Comparative tolerability of drug therapies used to treat incontinence and enuresis.

Drug therapy for incontinence and enuresis has met with varying degrees of success. Currently, there is no medication available that specifically targets the lower urinary tract without having untoward effects elsewhere in the body. Patients with urge incontinence are the most difficult group to treat. The agents most commonly used to treat urge incontinence, i.e. anticholinergics, musculotropics and tricyclic antidepressants, are limited in their effectiveness and have anticholinergic adverse effects. Other medications with theoretical treatment potential such as nonsteroidal anti-inflammatory drugs and calcium antagonists require more in depth clinical study before widespread use is appropriate. Although estrogen is well tolerated, its role in the treatment of incontinence in postmenopausal women may be limited. Medical treatment for stress incontinence is most successful in patients with a mild condition. Drugs with alpha-adrenergic activity alone or in combination with estrogen in postmenopausal women, are fairly effective and demonstrate few adverse effects at doses used to treat stress incontinence. Enuresis pharmacotherapy consists mainly of desmopressin and tricyclic antidepressants. Adverse effects are minimal with the doses commonly used. While the majority of patients improve with therapy, a significant portion relapse after treatment is terminated. Tolerability of a particular therapy depends on the effectiveness and adverse effects of the agent, the severity of incontinence and the general health of the patient. In general, patients are willing to accept a greater degree of inconvenience if a drug produces the desired effect. However, individualisation of therapy should be used to maximise compliance and outcome. Blinded, dose-titration studies are needed to better determine doses for optimum tolerability. Research into drugs specifically targeting the lower urinary tract may lead to more effective and well tolerated therapy for incontinence and enuresis.

Taking responsibility for cancer treatment.

One hundred and fourteen consecutive patients with early breast cancer were entered into a study on the psychological effects of involvement in treatment choice. All women were offered counselling throughout. One group of women (n = 34), were advised to undergo mastectomy, due to the nature or position of the tumour. These women fared less well psychologically when compared on a battery of measures, before and after surgery, with women who were involved in choosing their own treatment (n = 80). The latter group itself was randomly allocated into two groups for taking explicit responsibility for treatment choice, using a double-blind procedure. These were a Patient Decision Group (n = 41) and a Surgeon Decision Group (n = 39). Results support the hypothesis that over and above the benefits of receiving their preferred treatment, women can further benefit from taking explicit responsibility for their treatment choice.

Functional analysis in applied psychology.

Various clinical problems in recent years have been described under the general heading of 'functional analyses'. The present paper considers the background to the notion of a functional analysis and some of the differences between functional analysis and more traditional approaches. The processes involved in producing such analyses of the origin and maintenance of clinical problems are outlined, using a clinical case as an illustration. It is suggested that, amongst the features highlighted by such analyses, feedback loops will often be apparent, and that these may provide particularly valuable targets for intervention. Moreover it appears that the use of such analyses transcends, at least to some extent, the type of problem or client (in being applicable to institutional or individual problems) and in particular that the use of functional analyses transcends theoretical biases of the clinician. In this respect it provides a potential common ground for workers of different orientations.

Treatment decision making in women newly diagnosed with breast cancer.

The purpose of this study was to explore the hypothesis that women with breast cancer had specific preferences about the degree of control they wanted over treatment decision making. One hundred fifty women, newly diagnosed with breast cancer, were interviewed and their preferences for participation in treatment decision making were established using a measurement tool designed to elicit decision-making preferences (Degner LF, Sloan JF. Decision making during serious illness: What role do patients really want to play? J Clin Epidemiol 1992;45:944-50). Two hundred women with benign breast disease served as a descriptive comparison group. Unfolding theory (Coombs CH. A theory of data. New York: John Wiley & Sons, 1964) provided a means of analyzing the data so that the degree of control preferred by each woman could be established. The majority of the newly diagnosed women preferred to play a passive role in treatment decision making, leaving the decision-making responsibility to their physician, whereas the benign control group preferred a collaborative role in which joint decisions could be made between the patient and the physician. The implications of the results for patient participation are discussed.

Psychological impact of predictive testing for colonic cancer.

Advances in DNA technology have facilitated presymptomatic testing for an inherited predisposition to a number of autosomal dominant cancer syndromes. While testing is generally undertaken with informed consent and within a counselling protocol, there is still much to be learned about the psychological impact of DNA testing in a predictive setting. In this study, patients' experiences were recorded using in-depth interview techniques following earlier testing for hereditary non-polyposis colorectal cancer which was coordinated through an hereditary cancer registry. Thematic analysis of the transcripts revealed consistent issues pertaining to identity as well as emotional responses to previous preventative strategies and ongoing cancer screening options.

