Fish consumption and school grades in Swedish adolescents: a study of the large general population

AIM

To study the associations between fish intake and academic achievement as cognitive parameter among Swedish adolescents.

METHODS

In 2000, a questionnaire including respiratory items, socioeconomic conditions and dietary information was mailed to all schoolchildren (n = 18 158), aged 15 and living in Västra Götaland region of Sweden. The questionnaire was returned by 10 837 subjects. One year later, the total school grades for each subject who had completed the questionnaire and who included their full personal identification number were obtained from the national registers. Multiple linear regression models were applied to evaluate the association between fish intake and academic grades among 9448 schoolchildren, while adjusting for potential confounders, e.g. parents' education.

RESULTS

Grades were higher in subjects with fish consumption once a week compared with subjects with fish consumption of less than once a week (reference group) [increment in estimate 14.5, 95% confidence interval (CI) 11.8-17.1]. Grades were even higher in subjects with fish consumption of more than once a week compared with the reference group (increment in estimate 19.9, 95% CI 16.5-23.3). In the model stratified for parents' education, there were still higher grades among subjects with frequent fish intake in all educational strata (p < 0.01).

CONCLUSION

Frequent fish intake among schoolchildren may provide benefits in terms of academic achievement.

Exposure-response relations for work related respiratory symptoms and sensitisation in a cohort exposed to alpha-amylase

AIMS

To explore relations between exposure to fungal alpha-amylase and the risk of new work related respiratory symptoms or sensitisation.

METHODS

A prospective cohort study among 300 bakers and millers was followed up for a maximum of seven years. Exposure to alpha-amylase was estimated by air measurements and questionnaires and classified into three categories. Symptoms were recorded with a self-administered questionnaire and skin sensitisation assessed using skin prick test (SPT).

RESULTS

There were 36 new cases of chest symptoms, 86 of eyes/nose symptoms, and 24 of a positive SPT to alpha-amylase. There were exposure-response relations for chest and eyes/nose symptoms and for sensitisation, and a significantly increased prevalence ratio for chest symptoms in the highest exposure category.

CONCLUSION

A reduction in alpha-amylase exposure is likely to reduce the risk for respiratory morbidity in bakery workers.

Hand eczema in 45 bakers - a clinical study

The skin of bakers is heavily exposed to dough, spices, water and detergents. This is follow-up of a previous Swedish questionnaire study showing bakers to have a 3-fold increased risk of hand eczema. The aims were to establish diagnoses and to study consequences of hand eczema. From a cohort study of 2226 bakers, a random sample among bakers reporting hand eczema was examined. Of 60 randomly selected bakers reporting a history of hand eczema, 52 attended an examination comprising a standardized interview, documentation of clinical skin signs, patch testing and prick testing with standard and bakery series, and serum analyses. In all, 45 bakers confirmed a history of hand eczema, for which 11 (24%) had been on sick leave, with a median duration of 14 weeks. 13 (29%) had changed their occupation due to skin disease, 19 had positive patch test reactions to standard contact allergens - and 5 to bakery contact allergens. 16 bakers had positive prick tests to standard allergens, 10 to bakery allergens, of whom 9 reacted to flours. Since considerable medical and social consequences of hand eczema are seen, thorough diagnosis of contact allergy and IgE-mediated allergy in bakers, as well as preventive measures, are essential.

Incidence of asthma in female Swedish hairdressers

OBJECTIVE

To investigate the risk of asthma in hairdressers.

METHODS

The incidence of asthma was retrospectively estimated in a Swedish nationwide study including all female hairdressers certified from vocational schools from 1970 to 1995, and a stratified sample of women from the general population were referents. A postal questionnaire included questions on respiratory tract symptoms, atopy, smoking, working periods as a hairdresser, and number of specific hair treatments performed/week. Reported exposures were validated by occupational hygienists. Rate ratios of incidence (IRRs) of asthma were estimated by Poisson regression, adjusted for calendar year of observation, hay fever, smoking, and region of domicile.

