harassment by patients, 31 felt supported by colleagues, while of the 13 who had reported harassment by colleagues, eight felt supported. Two-thirds of the respondents considered sexual harassment 'some-times' or 'frequently' a problem for the profession. Diagnoses of confusional states, mania or schizophrenia made subjects less likely to consider unwanted sexual behaviour to be 'sexual harassment' (86%, 80%, and 67%, respectively), but not for other diagnoses. Levels of threatening and intrusive sexual harassment are unacceptably high in this study group. Health trusts should adopt policies of 'zero tolerance' and all incidents should be reported. Psychological impact on victims should be acknowledged even when the behaviour of the perpetrator can be explained by diagnosis.

Anorexia nervosa: changes in sexuality during weight restoration.

OBJECTIVE: We examined changes in sexual drive during weight restoration in patients with anorexia nervosa. METHODS: Eleven women with anorexia nervosa prospectively completed the Sexual Daydreaming Questionnaire (SDQ) and the Hospital Anxiety and Depression Scale (HADS) at five time points during inpatient treatment involving weight restoration. SDQ and HADS scores were recorded every 4 weeks until 8 weeks after subjects had reached the mean matched population weight (MMPW), which was monitored against body mass index (BMI). Histories were 'taken for purging, self-cutting, childhood sexual abuse, and number of sexual partners. Repeated-measures analysis of variance, regression analyses, and t tests were performed. RESULTS: BMI and sexual daydreaming were closely associated (p < .001). BMI and depression also achieved a statistically significant association (p = .046), with "caseness" for anxiety disorder throughout. Higher levels of sexual drive at MMPW seemed to be associated with purging, self-cutting, and childhood sexual abuse but not at low weight. Levels of sexual drive did not reflect previous sexual behavior. CONCLUSIONS: An increase in sexual drive accompanies weight restoration in patients with anorexia nervosa, which is consistent with psychological and physiological explanations of altered sexuality. Transient depression is also associated with weight gain. Changes in sexuality should be considered in both recovery and treatment failure.