Pilot Study on Music in the Waiting Room of Outpatient Pain Clinics

BACKGROUND

This study explores live and recorded music listening in the outpatient pain clinic. There is evidence demonstrating the effectiveness of live and recorded music in a hospital setting but a comparison study of this kind has yet to be conducted.

METHODS

A multimethod survey study design was used. A questionnaire utilizing rating scales was self-administered across two outpatient pain clinic waiting rooms. Patients were included through convenience sampling. In one clinic, a playlist of recorded music curated by two of the authors was provided. In the second clinic, a music therapy student played live music using guitar, flute, and voice. The questionnaire gathered data on music's impact on pain and emotional states, as well as attitudes toward music in the waiting room. Quantitative data was analyzed using descriptive statistics and qualitative data, gathered in the questionnaires open ended question, was analyzed using thematic analysis.

RESULTS

The questionnaire was completed by 200 adult patients. Patients reported lowered levels of anxiety, stress, and pain in both clinics, as well as a shorter waiting time and more caring experience. Patients in the live music clinic reported that music lowered levels of stress, nervousness, agitation, and pain more than in the recorded music clinic.

CONCLUSIONS

Participants in this study identified that music is a useful tool in the pain clinic waiting room. This study contributes to evidence that music should be considered as a complimentary treatment for people living with pain and in the wider hospital setting. Additional research is warranted with a control group, pre- and posttesting, and studies of music in hospitals in a range of cultural contexts.

Psychiatry heal thyself: a lifestyle intervention targeting mental health staff to enhance uptake of lifestyle interventions for people prescribed antipsychotic medication

Introduction

People experiencing severe mental illness (SMI) face a shortened life expectancy of up to 20 years, primarily due to preventable cardiovascular (CV) diseases. Lifestyle interventions are effective in reducing CV risk, yet examples of service-wide interventions are lacking. Staff culture remains a barrier to the successful implementation of lifestyle interventions. The Keeping the Body in Mind (KBIM) program, established by SESLHD (Australia), aims to close the gap in life expectancy through multidisciplinary teams, including clinical nurse consultants, dieticians, exercise physiologists, and peer support workers. Prior to the KBIM rollout, an individualized lifestyle intervention called Keeping Our Staff In Mind (KoSiM) was offered to all district mental health staff.

Objective

KoSiM examined the effectiveness of a staff intervention to improve physical health, confidence, knowledge and attitudes of mental health staff.

Methods

Mental health staffs were invited to participate in an online survey and a 4-week individualized intervention including personalised health screening and lifestyle advice, with a 16-week follow-up. Outcomes assessed included: attitudes, confidence and knowledge regarding metabolic health, weight, waist circumference (WC), blood pressure, sleep, diet, physical activity and exercise capacity.

Results

Of a total of 702 staff, 204 completed the survey (29%). Among those completing the survey, 154 staff (75%) participated in the intervention. A mean decrease in waist circumference of 2 ± 2.7 cm, (P < 0.001) was achieved. Among staffs that were overweight or obese at baseline, 75% achieved a decrease in WC.

Conclusion

Improving staff culture regarding physical health interventions is an important step in integrating lifestyle interventions into routine care.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Abstract P6-16-10: Is pregnancy testing during chemotherapy standardized?

The initiative to improve awareness about the risks of infertility for premenopausal patients receiving chemotherapy has improved significantly over time. While the risks for infertility are high, there is still a small risk of pregnancy during chemotherapy. The incidence of cancer diagnosed during pregnancy is 0.1-0.2%. The incidence of women who become pregnant while on chemotherapy is less clear but does occur. Amenorrhea commonly occurs during chemotherapy but this does not necessarily correlate with lack of ovarian function. Treating a patient with an unidentified pregnancy is an adverse event which must be avoided given the high risk it poses to the fetus, especially during the first trimester. Pregnancy testing prior to the initiation of chemotherapy is recommended by the NCCN and ASCO. However, recommendations on how to monitor for pregnancy after an initial screen are inconsistent and lack standardization. Formal guidelines and policies are needed to prevent and/or identify pregnancies while on chemotherapy.

