A randomised trial of two methods of issuing prenatal test results: the ARIA (Amniocentesis Results: Investigation of Anxiety) trial

BACKGROUND

Many pregnant women experience anxiety while waiting for the results of diagnostic tests. Policies and practices intended to reduce this anxiety require evaluation.

OBJECTIVES

To test the following two hypotheses: * That giving amniocentesis results out on a fixed date alters maternal anxiety during the waiting period, compared with a policy of telling parents that the result will be issued "when available" (i.e. variable date). * That issuing early results from a rapid molecular test alters maternal anxiety during the waiting period, compared with not receiving any results prior to the karyotype. The effects of the two interventions on anxiety 1 month after receiving karyotype results were also examined.

DESIGN

A multicentre, randomised, controlled, open fixed sample, 2 x 2 factorial design trial, with equal randomisation.

SETTING

The prenatal diagnosis clinics in 12 hospitals in England offering amniocentesis as a diagnostic test for Down's syndrome.

SAMPLE

Two hundred and twenty-six women who had had an amniocentesis were randomised between June 2002 and July 2004. Eight women with abnormal results or test failure were excluded post-randomisation.

INTERVENTIONS

Issuing karyotype results on a prespecified fixed date, rather than issuing them as soon as they became available. Issuing karyotype results alone, or subsequent to issuing results from a rapid molecular test for the most common chromosomal abnormalities.

MAIN OUTCOME MEASURES

Average anxiety during the waiting period, calculated using daily scores from the short version of the Spielberger State-Trait Anxiety Inventory (STAI). Anxiety 1 month after receiving karyotype results, measured using the short form STAI.

RESULTS

Issuing early results from a partial but rapid test reduced maternal anxiety by a clinically significant amount during the waiting period (mean daily score 12.5 versus 14.8; scale score difference -2.36, 95% CI -1.2, -3.6), compared with receiving only the full karyotype results. There was no evidence that giving out karyotype results on a fixed or on a variable date altered maternal anxiety during the waiting period (mean daily score 13.2 versus 14.2; scale score difference -1.02, 95% CI -2.2, 0.2). One month after receiving normal karyotype results, anxiety was low in all groups, but women who had been given rapid test results tended to be more anxious than those who had not (mean single day score 9.2 versus 8.3; mean scale score difference 0.95, 95% CI -0.03, 1.9). This small to moderate effect did not reach conventional levels of statistical significance.

CONCLUSIONS

Rapid testing was a beneficial addition to karyotyping, at least in the short term. This does not necessarily imply that early results would be preferred to comprehensive ones if women had to choose between them. Because there are no clear advantages in anxiety terms of issuing karyotype results as soon as they become available, or on a fixed date, women could be given a choice between them.

Amniocentesis results: investigation of anxiety. The ARIA trial

OBJECTIVES

The Amniocentesis Results: Investigation of Anxiety (ARIA) trial tested two hypotheses: first, that giving amniocentesis results out on a fixed date alters maternal anxiety during the waiting period, compared with a policy of telling parents that the result will be issued 'when available' (i.e. a variable date), and secondly, that issuing early results from a rapid molecular test alters maternal anxiety during the waiting period, compared with not receiving any results prior to the karyotype. The effects of the two interventions on anxiety 1 month after receiving karyotype results were also examined.

DESIGN

A multi-centre, randomised, controlled, open fixed sample, 2 x 2 factorial design trial, with equal randomisation.

SETTING

Twelve hospitals in England offering amniocentesis as a diagnostic test for Down's syndrome.

PARTICIPANTS

A total of 226 women who had had an amniocentesis were randomised between June 2002 and July 2004. Eight women with abnormal results or test failure were excluded post-randomisation.

INTERVENTIONS

Issuing karyotype results on a prespecified fixed date, rather than issuing them as soon as they became available and issuing karyotype results alone, or subsequent to issuing results from a rapid molecular test for the most common chromosomal abnormalities.

MAIN OUTCOME MEASURES

Average anxiety during the waiting period, calculated using daily scores from the short version of the Spielberger State-Trait Anxiety Inventory (STAI). Recalled anxiety, measured 1 month after receiving karyotype results, using a rating scale. Anxiety at the 1-month follow-up, measured using the short-form STAI.

RESULTS

There was no evidence that giving out karyotype results on a fixed or on a variable date altered maternal anxiety during the waiting period. However, the analysis only had sufficient power to detect a moderate to large effect. Issuing early results from a partial, but rapid, test reduced maternal anxiety during the waiting period, compared with receiving only the full karyotype results. This was a moderate to large effect. In addition, group differences in recalled anxiety reflected fairly closely the differences in anxiety women had experienced while waiting for results. One month after receiving normal karyotype results, anxiety was low in all groups, but women who had been given rapid test results were more anxious than those who had not. This was a small to moderate effect.

CONCLUSIONS

Since there are no clear advantages in anxiety terms of issuing karyotype results as soon as they become available, or on a fixed date, women could be given a choice between them. Rapid testing was a beneficial addition to karyotyping, at least in the short term. This does not necessarily imply that early results would be preferred to comprehensive ones if women had to choose between them. There should be further research, including more qualitative studies, into the causes, characteristics and consequences of anxiety associated with prenatal testing. The effects of different testing regimes on short- and long-term anxiety, on the preferences of women and on the relationship between anxiety and preference should be investigated. More research is needed on the ways in which information might be used to minimise anxiety in different testing regimes. Further research is also required into the policy implications of incorporating individual preferences for different testing regimes into prenatal testing programmes.

Is exocrine pancreatic insufficiency in adult coeliac disease a cause of persisting symptoms?

BACKGROUND

Patients with coeliac disease may have diarrhoea despite being on a gluten-free diet.

