'Painting a path to wellness': correlations between participating in a creative activity group and improved measured mental health outcome.

Responding to a call for quantitative outcome evidence about the therapeutic relationship between creative activity and mental health, this study examined the mental health outcomes of inpatients participating in art- and craft-based creative therapies at a private psychiatric hospital over a 5-year period. The creative activity group sample (n= 403) improved from admission to discharge across four different psychometric measures with moderate to strong mean effect sizes. Reductions from pre- to post-treatment in both self-reported and clinician-rated symptoms are clearly demonstrated for the creative activity group participant sample. Research findings establish that participation in creative activity has potential benefits for people experiencing mental health problems.

The double wire technique: an improved method for treating challenging ureteroileal anastomotic strictures and occlusions.

Up to 10% of patients who undergo ileal conduit urinary diversion may go on to develop ureteroileal anastomotic stenosis (UIAS); this can lead to recurrent urinary tract infections and deterioration in renal function. Classical management has been open revision of the anastomosis. We describe a novel technique that allows balloon dilatation and ureteral stent placement in a retrograde fashion. All patients in this study had undergone radical cystectomy and ileal conduit formation with Wallace type end-to-end refluxing uretero-intestinal anastomosis. After initial retrograde loopogram, a 6F MPA-1 catheter and an 0.035 inch extra stiff guide was passed to the distal ostium. Subsequently, a customised 8F bright tip MPA-1 guiding catheter was advanced over the guide wire which allowed effective splinting of the equipment to facilitate greater control of a second catheter and guide wire combination to access the stenotic or occluded anastomosis. Results show that a total of ten anastomoses were treated; nine anastomoses were successfully treated with a primary retrograde approach with no intra or post-procedural complications. After a mean follow-up of 19 months (5-33 months), as assessed by ascending loopograms, all anastomoses remained open. In conclusion, morbidity of open surgery has resulted in the popularization of endourological techniques in treating anastomotic stenoses. However, key to these endourological techniques is access to the anastomosis; typically, this has been via a percutaneously placed nephrostomy. The ideal route to the anastomosis is via a retrograde approach; we have illustrated a safe and successful novel technique that utilized two guidewires and a guiding catheter, allowing retrograde ureteral access.

Measuring mental health outcomes in a private psychiatric clinic: Health of the Nation Outcome Scales and Medical Outcomes Short Form SF-36.

OBJECTIVE: This study reports on data collected from the routine use of the Health of the Nation Outcome Scales (HoNOS) and the Medical Outcomes Short Form (SF-36). Three main aims were addressed in using these measures: (i) to establish patient disability levels; (ii) to determine the level of treatment effectiveness; and (iii) to explore the ability of these instruments to predict length of stay and mood change. METHOD: The clinician-rate HoNOS and the patient-rated SF-36 were included in the assessment battery, at admission and discharge, of consecutive inpatients (n = 754) at one private psychiatric facility over a 2-year period. RESULTS: The sample, on admission, was comparable in illness severity to levels reported at other Australian private psychiatric facilities. Treatment was shown to be effective, and the degree of changes in HoNOS ratings compared favourably with other private psychiatric facilities. Certain factors underlying the structure of the HoNOS and the SF-36 only weakly predicted length of stay and changes in depression and anxiety levels. CONCLUSION: The HoNOS and the SF-36 provided valid and reliable data on patient function, with the HoNOS being most sensitive to treatment change. However, neither instrument proved useful in predicting length of stay or levels of depression and anxiety at discharge.

Testing a genetic structure of blood-injury-injection fears.

Multivariate genetic analyses were used to examine the genetic and environmental contributions to individual differences in fears of blood, injury, and injections in 659 twin pairs who completed questions concerning fear and fainting around blood, injury, and injections, and fainting in situations not involving blood, as well as the personality scales of Neuroticism, and Harm Avoidance. There was significant familial aggregation of blood fears but univariate analyses were unable to distinguish between additive genetic or shared environmental variables, or both, as the cause. The same was true of blood fainting. Non-blood-injury fainting was best explained by a model assuming shared and unique environmental variables. However, multivariate genetic analyses, which capitalise on extra information contained by all the covariance terms, indicated that the variance in blood-injury-injection fear was principally attributable to unique environmental events specific to this fear and additive genetic factors shared with fainting. The data are discussed in the context of models of blood-injury phobia that identify the need to consider separate etiological mechanisms for fear and fainting.

The Blood-Injection Symptom Scale (BISS): assessing a structure of phobic symptoms elicited by blood and injections.

