Psychological impact and acceptability of magnetic resonance imaging and X-ray mammography: the MARIBS Study.

BACKGROUND: As part of the Magnetic Resonance Imaging for Breast Screening (MARIBS), Study women with a family history of breast cancer were assessed psychologically to determine the relative psychological impact and acceptability of annual screening using magnetic resonance imaging (MRI) and conventional X-ray mammography (XRM). METHODS: Women were assessed psychologically at baseline (4 weeks before MRI and XRM), immediately before, and immediately after, both MRI and XRM, and at follow-up (6 weeks after the scans). RESULTS: Overall, both procedures were found to be acceptable with high levels of satisfaction (MRI, 96.3% and XRM, 97.7%; NS) and low levels of psychological morbidity throughout, particularly at 6-week follow-up. Low levels of self-reported distress were reported for both procedures (MRI, 13.5% and XRM, 7.8%), although MRI was more distressing (P=0.005). Similarly, higher anticipatory anxiety was reported before MRI than before XRM (P=0.003). Relative to XRM, MRI-related distress was more likely to persist at 6 weeks after the scans in the form of intrusive MRI-related thoughts (P=0.006) and total MRI-related distress (P=0.014). More women stated that they intended to return for XRM (96.3%) than for MRI (88%; P<0.0005). These effects were most marked for the first year of screening, although they were also statistically significant in subsequent years. CONCLUSION: Given the proven benefits of MRI in screening for breast cancer in this population, these data point to the urgent need to provide timely information and support to women undergoing MRI.

Colorectal MDTs: the team's perspective.

OBJECTIVE: Multidisciplinary teams (MDTs) are an integral part of the National Cancer Plan. However, there is surprisingly little empirical research on how these are perceived by colorectal surgeons (CRSs) and colorectal clinical nurse specialists (CNSs). The purpose of this study therefore was to obtain the views of a national cohort of CRSs and CNSs regarding various important aspects of MDT functioning and role of CNS in current setting. METHOD: Two hundred and fifty-three CRSs and 177 CNSs, identified from the Association of Coloproctologists of Great Britain and Ireland, responded to an ad hoc postal questionnaire. RESULTS: 96.5% of respondents considered that MDTs improved the overall quality of care of colorectal cancer patients, and 78.6% thought MDTs were good for their morale. Eighty per cent considered that they improved training. Seventy-three per cent of surgeons and nurses thought that MDTs were cost effective, and 89% did not consider them to be a passing fad. However, more than half (50.4%) of the CRSs and 35.2% of the CNSs stated that their job plan did not contain adequate time to attend MDT meetings. Compared with CRSs, CNSs were significantly more likely to have positive views regarding the MDT (P < 0.005). CONCLUSION: CNSs and CRSs consider that colorectal MDTs have very beneficial effects on patient care, training and morale. However, many surgeons and nurse specialists consider that attendance at MDTs is not taken into account adequately in terms of their job plans, and this issue needs to be addressed.

Vascular endothelial growth factor and psychosocial factors in colorectal cancer.