Attitudes of health professionals to child sexual abuse and incest.

While there has been increasing interest in the topic of child sexual abuse, few studies have focused on attitudes or the determinants of such attitudes held by professionals. To what extent concern is based on stereotyping or factual knowledge is not clear. The present study uses a combination of experimental and survey methodologies to address these issues. Sample case histories were issued to subjects who were then asked to complete a questionnaire on topics relating to the case and to incest in general. Results showed that the type of sexual activity involved influenced responses; type of relationship between adult and child, less so. Estimates of incest were low, but incest was considered, especially by female respondents, to be harmful to the victim.

Professionals' attributions of censure in father-daughter incest.

Despite the recent increase in interest in the area of child sexual abuse, few studies have explored the attitudes of professionals involved in working with children. The present study investigates variables relating to the attribution of censure by two professional groups (teachers and social workers), to a victim of father-daughter incest, the father, and nonparticipating mother. Subjects were given one of four brief histories of a 14-year-old girl who had been sexually abused by her father. Cases varied according to whether the child had/had not resisted her father's advances and whether she had/had not had other sexual experiences. Subjects then completed a questionnaire and indicated the extent to which they attributed censure to the child, her mother, and father, and the extent to which they believed she would be affected by her experiences. Results showed that responses were influenced by the level of resistance, other sexual experiences, and respondents' sex and occupation.

A dual process model of perfectionism based on reinforcement theory.

This article begins with a brief review of the current literature on the structure and measurement of perfectionism. It is concluded from this review that two major types can be distinguished, a normal/healthy form and a pathological form. These two forms are then defined as positive and negative perfectionism and related directly to Skinnerian concepts of positive and negative reinforcement. The positive/negative distinction is then further elaborated on in terms of approach/avoidance behavior, goal differences, self-concept involvement, emotional correlates, and the promoting environment. Finally, some of the more obvious theoretical and practical implications are briefly explored.

Judo as a possible cause of anoxic brain damage. A case report.

The rules of judo provide for strangulation techniques in which the blood supply to the brain is blocked by pressure on the carotid arteries; such techniques produce anoxia and possible unconsciousness if the victim fails to submit. A case is presented of a patient with signs of anoxic brain damage, with psychometric investigation showing memory disturbance consistent with a left temporal lobe lesion. This patient had been frequently strangled during his career as a judo player; it is suggested that such frequent strangulation was the cause of the damage. Such an observation indicates the need for caution in the use of such techniques.

Conflicting attitudes to corneal and organ donation: a study of nurses' attitudes to organ donation.

The demand for transplantable organs and tissues is steadily increasing and action is necessary to improve the organ and tissue donation rates. Previous research has suggested that nurses have a substantial influence on the rates of donation in the clinical area. Nurses (N = 150) were asked to complete a number of measures to assess positive and negative attitudes towards cadaveric organ donation, with 112 (74.6%) responding. The findings identified conflicting attitudes particularly in relation to corneal donation; 25% of the respondents would not donate their corneas. Reasons given included fear of disfigurement, religious factors such as the need to see into the next life, and dislike of the thought of donation of eyes but without knowing why. The majority of the respondents were in favour of donation generally and many carried or had signed donor cards. Nurses are usually the professionals who have the most contact with the patient in the clinical and are therefore able to identify potential donors. It seems likely that nurses with conflicting attitudes to donation are less likely to undertake the emotional costs involved when relatives of potential donors are approached re donation, than those who have more positive attitudes.

Starting up stress thallium cardiac imaging services.

This paper presents an evaluation of alternative methods for a hospital to establish stress thallium cardiac imaging services at a group of physicians' office. Volume-cost-profit analysis, break-even analysis and capital budgeting techniques were used to determine the most feasible method from a financial perspective without sacrificing quality of services. The main focus of this evaluation centers upon three alternative methods of procuring an imaging camera: (1) purchasing a new camera, (2) purchasing used equipment, or (3) leasing a new camera. Budgeted income statements were constructed using relevant revenue and cost information for each alternative. The payback period, net present value and the internal rate of return for each method of procuring a camera was computed. In addition, the break-even point was also determined for each alternative. After the analysis was completed, it was concluded that the method of choice, without sacrificing quality of service delivery, was that of purchasing a used camera.

Simple micromethod for detecting antifungal activity.

A bioassay that can be carried out on thin-layer chromatograms is described for rapid detection of antifungal or general cytotoxic activity with microquantities of test compound.

The effect of minimal interventions by general practitioners on long-term benzodiazepine use.

