Achieving long-term compliance with colonoscopic surveillance guidelines for patients at increased risk of colorectal cancer in Australia.

We have previously demonstrated that we could improve colonoscopic surveillance practice for patients at increased risk of colorectal cancer by the adoption of guidelines, facilitated by a nurse co-ordinator. This study was to determine whether we could sustain this improvement over a longer period (4 years). All colonoscopic surveillance decisions made by the co-ordinated colorectal screening programme of our hospital between 2000 and April 2004 were reviewed. Reasons for variance were recorded, and surveillance decisions made in the last 4 months of the study time were compared with decisions made 4 years previously, both before and after the introduction of the co-ordinated programme. Between 2000 and 2004, 1794 surveillance decisions were made with variance occurring in 100. In the last 4 months of the period of study, 98% of decisions matched guidelines, suggesting that the improvement made following the adoption of the guidelines (45-96% p < 0.05) could be maintained. Reasons for variance from guidelines included a belief that the particular clinical scenario was not covered in the guidelines, disagreement with the guidelines or patient anxiety. Adherence to evidence based medicine guidelines for colonoscopy surveillance can be maintained over time at a high level. A number of clinical scenarios are not covered adequately by the existing guidelines and continue to generate disagreement amongst clinicians.

A model for cystic endometrial hyperplasia/pyometra complex in the bitch.

The objective of this study was to develop a reliable model for the study of the cystic endometrial hyperplasia and pyometra complex (CEH/P) in the bitch. Greyhound bitches (n = 15) were ovariectomised and allocated into three groups (Group 1, n = 5; Group 2, n = 5; Group 3, n = 10, including 5 used from Group 1). Simulated proestrus, estrus and diestrus were induced by treatment with estradiol benzoate and megestrol acetate. The duration of cervical opening during estrus was determined by the intra-vaginal infusion of radio-opaque medium and subsequent radiography of the uterus (Group 1). One milliliter of a culture of Escherichia coli (with five uro-pathogenic virulence factors as identified by PCR: pap, sfa, hlyA, cnf1 and fim) was inoculated intra-vaginally daily throughout the simulated estrus (Group 2). One milliliter of the culture (n = 6) or sterile Luria-Bertani broth (n = 4) was introduced directly into the uterus on simulated diestrus Days 8 or 12 (Group 3). Necropsies were performed 12 and 7-14 days after the inoculation (Groups 2 and 3). The cervix remained open throughout the duration of simulated estrus (5-6 days) in four out of five bitches, and for a shorter duration (3 days of a 6-day estrus period) in one bitch (Group 1). CEH/P was induced by inoculation of bacteria into the uterus (10/10 bitches) but not into the vagina (0/5 bitches), (P = 0.003). A model for the study of CEH/P has been validated.

Interval faecal occult blood testing in a colonoscopy based screening programme detects additional pathology.

BACKGROUND: Colonoscopic based surveillance is recommended for patients at increased risk of colorectal cancer. The appropriate interval between surveillance colonoscopies remains in debate, as is the "miss rate" for colorectal cancer within such screening programmes. AIMS: The main aim of this study was to determine whether a one-off interval faecal occult blood test (FOBT) facilitates the detection of significant neoplasia within a colonoscopic based surveillance programme. Secondary aims were to determine if invitees were interested in participating in interval screening, and to determine whether interval lesions were missed or whether they developed rapidly since the previous colonoscopy PATIENTS: Patients enrolled in a colonoscopic based screening programme due to a personal history of colorectal neoplasia or a significant family history. METHODS: Patients within the screening programme were invited to perform an immunochemical FOBT (Inform). A positive result was followed by colonoscopy; significant neoplasia was defined as colorectal cancer, adenomas either > or =10 mm or with a villous component, high grade dysplasia, or multiplicity (>/=3 adenomas). Participation rates were determined for age, sex, and socioeconomic subgroups. Colonoscopy recall databases were examined to determine the interval between previous colonoscopy and FOBT offer, and correlations between lesion characteristics and interval time were determined. RESULTS: A total of 785 of 1641 patients invited (47.8%) completed an Inform kit. A positive result was recorded for 57 (7.3%). Fifty two of the 57 test positive patients completed colonoscopy; 14 (1.8% of those completing the FOBT) had a significant neoplastic lesion. These consisted of six colorectal cancers and eight significant adenomas. CONCLUSIONS: A one off immunochemical faecal occult blood test within a colonoscopy based surveillance programme had a participation rate of nearly 50% and appeared to detect additional pathology, especially in patients with a past history of colonic neoplasia.

Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home: systematic review.