BACKGROUND: Vascular endothelial growth factor (VEGF) and psychosocial factors have both been shown to have independent prognostic value in colorectal cancer. Recently, an association between VEGF and psychosocial factors has been reported in patients with ovarian cancer. METHODS: A consecutive series of eligible patients undergoing elective resection for colorectal cancer were invited to participate. Standardized measures of various aspects of quality of life (QoL) were administered 5-12 days before surgery, and again 6-8 weeks after the operation, blood samples were obtained at the same times. Solid phase ELISA was used for VEGF-A analysis using serum samples. Correlations and multiple regression analysis were used to examine the relationship between VEGF and psychosocial factors. RESULTS: One hundred and four patients with colorectal cancer were recruited. Seventy (67%) were male and the mean age was 67.6 years.A significant positive correlation was found between preoperative VEGF level and preoperative depression (r=0.227, p=0.03). Preoperative VEGF was negatively correlated with preoperative cancer-related concerns (r=-0.273, p=0.009) and positive affectivity (r=-0.219, p=0.05). Linear regression using TNM stage as a covariate showed that cancer-related concerns were an independent predictor of preoperative VEGF levels (p=0.02). Preoperative cancer-related concerns and global QoL were negatively correlated with postoperative VEGF (r=-0.381, p=0.001, r=-0.264, p=0.005), whereas preoperative depression correlated positively with postoperative VEGF (r=0.333, p=0.003). Linear regression analysis showed that preoperative HADS depression (p=0.005) and cancer-related concerns (p=0.002) were independent predictors of postoperative VEGF levels. Postoperative VEGF was significantly correlated with postoperative anxiety (r=0.249, p=0.02), depression (r=0.289, p=0.01), and functional well-being (r=-0.242, p=0.03). Linear regression analysis showed that postoperative anxiety (p=0.048), depression (p=0.013) and functional well-being (p=0.046) independently predicted postoperative VEGF-A levels. CONCLUSION: Various psychosocial factors, particularly cancer-related concerns and depression, appear to be related to preoperative and postoperative VEGF level in patients with newly diagnosed colorectal cancer. However, the clinical significance of these findings needs to be addressed in longitudinal follow-up studies of recurrence and survival. Future prognostic studies involving VEGF and related cytokines should assess psychosocial variables at various time points and include these in a multivariate analysis of outcomes.

Patient personality predicts postoperative stay after colorectal cancer resection.

OBJECTIVE: Postoperative length of stay (LOS) is an important outcome after colorectal cancer surgery. The aim of this study was to evaluate the putative effects of personality, mood, coping and quality of life on LOS. METHOD: A consecutive series of 110 eligible patients undergoing elective resection for colorectal cancer were invited to participate in the study. A battery of psychometric questionnaires including the Hospital Anxiety and Depression Scale, the Functional Assessment of Cancer Therapy (colorectal), the Courtauld Emotional Control Scale, the Positive and Negative Affectivity Scale and the Eysenck Personality Questionnaire (EPQ) were administered 5-12 days before surgery. Nonparametric correlations were computed for psychometric scores, demographic variables and the LOS. Factors found to be significantly correlated on this analysis were entered into a multiple regression model to determine the independent predictors of LOS. RESULTS: One hundred and four patients with colorectal cancer participated. Seventy were male (67%) and the mean age was 68 years (range 39-86). The median LOS was 10 days (range 4-108). LOS was negatively correlated with pre- and postoperative albumin levels, PANAS +ve affect, Functional Assessment of Cancer Therapy questionnaire with the colorectal module functional well-being score and EPQ extroversion score. LOS was strongly positively correlated with postoperative morbidity. LOS was positively correlated with CECS anger score, age and being male. Postoperative morbidity (beta = 0.379, P = 0.007) and extroversion (beta = -0.318, P = 0.05) were independent predictors of LOS. CONCLUSION: Personality as measured by EPQ predicts postoperative LOS in patients with colorectal cancer. Extroverts have a higher pain threshold and this may be part of the explanation.

Stress and burnout in colorectal and vascular surgical consultants working in the UK National Health Service.