We surveyed five breast medical oncologists and six infusion nurses at a busy urban breast center to determine their baseline practices in regards to pregnancy counseling and testing. Of physicians and nurses surveyed, 40% (2/5) and 33% (2/6) respectively have diagnosed a pregnancy while on chemotherapy. When surveyed about counseling patients on the risks of pregnancy, 80% of physicians counsel patients prior to initiation of chemotherapy, but one physician and one infusion nurse said they do not counsel patients about the risk of pregnancy at any time but do discuss the risks of infertility. All physicians surveyed check a pregnancy test prior to the initiation of chemotherapy, but 60% check urine and 40% check serum. Thereafter 60% will check a pregnancy test after initial screen if the patient is concerned and 40% will check intermittently during chemotherapy. Of the nurses surveyed, 33% will check a pregnancy test after initial screen if the patient is concerned and 50% check intermittently during treatment. Half of the infusion nurses said they ask patients if they are concerned they may be pregnant intermittently during chemotherapy and 50% answered that they do not ask again after the initial screen. On subsequent screens the choice of urine or serum hCG testing varies and is not standardized.

These survey results demonstrate that both pregnancy counseling and pregnancy screening practices vary widely even within the same institution. A standardized approach is essential to increase awareness of pregnancy risk while on chemotherapy, improve education of this risk to patients, prevent unwanted pregnancies, and identify pregnancies as soon as possible. We have initiated a quality improvement project to check urine pregnancy tests monthly in all premenopausal patients (age &lt;55) receiving chemotherapy for breast cancer. Based on our findings we will institute a protocol at our institution for uniform teaching on the small risk of pregnancy and uniform pregnancy testing while on chemotherapy.

Citation Format: Berger N, Fitzpatrick K, Klein P. Is pregnancy testing during chemotherapy standardized? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-16-10.

Abstract P5-13-19: Addressing non-adherence for breast cancer screening across ethnicity in southern Arizona

Background In Arizona, female breast cancer has the highest incidence rate and the second highest death rate compared to all other cancers. This ongoing single arm intervention study investigates non-adherence with recommended annual mammography or follow-up breast imaging. Data collected for this study is both retrospective, using the university Electronic Health Record (EHR) system (January 1, 2014 to September 30, 2017), and prospective, implementing a questionnaire during the intervention phase. Potential study participants were identified using EHR and categorized by BI-RADS (Breast Imaging-Reporting and Data System) 0 to 5. With IRB approval from University of Arizona, we designed a questionnaire to measure barriers to adherence and we navigate participants to schedule and attend follow-up appointments. This study's overall specific aims are to increase first time mammography screening by 25% among women in Southern Arizona; increase adherence or repeat screening rate by 20% among women lost to follow-up; establish the framework for a community- academic partnership in ethnically diverse areas. Women, age 40 and older who are not compliant with recommended annual mammograms or recommended follow-up screenings after a suspicious finding are eligible to participate in this study. Men and children, as well as women for whom breast imaging is not recommended are excluded from participating in this study. Results Patient's age was summarized by mean ± standard deviation for continuous variables and frequency and the associated percentage for categorical variables. BI-RADS scores were classified into Negative, Benign, Possible Malignancy and Proven Malignancy and compared between ethnic and racial groups using Fisher's exact test. Of 8823 non-compliant woman over nearly 4 years of data, 0.2% are BI-RADS 4 and 5, 2.2% are BI-RADS 3, 96% are BI-RADS 1 and 2, and 0.3% are BI-RADS 0. The mean age is 61.59 years, with 25% reporting as Hispanic, 66% reporting as non-Hispanic women (NHW), and 10% preferring to receive care in Spanish. Initial data shows only .24% with proven malignancies. Further, the data reveals that Hispanics have a slightly higher rate of possible malignancy (.36%) than NHW (.18%); however, NHW show a slightly higher rate of proven malignancy (.27% compared to .18%, respectively). Discussion These data provide valuable information for the direction of this study; in particular, understanding the disparity between Hispanic and NHW malignancies and developing culturally competent interventions and education materials to increase compliance with breast cancer screening recommendations. Further, these data indicate our focus should be on screening compliance for BI-RADS 1 and 2. These data also point to a possible high non-compliance issue. Comparing non-compliance data from other regional clinics will continue to shape this study's direction. The target sample size for this study is 300 participants. We accept a 95% confidence level and a 5% margin of error. Out of 420 recruitment letters mailed, the navigators have reached 152 potential participants by phone and have a 26% study recruitment rate (n=40).