This article presents the results of a Cochrane review which was conducted to determine the effectiveness of providing written and verbal health information compared with verbal information only to patients being discharged from acute hospital settings to home. Only two trials met the review inclusion criteria. In both trials the participants were parents of children being discharged from hospital to home. The two outcomes measured in both trials were knowledge and satisfaction. The review confirms that providing written and verbal health information is more effective in improving knowledge and satisfaction than providing verbal information only for parents of children being discharged from hospital to home. There is no evidence of the effectiveness of the intervention in adults who provide their own care after discharge from hospital. Further research is required which involves adult patients being discharged from hospital to home, and research which measures a range of outcomes which include readmission rates, recovery times, patient/carer knowledge, complication rates, service utilization and costs (community, outpatient and inpatient), confidence in one's own care management, stress and anxiety levels, satisfaction with services provided prior to discharge, and adherence to recommended care.

Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home.

BACKGROUND: It is becoming commonplace for patients to be discharged earlier from acute hospital settings to their own homes and be required to manage various aspects of their own care. This has increased the need for detailed information to be given to patients and/or significant others to enable them to effectively manage care at home. It has been suggested that providing written health information can assist in this self management. OBJECTIVES: To determine the effectiveness of providing written health information in addition to verbal information for patients and/or significant others being discharged from acute hospital settings to home. SEARCH STRATEGY: Computerised searches from 1990 to June 2002 of the Cochrane Consumers and Communication Review Group Specialised Register and Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE, CINAHL, PsycINFO, ERIC, OVID (including Ageline, EBM Reviews, DARE, Best Evidence, Pre-MEDLINE and PsycARTICLES), Sociological abstracts, Austhealth and bibliographies in articles that met inclusion criteria. SELECTION CRITERIA: Articles were selected if they were randomised control trials or controlled clinical trials; included patients discharged from acute hospital settings to home; the patient and/or significant others received written health information and verbal information in the intervention group, and verbal information only in the control group; and the intervention (written health information and verbal information) was provided at discharge. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened abstracts to determine relevance. Relevant full paper copies were then reviewed against the inclusion criteria. The findings were extracted by one reviewer and confirmed by the other reviewer. The two trials that met the inclusion criteria were too disparate to warrant meta-analysis. MAIN RESULTS: The participants in the two trials were parents of children who were discharged from children's hospitals, one in the United States (n=197) the other in Canada (n=123). Provision of verbal and written health information significantly increased knowledge and satisfaction scores. REVIEWER'S CONCLUSIONS: This review recommends the use of both verbal and written health information when communicating about care issues with patients and/or significant others on discharge from hospital to home. The combination of verbal and written health information enables the provision of standardised care information to patients and/or significant others, which appears to improve knowledge and satisfaction. Many of our objectives could not be addressed in this review due to lack of trials which met the review's inclusion criteria. There is therefore scope for future research to investigate the effects of providing verbal and written health information on readmission rates, recovery time, complication rates, costs of health care, consumers' confidence level, stress and anxiety and adherence to recommended treatment and staff training in the delivery of verbal and written information. In addition there are other factors which impact on the effectiveness of information provided that were not considered in this review but are worthy of a separate systematic review, such as the impact of the patient and/or significant others being involved in the development of the written information, and cultural issues around development and provision of information. Due to concerns about literacy levels for some population groups, other systematic reviews should also focus on other modes of delivery of information besides the written format.

Crossover trial of pagoclone and placebo in patients with DSM-IV panic disorder.

Pagoclone is a cyclopyrrolone that is believed to act as a partial agonist at the gamma-aminobutyric acid (GABA)-A/benzodiazepine (BDZ) receptor. In theory, such partial agonists should be anxiolytic but lack the adverse side-effects of sedation, tolerance and withdrawal associated with full GABA-A/BDZ agonists. The objective of the randomized double-blind crossover study was to assess whether pagoclone was an effective anti-panic agent and also to assess its side-effect profile. Patients recruited had a diagnosis of Panic Disorder (DSM-IV) with at least one panic attack per week. Following a 2-week screening period, patients entered a 6-week trial consisting of two 2-week treatment periods, each followed by a 1-week washout. Patients were randomly assigned to receive either pagoclone 0.1 mg t.d.s. or placebo on their first treatment period and the converse on their second. The primary measure was daily panic attack dairy. Fourteen patients completed the study, the mean number of panic attacks during screening was 5.8+/-0.8 (SEM), this fell to 3.6+/-0.5 during treatment with pagoclone (p = 0.05) and 4.3+/-0.8 with placebo (p = 0.14). There was no significant difference on direct comparison of pagoclone with placebo or in any of the secondary measures (including Rickels withdrawal scale) or the adverse event profiles. The study provides preliminary evidence that pagoclone has anxiolytic properties in the absence of typical BDZ side-effects. This is consistent with its theoretical mode of action as a partial agonist at the GABA(A)/BDZ receptor.