BACKGROUND: It has been suggested that dealing with cancer is associated with increased stress and burnout in health-care professionals. The aim of this study is to examine the prevalence of psychiatric morbidity and burnout in surgeons working in the National Health Service (NHS), and the putative relationship between psychiatric morbidity, burnout and the amount of cancer-related work. METHODS: All consultant colorectal and vascular surgeons identified from their professional societies were sent a booklet consisting of questions about cancer-related and specialty-specific work load, job satisfaction and socio-demographics. It also included the General Health Questionnaire (GHQ-12), the Maslach Burnout Inventory (MBI) and the Coping Questionnaire. Logistic regression analysis was used to identify independent predictors of psychiatric morbidity (GHQ), burnout (MBI) and retirement intentions. RESULTS: Five hundred and one questionnaire booklets were completed and returned (response rate 58.7%). The mean age of respondents was 47 years (range 31-65). The majority of the surgeons were male (460, 92%). One hundred and sixty-three (33%) surgeons scored in the positive range of the GHQ, and 154 (32%) had high burnout on at least one subscale of the MBI. Three hundred and eighty-three (77%) surgeons stated that they intended to retire before the statutory retirement age. Level of work satisfaction and perceived adequacy of training in communication and management skills were significantly negatively correlated with GHQ and MBI scores. Surgeons who planned to take early retirement or wished to retire as soon as they could afford to were more likely to have psychiatric morbidity and/or burnout. Surgeons who were married or cohabiting were less likely to have psychiatric morbidity, and younger surgeons were more likely to have higher levels of depersonalization (DP). Work satisfaction was negatively correlated with psychiatric morbidity and all three burnout scales. Colorectal surgeons had a greater cancer-related workload than vascular surgeons (48.6 vs 7.5%, respectively, U=2667, p<0.005). However, there were no significant differences between the two groups in psychiatric morbidity, personal accomplishment and emotional exhaustion. Vascular surgeons, however, had significantly higher levels of DP (p=0.04). CONCLUSION: Levels of psychiatric morbidity, burnout and work dissatisfaction are worryingly high in colorectal and vascular surgeons and are likely to impact adversely on patient satisfaction and service quality. The number of surgeons intending to retire early is also a cause for concern both in terms of the overall number of trained surgeons in the NHS and in the balance between senior and junior surgeons. Apart from DP, these indicators of stress, however, were unrelated to cancer workload.

Stress and burnout among colorectal surgeons and colorectal nurse specialists working in the National Health Service.

BACKGROUND: It has been suggested that changes to the organization of the National Health Service (NHS) and clinical practices in dealing with cancer are associated with increased stress and burnout in healthcare professionals. The aim of this study, therefore, was to evaluate stress and burnout in colorectal surgeons (surgeons) and colorectal clinical nurse specialists (nurses) working in the NHS. METHOD: A list of all consultant surgeons and nurses was obtained from The Association of Coloproctology of Great Britain and Ireland. Participants were sent a questionnaire booklet consisting of standardized measures [General Health Questionnaire (GHQ), Maslach Burnout Inventory (MBI), Coping Questionnaire] and various ad hoc questions to obtain information about demographics, cancer workload and job satisfaction. Independent predictors of clinically significant distress and burnout were identified using logistic regression. RESULTS: Four hundred and fifty-five surgeons and 326 nurses were sent booklets. The response rate was 55.6% in surgeons and 54.3% in nurses. The mean age of the nurses was lower than that of surgeons (42.8 vs 47.7, P < 0.001). Psychiatric morbidity was similar in the surgeons and nurses as assessed using the GHQ (30.2% and 30.3% respectively). On the MBI, compared with nurses, surgeons had significantly higher levels of depersonalization (17.4%vs 7.4%, P = 0.003) and lower personal accomplishment (26.6%vs 14.2%, P = 0.002). Seventy-seven per cent of surgeons and 63.4% of nurses stated their intention to retire before the statutory retirement age. Coping strategies, especially those in which respondents isolated themselves from friends and family, were associated with higher psychiatric morbidity and burnout. Dissatisfaction with work, intention to retire early, intention to retire as soon as affordable and poor training in communication and management skills were also significantly associated with high GHQ scores and burnout in both groups. DISCUSSION: We found high levels of psychiatric morbidity and burnout in this national cohort of surgeons and nurses working in the NHS. However, psychiatric morbidity and burnout were unrelated to cancer workload. Nurses have lower burnout levels than surgeons and this may be related to their different working practices, responsibilities and management structure.

Psychosocial factors and quality of life in colorectal cancer.