Assessments for blood-injury-injection phobia measure feared stimuli and overt behaviours, but they have not systematically addressed the symptoms of fear and faintness. The Blood-Injection Symptom Scale (BISS) was developed to overcome this omission. An exploratory factor analysis grouped symptoms triggered by blood and injections into three internally consistent factors (faintness, anxiety and tension). A confirmatory factor analysis replicated the factor structure in a new sample. To test the construct validity of the BISS, an attempt was made to reproduce Ost's (1992, Journal of Abnormal Psychology, 101, 68-74) finding that fear was stronger among people with concerns about injections, while faintness was stronger among people with concerns about blood. A community sample of 80 individuals with concerns (i.e. fear or fainting) about blood or injections completed the BISS. Controlling faintness, individuals with concerns about injections reported more fear than people with concerns about blood. In contrast, controlling for fear, the latter reported more symptoms of faintness. These data suggest that the BISS generates stable and internally consistent subscales useful in the measurement of symptoms elicited by blood and injections.

Do specific anxiety disorders show specific drug problems?

OBJECTIVE: Comorbidity between anxiety and substance use disorders was examined. The hypothesis was tested that social phobics may report greater problem alcohol use (if alcohol is used to manage social anxiety) while problem use of sedative-hypnotics may be greater in people with panic (who may be over-prescribed anxiolytics because they repeatedly seek medical assistance). METHOD: Self-reported lifetime rates of drug and alcohol problems were assessed with the computerised Diagnostic Interview Schedule-Revised. Subjects were 146 consecutive patients treated for panic disorder (with and without agoraphobia) and social phobia at the Clinical Research Unit for Anxiety Disorders. RESULTS: High prevalences of alcohol problems (three times that expected) and problem use of sedative hypnotics (eight times that expected) were found in all diagnoses. Social phobics exhibited comparatively high rates of problem alcohol use, but no diagnostic specific differences in problem sedative-hypnotic use were found. CONCLUSION: Routine screening for drug and alcohol problems is necessary for patients with anxiety disorders.

Distinguishing panic disorder and agoraphobia from social phobia.

An attempt was made to differentially diagnose panic disorder with agoraphobia from social phobia on the basis of self-reported phobic situations, panic attack symptomatology, and feared outcomes. Sixty-nine patients with panic disorder (with and without agoraphobia) were compared with 69 patients with social phobia. Subjects completed a modified self-report version of the panic and phobia sections from the Composite International Diagnostic Interview to assess phobic situations, panic symptomatology, and feared outcomes. The two groups were distinguishable on all three measures. A diagnostic algorithm was developed that predicted the primary diagnosis allocated by a clinician for subjects who meet DSM-III-R criteria for panic disorder (with or without agoraphobia) rather than social phobia on the basis of self-reported phobic avoidance, panic symptomatology, and feared outcomes.

Panic provocation in the treatment of agoraphobia: a preliminary investigation.

The efficacy of panic provocation exercises in the treatment of agoraphobia is examined. Twenty six patients with agoraphobia were allocated to a cognitive-behavioural program with and without panic provocation exercises. Both programs significantly reduced symptoms. Despite a trend in favour of panic provocation, differences between treatments failed to reach significance. Results are discussed in terms of a cognitive model of panic and the manner in which future research into panic provocation should be conducted.

The "medicinal effect": a possible mechanism in the development of severe alcohol dependence.

An examination of the change in attractiveness of a flavor subsequent to pairing with recuperation from malaise was undertaken. Forty-five subjects consumed a flavor after the rotation-induced motion sickness at two different intervals. Twenty-four consumed, on three separate conditioning trials, the paired flavor immediately as malaise began to decline (short-delay group), the remainder, when malaise had completely diminished (long-delay group). All subjects also consumed an unpaired flavor the morning after each session. Analysis of variance revealed that the paired flavor was rated as more highly attractive than the unpaired flavor, and this effect was only present in the short delay group. These results were taken as supporting the existence of conditioned flavor preferences in humans and interpreted as a possible learning mechanism in the development of severe alcohol dependence.

Sending your teenagers away. Controlled stress decreases neurotic vulnerability.

OBJECTIVE: To study the effect of a controlled stressor on the rate of personality maturity. DESIGN: Eighteen-month prospective controlled study. SETTING: General community. EXPERIMENTAL: Exposed to the stress of 12 months' intercultural experience. CONTROL: Remained in usual environment. MAIN OUTCOME MEASURE: A measure of personality vulnerability/maturity derived from a canonical correlational combination of trait anxiety, locus of control, and defense style. RESULTS: Exchange students exposed to the stressor made significantly greater gains in personality maturity (0.28 vs 0.03 SD: P < or = .01) than did the control students matched on this measure at baseline. CONCLUSION: Exchange students exposed to the stress of living abroad showed a substantial decrease in vulnerability, which should decrease the risk of future neurotic disorders in this group.

Eye-movement desensitisation: a simple treatment for post-traumatic stress disorder?

Eye-movement desensitisation has been identified in a number of case studies to be an effective treatment for post-traumatic stress disorder (PTSD). A further case study reporting success is presented. The treatment appears rapid and may represent a potentially cost-effective treatment for PTSD. However, no treatment study to date has conformed to the ideal methodology of a double-blind placebo controlled trial and therefore its efficacy remains to be demonstrated. A minimal but stringent set of criteria for identification of treatment efficacy are outlined. The implications of eye-movement desensitisation being identified as an effective treatment for PTSD are discussed.

