MGMT458 U3 IP UPS Research Paper Example | Topics and Well Written Essays - 250 words

MGMT458 U3 IP UPS - Research Paper Example Internal package involves shipments done outside the USA and it operates in 220 nations (Dennis, 2011). The supply chain and freight wing involve forwarding and contract logistics operations. This involves the design, the execution and freight forwarding to destined places. The operations in this category also involve customs brokerage and customer care. The parcel industry in the American region has grown over the years, especially the freight transport section. The venture was transformed from a private enterprise to a full grown industry. The industry has a high amount of revenue, which surpasses most of the organizations engaging in the same business. The industry constitutes of Airborne, federal express, UPS and USPS.UPS makes the highest revenue per year, $20B, compared to the other carriers (Dennis, 2011). Information on the four carriers is available in the public domain. This enhances smooth flow of documents and other packages. Customers are able to access information on the carriers. This enhances efficiency and effectiveness of the carrier. Three of the four carriers have publicly traded shares, but the USPS is a government agency. Human resource retention is essential in the going concern of an entity. This can be achieved through thorough training of the personnel on the four sections of the parcel service delivery. A mastery of work skills makes employees appreciate their place of work, which will result in low rates of employee turnover. Additionally, the global operation scale will ensure that employees are satisfied with the dynamics of their respective places of

Welfare Feminism in Britain Essay Example | Topics and Well Written Essays - 2500 words

Welfare Feminism in Britain - Essay Example It is difficult for us to perceive woman's role as a 'job' because of the surroundings in which it takes place, particularly the family. The institution of the family in modern, post-war society has been subjected to much sociological and psychological examination. During the past seven years it has also been a focus of controversy on the political Left, amongst feminists, socialists, and radicals of all kinds. It has come under attack; it has been defended. Often this debate, originally political, has taken on a highly moralistic flavour, and while it is true that political passions are, ultimately, moral passions, morals about the family has all too often prevented a constructive analysis of this institution as it exists in our contemporary society. Yet it is not hard to understand why the subject should arouse passion; the same reason makes it hard to perceive woman's role within it. (Wilson, 1977, p. 8) A woman has always been subjected to physical care that is mediated by means of on-going emotional and physical relationships of the most intense kind; whether sexual or parental, a woman in particular are reared almost from birth, certainly from early childhood, to conceive of happiness and emotional fulfilment in terms of their future relationship with husband and children. To many it therefore seems alien or even blasphemous to discuss these relationships as jobs undertaken for the capitalist State. Nonetheless, such is the peculiar nature of the family. It plays what is in many ways a repressive role on behalf of the State, not only psychologically but also at the level of economic functioning, and yet at the same time offers the individual a unique opportunity for intimacy, comfort, and emotional support. According to Juliet Mitchell (1971) the individualistic competitiveness of the wider modern society is truly a 'prison of love' for woman. And the Welfare State has always been closely connected with the development of the family and has acted to reinforce and support it in significant ways. (Basch, 1974, p. 79) This it has done by offering various forms of service, both in money and in kind, and also by means of forms of social control and ideology. Thus the Welfare State is not just a set of services, it is also a set of ideas about women's role in society, in family, and not least important socially. In Victorian society women were, for the first time, valuable because they did not work. It was her status as a non-worker that gave woman as wife and mother a very special ideological role. The single woman was society's reject, for celibacy was not highly valued (so that the attempts within the Church of England to start religious orders for women could be seen as radical) while the fallen woman's lot was to be completely outcast (Basch, 1974, p. 81). Yet work had to be found for the army of surplus middle-class spinsters and to them fell the task of teaching their impoverished married sisters how to be better wives and mothers. So grew up a paradoxical situation that still marks social work today; whereby middle-class women with no direct experience of marriage and motherhood themselves took on the social task of teaching marriage and motherhood to working-class women who were widely believed to be ignorant and lacking when it came to their domestic tasks. (Wilson, 1977, p.

