A multidisciplinary, biopsychosocial treatment for non-cardiac chest pain.

BACKGROUND: Non-cardiac chest pain (NCCP) affects up to 80% of patients attending chest pain clinics, but its treatment is suboptimal. AIM: To describe the outcomes of a pilot, stepped care, biopsychosocial management programme in terms of improvements in chest pain, psychosocial scores and use of healthcare resources. METHODS: Of 198 referrals, 77 patients were suitable for the clinic and received a one hour biopsychosocial assessment. Stepped care consisted of assessment only, low intensity Cognitive Behaviour Therapy (CBT), or high intensity CBT. RESULTS: The proportion with pain occurring more than once monthly fell from 100% at baseline to 61% at 3 months (p < 0.001). Pain interference reduced significantly (p < 0.001) from 5.9 [SD 2.2] at baseline to 3.2 [SD 2.6] at 3 months. Depression scores improved from a mean 8.8 to 5.4 (p < 0.05) and anxiety from 6.9 to 4.6 (p < 0.05). Use of healthcare resources improved with a fall in consultations for chest pain over 6 months from a mean 2.6 to 0.1 (p < 0.05). The impact on work and social functioning reduced from 10.4 [SD 10.4] to 3.9 [SD 7.5]: [t (70) = 6.3, p < 0.001). Further improvements occurred at 6 months for chest pain frequency (which fell to 51%, p = 0.003), interference (2.6 [SD 2.1], p < 0.05) and avoidance of exercise (p = 0.03). Otherwise improvements were maintained between 3 and 6 months. CONCLUSION: A stepped-care biopsychosocial approach to NCCP is effective in reducing chest pain frequency and improving behaviour and wellbeing. It can be delivered in part by a nurse allowing integration into any chest pain clinic.

The rapid access chest pain clinic: unmet distress and disability.

AIMS: To determine the characteristics, clinical needs and level of health-care use of patients with non-cardiac (NCCP) and cardiac-chest pain (CCP) attending a Rapid Access Chest Pain Clinic in an inner-London Hospital. METHODS: A cross-sectional comparison of NCCP and CCP patients on measures of pain, mood, beliefs, somatic symptoms and use of services completed by patients attending the Rapid Access Chest Pain Clinic over an 18-month period. RESULTS: There were no significant differences between NCCP and CCP patients in terms of chest pain frequency, duration or severity or associated distress; however, NCCP were younger (53 vs. 60, OR = 1.05) and reported 'atypical' pain more frequently (82% vs. 50%, OR = 3.72). The NCCP group reported more panic-type beliefs about chest pain (5.8 vs. 4.3, P < 0.05) and lower 'illness coherence' (a patient's belief that the illness 'makes sense') (3.5 vs. 4.7, P < 0.05). Anxiety and depression scores were similar in both groups. Both groups had similar levels of health-care use but patients with NCCP saw more types of health-care worker (mean 1.7) than those with CCP (mean 1.4, P < 0.05). CONCLUSION: Patients with NCCP are as disabled and distressed as patients with CCP however current services fail to meet their needs. We suggest that a biopsychosocial approach should be explored.

Intrusions in trauma and psychosis: information processing and phenomenology.

BACKGROUND: Intrusions are common symptoms of both post-traumatic stress disorder (PTSD) and schizophrenia. It has been suggested that an information processing style characterized by weak trait contextual integration renders psychotic individuals vulnerable to intrusive experiences. This 'contextual integration hypothesis' was tested in individuals reporting anomalous experiences in the absence of a need for care. METHOD: Twenty-six low schizotypes and 23 individuals reporting anomalous experiences were shown a traumatic film with and without a concurrent visuospatial task (VST). Participants rated post-traumatic intrusions for frequency and form, and completed self-report measures of information processing style. It was predicted that, because of their weaker trait contextual integration, the anomalous experiences (AE) group would (1) exhibit more intrusions following exposure to the trauma film, (2) display intrusions characterized by more PTSD qualities and (3) show a greater reduction of intrusions with the concurrent VST. RESULTS: As predicted, the AE group reported a lower level of trait contextual integration and more intrusions than the low schizotypes, both immediately after watching the film and during the following 7 days. Their post-traumatic intrusive memories were more PTSD-like (more intrusive, vivid and associated with emotion). The VST had no effect on the number of intrusions in either group. CONCLUSIONS: These findings provide some support for the proposal that weak trait contextual integration underlies the development of intrusions within both PTSD and psychosis.

Acidification and urine calcium: is it a preanalytical necessity?

BACKGROUND: It has been suggested that for the accurate measurement of calcium in urine, samples must be collected into bottles containing acid. Acidification poses risks to both patients and laboratory staff. Here we reappraise whether acidification is a preanalytical necessity. METHODS: Twenty-four-hour urine samples were collected from 133 patients into bottles without acid or preservatives. In a subset of 29 patients, 10 mL aliquots were prepared to test the effect on urine calcium of 0.1, 1.0 and 5.0 mol/L hydrochloric acid (HCl). Calcium was then measured immediately after acidification, after 12 h and seven days storage at 4 degrees C. In a separate study, urine calcium concentrations in paired control (non-acidified) and acidified (with 5 mol/L HCl) samples were compared in 133 patients. When available, we recorded the time from start of urine collection to time of analysis. Calcium was measured using the cresolphthalein complexone colorimetric endpoint assay on the Roche Modular system. RESULTS: There was no significant difference in the calcium concentration in the 29 cases studied between the varying acid concentrations tested compared with non-acidified urine (P = 0.987). Overall, in 133 patients there was no difference between control and acidified samples (P = 0.888). We found no correlation between basal urine pH and urine calcium at all time points studied. CONCLUSIONS: Our results suggest that the acidification of urine samples is not a preanalytical necessity for the measurement of urine calcium.