RESULTS

The crude incidences of asthma/1000 person-years were: 3.9 during active years as a hairdresser, 2.8 among the hairdressers when not working in the profession, and 3.1 among the referents. The corresponding IRR for being an active hairdresser compared with the referents was 1.3 (95% confidence interval (95% CI) 1.0 to 1.6). Moderate effects on risk of asthma were found both from hairdressing work (IRR=1.6 (1.1 to 2.2) among never-smokers) and from smoking (IRR=1.6 (1.2 to 2.2) among referents). However, the combined effect from hairdressing work and smoking (IRR=1.5 (1.0 to 2.1)) was less than expected (p=0.02). No effect modification by respiratory atopy was found. The hairdressers most often performing hair bleaching treatments (IRR=1.5 (0.7 to 3.0)) or using hair spray (IRR=1.4 (0.8 to 2.4)) had, compared with the most infrequent users, a slightly, but not significantly higher incidence of asthma. Exposure to persulphates in hair bleach was estimated to be 0.04-0.15 mg/m(3) during mixing of the powder. Reported average number of bleaching treatments agreed well with those performed according to a diary.

CONCLUSIONS

Active hairdressing work was associated with a moderately increased incidence of asthma among lifelong non-smokers. The results are moderately supportive, but not conclusive, of associations between asthma and exposure to hair bleach or hair spray.

Adult-onset asthma is associated with self-reported mold or environmental tobacco smoke exposures in the home

BACKGROUND

In recent years, we have gained better knowledge about the influence of indoor environments on respiratory symptoms and asthma. The purpose of this study was to examine certain exposures in the home environment and the risk of adult-onset asthma.

METHODS

A nested case-referent study of adult-onset asthma was performed in a random population sample (n = 15813), aged 20-50 years. Cases for the study included subjects reporting "physician-diagnosed" asthma (n= 174). The referents (n = 870) were randomly selected from the whole population sample. The case-referent sample was investigated with a comprehensive mailed questionnaire about exposures in the home environment, asthma, respiratory symptoms, smoking habits, and atopy. Odds ratios (OR) with 95% confidence intervals (CI) were calculated while controlling for age, sex, smoking, and atopy.

RESULTS

Increased adjusted OR for asthma were associated with exposure to molds (OR 2.2, 95%, CI 1.4-3.5), environmental tobacco smoke (OR 2.4, 95%, CI 1.4-4.1), and the presence of a wood stove (OR 1.7, 95% CI 1.2-2.5).

CONCLUSIONS

This population-based case-referent study indicates that self-reported domestic exposures to molds or environmental tobacco smoke can be associated with adult-onset asthma.

Asthma on the job: work-related factors in new-onset asthma and in exacerbations of pre-existing asthma

Occupational asthma (OA) can be defined as variable airways narrowing causally related to exposure in the working environment to airborne dusts, gases, vapours or fumes. There are many agents in the work-place that can induce asthma or cause substantial deterioration in pre-existing asthma. It has been estimated that 5-15% of adult-onset asthma can be attributed to occupational exposures. Hence adult patients, especially those with new-onset asthma, must be investigated with regard to occupational risk factors for disease. The prognosis for OA is improved if the causal exposure is controlled either by controlling the exposure at the workplace or by moving the patient out of the workplace.

Exposure-response relations for self reported asthma and rhinitis in bakers

OBJECTIVES

To explore relations between two estimates of exposure to inhalable flour dust, and the incidence rates (IRs) of asthma and rhinitis in bakers.

METHODS

This was a retrospective cohort study among 2923 bakers. A posted questionnaire registered the disease and work history. For every year, each baker was assigned an estimate of the exposure concentration to inhalable flour dust derived from reported job-tasks and dust measurements. Exposure at onset of disease was expressed as current dust exposure concentration, and as cumulative dose of exposure to dust. A multiple Poisson regression analysis assessed the impacts of the exposure estimates on the IRs of asthma and rhinitis.