INTRODUCTION: Colorectal cancer (CRC) is one of the most common cancers in the UK. Quality of life (QoL) is increasingly being recognised as an important endpoint in the management of CRC. METHODS: Publications describing QoL in CRC were identified using Medline (PubMed) and PsychINFO. Reference lists of these articles were used to identify other relevant publications. RESULTS: Seventy-two publications described QoL changes in CRC. These were grouped into three categories: studies of psychological and psychiatric morbidity in CRC patients, QoL and survival in CRC and effects of psychological intervention on QoL and survival. CONCLUSION: Assessment of QoL is becoming increasingly important but is not routinely performed in CRC. Standard, validated and reliable questionnaires to evaluate the impact of cancer and its treatment in patients are available. There is an increasing need to establish comprehensive biopsychosocial databases to evaluate the relationship between QoL and survival in CRC.

Predictors of early postoperative quality of life after elective resection for colorectal cancer.

INTRODUCTION: Measurement of quality of life (QoL) is assuming increasing importance in cancer care. Predictors of early postoperative QoL after colorectal cancer resection are not clear and the aim of this study was to identify these factors. METHODS: A consecutive series of eligible patients undergoing elective resection for colorectal cancer were invited to participate. Standardised, reliable and validated psychological questionnaires (HADS, PANAS, MRS, FACT-C, EQ-5D) were administered seven days prior to surgery and then six weeks after discharge. RESULTS: One hundred and four patients with colorectal cancer were recruited. There were 70 males (67.3%) and the mean age of the group was 67.6 years. Postoperative anxiety and depression were closely related to the preoperative anxiety and depression scores (p < 0.001). Other QoL scores also showed significant correlation with the respective preoperative scores. Anxiety, depression, and FACT functional wellbeing scores were also correlated with the incidence of postoperative morbidity. On multiple regression analysis postoperative morbidity, tumour node metastasis (TNM) stage, presence of stoma and preoperative QoL scores were found to independently predict postoperative QoL scores. CONCLUSION: Routine preoperative QoL measurement in cancer patients can identify patients at risk of having a poor QoL postoperatively. Suitable psychological and pharmaceutical intervention can be planned in advance for this group.

Retinal lead toxicity.

A 35-year-old female who had suffered from acute lead poisoning when she was 22 years old, presented 13 years later with loss of vision in the right eye and normal vision in the left eye. She had a pale disc, narrowed arterioles and mid-peripheral heavy pigmentation, right eye being more affected than the left eye. Electrodiagnostic tests identified marked asymmetry of visual function. We would postulate lead retinal toxicity as the cause of the asymmetric findings.

Long-term outcome of cognitive behaviour therapy clinical trials in central Scotland.

