Two-week wait false alarms? A prospective investigation of 2WW head and neck cancer referrals.

Objectives i) To prospectively explore patients' experience through the two-week wait (2WW) referral process; ii) To compare the relative true malignancy diagnostic rate between general medical practitioners (GMPs) and general dental practitioners (GDPs) over a six-month period; iii) To compare management of 2WW referral cases between GMPs and GDPs before the referral and during the 2 weeks in regards to symptomatic support, investigations in primary care, and information communicated to patients and secondary care clinicians; iv) To investigate the benign conditions that comprise 2WW referrals by finding out the final diagnoses of all cases included in the study.Method The patient inclusion criteria were all 2WW referral patients who attended consultation clinics during the six-month study period in Royal Cornwall Hospital NHS Trust. We prospectively distributed patient questionnaires and clinician's referral assessment forms. We obtained the final diagnoses of all participants electronically, and also identified all malignancies diagnosed via routine referral route during the study period from the cancer services team.Results Two hundred and twenty patients referred via 2WW pathway participated in the study. Of these, 148 referrals were from GMPs and 72 from GDPs. The overall malignancy diagnostic yield was 6.2%; markedly higher from GMPs (9.5%) than GDPs (1.4%), and higher number than those from routine pathway. The GMPs and GDPs showed similar levels of clinical management and information exchange judging from the participants' responses. We also identified the top nine most commonly urgently referred benign conditions.Conclusion We reiterate the need for improved communication between clinicians and patients and between clinicians. We also suggest more focus on education in commonly encountered conditions as well as malignant lesions. The number of 2WW referrals we received from GMPs was nearly twice as many as those from GDPs, highlighting the importance of delivering oral medicine education to medical students, trainees and GMPs.

Why the high rate of dropout from individualized cognitive-behavior therapy for bulimia nervosa?

OBJECT: To investigate predictors of dropout from cognitive-behavior therapy for bulimia nervosa. METHOD: Pretreatment assessment measures were examined including the Eating Disorder Inventory-2, Body Satisfaction Questionnaire, Beck Depression Inventory, Beck Hopelessness Scale, the Locus of Control of Behavior Scale, and demographic and behavioral measures. RESULTS: Forty-three percent (n = 14) of clients with a DSM-IV diagnosis of bulimia nervosa dropped out of treatment prematurely. No differences were found between treatment completers and dropouts with respect to the initial severity of bulimia-related symptoms. Noncompleters were, however, found to have significantly higher depression and hopelessness scores as well as elevated levels of external locus of control. Discriminate analysis showed that these variables resulted in a 90% prediction accuracy of individuals who prematurely dropped out of treatment. DISCUSSION: Results suggest a need to focus treatment directly on factors such as hopelessness and depression in addition to standard bulimia procedures to ensure clients are able to engage in therapy.

Cyclooxygenase-2 inhibition by rofecoxib reverses naturally occurring fever in humans.

Cyclooxygenase (COX) exists as constitutive (COX-1) and inducible (COX-2) isoforms. Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen and diclofenac inhibit both COX-1 and COX-2. The role of COX-2 in the genesis of fever in monkeys and humans was examined with use of the specific COX-2 inhibitor rofecoxib. Rofecoxib was administered to monkeys made febrile by 6 microg/kg intravenous lipopolysaccharide. Induced pyrexia was followed by oral rofecoxib (1 or 3 mg/kg), diclofenac (3 mg/kg), or vehicle. Rofecoxib and diclofenac rapidly reversed the elevated temperature (P < .05 versus vehicle for 3 mg/kg rofecoxib and diclofenac at 70 to 90 minutes after dosing). A single-dose, parallel-group, double-blind randomized trial was conducted in 94 patients with fever caused by a viral-type illness. Mean baseline temperature was similar for all groups (-38.5 degrees C). Patients received oral doses of 12.5 mg rofecoxib, 25 mg rofecoxib, 400 mg ibuprofen, or placebo and the mean +/- SE change in oral temperature at 4 hours after dosing was -0.97 degrees C +/- 0.11 degrees C, -1.19 degrees C +/- 0.09 degrees C, -1.20 degrees C +/- 0.11 degrees C, and 0.01 C +/- 0.17 C, respectively (P < .001 for active treatments versus placebo). Specific inhibition of COX-2 by rofecoxib results in antipyretic activity in monkeys and humans comparable to dual COX-1/COX-2 inhibitors such as diclofenac or ibuprofen. The data support the hypothesis that it is the COX-2 isoform that is primarily involved in the genesis of fever in humans.

Mid-facial growth following functional cleft surgery.

The stigmata of lip and palate clefting are well recognized, but recently it has been thought that these may be exacerbated by the surgical repair. Functional repair, however, with re-establishment of muscle continuity may result in less disruption to normal facial growth. This study examines mid-facial growth in 10 consecutive children aged 6.5 years with complete unilateral cleft lip and palate who had undergone functional repair. Outcomes were compared with non-cleft children and children who had undergone non-functional surgery.

The galeo pericranial flap in oropharyngeal reconstruction.

Flap reconstruction of the oropharyngeal region using a galeo pericranial flap was performed in 26 patients. This paper describes the anatomy, technique and discusses the outcome of the surgery showing that all flaps but one had good long term vascularity. Good access to all areas of the oropharynx was possible, the flap length was up to 20 cm and width up to 15 cm. Complications were minimal but included a tendency to form intra oral fibrous bands, patchy alopecia of the composite using outer plate of calvarium. The galeo pericranial flap is a valuable technique and can be used successfully in suitable cases.

