Justifying the expense of the cancer Clinical Nurse Specialist.

In order to maximise patient care, assessment of the adequacy of the service provision by the Clinical Nurse Specialist (CNS) must be regularly undertaken. This study attempted to determine whether CNSs were providing an adequate service via retrospective and prospective audit. The results of a comprehensive audit of the work of the CNS within a tertiary referral Hepatobiliary Unit are presented. The audit involved postal and telephone questionnaires as well as prospective collection of data. The majority of responses from patients were positive, with many finding the CNS a useful and well-utilised contact. Overall, the CNSs performed well in each of their designated tasks; however, areas were still identified which could be further improved. Audit is essential in providing feedback to the CNS and to identify areas which require improvement. The CNS has evolved to meet a clinical gap in patient care, and as a result, the role of a CNS is frequently nebulous or poorly defined. This renders evaluation of the CNS problematic and fraught with difficulties. However, a thorough assessment can still be made using carefully constructed audit looking at each task of the CNS.

A fuller understanding of pancreatic neuroendocrine tumours combined with aggressive management improves outcome.

BACKGROUND: Neuroendocrine tumours of the pancreas (PNETs) represent 1-2% of all pancreatic tumours. The terms 'islet cell tumours' and 'carcinoids' of the pancreas should be avoided. The aim of this review is to offer an overview of the history and diagnosis of PNETs followed by a discussion of the available treatment options. METHODS: A search on PubMed using the keywords 'neuroendocrine', 'pancreas' and 'carcinoid' was performed to identify relevant literature over the last 30 years. RESULTS: The introduction of a revised classification of neuroendocrine tumours by the World Health Organisation (WHO) in 2000 significantly changed our understanding of and approach to the management of these tumours. Advances in laboratory and radiological techniques have also led to an increased detection of PNETs. Surgery remains the only treatment that offers a chance of cure with increasing number of non-surgical options serving as beneficial adjuncts. The better understanding of the behaviours of PNETs together with improvements in tumour localisation has resulted in a more aggressive management strategy with a concomitant improvement in symptom palliation and a prolongation of survival. CONCLUSION: Due to their complex nature and the wide range of therapeutic options, the involvement of specialists from all necessary disciplines in a multidisciplinary team setting is vital to provide optimal treatment of this disease.

Cystic lesions of the pancreas. A diagnostic and management dilemma.

BACKGROUND/AIMS: Due to enhanced imaging modalities, pancreatic cysts are being increasingly detected, often as an incidental finding. They comprise a wide range of differing underlying pathologies from completely benign through premalignant to frankly malignant. The exact diagnostic and management pathway of these cysts remains problematic and this review attempts to provide an overview of the pathology underlying pancreatic cystic lesions and suggests appropriate methods of management. METHODS: A search was undertaken with a Pubmed database to identify all English articles using the keywords 'pancreatic cysts', 'serous cystadenoma', 'intraductal papillary mucinous tumour', 'pseudocysts', 'mucinous cystic neoplasm' and 'solid pseudopapillary tumour'. RESULTS: The mainstay of assessment of pancreatic cysts is cross-sectional imaging incorporating CT and MRI. Fine-needle aspiration (FNA) (often with endoscopic ultrasound) may provide valuable additional information but can lack sensitivity. Symptomatic cysts, increasing age and multilocular cysts (with a solid component and thick walls) are predictors of malignancy. A raised cyst aspirate CEA, CA 19-9 and mucin content (including abnormal cytology), if present, can accurately distinguish premalignant and malignant cysts from benign ones. CONCLUSION: In summary, all patients with pancreatic cystic lesions, whether asymptomatic or symptomatic, must be thoroughly investigated to ascertain the underlying nature of the cyst. Small asymptomatic cysts (<3 cm) with no suspicious features on imaging or FNA may be safely followed up. Follow-up should continue for at least 4 years, with a repeat FNA if needed. An algorithm for the management of pancreatic cystic tumours is also suggested. and IAP.

Clomipramine treatment of trichotillomania: a follow-up report on four cases.

Four consecutive patients treated for trichotillomania (hair pulling) with clomipramine reported initially dramatic reductions in symptoms. However, three of the four patients had relapsed completely at 3-month follow-up, although all four were still taking previously effective levels of the drug. The fourth patient relapsed for about 2 weeks but regained initial treatment benefits. Implications for the treatment of trichotillomania are discussed.

Panic onset and major events in the lives of agoraphobics: a test of contiguity.

Major life events were reported in greater numbers and by a higher percentage of 50 index agoraphobics during a time period around panic onset than during either a within-subjects or a between-subjects control period. These differences were found for analyses of life events in general, events that preceded panic, and foreseeable events that occurred shortly after panic onset. Though many events involved separation or interpersonal conflict, other types of events were frequently reported. Results provide more convincing evidence than prior studies of a contiguous relationship between life events and onset of panic attacks associated with agoraphobia.

Help-seeking patterns of community residents with depressive symptoms.

From a community sample, fifty-five individuals identified as having three or more symptoms of depression were asked if and where they had sought help and how they found or would find treatment. Only 20 subjects (33.9%) reported having sought professional help. No demographic differences were found between help-seekers and non-help-seekers. Eighty percent of the help-seekers had seen a mental health professional while 20% had seen a non-psychiatric physician. However, non-psychiatric physicians and friends or personal acquaintances were most frequently cited as the first point of contact for locating treatment. Results suggest that most individuals with a moderate number of depressive symptoms do not seek professional assistance but that, among those who do, a majority is eventually seen by a mental health professional. Virtually all utilize intermediaries other than mental health professionals, however, to locate assistance. The non-psychiatric physician plays a prominent role in locating help for depressed individuals, which suggests the need to educate physicians about appropriate treatment referral.