Tuberculosis in HIV infected patients Essay Example | Topics and Well Written Essays - 1000 words

Tuberculosis in HIV infected patients - Essay Example This paper shall discuss tuberculosis among HIV patients, including its management, and expected patient outcomes. Discussion According to the US Centers for Disease Control and Prevention, TB is the leading cause of death among HIV patients with almost one in four deaths attributed to tuberculosis. Statistics also indicate that about 20% of patients with TB and HIV have died in 2007; and individuals with HIV and TB account for 32% of patients having died during TB treatment (CDC). These figures indicate the impact of the TB on the HIV patient, how it exacerbates the patient’s condition and even places him at a significant and mortal risk. There are significant challenges which health professionals face with the treatment of TB among HIV patients. It is also important to note that multi-drug resistant tuberculosis (MDR-TB) can manifest among HIV patients. This is unfortunate because these patients would often manifest resistance to two of the best anti-TB drugs – isonia zid and rifampicin (CDC). This type of TB is very difficult to treat and is sometimes a death sentence for HIV patients. Experts suggest that in order to control the occurrence of MDR-TB, the treatment has to be improved not just in the US, but all over the world. The most effective treatment for TB is still the DOTS treatment or the directly-observed therapy; and in order to improve the treatment of MDR-TB, the application of the DOTS must be expanded (CDC). The treatment of TB among HIV patients is more or less similar to the treatment of adult TB patients without HIV. However, managing this disease among HIV patients is complicated; moreover, these patients must also seek care from health professionals with expertise in managing HIV patients with TB (CDC). Since HIV patients are usually already taking in numerous medications, it is important for health experts to note which drugs would have negative interactions with each other, so as not to further exacerbate the patient’ s condition. These experts are also focusing their health programs towards preventing the spread of this disease among the non-HIV population, and more particularly among the HIV population (CDC). Various methods for the management of TB among HIV patients have been suggested. In a paper by Madhi, et.al., (p. 21) the authors sought to evaluate the use of isoniazid prophylaxis against TB among HIV infected children and uninfected children exposed to HIV during the their prenatal period. The authors considered about 540 HIV infected and 804 uninfected infants, assigning them to the isoniazid or the placebo group for 96 weeks. The respondents were assessed on tuberculosis disease, death among HIV-infected children and latent TB infection (Madhi, et.al., p. 21). The study established that the use of primary isoniazid prophylaxis among HIV-infected children and uninfected children did not improve their TB-disease free survival. In effect, even with the application of antiretroviral thera py, TB among HIV infected children remained high (Madhi, et.al., p. 21). There is a need to review the available treatment methods for these children, in order to establish appropriate preventative measures on the occurrence of TB. Martinson’s paper below provides an alternative to the isoniazid treatment. Martinson (p. 11) sought to evaluate the use of three new regimens for latent TB which may be more effective than the standard isoniazid treatment. The authors assigned respondents with HIV and TB and who were not

Planning and Managing for the Future - Inverleith Hotel - Edingburgh Assignment

Planning and Managing for the Future - Inverleith Hotel - Edingburgh - Assignment Example In addition, the managers and employees are identified to be focusing on the preferences of the customers facilitating in attracting more customers, which in turn aids towards the development of the hotel (Annual Report, 2014). One of the weaknesses of hotel is the limited sales volume and number of rooms, which is affecting the visibility of the brand name of the hotel. The major opportunity of the hotel is the competency of the employees based on which the hotel is able to perform its operations in a competitive manner. The entrance of new hotel can be one of the major threats for B&B. The owners and managers play a vital role towards the improvement of the performance of the hotel based on their good managerial skills. The owners and managers always support the employees in their work, so that the employees can perform their work effectively for meeting the satisfaction level of the customers (Annual Report, 2011). In the context, the assignment focuses on evaluating the plans as well as objectives of Inverleith Hotel (B&B) for having a better understanding of the performance of the company. Accordingly measures are needed to be adopted for implementing the changes effectively for enhanced growth as well as development of the hotel. The current business objectives and plans of Inverleith Hotel (B&B) are to increase exposure and expand market by using new and advanced technology. Other current business objective and plan is to increase the number of customers with the aim of increasing the profit as well as economic growth of the hotel. The hotel has planned to improve the quality of food products and also provide the best services to the customers based on the requirements of the customers (Annual Report, 2013). The business plans to hold a strong market position in the international market. The current business objectives and plans have been to enhance the performance of the hotel. To improve the current performance, the owners and