AIM

To assess whether exocrine pancreatic insufficiency causes persisting symptoms compared with controls, we determined whether pancreatic enzyme supplementation provided symptomatic benefit in coeliac patients with chronic diarrhoea.

METHODS

Patients (n = 259) were subdivided into four groups: (a) new coeliac disease (n = 57), (b) coeliac disease patients on a gluten-free diet without gastrointestinal symptoms (n = 86), (c) coeliac disease patients on a gluten-free diet with chronic diarrhoea (n = 66) and (d) patients with chronic diarrhoea without coeliac disease (n = 50). Stool frequency and weight, before and after treatment with pancreatic enzyme supplementation were recorded.

RESULTS

The prevalence of a low faecal elastase-1 within the groups was: group (A) six of 57 (11%), group (B) five of 86 (6%), group (C) 20 of 66 (30%) and group (D) two of 50 (4%). Low faecal elastase-1 was more frequent in coeliac disease patients with chronic diarrhoea vs. other subgroups of coeliac disease (P < or = 0.0001) and controls (P < or = 0.0003). In 18 of 20 stool frequency reduced following pancreatic enzyme supplementation from four per day to one (P < or = 0.001). No weight increase (P = 0.3) was observed.

CONCLUSIONS

Low faecal elastase is common in patients with coeliac disease and chronic diarrhoea, suggesting exocrine pancreatic insufficiency. In this group of patients, pancreatic enzyme supplementation may provide symptomatic benefit.

Requirement for Akt-mediated survival in cell transformation by the dbl oncogene

The dbl oncogene product is the founding member of a large family of oncogenic proteins that function by activating the small GTP-binding proteins Cdc42, Rac and Rho. Through its substrate GTPases, Dbl transduces proliferative signals from cell-surface receptors to diverse cellular effectors and signaling pathways. The mechanisms by which these multiple signals are integrated, as well as their relative contribution to Dbl-induced cell transformation, are presently poorly understood. We investigated the role of the survival regulators PI3-kinase and Akt in Dbl-induced cell transformation. We found that Dbl induced the phosphorylation of Akt on threonine 308, through the GTPases Rac and Cdc42 and in a PI3-kinase dependent manner. Pharmacological or biochemical interference with this pathway lead to a marked, dose-dependent inhibition of the focus formation activity exhibited by Dbl-expressing cells. Dbl expression stimulated the phosphorylation of the anti-apoptotic Akt substrate Bad, and caused a marked decrease in basal levels of apoptosis. Finally, we found that activated Cdc42 existed in cells in complex with phosphoionositide-dependent kinase-1 (PDK1), the downstream mediator of PI3-kinase action. The data indicate that Dbl signaling stimulate the formation of a novel survival complex, through which anti-apoptotic signals are generated and propagated.

The α‐Tocopherol Transfer Protein

Almost a century ago, plant extracts were documented to be critical for the fertility of rodents. This activity was later ascribed to vitamin E, a term comprising a number of structurally related plant lipids that function as fat soluble antioxidants. The alpha-tocopherol transfer protein (TTP) is a critical regulator of vitamin E status that stimulates the movement of vitamin E between membrane vesicles in vitro and facilitates the secretion of tocopherol from hepatocytes. Heritable mutations in the ttpA gene cause ataxia with vitamin E deficiency (AVED), an autosomal recessive disorder characterized by low plasma vitamin E levels and progressive neurodegeneration. This chapter summarizes recent advances in our understanding of the molecular and physiological aspects of TTP activity.

Thoracic ventral dural defect: Idiopathic spinal cord herniation

Thoracic ventral dural defect, and resultant idiopathic spinal cord herniation, is a rare but increasingly recognized cause of a chronic progressive thoracic myelopathy, particularly in middle-aged women. A neurosurgically confirmed case is presented, together with a review of the pathogenesis, clinical presentation, imaging features, treatment options and progress of this entity post-treatment.

A scale for rating the quality of psychological trials for pain

This paper reports the development of a scale for assessing the quality of reports of randomised controlled trials for psychological treatments. The Delphi method was used in which a panel of 15-12 experts generated statements relating to treatment and design components of trials. After three rounds, statements with high consensus agreement were reviewed by a second expert panel and rewritten as a scale. Evidence to support the reliability and validity of the scale is reported. Three expert and five novice raters assessed sets of 31 and 25 published trials to establish scale reliability (ICC ranges from 0.91 to 0.41 for experts and novices, respectively) and item reliability (Kappa and inter-rater agreement). The total scale score discriminated between trials globally judged as good and poor by experts, and trial quality was shown to be a function of year of publication. Uses for the scale are suggested.

Structure-function relationship in the tocopherol transfer protein

The role of specific amino acid residues in mediating the biochemical functions of tocopherol transfer protein (TTP) was investigated using site-directed mutagenesis and functional assays. These findings further current understanding of TTP mechanism of action and its role in human health.

Self-administered subcutaneous fluid infusion at home in the management of fluid depletion and hypomagnesaemia in gastro-intestinal disease

BACKGROUND AND AIMS

In short bowel fistula and some other gastrointestinal (GI) diseases, salt, water and magnesium (Mg) balance may continue negative despite oral treatment, even in patients with adequate nutritional status. This study describes the use of self-administered subcutaneous fluid infusions (HSCF) to treat this problem.

PATIENTS & METHODS

HSCF was administered to patients with GI failure and adequate macro-nutrient status (BMI) when GI salt, water and magnesium balance continued negative despite optimal diet, drug and supplemental treatment. Mg depletion was confirmed using the Mg load test. Patients were taught to self-administer 0.5-1.0 l 0.9% saline +/-0.5 l 5% dextrose +/-2-4 mmol MgSO4 subcutaneously by gravity drip during 6-12 h overnight, 3-7 days/week. Water and Na balance were assessed (weight, serum creatinine, urea, Na) at baseline and at 1 and 3 months of treatment, but also monitored carefully during the first few days of treatment. Serum Mg was measured at baseline and at 2 and 4 weeks.

