The benefits of index telephone consultations in patients referred on the two-week wait colorectal cancer pathway.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic led to hospitals in the UK substituting face-to-face (FtF) clinics with virtual clinic (VC) appointments. We evaluated the use of virtual two-week wait (2-ww) lower gastrointestinal (LGI) clinic appointments, conducted using telephone calls at a district general hospital in England. METHODS: Patients undergoing index outpatient 2-ww LGI clinic assessment between 1 June 2019 and 31 October 2019 (FtF group) and 1 June 2020 and 31 October 2020 (VC group) were identified. Relevant data were obtained using electronic patient records. Compliance with national cancer waiting time targets was assessed. Environmental and financial impact analyses were performed. RESULTS: In total, 1,531 patients were analysed (median age=70, male=852, 55.6%). Of these, 757 (49.4%) were assessed virtually via telephone; the remainder were seen FtF (n=774, 50.6%). Ninety-two (6%, VC=44, FtF=48) patients had malignant pathology and 64 (4.2%) had colorectal cancer (CRC); of these, 46 (71.9%, VC=26, FtF=20) underwent treatment with curative intent. The median waiting times to index appointment, investigation and diagnosis were significantly lower following VC assessment (p<0.001). The cancer detection rates (p=0.749), treatments received (p=0.785) and median time to index treatment for CRC patients (p=0.156) were similar. A significantly higher proportion of patients were seen within two weeks of referral in the VC group (p<0.001). VC appointments saved patients a total of 9,288 miles, 0.7 metric tonnes of CO2 emissions and £7,482.97. Taxpayers saved £80,242.00 from VCs. No formal complaints were received from patients or staff in the VC group. CONCLUSION: Virtual 2-ww LGI clinics were effective, safe and were associated with tangible environmental and financial benefits.

Magnetic resonance enterography in Crohn's disease: a comparison with the findings at surgery.

AIM: Magnetic resonance (MR) enterography is a radiation-free small bowel investigation which identifies luminal and extra-luminal pathology in patients with Crohn's disease. Most studies have validated MR against conventional radiology. We evaluated the results of MR enterography by comparison with findings at elective surgery for patients with Crohn's disease, including complex pathology. METHOD: Between January 2007 and March 2012 the results of preoperative MR enterography for Crohn's disease in consecutive patients in one unit were compared with the detailed findings at surgery. RESULTS: Fifty-one patients underwent 55 laparotomies during the study period. MR enterography identified the presence of Crohn's disease in the distal ileum in 33/34 patients, in the proximal ileum in 7/12 patients, in the jejunum in 7/8 patients, in the large bowel in 10/11 patients and in the duodenum in one of two patients. MR enterography identified ileo-enteric fistula in 10/12 patients, ileosigmoid fistula in all of seven patients and other fistulae in 10/11 patients. An abscess was identified on MR enterography in eight of nine patients. Within abnormal distal ileal segments, the mean contrast enhancement ratio of acute inflammation was 2.39 ± 0.59 compared with 1.82 ± 0.63 (P < 0.05) in segments with fibrosis only. CONCLUSION: Magnetic resonance enterography identifies small bowel Crohn's disease with an accuracy similar to or better than those of previously published series. Fistulation, abscess formation and large bowel disease can be reliably identified and disease activity assessed. Normal, uninvolved small bowel length can also be measured. Discrete proximal small bowel lesions may not always be detected. In our practice, MR enterography has replaced conventional radiology in the assessment of symptomatic patients with Crohn's disease.

Patients at risk: addressing addiction in patients undergoing hematopoietic SCT.

Addictive disorders are common and underdiagnosed in the general medical population. While it is well recognized that alcohol consumption is linked to cancers of the head and neck as well as the large bowel, its association with cancers for which hematopoietic SCT (HSCT) is a modality of treatment is not as clear. Further, the complications of alcohol or other drug addiction in patients undergoing HSCT has not been well studied. However, patients with comorbid substance use disorders (SUDs) are at higher risk for morbidity and mortality while undergoing HSCT due to medical sequelae of SUDs and issues of social support, adherence to treatment plans, and impairment of judgment and decision-making. Behavioral patterns of patients with SUDs are clearly relevant factors to consider in patient selection, management and outcome. We offer a review of the existing literature and recommendations for assessment and management of this patient population.