American Indian History Essay Example | Topics and Well Written Essays - 500 words

American Indian History - Essay Example One of the common complaints in all the colonies was their policies on land ownership and governance. The policies and land rates imposed by the colonies were diminishing to the American Indian community who were the original owners. American Indians only had their land to show for their wealth, and that is what colonies were after. In another similarity, all the three colonies wanted to change the cultural and religious preferences of the Indians which the American Indians were against (Calloway, 2012). European and American policies on land ownership denied the Native Americans the right to own land in United States (Calloway, 2012). This made the American and European policies dictate the use of the lands. The Native Americans were denied the right of exploiting land with their cultural and religious activities. Additionally, Native Americans were against the development of land in their community since the lands were the source of their food. The developments of these lands would reduce the number of buffaloes available for hunting. Native Americans used the land mostly for farming. With the introduction of American and European policies, they were forced to pay taxes for their land and what the produced from the fields (Calloway, 2012). This was one of the main sources of conflict. The policies of removal, detribalization and Americanization were not received well by the Native American population. The Americans felt threatened by the compact religious and cultural background of the American Indians. For this reason, they set to stop the practicing both their religious and cultural practices. However, this move was not successful as Native Americans put up a strong opposition on the issue. The Native American population formulated ways in which they practiced their religious and cultural practices without the recognition of the government. Since the twentieth century, Native Americans decided to take control of their lands and lives. Firstly, many

Kobe Bryant vs Michael Jordan Essay Example for Free

Kobe Bryant vs Michael Jordan Essay At the age of 33, Jordan had played only 10 seasons while Bryant has played 16. Two of those seasons for Jordan saw him playing in less then 20 games. While Jordan left North Carolina after his junior season, Bryant entered the league right out of high school. Therefore Bryant basically has a three-year head start on his NBA career. Jordan only played 15 seasons compared to Bryants 16 yet he scored nearly 3,000 more points, 800 steals, 300 blocks, 200 assists and 500 rebounds. Bryant has played in 89 more games than Jordan. One more stat to throw at you: Jordan shot 49. percent from the field for his career while Bryant has shot only 45. 3 percent. Maybe you dont like stats. Maybe you feel trophies on the mantle judge greatness. Jordan led the league in scoring 10 times. He led the league in steals three times and also was named the Defensive Player of the Year once. Also lets not forget his five regular season MVPs and his six NBA Championships to go along with his six Finals MVPs. Bryant has led the league in scoring twice, and while he has been named to an All-Defensive team 12 times, he has never won the Defensive Player of the Year. While he has won five NBA Championships, he has only been named the Finals MVP twice. Bryant won the regular season MVP once. So Jordan has the edge in the stats as well as the trophy count. He also did the unthinkable and came out of retirement twice. His first retirement nearly lasted two seasons while the second last three years. Now while I pointed out errors in the video, the biggest error it made was show not how great Kobe Bryant is but how great Michael Jordan was. They say imitation is the greatest form of flattery and the video clearly shows that Bryant has tried his best to be like Mike. I know this article wont end this debate. While is easy to prove Jordans greatness now, in a few years Bryant will or should hold the edge in every statistical category. Also with the additions of Steve Nash and Dwight Howard, he could surpass Jordan in the title count. Whatever happens over the next few years, one thing wont change. In my opinion Michael Jordan is not only the greatest shooting guard but is by far the greatest player I have ever seen, but that is just my humble opinion.