Late-life-onset panic disorder: clinical and demographic characteristics of a patient sample.

Although panic disorder is generally believed to begin in young adulthood, 13 cases of panic disorder with an initial onset after age 60 years have recently been seen at our clinics. Other than the time of life in which the first panic attack occurred, clinical and demographic profiles of these 13 patients were similar to those that have been reported for panic disorder patients whose panic began earlier in life. These findings indicate that panic disorder can affect older adults with no previous history of panic attacks, but further research is needed to determine the clinical and theoretical significance of late-life-onset panic disorder.

Use of mobile phones in the behavioral treatment of driving phobias.

Results of two case studies are presented to illustrate the use of mobile phones with in vivo exposure treatment of refractory driving phobias. Number of miles driven and subjective ratings of anxiety were recorded during a baseline phase and 8 weeks of treatment involving a total of 24 driving practices. One subject's use of a mobile phone increased the number of miles driven alone, but the second subject made little progress and regressed following removal of the phone. These two cases and our experience with other patients suggest that mobile phones can benefit many individuals whose therapeutic progress is impeded by a fear of driving alone, but that phones are counterproductive for certain patients. The potential benefits and disadvantages of using mobile phones are discussed.

Habituation to fear stimuli in a case of obsessive compulsive disorder: examining the generalization process.

The purpose of this investigation was to determine if habituation of anxiety to a visual form of the number 13 would generalize to other forms (auditory, behavioral and cognitive) of the number 13 in a 20-year-old male with obsessive compulsive disorder. Treatment included exposure and response prevention. A multiple baseline design across fear stimulus forms was used. Habituation to the visual form began generalizing to other forms of the number 13 before prolonged exposures to these three stimulus forms were instituted. Results suggest that exposure to a single stimulus form may result in sufficient generalization of treatment effects in cases involving seemingly independent fear responses to several forms of a stimulus.

Inpatient behavior therapy: the St. Louis University model.

Many of the problems that impede the practice of behavior therapy on traditional psychiatric and medical inpatient services can be avoided by a separate behaviorally-oriented inpatient unit, but few guidelines exist for establishing such a unit. The present paper describes the inpatient Behavioral Treatment Unit developed at St. Louis University Medical Center. Critical administrative and clinical features of the Unit are discussed, including the administrative philosophy which emphasizes unit autonomy and participative management, the central role of nursing staff, the importance of the clinical team system, the development of referral sources, admission procedures and criteria, and basic approaches to assessment and treatment.

Managing panic attacks in emergency patients.

Patients experiencing panic attacks often seek help at emergency departments. However, the symptoms of panic can be difficult to distinguish from some common medical emergencies. Furthermore, many emergency medicine clinicians may not be equipped to deal effectively with panic attacks and related psychiatric conditions such as panic disorder and agoraphobia. Early misdiagnosis and inadequate management of panic attacks can have devastating long-term clinical and financial consequences. The purpose of this paper is to provide information designed to increase the comfort and efficacy of emergency physicians and allied professionals in dealing with panic attacks. The authors offer guidelines regarding differential diagnosis, present strategies for management of acute symptoms of panic and anxiety, and make recommendations for brief postpanic clinical intervention.

Prevalence of various depressive symptoms in a sample of the general population.

Data on prevalence of and demographics associated with various symptoms of depression are reported for a sample of the general population. Of the nine symptoms assessed, the most frequently occurring were dysphoric mood (17.8%), increased sleep (15%), and loss of interest in other people or activities previously enjoyed (11.8%). 39% of subjects reported one or more symptoms of depression. 8% of subjects reported wondering if life is worth living, a symptom that in and of itself is suggestive of clinically significant depression. The number of depressive symptoms reported was related to income, education, age, and residence (city versus county), but not to sex. The findings provide evidence that various symptoms of depression may be more common in the general population than previously suspected.

The impact of potential islet precursor cells on islet autotransplantation outcomes.

Islet autotransplant patients represent excellent subjects to assess the posttransplant impact of islet precursors, as chronic pancreatitis (CP) causes an elevation of ductal cells, pancreatic precursors cells, and hormone-positive acinar cells. The relationship between these cell types and autograft outcomes should be more apparent than would be the case in the context of an allograft program with confounding immunological variables. To improve diabetic control following total pancreatectomy for CP, nonpurified islets were autotransplanted into the liver. Pancreas specimens were recovered from 23 patients and stained for antigens including: insulin, glucagon, cytokeratin 19, cytokeratin 7, and PDX-1. In line with previous reports, the prevalence of ductal cells, non-islet endocrine cells and non-islet PDX-1-expressing cells was significantly higher in CP glands compared with normal pancreata. When correlating follow-up data (i.e., fasting and stimulated C-peptide/glucose levels and HbA1c%) with pancreas immunoreactivity, high levels of ductal cells, non-islet PDX-1-positive cells, and non-islet glucagon-positive cells were associated with superior outcomes, detectable up to 2 years posttransplant. To conclude, the acinar parenchyma and ductal epithelium of the CP pancreas show an upregulation of both endocrine and pre-endocrine cell types, which appear to have a positive effect on islet graft outcomes in autotransplantation setting.