Informed consent: using a structured interview changes patients' attitudes towards informed consent.

Patients want to know more about their condition and its proposed treatment. Gaining patients' confidence before treatment reduces the changes of their seeking legal redress for an unexpected outcome. As part of a prospective study of informed consent for surgery we have assessed the attitudes of patients towards informed consent when different types of consent interview are used. We found that most patients are happy to do as their doctor advises but think the informal consent interview is important because it gives them information; they also want to know about most, but not all, complications of the procedure. One quarter worried about the anaesthetic, about one eighth worried about 'not waking up' and similar proportions worried about complications and other things such as pain and nausea. Most patients think that the consent form is a legal document. In addition patients who had an informal interview felt obliged to sign the consent form and thought it had medicolegal implications. In contrast those who had a structured interview felt less obliged to sign the consent form and more involved in the decision to operate.

Informed consent: the assessment of two structured interview approaches compared to the current approach.

We prospectively studied 190 patients undergoing tonsillectomy or nasal surgery to assess the value of two structured interview techniques. There were four groups: Group A did not have a consent interview during the study period. Group B had an informal interview. Group C had a structured interview and Group D had a structured interview and were given an information sheet. Anxiety assessments were made and patients' recall of the operation name, details of the operation and its complications was assessed. Patients had higher than normal anxiety levels when admitted, but several hours after the interview anxiety was normal for Groups B, C and D. Group A maintained a higher anxiety level. Only 37 per cent correctly recalled the operation name, where as 87 per cent of all groups recalled the explanation of the operation. However, Groups C and D recalled a higher mean number of complications per patient. A structured interview when obtaining informed consent increases the number of complications recalled without increasing pre-operative anxiety.

Social relationships, adversity and neurosis: a study of associations in a general population sample.

A standardized study of the point prevalence of non-psychotic disorder was carried out on a systematic sample of Canberra residents (N = 756). Rates were estimated for PSE CATEGO diagnoses and the Index of Definition. The association between neurosis and deficiencies in social relationships was examined, using the Interview Schedule for Social Interaction (ISSI). An objective measure of exposure to adversity was also obtained at interview. Both attachment and social integration (affectionally close and more diffuse relationships) were found to be negatively associated with neurosis. This association holds in its own right, in addition to an interaction with the load of adversity. The associations are weaker for men. The significance of this work lies in its demonstration of an association between neurosis and the lack of social ties, and in its attempt to obtain a specification of those elements in social relationships which, when deficient, may be associated with neurosis. The direction of causality has now to be investigated.

Psychiatric disorder in Canberra. A standardised study of prevalence.

A standardised survey of prevalence has been carried out in a general population. The epidemiological method employed is innovative in its use of two established instruments, the GHQ and the PSE, harnessed together in a two-phase design. 756 persons were interviewed, giving a response rate of 85% in phase 1. 157 were then interviewed with the PSE in phase 2 within a few days, giving a response rate of 92% in this weighted subsample. The point prevalence of non-psychotic morbidity, based on the distribution of GHQ scores, is higher than elsewhere in Australia, the excess being in Canberra males. The PSE data weighted back to represent the total population, show a distribution of morbidity in women which is remarkably similar to that in the very different population of Camberwell. The overall point prevalence of threshold and definite cases is 9.0% +/- 3.2. Case rates did not vary significantly with age or sex, but were higher in the separated, the single and the widowed. This study represents an advance in the reliable and economical detection of psychiatric morbidity at specified levels of severity in general populations.

Neurosis and social bonds in an urban population.

The hypothesis that a deficiency in social bonds is a significant causal factor in neurosis was examined in a sample of an urban population (N = 756). The General Health Questionnaire was used as a measure of morbidity while social bonds were measured by the Interview Schedule for Social Interaction. An association was found between neurosis and a deficiency, particularly a perceived deficiency, in social bonds. Attention is now being directed to the interpretation of this association and to establishing the direction of causality.

Length of residence, life change and psychiatric morbidity in an Australian urban population.

A component of a large population study of a random sample of 750 Canberra residents is described, in which length of residence in Canberra is related to the quality and quantity of recent life experiences, and to indices of minor psychiatric morbidity (the General Health Questionnair and the Zung Depression Scale). Life event frequency, but neither measure of morbidity, distinguished between persons with different lengths of residence in Canberra. It can be suggested that a random sample, containing an under-representation of migrants and persons moving from rural to urban environments, in whom the transition in shifting place of residence would be expected to be greatest, is an inappropriate sample to test hypotheses concerning length of residence and psychiatric morbidity, Future studies should give due emphasis to the adequate inclusion of these groups of persons.

Social bonds in the epidemiology of neurosis: a preliminary communication.

In a random sample of the general population (N = 142) a strong inverse relationship was found between social bonds and the presence of neurotic symptoms. This association was strongest in the case of close affectional ties. Together, measures of social bonds accounted for 47 per cent of the variance in neurotic symptoms. While there is likely to be contamination between the two sets of variables, and while the data do not indicate the direction of causality, these findings constitute an aetiological lead which should be pursued.