Seventy one long-term users of benzodiazepines were asked by their general practitioners in a letter or short interview to reduce their medication. Twenty two patients were successful in giving up or reducing their consumption to less than 100 tablets per annum. There were no clear predictors of success in terms of patient characteristics, duration of drug use, type of benzodiazepine, reason for drug use or strategy employed to reduce medication. However, patients who were successful at reducing their medication had a significantly lower mean baseline drug consumption than unsuccessful patients. The implications of this study are that a proportion of long-term users who are not in current crisis, especially those with relatively low consumption, can reduce or stop benzodiazepine treatment with minimal difficulty.

Continuing professional education: identifying the characteristics of an effective system.

The need for a functioning system of continuing professional education (CPE) in nursing, midwifery and health visiting has received increased attention in recent years. However, whilst the literature describes a number of benefits, detailed empirical studies have been limited. There is, in particular, a dearth of information on nurses' perceptions of the important components of a CPE programme. Using the results of a recent evaluation of the Welsh National Board's Framework for Continuing Education, this paper highlights a number of key issues identified by practitioners, educators and managers throughout Wales. Using a structure-process-outcome model, attention is focused on the outcomes of CPE and the structure and process variables which facilitate or inhibit success. The results indicate a strong commitment to the principles of CPE and identify a complex range of perceived benefits. Potential barriers inhibiting both the uptake of CPE and the achievement of subsequent change are discussed and the need to create an equitable, well-resourced system is stressed.

The experience of opioid abstinence: the relevance of motivation and history.

Questionnaire measures relating to a recent episode of unmodified heroin withdrawal (the target episode) were obtained from 70 subjects. The duration of the target episode, but not reported distress during the episode, correlated with the amount of heroin consumed in the previous 3 months. Data from scales measuring motivation during the target episode were factor analysed and two factors emerged, one relating to motivation concerning private affairs and the other relating to motivation derived from public sources. High scores for private affairs motivation were correlated with success in the target episode whilst there was a trend for public affairs based motivation to be associated with failure. Private affairs motivation was negatively correlated with length of heroin use but positively correlated with the number of coping strategies employed in withdrawal. The implications of these findings for the treatment of heroin users are discussed.

A descriptive study of meaning of illness in chronic renal disease.

AIM: To explore the subjective meaning of illness in a sample of renal patients. BACKGROUND: Patients' illness representations, such as the meaning they attach to illness, may affect their coping and adaptation. Improved understanding in this area may therefore benefit patient care. Meaning of illness has not previously been explored in renal disease. DESIGN AND METHODS: Cross-sectional survey (n=405) in a single regional renal unit in the North of England. Ethical approval was obtained and patients gave written consent. The instrument used was an eight-item schema, based on the work of Lipowski (1970, Psychiatry in Medicine 1, 91-102). Field notes regarding rationale for choice were recorded concurrently, then content analysed to enable identification of themes. The chi-square test (significance level P < 0.05) was used to analyse differences in selected meaning in older and younger patients; males and females; and patient groups (predialysis, haemodialysis and transplant). FINDINGS: 'Challenge' was selected by most patients (n=253, 62.5%), with similar results in all three patient groups. Slightly more older than younger patients selected 'challenge', although the difference was not statistically significant and older patients more commonly had a fatalistic interpretation of the option. More men selected 'challenge' than women. Those selecting 'challenge' and 'value' appeared to have a more positive outlook than other patients. CONCLUSIONS: Patients had identifiable meanings for their illness, and these may be associated with their response to renal disease. The schema appeared to be comprehensive, but is in need of further refinement. Consideration of the possible influence of social desirability is necessary.

Patients' perceptions of magnetic resonance imaging.

There are several anxiety-related reactions associated with magnetic resonance imaging (MRI). Patients who experience such reactions may disrupt the examination or move so much that images are degraded. These experiences may also influence patients' perceptions of the quality of their care. The objective of this study was to further assess the subjective experiences of patients undergoing MRI in an attempt to identify those patients likely to have problems and factors affecting their experiences. Five hundred consecutive patients undergoing MRI were surveyed using questionnaires before and immediately after imaging. Anxiety was measured using the state anxiety component of the state-trait anxiety inventory. All patients exhibited some degree of pre-imaging anxiety. This was particularly associated with a previous 'unpleasant' imaging experience. Patients who experienced problems during MRI had pre-imaging anxiety levels equivalent to patients about to undergo surgery, were more likely to react badly when first seeing the scanner and were more likely to leave the MRI unit with even greater feelings of anxiety than when they arrived. In contrast to previous studies, anxiety was not associated with either the patient's understanding of the procedure or the duration of the examination. Several features have been identified which could improve the patient's experience (e.g. better information sheet). Awareness of MRI-related anxiety should also be considered when assessing the impact of MRI on outcome for the patient.