Citation Format: Huff AJ, Gomez J, Calhoun E, Hsu C-H, Chalasani P, Fitzpatrick K, Borders M, Lang L, Prado Y. Addressing non-adherence for breast cancer screening across ethnicity in southern Arizona [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-19.

White matter hyperintensity volume is increased in small vessel stroke subtypes

OBJECTIVE

White matter hyperintensity (WMH) may be a marker of an underlying cerebral microangiopathy. Therefore, we hypothesized that WMH would be most severe in patients with lacunar stroke and intracerebral hemorrhage (ICH), 2 types of stroke in which cerebral small vessel (SV) changes are pathophysiologically relevant.

METHODS

We determined WMH volume (WMHV) in cohorts of prospectively ascertained patients with acute ischemic stroke (AIS) (Massachusetts General Hospital [MGH], n = 628, and the Ischemic Stroke Genetics Study [ISGS], n = 263) and ICH (MGH, n = 122).

RESULTS

Median WMHV was 7.5 cm³ (interquartile range 3.4-14.7 cm³) in the MGH AIS cohort (mean age 65 ± 15 years). MGH patients with larger WMHV were more likely to have lacunar stroke compared with cardioembolic (odds ratio [OR] = 1.87 per SD normally transformed WMHV), large artery (OR = 2.25), undetermined (OR = 1.87), or other (OR = 1.85) stroke subtypes (p < 0.03). These associations were replicated in the ISGS cohort (p = 0.03). In a separate analysis, greater WMHV was seen in ICH compared with lacunar stroke (OR = 1.2, p < 0.02) and in ICH compared with all ischemic stroke subtypes combined (OR = 1.34, p < 0.007).

CONCLUSIONS

Greater WMH burden was associated with SV stroke compared with other ischemic stroke subtypes and, even more strongly, with ICH. These data, from 2 independent samples, support the model that increasing WMHV is a marker of more severe cerebral SV disease and provide further evidence for links between the biology of WMH and SV stroke.

Species differences in the pharmacokinetics and metabolism of reparixin in rat and dog

The pharmacokinetics and metabolism of reparixin (formerly repertaxin), a potent and specific inhibitor of the chemokine CXCL8, were investigated in rats and dogs after intravenous administration of [14C]-reparixin L-lysine salt. Protein binding of reparixin was investigated in vitro in rat, dog, rabbit, cynomolgus monkey and human plasma. Plasma protein binding of reparixin was >99% in the laboratory animals and humans up to 50 microg ml-1, but lower at higher concentrations. Although radioactivity was rapidly distributed into rat tissues, Vss was low (about 0.15 l kg-1) in both rat and dog. Nevertheless, reparixin was more rapidly eliminated in rats (t1/2 approximately 0.5 h) than in dogs (t1/2 approximately 10 h). Systemic exposure in dog was due primarily to parent drug, but metabolites played a more prominent role in rat. Oxidation of the isobutyl side-chain was the major metabolic pathway in rat, whereas hydrolysis of the amide bond predominated in dog. Urinary excretion, which accounted for 80-82% of the radioactive dose, was the major route of elimination in both species, and biotransformation of reparixin was complete before excretion.