Corticosteroids and Mental Disorder

Corticosteroids and Mental Disorder Abstract Corticosteroid medication is an essential treatment in almost all medical specialties. Psychiatric side effects of corticosteroids may be both common and severe and include psychosis, mania, depression, delirium and dependence. Only a small evidence base exists about susceptibility to and epidemiology of these conditions. Corticosteroid induced psychiatric disorder typically has an acute onset and is dose related. Manic symptoms predominate acutely however long term use may be associated with depression. Steroid dependence and withdrawal syndromes have been documented. Case reports suggest that a combination of mood stabilizers and antipsychotics may be useful in management severe acute effects. This article will give psychiatrists working in a general hospital a guide to the epidemiology, clinical presentation and management of corticosteroid induced psychiatric disorder. Introduction Corticosteroids were first introduced into medical practice in the late 1940s, since when they have been used by almost all medical specialists as effective treatment for autoimmune and inflammatory conditions. Over 5 million prescriptions are written for corticosteroids in the UK each year, at a cost of over  £100 million. (NHS Health Care Statistics 2005) About 1% of the general population and as many as 7% of hospitalized patients are receiving oral corticosteroid therapy at any given point in time. (NHS Health Care Statistics 2005) Whilst being renowned for important therapeutic actions they can have many adverse effects which must be considered in long term treatment. Physical effects such as osteoporosis, central obesity and immunosuppression are frequent in patients receiving corticosteroids. Psychiatric effects include alterations in mood, delirium, dementia and psychosis. As corticosteroids have a critical place in the management of chronic disease, psychiatrists should be equipped with the knowledge to recognize and manage corticosteroid induced mental disorder. This article describes the epidemiology, clinical presentation and management of these conditions. Indications and Pharmacology There are several forms of corticosteroid medication licensed in the UK, including: betamethasone, cortisone acetate, deflazacort, hydrocortisone, methylprednisolone (prednisolone) and triamcinolone. Each of these drugs has varying degrees of mineralocorticoid and glucocorticoid activity. All of the above preparations exist in oral or intramuscular form. Inhaled steroid preparations are also will not be discussed as there is little evidence that they can induce mental disorder. The main indications for these medications are: Suppression of inflammatory and allergic bowel disease; chronic or treatment resistant Asthma and COPD; Immunosuppression in Acute Lymphoblastic Leukemia, Hodgkins and non-Hodgkins disease, and Hormone sensitive breast cancer; Palliation of symptomatic end-stage malignant disease; Organ transplant rejection; Auto-immune (Rheumatic) disease such as Systemic Lupus Erythematosis and Wegners Granulomatosis. Corticosteroids are rapidly absorbed across the Gastro Intestinal  membrane following oral administration. Peak effects can be observed after 2 hours. The circulating drugs bind extensively to the plasma proteins Corticosteroid Binding Globulin (CBG), albumin and transcortin, with only the unbound portion of a dose active. Systemic prednisolone is quickly distributed into the kidneys, intestines, skin, liver and muscle. Corticosteroids also distribute into the breast milk and cross the placenta. Corticosteroids are predominantly metabolized by the liver to active metabolites then further metabolized to inactive compounds. These inactive metabolites, as well as a small portion of unchanged drug, undergo urinary excretion. The plasma elimination half-life is 1 hour whereas the biological half-life of prednisone is 18-36 hours. Corticosteroids act as glucocorticoid receptor agonists. On binding, the corticoreceptor-ligand complex translocates itself into the cell nucleus, where it binds to Glucocorticoid Response Elements (GRE) in the promoter region of target genes. Insert Figure 1 about here The DNA bound receptor then interacts with basic transcription factors, altering gene expression. There are high concentrations of CBG in specific brain areas such as the hippocampus and pre-frontal cortex and these can therefore be thought of as a potential mediator of corticosteroid induced psychiatric disorder. Chronic disease and corticosteroids In parallel to the psychiatric