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

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

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

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

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

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

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

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

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

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