RESULTS

IRs of asthma and rhinitis increased by dust concentration at onset of disease. The IR of asthma for the bakers with highest exposure (dough makers) was 7. 3/1000 person-years in men and 6.5 in women and for rhinitis 43.4 and 38.5, respectively. There was a significant association between the dust concentration at onset of disease and the risk for asthma or rhinitis, but not of the cumulative exposure.

CONCLUSION

The risk of asthma seemed to be increased at inhalable dust concentrations >/=3 mg/m(3) (dough making or bread forming), whereas the risk of rhinitis was increased at all concentrations >/=1 mg/m(3), indicating an increased risk in all bakery job-tasks. The risks seemed to be less dependent on the cumulative exposure dust than the inhalable dust concentrations.

Adult-onset asthma and occupational exposures

OBJECTIVES

This study examined certain occupational exposures and the risk for adult-onset asthma.

METHODS

A nested case-referent study of adult-onset asthma was performed on a random population sample (N=15813), aged 21 to 51 years. Cases for the study included 2 groups: subjects reporting "physician-diagnosed" asthma (N=251) and a broader "asthma" group (N=362). The "asthma" group consisted of subjects with "physician-diagnosed" asthma (N=251) and subjects reporting asthma-like symptoms without having "physician-diagnosed" asthma (N=111). The referents (N=2044) were randomly selected from the whole population sample. The case-referent sample was investigated with a comprehensive questionnaire about occupational exposures, asthma, respiratory symptoms, smoking, and atopy. Odds ratios were calculated with stratification for gender, year of diagnosis, and birth year.

RESULTS

The highest odds ratio for "physician-diagnosed" asthma was associated with exposure to flour dust [odds ratio (OR) 2.8, 95% confidence interval (95% CI) 1.5-5.2] and the occupational handling of resin-based paints (isocyanates) (OR 3.0, 95% CI 1.6-5.9). Exposure to welding fumes, textile dust, and work with glues containing acrylates was also associated with an increased odds ratio for "physician-diagnosed" asthma. Including persons with asthma-like symptoms (ie, the asthma group) showed similar results.

CONCLUSION

This population-based case-referent study from Sweden indicates that occupational exposure to acrylate-based compounds and welding fumes is associated with increased risk for adult-onset asthma.

Bakery work, atopy and the incidence of self-reported hay fever and rhinitis

The aims of this study were to estimate the risk to bakers of developing hay fever and rhinitis, to assess the modifying effect of atopy and to estimate the occurrence of job change due to nasal symptoms. A retrospective cohort study was performed among bakers trained in Swedish trade schools from 1961 to 1989 (n=2,923). School control subjects (n=1,258) comprised students in other programmes in the trade schools and population controls (n=1,258) were randomly selected from the general population. A questionnaire on hay fever, rhinitis, the year of onset of these diseases, change of work due to nasal symptoms and work history was mailed to all participants. The atopic state of the responders was assessed by questions on allergic diseases in childhood and among next of kin. Incidence rates for hay fever and other rhinitis were calculated. The relative risk (RR) for hay fever when working as a baker compared with all control subjects combined was increased in males (RR=1.9, 95% confidence interval (CI) 1.2-2.9). The RR for rhinitis in male bakers compared with combined control subjects was 2.8 (95% CI 2.3-3.4) and for female bakers 2.0 (1.6-2.7). Of the bakers, 6.1% had changed job due to nasal symptoms, significantly more than the controls. A history of respiratory atopy increased the incidence rates of hay fever and rhinitis, with a synergistic effect between atopy and bakery work in males. In conclusion, Swedish bakers, mainly working in the 1970s and 1980s, had an approximately doubled risk of developing rhinitis. Male bakers also had an increased risk for hay fever. There was a synergistic effect of bakery work and atopy such as a family history of hay fever. Bakers also changed job due to nasal symptoms more often than control subjects.