side effects of corticosteroid therapy, most chronic medical conditions may be associated with considerable psychiatric morbidity. A primary objective of the psychiatrist is to distinguish between the psychiatric effects of chronic illness and corticosteroids. The 1-year prevalence for ICD-10 depressive episode alone is 3 ·2% (95% CI 3 ·0-3 ·5) and an average of between about 9% and 23% of patients with one or more chronic physical diseases have co-morbid depression. In an international meta-analysis, patients with a variety of chronic physical diseases and co-morbid depression had significantly worse health scores than those with chronic disease alone. (Moussavi et al 2007) There are many potential reasons for this, including physical symptoms such as pain and secondary disability leading to loss of function. Studies of depression amongst the medically ill almost always fail however to account for possible corticosteroid effects. In patients with severe COPD given 30 mg of prednisolone for 14 days, when lung spirometry and mood state were measured, no changes in spirometry were detected until 7 days of active therapy. However, small but significant reductions in anxiety and depression were measured after 3 days of prednisolone and before any measurable improvement in lung function. This single study is a major part of a small evidence base suggesting that corticosteroids produce a mild sense of wellbeing rather than the wellbeing necessarily being a consequence of physical improvement. (Swinburn et al 1988) Classification, Epidemiology and Clinical Features Psychiatric side effects were first described and classified by Rome and Braceland in 1952 shortly after the initial introduction of corticosteroids into the pharmacopoeia. As can be noted in Table 1, the descriptions of symptoms in 1952 have an implicit hierarchy which places psychosis above ego disturbance of a neurotic nature and places these above euphoria. (Rome and Braceland 1952) Insert Table 1 about here Epidemiology The proportion of patients developing psychiatric symptoms during corticosteroid therapy has been reported to range from 3 to 75 percent, with a weighted average of about 28 percent. (Lewis and Smith 1983) Amongst the larger studies, the Boston Collaborative Drug Surveillance Program (Boston Collaborative Drug Surveillance Program 1972) monitored 718 hospitalized medical patients who received prednisolone, of whom just 21 (3%)had acute psychiatric reactions: in 6 of 463 (1%) patients receiving 40mg prednisolone, 8 of 175 (5%) patients receiving 41-80mg and 7 of those receiving above 80mg (18%). The dose-response trend was significant, but the study was conducted in 1972 and deals with relatively small numbers of affected subjects who underwent only a basic psychiatric screening. In terms of speed of onset, symptoms appear to develop rapidly. In groups of both patients and healthy subjects, psychiatric symptoms occurred between 3 days and one week. (Lewis and Smith 1983, Hall 1979, Naber 1996) Evidence shows that significantly more women than men (P =0.009) develop psychiatric symptoms as a function of corticosteroid treatment. (Nielsen et al 1963) Prednisolone is the medication most cited to cause psychiatric side effects. In case reports, prednisolone was responsible for 37 cases followed by methylprednisolone, dexamethasone betamethasone, and hydrocortisone. (Lewis and Smith 1983) When dose equivalences were calculated, ranging from 5 to 200mg prednisolone per day, a mean dose of 58.3mg per day or more was cited as substantially raising the risk of a psychiatric reaction. This does not mean that psychiatric reactions only occur at higher dosages. While dosage is not related to the risk of developing mental disturbances, dosage nor duration of treatment seems to impact upon the time of onset, duration, severity, or type of mental disturbances and it is unclear whether patients with a history of psychiatric disorder are predisposed to such disturbances. (Ling 1981) Affective Symptoms The most common psychiatric reaction during glucocorticoid therapy is mood change, which accounts for almost 90 percent of the psychiatric reactions (Hall 1979, Stiefel 1989) In a review of 56 case studies of psychiatric reactions to steroids, of those reporting mood symptoms (45 cases), mania was observed in 48%, depression in 25%, and a mixed state in 9%. (Flores and Kenna) Reversible mood change can be seen in healthy control subjects after administration of prednisone and dexamethasone. One study showed that 8/12 healthy controls experienced this, with manic symptoms predominating. (Brown 