Early results of immediate repair of obstetric third-degree tears: 65% are completely asymptomatic despite persistent sphincter defects in 61%.

OBJECTIVE: The outcome of immediate repair of obstetric third-degree tears is poorly documented. Immediate repair may give better functional results than delayed repair because scarring is reduced. This aim of this prospective study was to examine the early outcome of immediate repair of third-degree tears. METHOD: A total of 121 women who had immediate repair of obstetric third-degree tears underwent interview, anal ultrasonography and anorectal physiology. RESULTS: At review, 79 (65%) were completely asymptomatic (score = 0), 23 (19%), had minor flatus incontinence or mild urgency causing no compromise to their quality of life (score 1-4), and 19 (16%) had clinically embarrassing faecal incontinence (score 5-24). Thirty-nine (32%) had an intact internal anal sphincter (IAS) and external anal sphincter (EAS) (i.e. a successful repair), eight (7%) had a defect in the IAS alone but the EAS was intact (i.e. a successful repair but a residual IAS defect), 43 (35%) had a residual defect in the EAS alone (IAS intact) and 31 (26%) had a persistent defect in the IAS and EAS. Residual defects in either or both of the sphincters were associated with a significantly higher incidence of abnormal resting and squeeze anal pressures. Anal manometry had no correlation with symptoms. The highest proportion of severe incontinence was in those with an IAS defect alone (37%) and when there was a residual IAS and EAS defect (24%). Only 2 of 39 (5%) with an intact IAS and EAS had severe incontinence and only 8 of 43 (18%) with a residual EAS defect alone had severe faecal incontinence. CONCLUSION: These results indicate a good outcome following immediate repair of third-degree obstetric tears and emphasize the role of the IAS in providing continence.

Detection of BRAF mutations in colorectal tumours and peritoneal washings using a mismatch ligation assay.

AIMS: To detect cells bearing BRAF mutations in colorectal tumour samples and peritoneal washings, using a mismatch ligation assay (MLA). METHODS: DNA from 46 colorectal tumours was studied. Part of exon 15 of the BRAF gene was amplified using the polymerase chain reaction, and T-->A mutations at codon 600 were detected using MLA. When a mutation was detected, the same mutation was sought in peritoneal washings from that patient. RESULTS: BRAF mutations were detected in five of the 45 analysable tumour samples. In four cases, this result was confirmed by sequencing analysis. More tumours with BRAF mutations were Dukes' stage C or D rather than A or B (p < 0.02). Dilution experiments revealed that one mutant cell could be detected in 1000 normal cells. Cells with the same BRAF mutation were present in the peritoneal washing taken at the start of the operation in four of the five patients. CONCLUSIONS: MLA is a suitable technique for the detection of BRAF mutations, and allows the detection of small numbers of isolated tumour cells shed from the primary tumour.

Training residents for community psychiatric practice: the resident perspective.

OBJECTIVE: To capture the views and experiences of psychiatry residents in 5 Canadian training programs with respect to community psychiatric training. METHOD: We sent a questionnaire regarding respondent demography, career interests, and community psychiatry training experiences to psychiatry residents at 5 training programs in Ontario. We undertook descriptive analyses and frequency comparisons on the returned data. RESULTS: The overall response rate was 48%, with considerable variation between programs. With respect to career planning, respondents indicated highest interest in urban hospital-based practice. An interest in additional community psychiatry training was, however, expressed, particularly by junior residents. Residents' suggestions for improving community psychiatry training included better promotion of training opportunities, improved quality of supervision in community settings, and more didactic teaching. CONCLUSION: Psychiatry residents are obtaining training experiences in community psychiatry, but objectives and guidelines are quite variable, as is reflected in their understanding of the definition of "community psychiatry." Residents' career paths are still focused on urban hospital-based practice or solo private practice, which likely reflects their prevalent training experiences. There is, however, interest in community psychiatry training. Junior residents may be more open to this type of practice, and curricula should allow more exposure to community psychiatry at this stage of training.