RESULTS

In 10 patients (mean age 65.3+/-13.5 years) Na and water balance was rapidly restored. At baseline, 1 and 3 months, serum biochemical results were: Eight patients received 8-28 mmol MgSO4/week in the infused fluid. Serum Mg [0.7-1.0 mmol] at baseline, 2 and 4 weeks was 0.49+/-0.06, 0.79+/-0.18, 0.83+/-0.10 mmol/l (P=0.002). Tolerance was good; transient oedema developed in 2 patients, resolved by reducing infusion dose. No patient developed hypokalaemia.

CONCLUSIONS

Subcutaneous self-administered fluid infusion at home (HSCF) is an easily managed, safe and effective method of restoring and maintaining water, salt and Mg balance in patients with large GI fluid losses but adequate macronutrient status, particularly in the frail or elderly in whom home parenteral nutrition may be difficult.

Possible selves in chronic pain: self-pain enmeshment, adjustment and acceptance

The aim of this study was to test whether enmeshment of self and pain predicted adjustment (depression and acceptance) in a chronic pain population. 89 chronic pain patients completed standardized self-report measures of depression and acceptance and generated characteristics describing their current actual self, hoped-for self and feared-for self, and made judgments about the degree to which their future possible selves (hoped-for and feared-for) were dependent on the absence or presence of pain, i.e. enmeshed with pain. Hierarchical multiple regression analyses showed that after accounting for the influence of demographics (age, gender), pain characteristics and the degree of role interference attributable to pain, the proportion of hoped-for self characteristics that could be achieved even with the presence of pain predicted the magnitude of depression and acceptance scores. The findings are discussed with reference to the enmeshment hypothesis and theories of self-discrepancy, self-regulation and hopelessness.

Psychological treatments for irritable bowel syndrome: a systematic review and meta-analysis

This study conducted a systematic review to assess the quality of existing literature on psychological treatments for irritable bowel syndrome and to quantify the evidence for their efficacy. Three independent reviewers (2 from England, 1 from the United States) coded the quality of 32 studies, 17 of which provided data suitable for meta-analysis. Meta-analysis of efficacy data (50% reduction of symptoms) gave an odds ratio of 12 (95% confidence interval = 5.56-25.96) and a number needed to treat of 2. Psychological treatments are, as a class of interventions, effective in reducing symptoms compared with a pooled group of control conditions. Questions regarding the relative superiority of specific psychological treatments and influence of active versus nonspecific treatment effects remain unanswered.

The dl1520 virus is found preferentially in tumor tissue after direct intratumoral injection in oral carcinoma

PURPOSE

dl1520 (also known as Onyx-015) is an E1B-deleted adenovirus designed to selectively lyse p53-deficient cancer cells. Clinical trials involving patients with recurrent squamous cell carcinoma of the head and neck have shown clinical efficacy, but no direct evidence as to the tumor or p53 selectivity of the virus was demonstrated. We wanted to determine whether dl1520 is selective for survival and replication within tumor tissue after direct injection and whether this is determined by p53 status of the tissues. We also wanted to ascertain whether the virus has any macroscopic effect on normal tissue.

EXPERIMENTAL DESIGN

An open-label Phase II trial was devised in which a fixed dose of the virus was administered to 15 patients via a direct intertumoral injection before surgery for untreated oral squamous cell carcinoma. The agent was also delivered into an area of adjacent normal buccal mucosa. Specimens of the excised tumor and of biopsies of the injected normal tissue were assessed for viral presence and p53 status.

RESULTS

We demonstrated that the virus replicates selectively in tumor as opposed to normal tissue after this direct injection. It was not possible to determine whether this selectivity was p53 related. It was found that dl1520 triggers an early rise in apoptosis levels in injected normal tissues. No adverse effects of viral injection were noted.

CONCLUSIONS

This is the first report of injection of dl1520 into previously untreated squamous cell cancer. The data support the concept that dl1520 is replication deficient in normal, compared with cancerous, tissues and has potential as a selective anticancer agent against tumor tissues.

Cognitive-Behavioral Treatments for Chronic Pain

Since the introduction of behavioral medicine in the early 70s, cognitive-behavioral treatment interventions for chronic pain have expanded considerably. It is now well established that these interventions are effective in reducing the enormous suffering that patients with chronic pain have to bear. In addition, these interventions have potential economic benefits in that they appear to be cost-effective as well. Despite these achievements, there is still room for improvement. First, there is a substantial proportion of patients who do not appear to benefit from treatment interventions available. Second, although the effect sizes of most cognitive-behavioral treatments for chronic pain are comparable to those in psychopathology, they are quite modest. Third, there is little evidence for differential outcomes for different treatment methods. Fourth, there still is relatively little known about the specific biobehavioral mechanisms that lead to chronic pain and pain disability. One direction is to better match treatment programs to patients' characteristics. This can be done according to an "Aptitude X Treatment Interaction" framework, or from the perspective of the Moderator-Mediator distinction. In this introduction to the special series on what works for whom in cognitive-behavioral treatments for chronic pain, we review existing knowledge concerning both moderating and mediating variables in cognitive-behavioral treatments for chronic pain. We further argue in favor of theory-driven research as the only way to define specific a priori hypotheses about which patient-treatment interactions to expect. We also argue that replicated single-participant studies, with appropriate statistics, are likely to enhance new developments in this clinical research area.