1998) A further study which looked at methylprednisone in ophthalmology patients, all of whom were free of psychiatric disorder, found that 36% developed mania or depression during high dose steroid treatment. (Naber 1996) Studies examining the consequences of low dose steroid treatment have found little or no affective symptomatology (Swinburn 1988). With regard to steroid induced mania, patients typically report sudden euphoric mood, excessive energy, indefatigability and some grandiosity. In addition to the rapid development of mood symptoms, suicidality can be associated with steroid treatment. (Flores and Kenna). In addition to mood symptoms patients have been reported to experience sleep disturbances and weight gain. Recurrent affective disorder A further important consideration is whether any such affective disturbance involves one isolated episode or leads on to recurrent disorder. Nine patients whose initial clinical presentation met DSM-IV criteria for a steroid-induced mood disorder were shown in the long term to have a clinical course of bipolar disorder. (Wada 2001) Seven patients initially developed a manic or hypomanic state with sub-acute onset ranging from 1 to 3 months and six patients had manic episodes accompanied by psychotic features. The proportion of manic episodes relative to total mood episodes of the 9 patients was 66%, suggesting manic predominance. Seven patients had future mood episodes that had no direct relationship to corticosteroid therapy and were preceded by various psychosocial stressors. Four of 5 patients who received future steroids rapidly became manic or hypomanic. Recurrent cases of corticosteroid-induced mood disorder therefore appear to have clinical features such as sub-acute onset, fr equent accompanying psychotic features, and similar recurrent episodes in association with psychosocial stressors and corticosteroid use. Psychotic Symptoms In a review of 55 case reports of steroid induced psychiatric disorder, 58% of cases demonstrated psychotic symptoms. (Ling 1981) In 72% of the cases with psychotic symptoms, they were combined with an affective disorder. Similarly, in a review of 79 case reports there was a 71% incidence of psychotic symptoms with affective symptoms reported in over 75% of these. Hallucinations occurred in 58% of the cases and delusions in 74% .(Lewis and Smith 1983) In a more recent review of 56 case reports, psychotic symptoms were reported in 65% of cases. In eight of these, the development of psychotic symptoms was more clearly associated with the withdrawal, rather than with the administration, of steroids. (Flores and Kenna) Interestingly, but perhaps coincidentally, seven of these eight cases occurred in female patients. All eight cases included mood disturbance; 2 with depression, 4 with mania, and 2 with a mixed state. Cognitive effects The cognitive effects of corticosteroid therapy have been seen in patients receiving short term or long-term corticosteroids, and relate primarily to declarative or verbal memory. (Flores and Kenna) In one study, patients on corticosteroids had poorer performance on the Rey Auditory Verbal Learning Test (RAVLT), (a measure of declarative memory), the Stroop Color Word Test (a measure of working memory) performance, smaller hippocampal volumes and lower levels of N-acetyl aspartate (a putative marker of neuronal viability in the temporal lobe region). (Brown 2001) Deficits in declarative memory have been observed in subjects receiving as low as 4 to 5 days of dexamethasone or prednisone. (Newcomer 1999) A dose-dependent impairment in declarative memory has been reported with high dose (160 mg/day), but not low dose (40 mg/day) hydrocortisone. It appears that these cognitive impairments may be reversed with the reduction or withdrawal of corticosteroids. Similar results for declarative memory deficits are found in persons with Cushings disease. Such findings are consistent with reductions in hippocampal volume which are correlated with cortisol levels. (Starkman 1992) Steroid Dependence and withdrawal Several case reports suggest that corticosteroids may be abused for their euphoric effects. (34) Typically this will involve higher doses of oral systemic steroids although there is one report of dependence secondary to a nasal spray. (35) In a case review, 8 patients out of 11 cases of steroid dependency had a previous psychiatric history (predominantly depressive symptomatology), and 4 had a history of drug or alcohol mis-use or dependence. It has been suggested that patients who may request higher steroid doses or who resist