Predictors of outcome in a short-term psychiatric day hospital program.

This study assessed selected chronicity, social support, and personality variables as predictors of outcome in a 3-week psychiatric day hospital program. Measured outcome included pre- and post-treatment scores on the BDI, STAI, and SCL-90-R from 224 patients. A single outcome variable based on the average standardized residual changes scores for these measures was derived to assess whether symptom severity at discharge was greater or less than predicted. Predictor variables were analysed using multiple regression. Chronicity variables predicted outcome, with patients hospitalized more than once and those with personality disorders more symptomatic than expected after treatment. Social support and personality variables failed to predict outcome; however, patients who scored higher on the MMPI Si scale were more symptomatic than expected at discharge. Although these results possess marginal clinical utility in terms of accounting for symptom change variation, this study overcame some methodological difficulties seen in prior day hospital literature. Future research should consider a prospective approach, including random treatment assignment, comprehensive and diverse outcome measures, and exploration of specific diagnostic groups.

Clinical rating of compliance in chronic hemodialysis patients.

OBJECTIVE: To develop a clinical rating scale of treatment compliance for use in chronic hemodialysis patients and to test its reliability and validity. METHOD: Forty-eight of 65 patients undergoing hemodialysis treatment at the Ottawa General Hospital during June 1994 met criteria for inclusion and completed the study. Patients underwent a 10-15-minute interview, with 1 of 2 independent clinical interviewers, regarding diet, fluid intake, prescribed medication usage, smoking, alcohol or drug use, and hemodialysis treatment attendance. Following each interview, a predesigned 3-point rating scale evaluating compliance in each of 6 domains (yielding an 18-point total score) to the treatment regimen was completed. Compliance ratings on 10 patients assessed independently by both interviewers were used to establish scale reliability. Criterion validity was assessed by correlating compliance scale scores with 3 biological measures (weight gain [kg], K+ [mmol/l], and PO4 [mmol/l]). RESULTS: Reliability between clinical interviewers using the overall compliance scale score (Intraclass correlation coefficient = 0.825) as well as component subscales was high (kappa values, 0.33-1.00). Biological measures of compliance correlated well with each other but poorly with clinical ratings (range 0.01-0.16). Biological measures identified compliance as being poorer than that found with the clinical interview scale. CONCLUSIONS: The Compliance Rating Scale (CRS) was shown to be reliable but was not well-validated against selected biological measures. Discrepancies between these 2 methods of assessing compliance may be due to differing underlying compliance constructs or patient or interviewer biases. The CRS has value as a patient education tool in that it can be used to instruct patients regarding the benefits of adhering to the treatment regimen.

Sleep spindles and arousal: the effects of age and sensory stimulation.

This study assessed a proposed sleep-preserving role for sleep spindles by evaluating variations in this activity as a function of factors, both naturally occurring and experimentally induced, known to affect and effect arousal from sleep. These factors included age, auditory stimulation, and experimentally induced arousal from sleep. Analyses were based on data from 84 males (5-49 yrs. old) from normal and clinical (hyperactive, enuretic, and chronic pain) populations who had participated in sleep auditory arousal threshold studies involving adaptation and 1-2 experimental nights. Spindles on experimental nights were visually analyzed and incidence determined for the two minutes preceding and throughout all Stage 2 arousal attempts. Prestimulation spindle occurrence in 39 preadolescent subjects with two experimental nights did not vary significantly from night-to-night, and prestimulation period comparisons between clinical groups and their respective controls were also non-significant. Anticipated relationships between spindle activity and indices of arousal-either inverse with respect to known variations in arousal threshold, i.e., decreases with age and across the night, or direct with respect to stimulus intensity particularly on trials when arousal did not occur-were not observed. Instead, all age groups showed significant decreases in spindle density as an increasing negative function of stimulus intensity. These findings suggest that to the extent to which sleep spindles can be considered to play a role in sleep preservation by inhibiting or attenuating potentially arousing stimuli, these effects appear to be restricted to endogenously generated stimuli and are passive rather than reactive in nature.