Reassurance and the anxious cancer patient

Many cancer patients are anxious even when disease is in remission. Anxiety about health, ‘health anxiety’, has distinct features, notably seeking medical reassurance about symptoms. Doctors may then communicate that these symptoms are not due to serious illness, a process known as ‘reassurance’. However, reassurance may inadvertently perpetuate some patients' anxiety. We aimed to observe the relation between symptoms, anxiety and reassurance in consultations with cancer patients. A total of 95 outpatients, with breast or testicular cancers in remission, completed questionnaires measuring health anxiety at study entry, then general anxiety – before a consultation, immediately afterwards, 1 week later, and before their next consultation. We examined symptoms reported and reassurance by oncologists from audio recordings of consultations, and the outcome of subjects' anxiety. The results showed that substantial health anxiety was reported by one-third of the patients. Patients with higher levels of health anxiety reported more symptoms during consultations. Reassurance was ubiquitous, but not followed by an enduring improvement in anxiety. Certain forms of reassurance predicted increased anxiety over time, particularly for subjects who were most anxious. In conclusion, health anxiety can be a problem after cancer. Reassurance may not reduce patients' anxiety. Some reassurance was counterproductive for the most anxious patients. Oncologists may need to use reassurance as a procedure, balancing risk, and benefits, and patient selection and to manage cancer patients in remission.

Developing a treatment manual for attention management in chronic pain

This article reports the development of a protocol for the therapeutic application of "attention control" for chronic pain. Attention control is the limitation of the impact of pain by switching or retunning attention. An expert systems approach was used to develop the protocol. In the first stage an extensive literature search retrieved published and unpublished accounts of attention control strategies and a draft treatment manual was prepared. In the second stage 6 experts were recruited and they independently read and reviewed the draft manual. They were interviewed using a semi-structured protocol to elicit their views on the draft manual. The manual was then revised to accommodate the information and expertise. In addition to providing expert opinion on the manual the experts also raised issues about the process of change in psychological treatment for chronic pain. These issues were organized into a process model of change in chronic pain.

A randomised trial of photographic reinforcement during postoperative counselling after diagnostic laparoscopy for pelvic pain

OBJECTIVE

To measure the effect of seeing a photograph of the pelvic findings at laparoscopy.

SETTING

Two university teaching hospitals.

METHOD

A randomised-controlled trial.

SUBJECTS

Two hundred thirty-three women undergoing diagnostic laparoscopy for the investigation of chronic pelvic pain.

INTERVENTIONS

At operation a Polaroid print was taken of the pelvis. If this was of satisfactory quality, the patient was randomly allocated to either see, or not see, the print during the postoperative consultation.

MAIN OUTCOMES

Pain severity and pain belief scores at 3 and 6 months.

ANALYSIS

By intention to treat.

RESULTS

Postoperative consultations with photographs did not improve immediate understanding and satisfaction with the consultation. In addition, compared to controls, both patients and doctors did not perceive particular benefit for communication from the photograph. There was a consistent trend to more pain in the photographic reinforcement group and more negative pain beliefs. At 3 months, the average within person differences showed some benefit in visual analogue pain scores, McGill affect scores, 'permanence' and 'self-blame' scores. These benefits were not statistically significant. At 6 months, there was a consistent pattern of benefit from pain severity and pain beliefs, again these benefits were not statistically significant.

CONCLUSION

No clear benefits result from showing patients photographs of their pelvis.

The role of neurotransmission and the Chopper domain in p75 neurotrophin receptor death signaling

The role of p75 neurotrophin receptor (p75NTR) in mediating cell death is now well characterized, however, it is only recently that details of the death signaling pathway have become clearer. This review focuses on the importance of the juxtamembrane Chopper domain region of p75NTR in this process. Evidence supporting the involvement of K+ efflux, the apoptosome (caspase-9, apoptosis activating factor-1, APAF-1, and Bcl-xL), caspase-3, c-jun kinase, and p53 in the p75NTR cell death pathway is discussed and regulatory roles for the p75NTR ectodomain and death domain are proposed. The role of synaptic activity is also discussed, in particular the importance of neutrotransmitter-activated K+ channels acting as the gatekeepers of cell survival decisions during development and in neurodegenerative conditions.

Use of multidetector-row CT colonography for detection of colorectal neoplasia in patients referred via the Department of Health "2-Week-wait" initiative

AIM

Patients referred under the Department of Health 2-week wait initiative with symptoms of colorectal cancer frequently undergo whole-colon examination. We investigated the use of computed tomography (CT) colonography as an alternative to colonoscopy in this scenario.

MATERIALS AND METHODS

Fifty-four consecutive patients, referred via the 2-week wait initiative and scheduled for colonoscopy, consented to undergo multidetector CT colonography immediately before endoscopy. The site and morphology of any polyp or cancer detected by CT was noted and comparison made with subsequent colonoscopy.

RESULTS

Colonoscopy detected polyps or cancer in 29 patients (53.7%). CT colonography prospectively detected 18 of 41 (44%) polyps of 1-5 mm, three of four (75%) polyps of 6-9 mm, four of four (100%) polyps 10 mm or larger, and five of six (83%) cancers. The missed cancer occurred early in the series and was a perceptive error. The overall sensitivity, specificity, positive predictive value and negative predictive value of CT colonography for cancer and polyps 10 mm or greater on a per patient basis were 90, 100, 100 and 98%, respectively. CT detected one renal cancer and one colonic cancer, initially missed due to incomplete colonoscopy.

CONCLUSION

CT colonography is a robust technique for investigation of symptomatic patients. The learning curve must be overcome for optimal performance.

Optimizing bowel preparation for multidetector row CT colonography: effect of Citramag and Picolax

AIM

To compare the adequacy and acceptability of Picolax and Citramag bowel cleansing agents for CT colonography.