The risk of asthma in relation to occupational exposures: a case-control study from a Swedish city

The purpose of this study was to estimate the risk of adult asthma in relation to certain occupational exposures. The study was designed as a case-control study in Göteborg, including 321 subjects with asthma, born between 1926 and 1970. Controls (n=1,459) were randomly selected from the same area from registers of the 1986 population. Questionnaire information was collected in 1996, and included occupational exposures and smoking habits. Odds ratios were calculated for exposure before asthma onset, stratified by sex and age-class. The highest risks for asthma were associated with exposure to grain dust (odds ratio (OR) 4.2, 95% confidence interval (CI) 1.6-10.7) and flour dust (OR 2.8, 95% CI 1.1-7.2). Among males, significantly increased risks were observed after exposure to flour dust, welding fumes, man-made mineral fibres, and solvents. Among females, increased risks for asthma were associated with exposures to paper dust and textile dust. In logistic regression models controlling for age, smoking, sex and interacting exposures, increased risks were seen for welding fumes (OR 2.0, 95% CI 15-3.4), man-made mineral fibres (OR 2.6, 95% CI 1.4-7.3) and solvents (OR 2.2, 95% CI 1.2-3.2). The fraction of asthma attributed to occupational exposures after adjusting for sex, smoking and age was 11% (95% CI 7-14%). In conclusion, exposure to welding fumes, man-made mineral fibres, solvents and textile dust is associated with increased risk for asthma.

The association between epidemiological measures of the occurrence of asthma

SETTING

The prevalence of asthma is useful for studying the causes of asthma.

OBJECTIVE

To ascertain whether there is a relationship between the prevalence and incidence of asthma.

DESIGN

The association between age and the occurrence of asthma was analysed in an epidemiological study of 15,813 persons.

RESULTS

Different conclusions were reached depending on whether the point prevalence, cumulative prevalence or the incidence rates were studied. The relation between the incidence and prevalence of asthma is described in two epidemiological models, and none of the models seem to fit empirical data. Furthermore, it is shown that estimating incidence rates by prospectively measuring the point prevalences may introduce a considerable bias if the reliability of the diagnosis of asthma is around or below an agreement of 99%, which is probably usually the case. Including asthmatic symptoms during the last year in the definition of point prevalence means that there is no simple relation between incidence rates and point prevalences.

CONCLUSION

The point prevalence may be a biased measure in the study of the etiology of asthma, as there is no simple relationship between the incidence and prevalence of asthma.

Occurrence of self reported hand eczema in Swedish bakers

OBJECTIVES

To estimate the risk of bakers developing hand eczema. The importance of atopy was studied as well as change of job due to hand eczema.

METHODS

A retrospective cohort study was performed among bakers trained in Swedish trade schools in 1961-89 (n = 2923). School referents followed other programmes (n = 1258); population controls were randomly selected from the general population (n = 1258). A questionnaire on self reported hand eczema, year of onset of hand eczema, change of work due to hand eczema, childhood eczema, family atopy, and work history was posted to all participants.

RESULTS

The incidence of hand eczema among male controls was 4.4-5.4 cases/1,000 person-years compared with 16.7 for bakery work. The corresponding figures for women were 11.3-14.1 compared with 34.4. The relative risk for male bakers was 3.5 (95% confidence interval (95% CI) 2.8 to 4.5) and for female bakers 2.8 (2.2 to 3.6). Skin atopy increased the incidence about threefold and a synergistic effect of atopy and exposure was indicated. Also, bakers had changed job significantly more often than controls.

CONCLUSIONS

Swedish bakers, mainly working during the 1970s and 1980s, have about a threefold increased risk of hand eczema. There seems to be a synergistic effect of atopy and occupational exposure.