Factors associated with unplanned discharge from psychiatric day treatment programs. A multicenter study.

This study describes and evaluates the adequacy of sociodemographic and clinical descriptors as potential predictors of unplanned discharge from and completion of psychiatric day treatment programs. A 2-year retrospective chart review was completed on all patients (N = 327) attending three university-affiliated day treatment programs. Statistical comparisons were made between those patients who completed and those who had unplanned discharge. Logistic regression was used to generate a predictive model of unplanned discharge using identified variables. The rate of unplanned discharge was 54%. Factors associated with program completion were diagnoses of major depression or posttraumatic stress disorder, a history of completing a prior day treatment program, and higher education levels. Active substance abuse and a history of three or more inpatient admissions were associated with unplanned discharge. The predictive model was able to correctly classify 71% of patients completing day treatment programs and 43% of patients with unplanned discharges. Traditional demographic and clinical variables contribute differentially to program completion/noncompletion. Given the relatively poor predictability of unplanned discharge in this study, patient selection practices based on these factors alone may be somewhat limiting. Interactive effects of patient and program characteristics need to be addressed to improve program outcome.

Elevated sleep arousal thresholds in enuretic boys: clinical implications.

Enuretic children are described as difficult to arouse from sleep. We studied auditory sleep arousal thresholds in enuretic boys and report on the clinical implications of these findings. Fifteen enuretic and 18 control subjects (7-12-year-old males) were studied in a sleep laboratory for four consecutive nights using standard polysomnographic recording techniques. Sleep was undisturbed for the initial two nights and waking thresholds were measured on the following two nights. Enuretic children wet most frequently in the first two-thirds of the night. Arousal attempts were successful 39.7% of the time in controls and only 9.3% of the time in enuretics. In conclusion, enuretic males were more difficult to arouse than age-matched controls. The elevated arousal thresholds may be due to delayed maturation. Treatment programmes that rely on awakening should be aware of these features.

Acute day hospitalization as an alternative to inpatient treatment.

OBJECTIVE: This paper describes the administrative process by which the Ottawa General Hospital (OGH) closed 6 beds and used the staff and space resources thus released to set up an acute day hospital (ADH) for the treatment of 8 acutely ill psychiatric patients. Outcome data are presented on the first 160 patients admitted to the ADH. METHODS: Demographic and clinical information including diagnostic (DSM-III-R; Global Assessment of Functioning [GAF]) and questionnaire data (Symptom Checklist-90 Revised [SCL-90R]; Beck Depression Inventory [BDI]; State-Trait Anxiety Inventory [STAI]; patient satisfaction) were obtained from 160 ADH patients at admission and discharge. Forty-two of these patients provided follow-up data 3 to 6 months postdischarge. The outcome of ADH patients was compared with that of a retrospectively obtained random sample (n = 100) of inpatients on selected diagnostic and demographic variables. RESULTS: On clinician-rated and self-report clinical scales, ADH patients showed significant clinical improvement reflected in higher GAF scores and less psychological distress, depression, and anxiety at discharge relative to admission. There were no significant group differences in outcome indices except for shorter length of stay in the ADH group compared with inpatients. The ADH group rated the program highly in help received and quality of service. Short-term follow-up showed that gains made during treatment were maintained 3 to 6 months later. CONCLUSIONS: These results show that a time-limited day hospital program is clinically effective for acutely ill psychiatric patients and leads to a more efficient use of inpatient resources. We believe that partial hospitalization for the treatment of acute psychiatric disorders may have wide application in psychiatric hospital practice.

Heart rate associated with sleep onset in preadolescents.