MATERIALS AND METHODS

Multidetector row CT colonography was performed in 124 subjects; 43 had been prepared with Picolax and 81 with Citramag. Datasets were assessed for retained fluid and solid residue, and overall adequacy of segmental visualization. Preparation acceptability was also assessed.

RESULTS

There was significantly less retained fluid with Picolax. The odds of being in the next higher category for retained fluid when using Picolax were 0.33 (CI: 0.22-0.50, p<0.0001) when compared with Citramag, for all segments combined. However there was significantly more retained solid residue with Picolax. The odds of being in the next higher category for retained residue when using Picolax were 2.44 (CI: 1.41-4.24, p=0.002) when compared with Citramag, for all segments combined. There was no significant difference with respect to overall segmental visualization: the odds of a segment being adequately visualized when using Picolax were 1.52 (CI: 0.88-2.65, p=0.14) when compared with Citramag. There was no significant difference with respect to acceptability.

CONCLUSION

Picolax results in a significantly drier colon than Citramag and associated with more retained residue. We found Picolax the more suitable preparation for CT colonography.

Role loss and emotional adjustment in chronic pain

Chronic pain interrupts behaviour, interferes with functioning, and may affect a person's identity: their sense of self. We tested whether loss of role and personal attributes and current and past self-concept differentiation, predicted adjustment as indexed by measures of depression. Chronic pain patients (n=80) completed measures of pain (MPQ), disability (PDI), depression and anxiety (BDI, HADS). Measures of role and attribute loss and self-concept differentiation were derived from a Role-Attribute Test in which participants identified four social roles in four domains (friendship, occupation, leisure, family) and nominated two personal attributes in each role prior to pain onset and current. Participants reported mean losses of 3.38 roles, and 6.97 attributes. Greater losses were observed in friendship, occupation and leisure domains compared with the family domain. Multiple regression analyses revealed that after controlling for demographic and clinical differences, role and attribute loss predicted depression scores. There was no evidence that depression was associated with past self-concept differentiation. The results are discussed with reference to the methodology used and the relevance of self-identity to understand adjustment to chronic pain.

Psychological therapies for the management of chronic and recurrent pain in children and adolescents

BACKGROUND

An increasing number of children suffer with pain that lasts for six months or longer. Traditional treatment for such pain has been pharmacological and/or physical. Increasingly, following developments in the field of adult chronic pain management, psychological therapies are being employed to treat children with chronic or recurrent pain.

OBJECTIVES

To assess the effectiveness of psychological therapies in treating chronic or recurrent pain in children and adolescents, and to test the null hypothesis that psychological therapies are no more effective than placebo, waiting list control or standard medical care.

SEARCH STRATEGY

Electronic searches of the Cochrane Register of Randomised Controlled Trials, MEDLINE (1966-1999), Social Sciences Citation Index (1981-1999) and PsycLit (1974-1999) were made. RCTs were also sought in references of all identified studies, meta-analyses and reviews, and first authors and experts within the field were contacted. Date of the most recent search: December 1999.

SELECTION CRITERIA

RCTs with at least five participants in each study arm which compared psychological therapies with placebo, waiting list or standard medical care for children or adolescents with chronic or recurrent pain were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Data were inspected for heterogeneity. For homogeneous dichotomous data the odds ratio with 95% confidence interval were calculated on an intention to treat basis.

MAIN RESULTS

Thirty papers were recovered, representing 28 RCTs. Of these, 18 were analysable and included a total of 808 patients, 438 of whom entered treatment conditions. Fifteen were trials of chronic or recurrent headache; two for recurrent abdominal pain; and one for sickle cell pain. Only pain experience data from 13 trials were meta-analysable. Two meta-analyses were conducted. The first analysis of single treatments versus controls gave a pooled odds ratio of 8.83 (95% CI 4.33 to 18.03; z=5.98, P < 0.00001, df = 12 ). The second analysis (combined treatment versus control) produced a similar estimate: pooled odds ratio = 8.64 ( 95% CI = 4.13 to 18.07; z-5.73, P < 0.00001, df = 9 ). Both analyses indicate that psychological treatment is effective when compared with a pooled group of control conditions. From the pooled data set the NNT was 2.32 (95%CI 1.96 to 2.88).

REVIEWER'S CONCLUSIONS

There is very good evidence that psychological treatments, principally relaxation and cognitive behavioural therapy, are effective in reducing the severity and frequency of chronic headache in children and adolescents. There is at present no evidence for the effectiveness of psychological therapies in attenuating pain in conditions other than headache, and little evidence for the effectiveness of psychological therapies in improving non-pain outcomes.

Systematic review of randomised controlled trials of psychological therapy for chronic pain in children and adolescents, with a subset meta-analysis of pain relief

A systematic review and subset meta-analysis of published randomised controlled trials of psychological therapies for children and adolescents with chronic pain is reported. A search of four computerised abstracting services recovered 123 papers from which 28 potential trials were identified. Eighteen met the criteria for inclusion in the review. The majority of these papers reported brief behavioural and cognitive behavioural interventions for children with headache and many were conducted in community (i.e. school) settings. Meta-analysis was applicable for 12 headache trials and one trial of recurrent abdominal pain using the Pain Index. The odds-ratio for a 50% reduction in pain was 9.62 and the number needed to treat was 2.32, indicating that the psychological treatments examined are effective in reducing the pain of headache. The quality of the 18 trials retrieved is narratively reviewed and suggestions for the development of trials in this field are made.