OBJECTIVES: To establish the long-term outcome of participants in clinical trials of cognitive behaviour therapy (CBT) for anxiety disorders and psychosis, examining the effectiveness and cost-effectiveness associated with receiving CBT in comparison with alternative treatments. DESIGN: An attempt was made to contact and interview all of the participants in eight randomised, controlled, clinical trials of CBT for anxiety disorders and two randomised, controlled, clinical trials of CBT for schizophrenia conducted between 1985 and 2001. Case note reviews of healthcare resources used in the 2 years prior to entering the trials and the 2 years prior to follow-up interview were undertaken. SETTING: Mixed rural and urban settings in five localities in central Scotland. Anxiety disorder trials were conducted mainly in primary care and included three with generalised anxiety disorder, four with panic disorder and one with post-traumatic stress disorder (PTSD). The psychosis studies (one on relapse prevention and one with chronic disorder) were conducted in secondary care. PARTICIPANTS: Of the 1071 entrants to the 10 studies, 489 agreed to participate (46% of original entrants, 52% of those available to contact). INTERVENTIONS: Follow-up interviews took place between 1999 and 2003, 2-14 years after the original treatment. Interviews for Trials 1-8 were conducted by a research psychologist blind to original treatment condition. Interviews for Trials 9 and 10 were conducted by community psychiatric nurses also blind to treatment condition. Case note reviews were completed following the interview. MAIN OUTCOME MEASURES: For Trials 1-8 the main interview-based outcome measures were: Anxiety Disorders Interview Schedule-DSM-IV for diagnosis and co-morbidity, Clinical Global Severity (0-8) and the Hamilton Anxiety Rating Scale. The main patient-rated measures were: Brief Symptom Inventory, SF-36 II, Clinical Global Improvement (1-7), and the Positive and Negative Affect Scale. For Trials 9 and 10 the primary outcome measure was the interview-based Positive and Negative Syndrome Scale (PANSS). RESULTS: For the anxiety disorder studies (Trials 1-8), over half of the participants (52%) had at least one diagnosis at long-term follow-up, with significant levels of co-morbidity and health status scores comparable to the lowest 10% of the general population. Only 36% reported receiving no interim treatment for anxiety over the follow-up period with 19% receiving almost constant treatment. Patients with PTSD did particularly poorly. There was a 40% real increase in healthcare costs over the two time periods, mainly due to an increase in prescribing. A close relationship was found between poor mental and physical health for those with a chronic anxiety disorder. Treatment with CBT was associated with a better long-term outcome than non-CBT in terms of overall symptom severity but not with regard to diagnostic status. The positive effects of CBT found in the original trials were eroded over longer time periods. No evidence was found for an association between more intensive therapy and more enduring effects of CBT. Long-term outcome was found to be most strongly predicted by the complexity and severity of presenting problems at the time of referral, by completion of treatment irrespective of modality and by the amount of interim treatment during the follow-up period. The quality of the therapeutic alliance, measured in two of the studies, was not related to long-term outcome but was related to short-term outcome. The cost-effectiveness analysis showed no advantages of CBT over non-CBT. The cost of providing CBT in the original trials was only a very small proportion (6.4%) of the overall costs of healthcare for this population, which are high for both physical and mental health problems. In the psychosis studies (Trials 9 and 10), outcome was generally poor with only 10% achieving a 25% reduction in total PANSS scores from pretreatment to long-term follow-up, also cost-effectiveness analysis showed no advantages of CBT over non-CBT, although healthcare costs fell over the two time periods mainly owing to a reduction in inpatient costs. CONCLUSIONS: Psychological therapy services need to recognise that anxiety disorders tend to follow a chronic course and that good outcomes with CBT over the short term are no guarantee of good outcomes over the longer term. Clinicians who go beyond standard treatment protocols of about 10 sessions over a 6-month period are unlikely to bring about greater improvement. Poor outcomes over the long term are related to greater complexity and severity of presenting problems at the time of referral, failure to complete treatment irrespective of modality and the amount of interim treatment during the follow-up period. The relative gains of CBT are greater in anxiety disorders than in psychosis. Longitudinal research designs over extended periods of time (2-5 years), with large numbers of participants (500+), are required to investigate the relative importance of patient characteristics, therapeutic alliance and therapist expertise in determining the cost-effectiveness of CBT in the longer term.

Return to the asylum: the search for clients with enduring mental health problems in Italy.

Deinstitutionalization and community care were the most influential movements in the field of mental health in the last 30 years. In 1978 Italy was the first country to pass laws that would eliminate mental hospitals and replace them with community-based services. Italian ideas about community care provided inspiration for care in the community legislation when this was introduced in the UK. In order to be able to fairly assess and describe the benefits of Italian mental health care, the author visited a range of care facilities in a prescribed region in the north of Italy. In the course of investigation, the author sought to discover if the implementation of what were regarded by some as radical community attitudes in the care of people with mental health problems had led to innovative approaches when dealing with patients/clients requiring long-term care and treatment. Although the Italian approach is enlightened in many areas of care, the system still has to face up to the problems presented in caring for clients/patients with enduring mental health problems. The circumstances relating to care were unexpected and caused the author to revise his opinion of the Italian approach to community care.