It is well-established that heart rate is decreased in NREM sleep relative to wakefulness, but the extent and progression of variations in heart rate when NREM sleep is first initiated, i.e. at sleep onset, have not been detailed. Furthermore, since physiological variations which have been documented during the sleep onset period have been based on studies of adult subjects, developmentally related influences on this process have not been examined. The present investigation addressed these issues by examining beat-to-beat (RR interval) changes in heart rate during the transitions between wakefulness, initial Stage 1, and subsequent Stage 2 sleep in normal and reading disabled male preadolescents who participated in a four-consecutive-night baseline sleep study. To avoid the influence of sleep deprivation or the effects of multiple sleep onset attempts, only initial, uninterrupted sleep onset periods from post-adaptation nights were selected for study. For both groups the results indicated a significant slowing of heart rate beginning 30s prior to Stage 1 onset, and a further decrease within 30s of Stage 2 onset. In addition to providing new developmental data documenting heart rate variations in the wake/sleep transition, these results complement previous reports indicating motor and autonomic changes occurring in anticipation of Stage 1 onset. These data are also relevant to an ongoing controversy regarding whether initial Stage 1 or Stage 2 sleep should be considered as the time of sleep onset. To the extent that the systematic and coordinated variations across systems may be taken as an index of state change, and in the absence of remarkable differences in these variations between Stage 1 and subsequent Stage 2, the present data are most consistent with considering initial Stage 1 as the earliest EEG sign of physiological sleep onset.

Heart rate variations during sleep in preadolescents.

Heart rate variations during sleep have been documented for infant and adult populations, but not for children and adolescents. To provide normative data for the preadolescent age group, this investigation used a combination of time-domain measures and nonlinear procedures (Poincare plots) to describe heart rate variations during two consecutive nights of undisturbed baseline sleep in 14 normal 8- to 10-year-old males. Heart rate variables, based on all-night analyses of computer-determined beat-to-beat (RR) intervals, were related to sleep stage and sleep cycle measures within and across nights. Time-domain summary statistics revealed a tendency for higher mean heart rates in rapid eye movement (REM) compared to slow-wave (SW) and stage 2 sleep, but the differences were not significant. Heart rate variability, as measured by average RR interval standard deviation, was greatest in stage 2 and least in SW sleep, but it did not vary significantly across sleep stages. Analyses of heart rate variables across the initial four sleep cycles showed a significant heart rate decrease (quadratic trend) and a significant increase (linear trend) for heart rate variability. All effects replicated across nights. Poincare plots revealed wide-ranging individual differences, generally characterized by greater dispersion at longer RR intervals and a remarkable night-to-night consistency in whole-night as well as stage-specific patterns. The sleep-stage plots uniformly indicated reduced overall range and variability in SW relative to REM and stage 2 and a general equivalence of stage 2 and REM patterns. The results indicate several features of sleep-related heart rate variations in preadolescents that differ from those in adults. The differences can be attributed to developmental variations in autonomic cardiac control and are consistent with increased parasympathetic influences reported to occur at this time.

Characteristics of patients who choose between two types of group psychotherapy.

Patient selection or matching to group psychotherapy is usually done by therapists. An alternative is to allow patients to "sample" and then select from different group therapies. In the current study characteristics of patients (N = 20) who selected from two types of group psychotherapy in a day-treatment program were examined. Patients were assessed on measures of current psychiatric symptomatology (Symptom Checklist 90-Revised [SCL-90R]; Derogatis, Rickles & Rock, 1976), psychological mindedness (McCallum & Piper, 1990) and psychological defenses Mechanisms Inventory (Ihilevich & Gleser, 1986). The two groups did not differ with regard to symptomatology or psychological mindedness. It was found that patients who chose a verbal and process-oriented psychotherapy tended to have externalizing defenses (turning anger against others and projection), however. These defenses appear to be congruent with this more emotionally expressive therapy. Patients who chose a structured and activity-oriented group psychotherapy tended to have internalizing defenses (repression/denial and intellectualization). These defenses seem consistent with this group therapy, which emphasized less emotional expressiveness. The implications of patient choice for group therapy and patient selection practices are discussed.