Angiographically determined arteriopathy in liver graft dysfunction and survival.

We evaluated the contribution of flush and selective hepatic angiography in defining the extent and pattern of major vessel and microvascular arterial lesions and their significance in graft survival. The 50 consecutive patients investigated comprised three clinical groups: Group A (n = 18) were patients with severe graft dysfunction within the first seven days post-transplantation. In this group six of 18 angiograms demonstrated intrahepatic attenuation of the arterial tree suggestive of acute cellular rejection and four of these grafts were lost, compared to a 78% graft survival in the non-arteriopathic group. Group B (n = 16) comprised patients with clinically suspected hepatic arterial thrombosis or stenosis, these diagnoses were confirmed in all patients compared to only 10 positive findings with doppler ultrasonography. Graft survival was only 10% in those patients with artery thrombosis as compared to 100% in those with arterial anastomotic stenoses. Group C patients (n = 16) had histologically confirmed chronic allograft rejection and in ten of them (65%) evidence of arteriopathy was demonstrated despite histological evidence of arteriopathy being present in only 19% of patients. All patients in this group with arteriopathic changes lost their grafts with the exception of one successfully treated with FK506. In two other patients reversibility of chronic rejection was observed, neither of whom had evidence of an arteriopathy.

Warm turkey: other routes to abstinence.

The requirement of immediate and abrupt quitting ("cold turkey") can be an obstacle to the acceptance and accomplishment of abstinence as a long-term outcome. Three alternative "warm turkey" routes to abstinence are discussed: (a) sobriety sampling, (b) tapering down, and (c) trial moderation. Clinical research evidence and case examples are provided in support of these alternative approaches.

The insertion of chronic indwelling central venous catheters (Hickman lines) in interventional radiology suites.

The insertion of Hickman central venous catheters for chronic venous access is a procedure usually conducted in the operating theatre under local or general anaesthesia. In a prospective study over a one year period we have assessed the feasibility of radiologists inserting central venous catheters for long term access. A subclavicular approach to the subclavian vein with prior digital subtraction angiography or video imaging of the vein was the technique of choice. Thirty-one Hickman catheters were inserted in 21 patients. All but two patients had a haematological malignancy. Ages ranged from 19 to 77 years. The mean time for insertion was 43 min (range 20-80 min). The catheters remained in situ for between 2 days and 242 days with a mean of 86 days. There was one documented line infection; nine patients had episodes of septicaemia with identified organisms, and a further six had pyrexias of unknown origin during the line indwelling period. There were four documented line and or ipsilateral subclavian vein thromboses, and one death occurred within 36 hours of the procedure. We conclude that radiological placement is an excellent alternative to 'blind' surgical placement. Screening during insertion provides immediate facilities for correction of malposition and monitoring of immediate complications. The time taken for catheter insertion did not impede the usual patient throughout in the interventional radiology suite.

Chronic intussusception.

Chronic intussusception is a rare but completely correctable cause of failure to thrive in infants and children. The presenting features differ from acute intussusception. We present the case of a 16 month old boy presenting with a three week history of anorexia, diarrhoea, and weight loss with subsequent delayed diagnosis.

Pleuropulmonary haemangiopericytoma masquerading as a post-infective encysted pleural effusion.

Haemangiopericytoma, a rare mesenchymal tumour infrequently found within the thorax, is described in a patient who presented with a pleural mass following a lower respiratory tract infection. Specific radiological features leading to a diagnosis have previously been suggested; however, these are challenged in view of the findings in this case. Haemangiopericytoma ought to be considered in the differential diagnosis of an asymptomatic enlarging pleuropulmonary soft tissue mass.

Arachnoid cysts of the middle fossa predispose to subdural haematoma formation fact or fiction?

An association between arachnoid cysts of the middle fossa (ACMF) and complicating subdural haematoma (SDH) has been previously noted. More recently it has been hypothesized that ACMF may predispose to SDH formation. The Plymouth Neurosurgical Unit has treated twenty patients with ACMF between 1976-1985, seven of these being complicated by SDH. There was an age range of 11-56 years in those with SDH. Six of the seven patients with ACMF and SDH gave no significant trauma history. Four of these were males aged 11 to 20 years. The presenting histories, clinical findings and subsequent management of these patients were compared with the age-matched males with SDH alone (twelve patients). In the SDH alone group 100% suffered major skull trauma and 80% had demonstrable skull fractures. In addition the patients with ACMF were compared with patients presenting with other supratentorial arachnoid cysts in Plymouth. Only ACMF were associated with the development of SDH in our study. Three patients demonstrated total masking of the ACMF by isodense intracystic haematoma on computed tomography. In two of these patients the presence of an ACMF was suspected due to plain radiographic and CT enlargement of the middle fossa. It is advocated that with special reference to young males, in the absence of major skull trauma an ACMF should be suspected as a predisposing factor to SDH. Postoperative CT scans for at least one year are advisable in young patients with SDH as demonstration of the presence of an ACMF and SDH affects future management.