A confirmatory factor analysis of the Beck Depression Inventory in chronic pain

The Beck Depression Inventory (BDI) is widely used to assess depression in chronic pain despite doubts about its structure and therefore its interpretation. This study used a large sample of 1947 patients entering chronic pain management to establish the structure of the BDI. The sample was randomly divided to conduct separate exploratory (EFA) and confirmatory factor analyses (CFA). EFA produced many satisfactory two-factor solutions. The series of CFA generated showed reasonable fit for ten of those solutions. All included a first factor identified as negative view of the self (items: failure, guilt, self-blame, self-dislike, punishment and body image change), and a second factor identified as somatic and physical function (items: work difficulty, loss of appetite, loss of libido, fatigability, insomnia and somatic preoccupation). The remaining items (suicidal ideation, social withdrawal, dissatisfaction, sadness, pessimism, crying, indecisiveness, weight loss, irritability) loaded infrequently or not at all in the CFA solutions. They did not form a coherent factor but comprised items associated with negative affect. When compared with published data from samples of depressed patients drawn from mental health settings the mean item scores for items reflecting the negative view of the self were consistently statistically lower that that observed in samples; there was no consistent difference between the samples on the items reflecting somatic and physical function; but the mean scores for the remaining affect items were significantly greater in the mental health samples. This version of depression is strikingly different from the psychiatric model of depression (e.g. DSM-IV or ICD-10), which is primarily defined by affective disturbance, and secondarily supported by cognitive and somatic symptoms. The finding is consistent with a reconsideration of what constitutes depression in the presence of chronic pain. It also has important clinical implications: it may provide a way to distinguish depressed patients with typical cognitive biases, who require specific treatment for depression alongside pain management.

Oncostatin M induced alpha1-antitrypsin (AAT) gene expression in Hep G2 cells is mediated by a 3' enhancer

alpha(1)-Antitrypsin (AAT) is the major serine proteinase inhibitor (SERPIN A1) in human plasma. Its target proteinase is neutrophil elastase and its main physiological function is protection of the lower respiratory tract from the destructive effects of neutrophil elastase during an inflammatory response. Circulating levels of AAT rise 2-3-fold during inflammation and the liver produces most of this increase. The cytokines oncostatin M (OSM) and interleukin-6 have been shown to be mainly responsible for this effect, which is mediated via the interaction of cytokine-inducible transcription factors with regulatory elements within the gene. In the present study, we report for the first time that OSM stimulation of hepatocyte AAT occurs via an interaction between the hepatocyte promoter and an OSM-responsive element at the 3'-end of the AAT gene. This effect is mediated by the transcription factor signal transducer and activator of transcription 3 ('STAT 3') binding to an OSM-responsive element (sequence TTCTCTTAA), and this site is distinct from, but close to, a previously reported interleukin-6-responsive element.

Gene regulation of the serine proteinase inhibitors alpha1-antitrypsin and alpha1-antichymotrypsin

The serine proteinase inhibitors (serpins) are a superfamily of proteins with a diverse set of functions, including the control of blood coagulation, complement activation, programmed cell death and development. The most abundant serpins in human plasma are alpha(1)-antitrypsin (AAT) and alpha(1)-antichymotrypsin (ACT). During inflammation, circulating levels can increase by up to 3-fold for the former and by 4-5-fold for the latter. The major site for increased synthesis is the liver. Other tissues, such as the lung, are also capable of synthesizing AAT and ACT, and expression can be increased by up to 100-fold by cytokines. There is a tissue-specific promoter for the liver, and alternative promoters for other tissues that express AAT. Basal AAT expression is regulated by the synergistic action of the tissue-specific transcription factors hepatocyte nuclear factors 1alpha and 4. An enhancer positioned approx. 1.2 kb from the end of the last exon in the 3' flanking sequence modulates cytokine-induced expression by interleukin-6 and oncostatin M. Microcell hybrid transfection studies have shown that a sequence containing 15 kb of 5' flanking sequence is sufficient to allow stable expression of AAT in a position-independent manner. There is probably a single promoter for ACT. Oncostatin M-inducible elements have been identified in the 5' flanking sequence approx. 100 bp upstream from the transcription initiation site, and a further interleukin-1-responsive enhancer has been identified approx. 13 kb upstream. The pathways for a humoral response are being mapped at high resolution.

Cognitive-processing bias in chronic pain: a review and integration

Do patients with chronic pain selectively process pain- and illness-related stimuli? The evidence with regard to attention, interpretation, and recall biases is critically reviewed. A model is proposed to account for the findings in which it is suggested that biases in information processing in chronic pain are the result of overlap between 3 schemas: pain, illness, and self. With frequent repeated or continued experience of pain, the pain schema becomes enmeshed with illness and self-schemas. The extent of the enmeshment and the salient content of the schema determine the bias. A fundamental assumption is that all patients with pain selectively process sensory-intensity information. A clinical implication of the results is that processing biases that extend beyond this healthy and adaptive process to enmesh the self-schema with pain and illness schemas could maintain and exacerbate distress and illness behavior in patients with chronic pain.