Effects of a serotonin 5-HT(4) receptor antagonist SB-207266 on gastrointestinal motor and sensory function in humans

BACKGROUND

Serotonin 5-HT(4) receptors are located on enteric cholinergic neurones and may regulate peristalsis. 5-HT(4) receptors on primary afferent neurones have been postulated to modulate visceral sensation. While 5-HT(4) agonists are used as prokinetic agents, the physiological role of 5-HT(4) receptors in the human gut is unknown.

AIMS

Our aim was to characterise the role of 5-HT(4) receptors in regulating gastrointestinal motor and sensory function in healthy subjects under baseline and stimulated conditions with a 5-HT(4) receptor antagonist.

METHODS

Part A compared the effects of placebo to four doses of a 5-HT(4) receptor antagonist (SB-207266) on the cisapride mediated increase in plasma aldosterone (a 5-HT(4) mediated response) and orocaecal transit in 18 subjects. In part B, 52 healthy subjects received placebo, or 0.05, 0.5, or 5 mg of SB-207266 for 10-12 days; gastric, small bowel, and colonic transit were measured by scintigraphy on days 7-9, and fasting and postprandial colonic motor function, compliance, and sensation during distensions were assessed on day 12.

RESULTS

Part A: 0.5, 5, and 20 mg doses of SB-207266 had significant and quantitatively similar effects, antagonising the cisapride mediated increase in plasma aldosterone and acceleration of orocaecal transit. Part B: SB-207266 tended to delay colonic transit (geometric centre of isotope at 24 (p=0.06) and 48 hours (p=0.08)), but did not have dose related effects on transit, fasting or postprandial colonic motor activity, compliance, or sensation.

CONCLUSION

5-HT(4) receptors are involved in the regulation of cisapride stimulated orocaecal transit; SB 207266 tends to modulate colonic transit but not sensory functions or compliance in healthy human subjects.

Lack of pharmacokinetic interaction between ropinirole and theophylline in patients with Parkinson's disease

OBJECTIVE

Ropinirole and theophylline have the potential to interact, because they use the same hepatic cytochrome P450 (CYP1A2) as their major metabolic pathway. The present study investigated the effect of steady-state oral theophylline on the pharmacokinetics of ropinirole at steady state and the effect of steady-state ropinirole on the pharmacokinetics of a single intravenous (i.v.) dose of theophylline, both in patients with idiopathic Parkinson's disease (PD).

METHODS

Pharmacokinetic parameters (AUC and Cmax) for i.v. theophylline were compared before and after a 4-week period of oral treatment with ropinirole (2 mg t.i.d.) in 12 patients with PD. Patients were then maintained at this dose of ropinirole, and oral theophylline was co-administered at doses of up to 300 mg b.i.d. The parameters AUC, Cmax and tmax for ropinirole were compared before, during and after oral theophylline co-treatment.

RESULTS

Co-administration of ropinirole did not significantly change the pharmacokinetics of i.v. theophylline (mean AUC with and without ropinirole: 68.6 micog x h(-1) x ml(-1) and 70.0 microg x h(-1) x ml(-1), respectively: mean Cmax with and without ropinirole: 11.07 microg x ml(-1) and 11.83 microg x ml(-1), respectively). Similarly, there were no significant changes in ropinirole pharmacokinetics when the drug was co-administered with oral theophylline (mean AUC for ropinirole with and without theophylline: 21.91 ng x h(-1) x ml(-1) and 22.09 ng x h(-1) x ml(-1), respectively; mean Cmax for ropinirole with and without theophylline: 5.65 ng x ml(-1) and 5.54 ng x ml(-1), respectively; median tmax for ropinirole with and without theophylline: 2.0 h and 1.5 h, respectively).

CONCLUSION

These results suggest a lack of significant pharmacokinetic interaction between the two drugs at current therapeutic doses.