dose reduction despite their improving health should be carefully monitored. (Stoudemire 1994) In the more recent review of case studies (Flores and Kenna), the development of psychiatric symptoms was also associated with the withdrawal of steroids. Corticosteroid withdrawal symptoms generally include depression and fatigue but mania and delirium have also been reported during dose reduction or discontinuation. Psychiatric symptoms during steroid withdrawal generally improve or resolve when corticosteroids are re introduced. Cushings disease and psychiatric disorder Cushings syndrome relates to the multi-organ over exposure of iatrogenic or endogenous corticosteroid and is associated with a variety of psychiatric and psychological disturbances. In one study examining 43 patients before and after treatment for Cushings psychopathology was observed in a considerable number. Only 8 patients of 43 with active Cushings syndrome (19%) were without psychiatric symptoms. Psychiatric diagnoses included: neurotic depression in 20 (46%), possible neurotic depression in 1 (2%), reactive depression in 6 (14%), and non-specific neurotic symptoms in 8 (19%). Psychoses were suspected in 3 of the patients who were depressed, but none of the 43 patients with active Cushings syndrome had a definite diagnosis of Schizophrenia, Mania, Obsessive Compulsive Disorder or Generalised Anxiety Disorder. After treatment in 25 patients, when cortisol levels had been substantially reduced (to within normal limits in 88% of them), the percentage rated as psychiatrically asymptomatic increased from 19% to 68%. Scores for depression and anxiety showed significant improvements after treatment for Cushings syndrome and Eysenck Personality Inventory assessments showed a significant improvement in neuroticism score. (Kelly 1996) Treatment of Corticosteroid induced psychiatric disorder There is a very limited literature on the treatment of corticosteroid induced mental disorder, although it can be noted from the forgoing that psychiatric symptoms generally resolve with discontinuation of the medication. In one review of the literature, tapering the dose of steroids alone appears to be effective up to 90% cases. (Flores and Kenna) Case studies also suggest that switching steroids may be of value. (Okishiro et al 2009) The primary objective in managing these conditions is to balance the relative risk of psychiatric disturbance against the medical consequences of withdrawing the steroid. The management of corticosteroid induced psychiatric disorder can otherwise be largely divided into managing an acute psychotic/manic episode versus managing long term depressive symptoms and dependency. Although little evidence exists either way, it can be assumed that severe behavioral disturbance should be managed as it usually is symptomatically with appropriate doses of benzodiazepines and antipsychotics. In terms of managing acute psychotic/manic episodes one study found that of 27 patients treated with lithium carbonate prophylactically none developed severe mood symptoms while receiving corticosteroids. However, six out of 44 patients (14%) not receiving lithium developed mania or depression. (Falk 1979) Antipsychotics, specifically haloperidol, risperidone and olanzapine, are noted from case reports to be useful in mania, mixed affective states, psychosis and delirium. A further case report suggested the successful use of low-dose olanzapine (2.5 mg/day) for severe mood swings and suicidal ideation in a patient with asthma on chronic prednisolone therapy. With regard to depressive symptoms, several case reports have demonstrated some evidence with lithium following the onset of depressive symptoms. Carbemazepine has been reported to be useful in managing both manic and depressive symptoms secondary to corticosteroids. (Wada 2001) There appears to be little benefit from the use of tricyclic antidepressants and in fact, a worsening of neuropsychiatric symptoms has been reported. (Hall 1978) Case reports have been published describing the successful treatment of steroid-induced depression with sertraline, fluvoxamine, and fluoxetine. One such report supports the use of a combination of an antidepressant and antipsychotic in the treatment of steroid-induced psychotic depression (Ismail 2002). Case reports are noted to suggest the effectiveness of benzodiazepines, in the management of specific steroid-induced symptoms as insomnia and anxiety Conclusions Above all, it is clear that the literature on the psychiatric adverse effects of corticosteroids is limited and larger studies on medically ill populations need to be carried out. Clinical practice continues to be informed by case reports despite over 50 years of awareness of these problems. There exists a great opportunity for future research to find predictors of steroid response including their genetic and neuroimaging antecedents and it is clear that the literature could be enhanced with prospective studies and clinical trials. The ICD 10 codes steroid induced psychiatric disorder under F55.5 Abuse of non-dependence-producing substances Steroids or Hormones. No distinction is made about type or chronicity of symptoms. Arguably it may be more useful to classify steroids induced psychiatric disorder under F19.