Identification of selective inhibitors of cyclin dependent kinase 4.

A new structural type of kinase inhibitor, containing a benzocarbazole nucleus, has been identified. Members of the series are selective for inhibition of the cyclin dependent kinase family of enzymes. Although the cdks are highly homologous, representatives of the series showed intra-cdk selectivities, especially for cdk4. SAR studies elucidated the important features of the molecules for inhibition.

Reducing therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care: global measures of outcome in a randomised controlled trial.

BACKGROUND: Panic disorder, with and without agoraphobia, is a prevalent condition presenting in general practice. Psychological treatments are effective but are limited by restricted availability. Interest has grown in methods by which the efficiency and thus availability of psychological treatments can be improved, with particular emphasis on reduced therapist contact formats. AIM: To evaluate the relative efficacy in a primary care setting of a cognitive behaviour therapy (CBT) delivered at three levels of therapist contact: standard contact, minimum contact, and bibliotherapy. METHOD: A total of 104 patients were randomly allocated to receive standard therapist contact, minimum therapist contact or bibliotherapy, with 91 patients completing treatment. All patients received an identical treatment manual and were seen by the same psychologist therapist. Outcome was reported in terms of brief global ratings of severity of illness, change in symptoms, and levels of social disruption. These brief measures were chosen to be suitable for use in general practice and were used at treatment entry and endpoint. RESULTS: The standard therapist contact group had the strongest and most comprehensive treatment response, showing significant differences from the bibliotherapy group on all, and the minimum therapist contact group on some, endpoint measures. Some reduction in efficacy was therefore found for the reduced therapist contact groups. CONCLUSION: The standard therapist contact group showed the greatest treatment efficacy in the present study. As it was of notably shorter duration than many other current formulations of CBT, it represents a useful and efficient treatment for panic disorder and agoraphobia in primary care.

Analysis of site-specific phosphorylation of the retinoblastoma protein during cell cycle progression.

Differential phosphorylation of the retinoblastoma protein plays a pivotal role in cell cycle regulation. The retinoblastoma protein is specifically phosphorylated during the cell cycle by cyclin-dependent kinase complexes which intersect with many cellular signaling networks. Since the loss of the retinoblastoma signaling pathways occurs in a wide variety of human tumors, understanding the significance of site-specific phosphorylation can clarify the role of selected cyclin-dependent kinase complexes during cell cycle progression. Here we describe the phosphospecificity and cellular characterization of a panel of polyclonal antibodies that recognize unique phosphorylation sites within the retinoblastoma protein. These reagents were used to validate authentic cellular retinoblastoma phosphorylation sites at amino acids 780, 795, and 807/811 correlating with the G1-S transition.

Global measures of outcome in a controlled comparison of pharmacological and psychological treatment of panic disorder and agoraphobia in primary care.

BACKGROUND: Panic disorder, with and without agoraphobia, is a prevalent condition which presents primarily in general practice. Previous clinical outcome studies have been conducted mainly in specialist university departments or hospital settings, and have tended to employ complex rating scales that are not well suited for use as outcome measures in primary care. AIM: To evaluate the outcome, in a primary care setting, of fluvoxamine versus cognitive behaviour therapy, each used alone and in combination in a double-blind placebo-controlled framework, balanced for therapist contact. METHOD: A total of 149 patients satisfying DSMIII-R criteria for panic disorder were randomly allocated to receive one of the following: fluvoxamine, placebo, fluvoxamine plus cognitive behaviour therapy, placebo plus cognitive behaviour therapy, and cognitive behaviour therapy alone. These five treatment groups represent the minimum number acceptable for such a comparison to be made. All patients received an identical schedule of contact over 13 weeks. Measures of symptom severity, general health and social disruption were taken at entry point and end point; measures of change in symptoms were taken at end point only. Outcome was reported in terms of brief global ratings of severity of illness and change in symptoms, and of ratings of general health and social disruption that are suitable for use in general practice. RESULTS: All active treatment groups showed statistically significant advantages over placebo over a range of outcome ratings. The groups employing cognitive behaviour therapy showed the most robust and consistent response. CONCLUSION: The brief global measures reported here proved adequate to the task of assessing treatment outcome. Results indicate that treatments including cognitive behaviour therapy can be effective in the treatment of panic disorder and agoraphobia in primary care.