Ontogenetic variations in auditory arousal threshold during sleep.

Developmental variations in auditory arousal thresholds during sleep were investigated in four groups of normal male subjects--children, preadolescents, adolescents, and young adults. Arousal thresholds were determined during NREM and REM sleep for tones presented via earphone insert on a single night following two adaptation nights of undisturbed sleep. Age-related relationships were observed for both awakening frequency and stimulus intensity required to effect awakening, with awakenings occurring more frequently in response to lower stimulus intensities with increasing age. Although stimulus intensities required for awakening were high and statistically equivalent across sleep stages in nonadults, higher intensity stimuli were required in Stage 4 relative to Stage 2 and REM sleep in adults. These results confirm previous observations of marked resistance to awakening during sleep in preadolescent children and suggest that processes underlying awakening from sleep undergo systematic modification during ontogenetic development.

Sleep patterns in reading disabled children.

Sleep patterns in reading disabled (n = 24) and normal control (n = 15) 8-10-year-old boys were compared to examine suggested relationships among sleep, maturational and cognitive processes. Sleep was recorded in the laboratory for four consecutive nights (two adaptation, two baseline) using standard polysomnography. Analyses revealed variations across nights for both groups reflecting adaptation to the sleep laboratory, but such effects were attenuated in reading disabled subjects. Group comparisons on baseline sleep measures (nights 3 and 4 collapsed) revealed that reading disabled children showed significantly more stage 4 sleep, less rapid eye movement (REM) sleep, a longer REM onset latency and, related to this, an extended initial non-REM (NREM) cycle. Chronic sleep deprivation and maturational delay are prominent among factors that could result in such variations in sleep architecture, and these factors, alone or in combination, could impair information processing and contribute to cognitive deficits noted in reading disabled children.

Patient satisfaction with a psychiatric day treatment program.

Patient perceptions can contribute significantly to partial hospitalization program evaluation. A retrospective study of patients' satisfaction ratings and comments concerning a day treatment program using a discharge questionnaire yielded high degrees of satisfaction. This may reflect a priori selection biases toward patients who formed a working alliance within the program. Comparison with a group of patients admitted to the program who did not complete a discharge questionnaire failed to differentiate the two groups on the basis of demographic or clinical characteristics. Attendance by males admitted to the program who completed a questionnaire was significantly (p less than .01) more frequent than by males who did not complete the questionnaire. Consistency in individual component ratings with overall satisfaction with the program suggests nonspecific benefits, with group psychotherapy evoking polarized perceptions. The latter observation suggests the need for careful matching of patients with specific treatment modalities employed in a day treatment setting. Suggestions are made regarding the administration and construction of a patient satisfaction questionnaire as well as for the application of this measure in enhancing program efficacy.

Auditory arousal thresholds during sleep in hyperkinetic children.

Auditory arousal thresholds were determined throughout sleep (4-night protocol) in prepubertal nonmedicated and medicated hyperkinetic and normal control male children. The most striking result was the general inability to arouse children of all groups to behavioral response even at intensities up to 123 dB sound pressure level. Of total awakening attempts, 52.5% resulted in non-arousal, 13% resulted in partial, nonsustained physiological arousal responses, and 34.3% were associated with complete awakenings. A significant increase in proportion of awakenings and decrease in the frequency of nonarousals occurred across the night. The groups did not differ with respect to the number of arousal responses. Although nonmedicated hyperkinetic children tended to have lower arousal thresholds relative to children in both comparison groups, the only significant group difference was a lower threshold response in nonmedicated, relative to medicated, hyperkinetic subjects during stage 2 sleep. Arousal thresholds in hyperkinetic children receiving stimulant medication approximated those of normal control children. The enhanced sensitivity of nonmedicated hyperkinetic subjects to auditory stimuli during sleep is interpreted as indicating that processes responsible for elevating arousal threshold at this time are less effective in these children.