Intravenous safety and pharmacokinetics of a novel dimerizer drug, AP1903, in healthy volunteers

AP1903 is a novel gene-targeted drug that is being developed for use in drug-regulated cell therapies. An intravenous, single-blind, placebo- and saline-controlled, ascending-dose study was performed to evaluate the safety, tolerability, and pharmacokinetics of AP1903. Twenty-eight normal healthy male volunteers were randomized into five dosage groups of AP1903 (0.01, 0.05, 0.1, 0.5, and 1 mg/kg). Within each group, 4 volunteers received a single dose of AP1903, 1 volunteer received an equal volume of placebo, and 1 received an equal volume of normal saline. The only exception was in the 0.5 mg/kg group, in which 4 volunteers were dosed: 3 received AP1903 and 1 received normal saline. All dosages were administered as intravenous infusions over 2 hours. Clinical safety parameters were monitored, and serial blood and urine samples were collected for analysis of AP1903. No drug-related adverse events were observed at any of the dose levels with the possible exception of facial flushing in 1 volunteer at the 1.0 mg/kg dose level. AP1903 plasma levels were directly proportional to the administered dose, with mean Cmax values ranging from approximately 10 to 1,275 ng/mL over the 0.01 to 1.0 mg/kg dose range. Following the infusion period, blood concentrations revealed a rapid distribution phase, with plasma levels being reduced to approximately 18%, 7%, and 1% of the maximal concentration at 0.5, 2, and 10 hours postdose, respectively. AP1903 was shown to be safe and well tolerated at all dose levels and demonstrated a favorable pharmacokinetic profile at doses well above the anticipated therapeutic dose.

The Development of a Method to Assess Patients' Cognitive Representations of Epilepsy

Objective. The study describes the development of a new method for assessing cognitive representations of epilepsy.Methods. The study was a cross-sectional design contrasting the cognitive representations of three groups of epilepsy patients, varying in recency of onset (acute vs chronic) and the location of medical management (hospital vs community). A total of 94 patients were studied: 21 recent onset, 47 patients with chronic epilepsy attending the clinic and 26 patients with chronic epilepsy seen by general practitioners. An interview that combined open questions and structured questionnaire items was devised to assess six illness representation components; identity, beliefs about symptoms; causal beliefs; timeline, beliefs about temporal course; consequences, beliefs about the implications of epilepsy; control beliefs; and self-illness relationship, or the impact of epilepsy on patients' self perceptions.Results. The scales formed by the questionnaire items had satisfactory internal consistency. Further, the scales demonstrated logical interrelationships, and significant differences were found between the scales on group difference tests.Conclusions. Overall, the data provide support for the approach of administering quantitative illness representation scales within a brief structured interview format. The measure provides a way to elicit the health beliefs that determine patients' psychosocial reactions to epilepsy. Such insights are important in the development of effective psychological interventions.

Expression of individual lamins in basal cell carcinomas of the skin

In this study we used a unique collection of type specific anti-lamin antibodies to study lamin expression patterns in normal human skin and in skin derived from patients with basal cell carcinomas (BCCs). Lamin expression in serial sections from frozen tissue samples was investigated by single and double indirect immunofluorescence. In normal skin, lamin A was expressed in dermal fibroblasts and in suprabasal epithelial cells but was absent from all basal epithelial cells. Lamin C was expressed in dermal fibroblasts, suprabasal epithelial cells and a majority of basal epithelial cells. However, lamin C was not expressed in quiescent basal epithelial cells. Lamin B1 was expressed in all epithelial cells but was not expressed in dermal fibroblasts. Finally, lamin B2 was expressed in all epithelial cells but was not expressed in dermal fibroblasts. Finally, lamin B2 was expressed in all cell types in normal skin. Lamin expression was also investigated in a collection of 16 BCCs taken from a variety of body sites. Based upon patterns of lamin expression the BCCs were classified into four groups: A-negative (10/16 tumours), C-negative (5/16 tumours), A/C-negative (1/16 tumours) and A/B2-negative (1/16 tumours). Lamin expression was also compared to cell proliferation index by staining serial sections with the proliferation marker Ki67. 9/10 of the lamin A negative tumours were highly proliferative, whereas 4/5 of the lamin C negative tumours were slow growing. Thus as a general rule absence of lamin A was correlated with rapid growth within the tumour, while absence of lamin C was correlated with slow growth within the tumour. Our data supports the hypothesis that lamin A has a negative influence on cell proliferation and its down regulation may be a requisite of tumour progression.

Hair removal using the long-pulsed ruby laser in children

OBJECTIVE

The purpose of this study was to assess the efficacy of laser assisted hair removal in children aged 16 and under using the long pulsed ruby laser.

BACKGROUND DATA

Unwanted hair in the pediatric population can be due to congenital hairy nevi and hypertrichosis. Methods of effecting hair removal include shaving, electrolysis, and laser depilation. The long-pulsed ruby laser is an established treatment modality in adults, but its use specifically in children has not been investigated.

METHODS

Patients aged 16 or under undergoing treatment with the ruby laser for unwanted hair were assessed. Hair counts were determined before and after treatment and an assessment of overall satisfaction was made using a parental questionnaire.

RESULTS

Treatment was regarded as successful in 25 out of 28 cases where there was a clear reduction in hair growth at the site treated with an average fall in hair count of 63% at 6 months follow up. There was no scarring or hyperpigmentation in this group and no serious complications. Total suppression of hair growth was not permanent but usually lasted between 3 and 6 months. Few problems were encountered from using the technique specifically in children, and pain was well controlled in most cases.

CONCLUSIONS

We would recommend the long-pulsed ruby laser as a useful form of hair removal in children that is quick, simple and well tolerated. At present, the technique leads to hair loss that is temporary but most patients and their parents feel the treatment gives worthwhile benefits.

Frequent attenders' consulting patterns with general practitioners

BACKGROUND

Despite the growing literature on frequent attendance, little is known about the consulting patterns of frequent attenders with different doctors. To develop appropriate intervention strategies and to improve the clinical care of frequent attenders, a full understanding of these consulting patterns is essential.

AIMS

This paper has three aims: to determine whether frequent attenders consult more with some doctors than others; to determine how many different doctors frequent attenders consult with; and to determine whether frequent attenders exhibit greater continuity of care than non-frequent attenders.

METHOD

Analysis of a validated dataset of 592,028 consultations made by 61,055 patients from four practices over 41 months. Comparisons between the consulting patterns of the frequent attenders, defined as the most frequently consulting 3% of the population by practice, with non-frequent attenders and the overall practice populations.