The effect of steady-state ropinirole on plasma concentrations of digoxin in patients with Parkinson's disease

AIMS

The aim of this single-blind study was to assess the effect of ropinirole, a novel treatment for Parkinson's disease, on the steady-state pharmacokinetics and safety of digoxin in 10 patients with Parkinson's disease.

METHODS

There were three parts to the study: digoxin once daily plus placebo three times daily for 1 week; digoxin once daily plus ropinirole three times daily for 6 weeks; and digoxin once daily plus placebo three times daily for 1 week. Serial blood samples were collected over 24 h at the end of each part of the study for pharmacokinetic assessment. Pre-dose blood samples were collected on specific days throughout the study to assess the attainment of steady-state plasma levels of digoxin. The primary endpoints were AUC(0, tau) and Cmax for digoxin.

RESULTS

There was a mean decrease of 10% in digoxin AUC (0, tau) (90% CI: 0.79, 1.01) and a 25% decrease in digoxin Cmax (90% CI: 0.58, 0.97) when ropinirole was co-administered, compared with digoxin alone Cmin plasma values for digoxin, however, were fairly constant throughout the study (point estimates 0.99, 95% CI: 0.85, 1.15). Changes in trough levels of digoxin are believed to be the most reliable way of assessing steady-state concentrations of digoxin, and therefore the clinical significance of an interaction. Changes in Cmax are too readily influenced by other factors.

CONCLUSIONS

These results therefore indicate that on pharmacokinetic grounds no dose adjustment is necessary for digoxin co-administered with ropinirole.

Effect of food on the pharmacokinetics of ropinirole in parkinsonian patients

AIMS

Ropinirole is a specific non-ergoline dopamine D2-receptor agonist with antiparkinsonian properties. The pharmacokinetic parameters of ropinirole taken in the fasted condition were compared with those when it was co-administered with food.

METHODS

This was an open, randomized, two sessions cross over study in 12 patients with Parkinson's disease, comparing the steady-state pharmacokinetic profiles of ropinirole on two different study days: 'fasted' and 'fed'.

RESULTS

The mean Cmax was lower in the 'fed' regimen than in the 'fasted' one (-25%, P=0.002). The median tmax was observed 2.6 h later in the 'fed' regimen than in the 'fasted' regimen (P<0.05). There was a slight but significant decrease in AUC(0,8 h) in the 'fed' regimen (P=0.03).

CONCLUSIONS

Food decreases the rate of absorption of ropinirole, but has little effect on the extent of absorption.

Computer-enhanced medical decision making

Many clinicians balk at their first encounter with this intriguing technology, often fearful that information systems might usurp their autonomous role as a health care provider. Methods of implementation and application of this concept, and how it is beginning to find greater acceptance are discussed in this article.

Computer applications in health care

Computers are playing an ever-increasing role in health care. Computer-based medical records can improve data access, retrieval, output, decision support, and quality assurance. The author discusses computer innovation in medical record-keeping, laboratory data reporting, and drug delivery.

Physician experience with viewing digital radiographs in an intensive care unit environment

After several years of continuous operation, the utility of digital viewing stations as assessed by bedside clinicians has been investigated through the distribution of questionnaires to past and present users. The results of the questionnaire have indicated that the bedside physicians prefer using the workstations over handling film. For evaluation of line placements, chest tubes, and pleural effusions, the physicians prefer softcopy display over hardcopy. However, for analysis of air space disease and diagnosis of pneumothorax, images displayed on the workstation were not believed to be as useful as standard hardcopy.

Time comparison of intensive care units with and without digital viewing systems

As hospital radiology departments and intensive care units (ICUs) make plans to use or expand the usage of digital data outside of the radiology department, the need to assess the requirements of the potential recipients in the ICUs has become more important. The present operations in an ICU that uses digital viewing instead of film has been compared with a unit that does not. The difference in time between x-ray exposure and final image viewing was determined in both settings and compared. In this preliminary study, significant differences were found between the two units. The odds of having examination results actually accessed by the ordering physician in an hour or less were 9.5 times greater for the unit with digital viewing capability than for the one without it.

