Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomized controlled trial in phobia/panic disorder.

BACKGROUND: The demand for time-consuming psychotherapy of phobia/panic exceeds the supply of trained therapists. Delegating routine therapy aspects to a computer might ease this problem. METHOD: Ninety-three out-patients with phobia or panic disorder were randomized in a 2: 2 : 1 ratio to have self-exposure therapy guided either mainly by a stand-alone computer system (FearFighter) or entirely face-to-face by a clinician, or to have mainly computer-guided self-relaxation as a placebo. Both computer groups (FearFighter and relaxation) had brief back-up advice from a clinician. Primary outcome measures were self- and blind-assessor ratings of Main Problem and Goals, and Global Phobia. RESULTS: Drop-outs occurred significantly more often in the two self-exposure groups (43% if mainly computer-guided, 24% if entirely clinician-guided) than with self-relaxation (6%); the difference between the two self-exposure groups was not significant. Even with all drop-outs included, the mainly computer-guided exposure group and the relaxation group had 73% less clinician time per patient than did the entirely clinician-guided exposure group. The two self-exposure groups had comparable improvement and satisfaction at post-treatment and at 1-month follow-up, while relaxation was ineffective. Mean improvement on the primary outcome measures (self- and assessor-rated) was 46% computer, 49% clinician, 9% relaxation at post-treatment (week 10) and 58% computer, 53% clinician and -4% relaxation at 1-month follow-up (week 14). Mean effect sizes on the primary outcome measures were 2.9 computer, 3.5 clinician and 0.5 relaxation at post-treatment; and 3.7 computer, 3.5 clinician and 0.5 relaxation at 1-month follow-up. The assessor did not rate patients at follow-up. CONCLUSIONS: Despite its (non-significantly) higher dropout rate, self-exposure therapy for panic/ phobia cut clinician time per patient by 73% without losing efficacy when guided mainly by a computer rather than entirely by a clinician. The finding needs confirmation at a follow-up that is longer and includes a blind assessor. Self-relaxation had the highest rate of completers but was ineffective.

Reducing demands on clinicians by offering computer-aided self-help for phobia/panic. Feasibility study.

BACKGROUND: Many patients with phobia/panic find it hard to access effective treatment. AIMS: To test the feasibility of computer-guided exposure therapy for phobia/panic. METHOD: Self-referrals were screened for 20 min and, if suitable, had six sessions of computer-guided self-help (from a system called FearFighter). Pre- and post-treatment ratings of 54 patients were compared with those of 31 similar out-patients with phobia/panic who received the same treatment guided by a clinician. RESULTS: At pre-treatment, computer-guided cases were slightly less severe than clinician-guided patients. In a post-treatment intent-to-treat analysis, both groups improved comparably but computer-guided patients spent 86% less time with a clinician than did purely clinician-guided patients, who had no access to the computer system. CONCLUSIONS: Computer-guided self-exposure therapy appeared feasible and effective for self-referrals and saved much clinician time. A controlled study is now needed.

Drug interactions among commonly used medications. Chart simplifies data from critical literature review.

OBJECTIVE: To simplify risk assessment, we have developed a way to present critically appraised drug interaction information through a chart. DATA SOURCES: Fifty drugs most frequently prescribed by Canadian family physicians and 16 drugs and substances that frequently interact with these drugs were the basis for a literature review. Drug interaction textbooks and MEDLINE (from 1966 to 1994) were searched for documented interactions. Reports of additive effects and animal or in vitro studies were excluded. STUDY SELECTION: All reports of interactions were evaluated for clinical effect, clinical significance, and quality of evidence. SYNTHESIS: Of the 464 drug-drug or drug-substance pairs evaluated, 387 (83.4%) demonstrated an interaction, 59 (12.7%) documented no effect, and 18 (3.9%) pairs had conflicting evidence. Five percent of interactions were of major clinical significance; only 1.3% were of major clinical significance and supported by good-quality evidence. By using symbols, colours, and legends in a "grid-map" format, a large amount of drug interaction information was reduced to a single-page chart suitable for a desk reference or wall mounting. CONCLUSIONS: Our chart organizes a large amount of drug interaction information in a format that allows for rapid appreciation of outcome, clinical significance, and quality of evidence.

Investigations into the mechanism of action of the antibacterial agent norfloxacin.

Examination of the mechanism of action of norfloxacin upon susceptible strains of Escherichia coli K12 has shown that the drug exerts a potent bactericidal effect resulting from the inhibition of the A subunit of the essential enzyme DNA gyrase. It is also shown that the use of norfloxacin can reduce the total number of bacteria at the site of an infection as well as having significant effects upon the metabolism of treated cells in the interim period between the loss of viability and cell-lysis. These effects may provide a clue to a previously unsuspected mechanism of providing symptomatic relief which functions in parallel with the elimination of viable pathogenic bacteria.

In vitro studies on optimum preparation of coagulum for surgery of renal calculi.

In renal calculus surgery, human dried fibrinogen produces a coagulum with a much greater tensile strength, stickiness deformability and extractability than cryoprecipitate, which produces a relatively weak and friable clot. A useful coagulum may be prepared at room temperature at any convenient time prior to use if a mixture of 19 ml human dried fibrinogen solution and 1 ml thrombin solution is used. If mixed in a single syringe and injected within 35 s through a butterfly needle into the renal pelvis, complete mixing of the solutions is guaranteed. By using this simple method, the unpredictability of the coagulum can now be eliminated and a strong and elastic clot can be produced.

Anti blood group-M autoantibodies with livedo reticularis, Raynaud's phenomenon, and anaemia.

A 63-year-old woman presented with Raynaud's phenomenon and extensive cold-induced livedo reticularis. A skin biopsy showed no abnormality of the blood vessels but the blood contained high titres of a very unusual autoantibody against the M blood group, most active at low temperatures. An IgM cryoglobulin was detected, and anti-M activity was found in this fraction. The cells of the patient were grouped as MM. The direct antiglobulin test was positive due to C3 component of complement bound to the red cells. The haematological and biochemical results indicate a mild haemolytic process, which is at present well compensated.