Treatment-outcome research in panic disorder: dilemmas in reconciling the demands of pharmacological and psychological methodologies.

Panic disorder with or without agoraphobia has been the subject of sustained treatment-outcome research. Studies have been conducted by both pharmacologically- and psychologically-oriented researchers each employing their own methodologies. Problems arise in attempting to reconcile the demands of these two treatment-outcome methodologies, whilst at the same time ensuring that research designs reflect the reality of wider clinical practice. In the following discussion a series of studies comparing pharmacological and psychological treatments for panic disorder and agoraphobia are reviewed. The review highlights areas where the competing demands of research design and clinical applicability lead to dilemmas for the researcher. Attempts to overcome such dilemmas are described and alternative solutions discussed.

Controlled comparison of the characteristics of patients with panic disorder.

BACKGROUND: Increased general practice attendance rates have been associated with the diagnosis of mental illness but panic disorder has not been specifically investigated in this respect. In addition, studies have failed adequately to assess type and frequency of secondary care referral and patterns of psychotropic prescription in patients with panic disorder in relation to matched controls. AIM: This study set out to compare subjects with panic disorder with age and sex matched controls on measures of general practice consultation rate; psychotropic and non-psychotropic drug use; referral to secondary care, laboratory and radiological tests and hospital admissions; history of illness and complaints; and psychiatric comorbidity. METHOD: The study was carried out in nine practices in the Forth Valley area. One hundred patients with panic disorder, previously diagnosed using DSM III-R criteria, were identified and matched by age and sex with controls. Data were collected by review of general practice case notes. RESULTS: Subjects with panic disorder had significantly higher rates of general practice consultation over the 10 year period prior to DSM III-R diagnosis of panic disorder than controls. Subjects with panic disorder had also been prescribed a significantly greater number of psychotropic and non-psychotropic medications over this period, had had more secondary care investigations and had higher rates of mainly minor illness and related complaints than controls. High comorbidity of panic disorder with depression which had been diagnosed over the 10 year period prior to DSM III-R diagnosis of panic disorder was found. CONCLUSION: The results of this study describe a population of subjects with panic disorder who are long-term heavy users of primary care services. The results also suggest an association between panic disorder and both minor illness and psychiatric comorbidity over the 10 year period prior to DSM III-R diagnosis of panic disorder.

Linkage analysis in X-linked congenital stationary night blindness.

X-linked congenital stationary night blindness (XL-CSNB) is a nonprogressive disorder of the retina, characterized by night blindness, reduced visual acuity, and myopia. Previous studies have localized the CSNB1 locus to the region between OTC and TIMP on the short arm of the X chromosome. We have carried out linkage studies in three XL-CSNB families that could not be classified as either complete or incomplete CSNB on the criteria suggested by Miyake et al. (1986. Arch. Ophthalmol. 104: 1013-1020). We used markers for the DXS538, DMD, OTC, MAOA, DXS426, and TIMP loci. Two-point analyses show that there is close linkage between CSNB and MAOA (theta max = 0.05, Zmax = 3.39), DXS426 (theta max = 0.06, Zmax = 2.42), and TIMP (theta max = 0.07, Zmax = 2.04). Two multiply informative crossovers are consistent with CSNB lying proximal to MAOA and distal to DXS426, respectively. Multipoint analysis supports this localization, giving the most likely order as DMD-17 cM-MAOA-7.5 cM-CSNB-7.5 cM-DXS426/TIMP-cen, and thus refines the localization of CSNB.