Automated acuity scoring within a computer based medical record

This paper describes the initial development of a completely automated acuity scoring system that resides within the TMR bedside computing system at the Duke University Medical Center, Surgical Intensive Unit. The scoring system is based upon the APACHE II acuity scoring system and provides for the recalculation of acuity scoring at 12 hour intervals through the patient's ICU course. When comparing hand calculated versus computer generated acuity scores for 19 patients, discrepancies fell into three broad categories: 1) data available to the application differed from that available to the human scorer. 2) apparent transcription errors 3) data items lost or absent from the paper record. It remains to be determined if computer generated acuity scoring provides for a more accurate representation of the patient's acuity.

Studies of the pharmacokinetics and metabolism of 4-amino-propiophenone (PAPP) in rats, dogs and cynomolgus monkeys

The pharmacokinetics and metabolism of 4-aminopropiophenone (PAPP), a cyanide antidote, have been studied in rats, dogs and cynomolgus monkeys using 14C-PAPP. Radiolabelled material was rapidly excreted in all three species, mainly in urine. In rats, PAPP was metabolized by N-acetylation, while in dogs, ring and aliphatic hydroxylation occurred. In monkeys, both N-acetylation and oxidation took place. In the latter pathway, PAPP was oxidized to p-aminobenzoic acid which underwent amino acid-conjugation to p-aminohippuric acid. In rat blood in vitro, the PAPP metabolites, p-aminobenzoic, p-aminohippuric and N-acetyl-p-aminobenzoic acid were only weak methaemoglobin producers.

Bedside computerization of the ICU, design issues: benefits of computerization versus ease of paper & pen

This paper describes the design considerations for the implementation of a bedside computer system in an intensive care environment. Specific issues discussed include application design, implementation problems, design revisions, and design solutions. Specific examples of the above issues include passive data acquisition from bedside devices and computer systems, automated nursing assessments, respiratory therapy assessments and integrated reports.

Trimetrexate in prostatic cancer: preliminary observations on the use of prostate-specific antigen and acid phosphatase as a marker in measurable hormone-refractory disease

Thirty-one patients with bidimensionally measurable hormone-refractory prostatic cancer received trimetrexate (TMTX). Serial values of prostate-specific antigen (PSA) and acid phosphatase (SAP) were correlated with response. Five patients (17%; 95% confidence interval, 3% to 30%) achieved a partial remission for a median of 3 months (range, 3 to 7.5 months). Marker levels showed large variations with no discernible patterns. Serial PSA and SAP in 19 patients with abnormal baseline values showed a correlation with measurable disease response in only 68% (13 of 19) and 47% (nine of 19) of patients, respectively. Values were then smoothed using an exploratory data analysis technique of running medians and averages. Trends in marker changes were much more apparent. Several "decision rules" were evaluated for use of markers as indices of disease progression. A 50% increase from the patient's minimum value in either PSA or SAP on two successive determinations correlated with progression in 90% of cases in this trial. TMTX has modest activity in prostatic cancer, and further trials are not warranted. Biochemical markers do not uniformly reflect disease activity in hormone-refractory disease, and changes in biochemical markers must be interpreted cautiously when used as the sole end point to assess efficacy in clinical trials.

Rapid detection of herpes simplex virus (HSV) antigen in human ocular infections

The new HERPCHEK (Dupont, No. Billerica, MA) enzyme immunosorbent assay (EIA) was used in a double-blind clinical study for rapid and specific detection of ocular herpes simplex virus (HSV) infection. This 4-hour assay can be used to demonstrate conclusively the presence of HSV antigen without culture and thereby rapidly differentiate between HSV and other clinically similar ocular infectious diseases. Ocular samples were collected from 180 individuals including 30 patients with acute HSV, 90 with latent HSV (ie, currently asymptomatic but with a positive history), 11 with acute or latent varicella zoster virus, 30 with nonherpetic infections (due to adenovirus, Acanthamoeba or bacteria), and 19 normal controls. A clinical diagnosis was made by one of us (DPL) and duplicate tear-film samples obtained by swabbing the conjunctival cul-de-sac and cornea. Coded samples were tested by routine viral culture on Vero cell monolayers and also were run independently in the HERPCHEK test. During active HSV infection, the HERPCHEK correlated 100% with clinical diagnosis, and virus culture correlated 90% with clinical diagnosis. In all latent HSV ocular infections, other nonherpetic ocular infections and normal samples, both the HERPCHEK and culture assays were negative.