Nasal symptoms and indices of nasal inflammation in flour-dust-exposed bakers

OBJECTIVE

To analyze whether indices of nasal airway inflammation in bakers were related to nasal symptoms and exposure to airborne flour dust.

METHODS

A cross-sectional study was performed in 12 currently flour-exposed bakers. They were examined by nasal lavage (NAL), visual inspection, a test of mucociliary clearance, and nasal peak expiratory flow (nasal PEF). NAL fluid was analyzed according to the inflammatory markers eosinophil cationic protein (ECP), indicating eosinophilic activity; myeloperoxidase (MPO), indicating active neutrophils; hyaluronic acid (HA) from active fibroblasts; tryptase, indicating activation of mast cells; and albumin, indicating plasma exudation. The bakers were also questioned about respiratory symptoms and working history. Their current and cumulative exposure to inhalable flour dust was estimated after exposure measurements and information about earlier work tasks. Office workers (n=16) without occupational exposure to dust or any other known nasal irritant or sensitizer served as controls.

RESULTS

Personal inhalable dust measurements among the bakers working as dough makers or bread formers ranged from 1.0 to 3.8 mg/m3. Of the 12 bakers, 10 reported at least 1 nasal symptom (crusts, blockage, or a runny nose), a proportion significantly greater than that of the controls (P=0.009). Bakers with nasal symptoms had higher concentrations of markers of inflammation in their NALs as compared with nonsymptomatic bakers. The difference was significant for MPO (P=0.02) and HA (P=0.04) in relation to a runny nose. Tryptase was detected in only one NAL of the bakers. There was a positive correlation between the cumulative dose of inhalable flour dust and concentrations of MPO and HA in NAL. Two bakers were sensitized to wheat; they had the highest NAL concentrations of inflammatory markers.

CONCLUSIONS

Our results indicate that flour dust exposure in bakers at levels below the current occupational exposure limit causes nasal mucosal inflammation, which, in turn, is related to nasal symptoms. We propose that the inflammation may be nonallergic, characterized by activation of neutrophils and fibroblasts.

Late skin-prick-test reactions to malted wheat. Clinical observations and immunohistochemical characterization

This study reports late skin-prick-test (SPT) reactions in seven bakers and seven control subjects to malted wheat appearing after 6-10 h, and not preceded by an immediate-phase reaction. Two subjects in each group had a history of atopic symptoms and were Phadiatope positive. Serologic IgE analysis (RAST) of normal wheat flour and of malted wheat grain was negative in all subjects. Skin biopsy specimens were obtained 16-18 h after SPT to malted wheat grain and to histamine and from untested skin. The late SPT reactions in all participants had an urticarial appearance, clinically and in routine histology. Immunohistologically mild to moderate perivascular dermal cell infiltrates were observed in both groups, consisting mainly of CD4+ and HLA-DR+ cells. The number of CD1a+ epidermal cells was statistically significantly higher (P < 0.01) in the bakers' prick-tested skin compared to that of the controls, a fact which might reflect preparedness to react upon challenge. There were no statistical differences between the two groups in IgE+ epidermal cells or epidermal cells expressing the high-affinity IgE receptor (Fc epsilon RI). However, there was a correlation between serum-IgE levels and the number of IgE+ epidermal cells. The late skin reactions observed in both bakers and controls were probably more of an irritant or toxic than immune-mediated nature, but they raise the question of whether skin contact with malted flour contributes to an unfavorable prognosis of hand eczema in bakers.