-Mental and behavioral disorders due to multiple drug use and use of other psychoactive substances. Corticosteroid induced psychiatric disorder can pragmatically be classified at present as described in table 2. Insert Table 2 about here With regard to the acute corticosteroid syndrome, the clinical presentation can be diverse but the severity of the symptoms appears to be dose dependent and they tend to occur within the first week of steroid administration. Affective symptoms are most common and a hypomanic/manic presentation is most likely. Some patients appear to have sub clinical hypomanic symptoms which they do not report. Symptoms resolve in most cases on discontinuation of the steroid. Cases are best treated with a mixture of a mood stabilizer (possibly prophylactically) and antipsychotic. With regards to chronic steroid syndrome, the merits of continuation of the steroid must be considered and a small literature suggests that depression in this group can be managed with an SSRI and not a tricyclic antidepressant. In patients who are on long term steroids, a dependence and withdrawal syndrome may be seen. No evidence exists as to how this should be managed but again negotiation should occur between the clinicians and the patient on the need for steroids and a gradual tapering of dose should be considered. Presently it is not known whether individuals have idiosyncratic reaction to steroids or that, given a high enough dose everyone would suffer some mental disturbance. There is a suggestion that those with a previous affective disorder or a family history may be more susceptible to the adverse effects of steroids. If as many as 27% of those on high dose steroids suffer psychiatric symptoms, it is surprising that millions of patients do not present to psychiatric services. Case vignette: Steroid-induced psychosis A 40-year-old woman was admitted to a GI ward for corticosteroid treatment as a result of a flare-up of her inflammatory bowel disease (IBD). Her previous psychiatric history included recurrent depression, for which she had been successfully prescribed fluoxetine by her GP for several years. She was treated for 5 days with prednisolone 40mg IV which was then switched to oral prednisolone prior to her discharge home. Over the next week she progressively became increasingly irritable, experiencing hyperacusis, preferring to stay up all night doing housework and decorating, and suffered from marked lability of mood, fluctuating from euphoria to extreme despair and tearfulness, and anxiety. She began to experience command hallucinations of her late father, who had suffered from schizophrenia, telling her to kill herself, as he had in fact done a number of years earlier. She experienced delusions of being unclean and malodorous. She was visibly seen to be responding to unseen stimuli. She was unable to leave her home for fear that people wished to harm her. On day 5 post-discharge her family sought help from her GP who recommended that she stop her steroids, after noting that 18 years earlier she had experienced a similar episode in response to steroid treatment for her Crohns disease. Her GP prescribed Chlorpromazine but unfortunately the patient developed a marked pill-rolling tremor and akathisia. Next day the patient attended a GI outpatient clinic and due to her distress and anxiety a psychiatric opinion was immediately sought. She was informally admitted and commenced on olanzepine and diazepam with a significant diminution of her psychosis and anxiety such that after a few days she was able to be discharged home. Over the next several weeks she was closely followed-up by liaison psychiatry as an outpatient. Her psychotic symptoms had completely resolved with olanzapine treatment. She did, however, continued to experience low mood and anxiety as a result of on going stress associated with her IBD and required further treatment with antidepressant medications.