Midazolam sedation following open heart surgery

Midazolam given as hourly intermittent injections was compared with the same dose given by infusion for postoperative sedation in patients after cardiopulmonary bypass. A stable concentration was rapidly attained with the infusion whereas 6-8 h was required to attain stable plasma (trough) concentrations in the intermittent injection group. Plasma concentrations decreased rapidly to low values within 6 h of discontinuation of therapy. High plasma concentrations and a long (16 h) half-life were noted in one patient who may be a slow metabolizer of the drug.

Schmorl's nodes (intravertebral herniations of intervertebral disc tissue) in two historic British populations

The herniation of the nucleus pulposus into the vertebral body produces ectopic deposit of disc material which are known as Schmorl's nodes. This prolapsed disc tissue leaves characteristic deformations on the surface of the vertebral body and hence the incidence of this lesion can be studied in skeletal remains. This report describes the occurrence of Schmorl's nodes in TV8-SV1 in two historic adult British populations, one from Aberdeen and the other from London. In the Aberdeen group, both males and females showed a high incidence rate and severity of Schmorl's nodes. In the London group, the males had a similarly high affliction whereas the females were nearly free of the condition. The lesion had no significant predilection for any one particular vertebral surface. However, in males in both localities, the frequency of Schmorl's nodes was significantly higher in the thoracic region than in the lumbosacral region. In contrast, both groups of females showed similar node frequency in these two zones. The majority of Schmorl's nodes were localised in the central and central-posterior regions of the vertebral surface. When nodes occurred on successive vertebral surfaces, they often formed sequences showing similar shape and position. The aetiology of Schmorl's nodes is unclear. Various hypothetical causal factors were appraised in relation to the findings of this study. It was suggested that anomalies in vascular and/or notochordal regression may be related to the development of the lesion.

Cross-national reliability study of a schedule for assessing personality disorders

The inter-rater reliability of a schedule used to assess personality disorders was examined. The Personality Assessment Schedule (PAS) involves an interview with both the patient and a close informant and the ratings for the informant are given most weight in the final scoring. Videotaped interviews with 23 psychiatric patients, most of whom had a clinical diagnosis of personality disorder, and a close informant were scored by seven raters, four in the United Kingdom and three in the United States. Overall inter-rater reliabilities (using the intraclass correlation coefficient, RI) were generally good to excellent for each of the 24 personality variables tested, ranging between .66 and .94 for informants and between .51 and .91 for subjects. Corresponding reliability coefficients for overall mean PAS scores were .82 and .75, respectively. Consistent with these findings, there was little bias between the scores of American and British raters, although there was some tendency for American raters to score higher for the trait of eccentricity and lower for the trait of conscientiousness than was true for British raters. There was less bias for informants' ratings than for those of subjects. In a second set of analyses, it was shown that inter-rater reliability levels (using the Kappa statistic) were also good to excellent (.6 to .8) for the categorical diagnosis of personality disorder. These results, taken together, demonstrate that abnormal personality can be reliably assessed by both British and American raters.

Magnesium depletion and hypocalcaemia after removal of parathyroid carcinoma

A case of parathyroid carcinoma is described which presented with severe bone disease, complicated after parathyroidectomy by symptomatic hypocalcaemia and magnesium deficiency, both of which responded dramatically to the administration of magnesium. Urinary cyclic AMP assays were used to monitor parathyroid activity.