Sensitization and exposure to methylisothiazolinones (Kathon) in the pulp and paper industry--a report of two cases

Two cases of contact allergy to methylisothiazolinones from slimicides used in pulp and paper mills are described. The first patient worked as a batcher in a paper mill, and he was in charge of pumping slimicides containing methylisothiazolinones. During pumping, the liquid often overflowed, and his clothes were wet daily with slimicides. After 3 months of work, he began to suffer from dermatitis, which improved when he was away from work. A clinical investigation confirmed the dermatitis diagnosis and a positive skin patch test to Kathon CG was found. The second patient worked as an agent for a firm marketing slimicides containing methylisothiazolinones. One of his tasks was to pump slimicides into the mills, and during such operations his clothes often got wet from slimicides. After some years of work, he began to suffer from erythema and dermatitis after contact with the slimicides. A skin patch test showed a strongly positive reaction to Kathon CG. These case reports draw the attention to the fact that employees in the pulp and paper industry handling slimicides are exposed to extraordinarily high concentrations of methylisothiazolinones and run a substantial risk of being sensitized. The report also stresses the need for improved handling routines of those strong sensitizers in the paper mills.

Improved nasal clearance among pulp-mill workers after the reduction of lime dust

OBJECTIVES

The purpose of this study was to investigate nasal symptoms and function among workers exposed to lime dust and to determine if a reconstruction of the workplace improved the worker's nasal health.

METHODS

In 1992, pulp-mill workers (N = 15) exposed to lime dust and an equal number of matched unexposed referents were examined by questionnaires, nasal peak expiratory flow, the saccharin test, nasal lavage, and a clinical examination of the upper airways. The study was repeated one year later, after the pulp mill had been rebuilt. Dust levels were measured on both occasions with stationary and personal samplings.

RESULTS

In 1992 the total dust level was 1.2 mg.m-3. The saccharin test showed a significantly increased nasal transit time for the exposed workers in comparison with that of the unexposed referents (difference 3.5 min, 95% confidence interval 0.1-6.9 min). One year later the dust levels had decreased to 0.1 mg. m-3, and the difference in nasal transit time had decreased (difference- 0.8 min, 95% confidence interval -4.8-3.3 min).

CONCLUSIONS

Workers exposed to lime dust have an impaired mucociliary function. This impairment is probably due to the alkalinity of the lime. When dust levels are reduced, mucociliary function improves; therefore renovating a workplace to reduce dust levels has a positive effect.

Characterization of exposure to inhalable flour dust in Swedish bakeries

Bakery workers are at risk of developing respiratory symptoms, such as asthma and rhinitis. Exposure to inhalable flour dust in 12 Swedish bakeries was therefore determined: concentrations of airborne inhalable flour dust were measured with the IOM personal inspirable dust sampler and the particle size distribution assessed using the IOM personal inspirable aerosol spectrometer, and the fractions of alpha-amylase, water-soluble protein and total protein in flour dust were determined. A total of 129 measurements were performed of which 77 were repeated measurements. There was a clear hierarchy in geometric mean exposure among bakery workers, with in descending order doughmakers (5.46 mg m-3), bread-formers (2.69 mg m-3), oven workers (1.17 mg m-3), and packers and confectionery workers (0.53 mg m-3). The repeated measurements revealed that within each task group there were considerable differences in mean exposure among the workers: this was demonstrated by geometric standard deviations of between-worker variance of 1.63-1.77. Partitioning of the total variability of inhalable flour dust exposure showed that the task group was the principal source of variance, accounting for 61-69% of the total variability. The optimum grouping strategy was independent of whether the oven workers and the packers were assigned to the same or to different task groups. The doughmakers and the bread-formers are two clearly distinguishable exposure groups with largely overlapping exposure distributions. On average, the flour dust contained 9% total protein, 2.3% water-soluble protein and 0.03% alpha-amylase. The inhalable flour dust was characterized by a substantial proportion of particles with a d(ac) above 10 microns. It was estimated that the thoracic subfraction contributed 39% to the total mass of inhalable dust, and the respirable subfraction 19%.