RESULTS

There was considerable variation in the numbers and proportions of consultations with frequent attenders between individual doctors. Most of the frequent attenders consulted with most or all of the doctors within practices over the timeframe. Frequent attenders exhibited more continuity of care than non-frequent attenders.

CONCLUSION

The reasons why some doctors have more consultations with frequent attenders is unclear. Some doctors may actively encourage frequent attendance. While many frequent attenders have clear allegiances to one doctor, many also consult widely with a large number of doctors. The consequences of such behaviour are unknown. These findings have important implications in the development of appropriate interventions for reducing problematic frequent attendance.

'I always seem to be there'--a qualitative study of frequent attenders

BACKGROUND

Much is still unknown about the consultation behaviour of frequent attenders, including why they consult as often as they do and why they consult in the patterns that they do.

AIM

To determine why frequent attenders to general practice consult in the patterns that they do.

METHOD

A qualitative study based on semi-structured interviews. Twenty-eight frequent attenders were purposively sampled from three practices; 13 exhibited a 'burst and gap' pattern of attendance and 15 exhibited a 'regular' pattern of attendance.

RESULTS

A two-part model is proposed. The first part encompasses each individual decision to consult and is based around eight questions that may be asked as part of the decision-making process (these concern the perception of the general practitioner's [GP's] role, past experience of symptoms and consulting, comparison with others' consulting, relationship with the GP, balancing fears, lay consulting, individual reasons, and whether it was a symptom that they would not normally consult for). The second part determines the pattern of consulting and has four major themes: predominantly medical reasons for attending, experience of what happens during the consultation, accessibility of the GP, and periods of not consulting. Two further themes are proposed: 'multiplicity', whereby the reasons for consulting lead to further consulting for related and unrelated problems, and 'passivity', whereby consulting seems to be out of control.

CONCLUSIONS

The reasons underpinning each individual decision to consult were complex. The control that GPs were perceived to have over the pattern of consulting, for example concerning prescribing, review visits, and in addressing further help-seeking behaviour, may provide more possibilities for developing intervention strategies than targeting frequent attenders themselves. An understanding of the processes behind the consulting behaviour of frequent attenders may lead to more functional consultations and better clinical care as a result.

Availability bias in clinical formulation: the first idea that comes to mind

This study tested whether initial client formulations are based simply on the ideas that come most readily to mind, irrespective of the validity of these ideas. This phenomenon is known in decision theory literature as availability bias. The study tested the influence of two possible sources of availability bias in formulation: (a) theoretical orientation; and (b) a suggestion in a referral letter. Forty-four qualified and 20 trainee clinical psychologists participated in a procedure designed to reflect clinical practice. Clinical materials consisted of a fictional referral letter describing a client with adult attachment difficulties and post-traumatic stress disorder. Participants recalled information from the referral letter, described their areas of further interest and initial hypotheses. Results showed no evidence of an availability bias in clinical formulation as a result of theoretical orientation. Theoretical orientation towards attachment did appear to influence the availability of attachment ideas and predicted clinicians taking a stronger attachment focus when discussing the client. In particular, a self-report measure of theoretical orientation demonstrated high predictive validity. However, orientation towards attachment did not predict bias in the sense of selective recall of attachment information or neglect of alternative psychological frameworks. The study provided an inadequate test of availability bias as a result of a suggestion in the referral letter, possibly due to a ceiling effect, and no conclusions can be drawn as to clinical materials as a potential source of availability bias. The discussion addresses implications for further research and for a scientist-practitioner approach to individual case formulation.

Specificity of reference patterns in depressive thinking: agency and object roles in self-representation

This study investigated A. T. Beck's (1970) negative cognitive triad as a model of depressive thinking. A mixed clinical sample (N = 126) completed the Sentence Completion Test for Depression (SCD) and self-report measures of depression and anxiety. Two reference patterns were tested: agency roles, people who are the source of thoughts, feelings, and actions (self and others); and object roles, points of reference location (self, other, world, future, and past). Cognitive effects were highly specific to depression. With self in agent role, significant correlations were observed with negative self, world, and future references but not with other people or the past. With others in agent role, only negative self references were correlated with depression (e.g., "Some people would not ... put me out if I was on fire"), suggesting an interpersonal extension to the negative cognitive triad.

Assessment of immune response to meningococcal disease: comparison of a whole-blood assay and the serum bactericidal assay

A whole-blood assay (WBA), which assesses the complete bactericidal activity of blood, was compared with the serum bactericidal assay (SBA), which measures antibody and complement mediated cell lysis. Twenty children infected with serogroup B strains and 25 infected with serogroup C strains were studied 8-12 weeks after disease, and 29 healthy children were used as controls. The infecting strain (convalescent children only) and two reference strains, MC58 (B:15:P1.7, 16) and NCTC 8554 (C:NT:P1.5) were used. In children previously infected with a serogroup B strain, bactericidal activity was detected in 95% and 85% to their infecting strain by the WBA (>50% killing) and the SBA (s), respectively. Bactericidal activity to the reference serogroup B and C strain was detected by WBA in 70 and 75% of children, respectively, and the SBA in 45% and 20%. In contrast bactericidal activity was detected to both serogroup C strains in >80% of children previously infected with a serogroup C strain using either assay and in 48% (WBA) and 20% (SBA) to the reference serogroup B strain. Levels of bactericidal activity were detectable in fewer control children. Children convalescing from meningococcal disease develop an immune response to their infecting strain, detectable by both the WBA and SBA, which is independent of age. However, the WBA appears to be a more sensitive measure of bactericidal activity to heterologous strains than the SBA.