Modal attention asymmetry in patients with schizophrenia and bipolar disorder.

This cross-sectional study examined modal attention asymmetries in patients with schizophrenia (n = 47) and bipolar disorder (n = 42), as contrasted to a matched-sample comparison group of normal participants (n = 89). A test of continuous auditory and visual attention was the primary measure. The data were analyzed from 2 experimental conditions: simple modal responses (auditory and visual) and modal switching responses (ipsimodal and cross-modal switching). In the simple modal condition, patients with schizophrenia demonstrated a visual over auditory asymmetry; patients with bipolar disorder showed no differences. In modal switching conditions, however, patients with bipolar disorder displayed a significant auditory over visual asymmetry. No main effect was detected between medications and attention functioning. Results are discussed in light of differentiating these 2 populations on the basis of modal specificity of attention functioning.

A CAT-derived one to three session intervention for repeated deliberate self-harm: a description of the model and initial experience of trainee psychiatrists in using it.

We describe a new Cognitive Analytic Therapy (CAT)-based intervention for those who repeatedly self-harm. It is specifically designed to be deliverable by staff with no training in psychotherapy. The intervention is simply manualized into sequential tasks that are mediated by new CAT-style standardized tools. A particular feature of this intervention is the deliberate use of feelings elicited in the therapist ('counter-transference') as (a) a guide to how professional poise is being threatened or lost and (b) an indicator of the appropriate focus for this very brief therapy. The psychiatrists' reflection on their elicited feelings is mediated by a new CAT tool, the 'Assessor's Response File' developed in this project. Audiotape analysis suggested that following a very brief learning period, trainee psychiatrists were able to adhere to the structure of the model and arrive at an appropriate reformulation in the first session but tended to be collusive in reciprocating the patients' dysfunctional coping styles.

The psychobiology of anxiolytic drugs. Part 1: Basic neurobiology.

The authors provide an overview of the current state of knowledge with regards to the neurobiological mechanisms involved in normal and pathological anxiety. A brief review of the classification and cognitive psychology of anxiety is followed by a more in-depth look at the neuroanatomical and neurochemical processes and their relevance to our understanding of the modes of action of anxiolytic drugs. The serotonergic, noradrenergic, and gamma-aminobutyric acidergic systems are reviewed. The numerous physiological and pharmacological methods of anxiety provocation and the increasing importance of functional neuroimaging are also examined. The review provides an overview of the biology and basic pharmacology of anxiolytic drugs, and compliments the more clinically oriented companion review.

The psychobiology of anxiolytic drug. Part 2: Pharmacological treatments of anxiety.

Benzodiazepines have been the mainstay of pharmacological treatment of anxiety over the last 4 decades. The problems associated with their use prompted the research for alternative agents that would be useful in anxiety conditions. Old classes of antidepressants, such as tricyclic antidepressants and monoamine oxidase inhibitors, showed effectiveness in some anxiety syndromes, even in areas where benzodiazepines were not very effective. Newer antidepressants, the selective serotonin-reuptake inhibitors, also appear very useful in some anxiety states, and their favourable side-effect profile has elevated them to first-line treatment tools in these conditions. However, the ideal anxiolytic does not exist. Research with other new compounds is very active, and some experimental drugs show promise for the future.

Mechanisms of action of selective serotonin reuptake inhibitors in the treatment of psychiatric disorders.

Selective serotonin reuptake inhibitors (SSRIs) have demonstrated efficacy in depression and anxiety disorders. This raises the question of how the single action of serotonin reuptake inhibition can improve several psychiatric conditions. In order to understand this apparent paradox it is necessary to consider where SSRIs act in the pathogenic process underlying depression or anxiety disorders. Tryptophan depletion has been used extensively in research into depression and has shown that, in patients receiving an SSRI whose depression is in remission, depleting serotonin leads to recurrence of the disorder. Similar results have been found for panic disorder. This suggests that increased levels of serotonin are necessary in the synapse for the SSRI to be effective in the treatment of depression and panic disorder. In obsessive compulsive disorder, depletion of serotonin in patients recovered on an SSRI does not cause relapse; receptor adaptation may be more important. Variations within the SSRI drug class, such as the selectivity ratios for serotonin versus noradrenaline uptake, elimination half-life, and affinity for the 5-HT2 receptor have been identified and may be important determinants of efficacy, side effects and clinical use.

Koro in a Caucasian male with panic disorder.

A case of koro in a white English male is described. This is followed by a brief review of other similar cases and possible psychophysiological mechanisms.

Personal development planning.

Since the introduction of general management into the NHS in 1985, greater emphasis has been placed on managing the service through clearly defined objectives. Jill Sandford and Christine Rollin describe Lifespan Healthcare's personal development plan for managers, and report on some of the benefits it has brought the organisation.