Asthma and asthma-like symptoms in adults assessed by questionnaires. A literature review

The first widely used questionnaire in respiratory epidemiology was the questionnaire from the Medical Research Council (MRC) of Great Britain. In the first version, from 1960, there were only a few questions about wheezing, but in later editions, more questions about asthma and asthma-like symptoms were added. The MRC questionnaire initiated the development of other questionnaires such as the European Community for Coal and Steel (ECSC) questionnaire of respiratory symptoms and the questionnaire from the American Thoracic Society and the Division of Lung Diseases (ATS-DLD-78). In Tucson, Ariz, a questionnaire was developed in the 1970s that was focused on the subject's own report of asthma. In Great Britain, a questionnaire was developed in the 1980s with the intention of finding the most valid symptom-based items for identifying asthma, "the IUATLD (1984) questionnaire." When judging the validity of a questionnaire, it is essential to understand sensitivity and specificity. Sensitivity is the fraction of the truly diseased subjects found to be diseased using the questionnaire. Specificity is the fraction of the truly healthy subjects found to be healthy using the questionnaire. Regarding questionnaires dealing with asthma, the situation is confusing because of the absence of any gold standard for asthma. The most usual mode of validation has been to test the questionnaire against the results of a clinical physiologic investigation, often a nonspecific bronchial challenge test. Another approach has been to compare the answers from the questionnaire with the clinical diagnoses of asthma. When validated in relation to bronchial challenge tests, the questions about self-reported asthma have a mean sensitivity of 36 percent (range, 7 to 80 percent) and a mean specificity of 94 percent (range, 74 to 100 percent). The questions about "physician-diagnosed asthma" have even higher specificity, 99 percent. When validated in relation to a clinical diagnosis of asthma, the mean sensitivity for the question about self-reported asthma was 68 percent in the reviewed studies (range, 48 to 100 percent). The specificity was 94 percent (range, 78 to 100 percent). One problem in using the presence of bronchial hyperreactivity (BHR) as a gold standard for asthma is that many people with BHR report no respiratory complaints. In other words, the presence of BHR is a measure with high sensitivity but low specificity for asthma. The effect of using a methacholine challenge test as a standard for the disease will thus be an underestimation of the sensitivity of the questionnaire.(ABSTRACT TRUNCATED AT 400 WORDS)

Clinical and immunological responses to occupational exposure to alpha-amylase in the baking industry

alpha-Amylase is a starch cleaving enzyme often used in the baking industry as a flour additive. It is usually of fungal origin, produced by Aspergillus oryzae. One previous report has shown IgE antibodies and positive skin prick test against alpha-amylase in asthmatic bakers. This paper describes four alpha-amylase sensitised index cases with occupational asthma or rhinitis and the results of a cross sectional study of 20 workers from the same factory who were also exposed to alpha-amylase powder. Air sampling detected airborne alpha-amylase at a concentration of 0.03 mg/m3. Significantly more work related symptoms such as rhinitis and dermatitis were found among the alpha-amylase exposed workers compared with referents. A skin prick test to alpha-amylase was positive in 30% (6/20) of the exposed workers. Most of the persons showing a positive skin prick test had work related symptoms and were also skin prick test positive to common allergens. Nasal challenge tests with amylase were performed in selected cases and validated three cases of alpha-amylase induced rhinitis. Two non-symptomatic workers had precipitins to alpha-amylase. Specific IgG antibodies were shown by two further serological techniques. The nature and relevance of these antibodies are currently being studied. It is concluded that alpha-amylase powder is a potent occupational sensitiser. Precautions should be taken when handling this allergenic enzyme.

Bulimia and alcoholism: two sides of the same coin?

There has been an epidemic rise recently in the number of women evidencing bulimia, an addictive cycle of binge eating and purging of food. A significant number of bulimics are reported to abuse alcohol and drugs as well. There is a need to account for the serious problem of symptom substitution in substance abusing populations. Substance abuse is considered within the framework of ego growth, with a particular focus on developmental deficits and compensatory actions. Alcohol, food, and drugs all serve as attempts to minimize the impact of ego deficits. In this regard, the function the substance serves is more crucial than the specific substance abused. A treatment model for bulimia is outlined which addresses both the addiction at hand and the underlying developmental deficits.