Work-related post-traumatic stress symptoms in obstetricians and gynaecologists: findings from INDIGO, a mixed-methods study with a cross-sectional survey and in-depth interviews.

OBJECTIVES: To explore obstetricians' and gynaecologists' experiences of work-related traumatic events, to measure the prevalence and predictors of post-traumatic stress disorder (PTSD), any impacts on personal and professional lives, and any support needs. DESIGN: Mixed methods: cross-sectional survey and in-depth interviews. SAMPLE AND SETTING: Fellows, members and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG). METHODS: A survey was sent to 6300 fellows, members and trainees of RCOG. 1095 people responded. Then 43 in-depth interviews with trauma-exposed participants were completed and analysed by template analysis. MAIN OUTCOME MEASURES: Exposure to traumatic work-related events and PTSD, personal and professional impacts, and whether there was any need for support. Interviews explored the impact of trauma, what helped or hindered psychological recovery, and any assistance wanted. RESULTS: Two-thirds reported exposure to traumatic work-related events. Of these, 18% of both consultants and trainees reported clinically significant PTSD symptoms. Staff of black or minority ethnicity were at increased risk of PTSD. Clinically significant PTSD symptoms were associated with lower job satisfaction, emotional exhaustion and depersonalisation. Organisational impacts included sick leave, and 'seriously considering leaving the profession'. 91% wanted a system of care. The culture in obstetrics and gynaecology was identified as a barrier to trauma support. A strategy to manage the impact of work-place trauma is proposed. CONCLUSIONS: Exposure to work-related trauma is a feature of the experience of obstetricians and gynaecologists. Some will suffer PTSD with high personal, professional and organisational impacts. A system of care is needed. TWEETABLE ABSTRACT: 18% of obstetrics and gynaecology doctors experience post-traumatic stress disorder after traumatic events at work.

STRAWB2 (Stress and Wellbeing After Childbirth): a randomised controlled trial of targeted self-help materials to prevent post-traumatic stress disorder following childbirth.

OBJECTIVES: To test whether providing psychological self-help materials would significantly lower the incidence of post-traumatic stress disorder (PTSD) at 6-12 weeks postnatally. DESIGN: Open-label randomised controlled trial, with blinded outcome assessment. SETTING: Community midwifery services in two National Health Service (NHS) trusts in the North West. SAMPLE: A cohort of 2419 women receiving normal NHS postnatal care. METHODS: Midwives screened women for traumatic birth experience; 678 women who screened positively (28.1%) were randomly allocated to self-help with usual care (n = 336) or to usual care alone (n = 342). The self-help materials were a leaflet and online film designed to prevent the development of PTSD after trauma exposure through explaining how to manage early psychological responses. MAIN OUTCOME MEASURE: The primary outcome was a composite of diagnostic and subdiagnostic PTSD at 6-12 weeks postnatally using the gold-standard Clinician-Administered PTSD Scale (CAPS-5) interview. RESULTS: Of the 678 women correctly randomised plus the nine women randomised in error, 478 (70.5%) were followed up. Diagnostic or subdiagnostic PTSD rates at follow-up did not differ between groups who received self-help (26.7%, 65/243) or usual care alone (26.2%, 64/244) (intention-to-treat analysis: RR 1.02, 95% CI 0.68-1.53). Findings remained consistent in the per-protocol analysis (RR 1.04, 95% CI 0.85-1.27). Women viewed the materials very positively. There were no adverse effects. Health economic micro-costing indicated implementation would be very low cost. CONCLUSIONS: Many women experience a traumatic birth and risk developing PTSD, but self-help strategies without professional support are insufficient and should not be routinely introduced. TWEETABLE ABSTRACT: Self-help information alone does not reduce the number of women developing PTSD after a traumatic childbirth.

Identifying fear of childbirth in a UK population: qualitative examination of the clarity and acceptability of existing measurement tools in a small UK sample.

BACKGROUND: Fear of childbirth is related to but not synonymous with general anxiety, and represents a superior predictor for maternal and infant outcomes. There is a need to improve the identification and provision of support for women experiencing high fear of childbirth. However it is uncertain as to whether existing measurement tools have appropriate content validity (i.e. cover the relevant domains within the construct), practical utility, and whether they are acceptable for use with a UK population. This study aimed to (1) identify the utility and acceptability of existing measures of fear of childbirth (FOC) with a small UK sample and (2) map the content of existing measures to the key concepts of fear of childbirth established by previous research. METHODS: Ten pregnant women; five with high and five with low fear of childbirth participated in a cognitive interview covering four most commonly used measures of fear of childbirth: 1. The Wijma Delivery Expectancy Questionnaire (WDEQ A), 2. The Oxford Worries about Labour Scale (OWLS), 3. The Slade-Pais Expectations of Childbirth Scale - fear subscale (SPECS) and 4. The Fear of Birth scale (FOBS). Each measure was also reviewed by participants for ease and clarity of understanding and acceptability. The measures were then reviewed against the key domains identified in the fear of childbirth literature to ascertain the adequacy of content validity of each measure. Interviews were analysed using thematic analysis for each scale item. RESULTS: All measures except the FOBS, included items that either women did not understand or, if where there was understanding the meanings were inconsistent across women. All measures demonstrated limited acceptability and content validity for the specific construct of FOC. Therefore, none of the measurement tools currently used within the UK met criteria for understanding, acceptability and content validity for measurement of FOC. CONCLUSIONS: Findings emphasise a need to develop a specific fear of childbirth tool with good clarity which demonstrates appropriate content validity, and that is acceptable in presentation and length for pregnant women in a UK population.

Establishing a valid construct of fear of childbirth: findings from in-depth interviews with women and midwives.

BACKGROUND: Fear of childbirth (FOC) can have a negative impact on a woman's psychological wellbeing during pregnancy and her experience of birth. It has also been associated with adverse obstetric outcomes and postpartum mental health difficulties. However the FOC construct is itself poorly defined. This study aimed to systematically identify the key elements of FOC as reported by women themselves. METHODS: Semi-structured interviews with pregnant women (n = 10) who reported to be fearful of childbirth and telephone interviews with consultant midwives (n = 13) who regularly work with women who are fearful of childbirth were conducted. Interviews were analysed using thematic analysis for each group independently to provide two sources of information. Findings were reviewed in conjunction with a third source, a recently published meta-synthesis of existing literature of women's own accounts of FOC. The key elements of FOC were determined via presence in two out of the three sources at least one of which was from women themselves, i.e. the reports of the women interviewed or the meta-synthesis. RESULTS: Seven themes were identified by the women and the consultant midwives: Fear of not knowing and not being able to plan for the unpredictable, Fear of harm or stress to the baby, Fear of inability to cope with the pain, Fear of harm to self in labour and postnatally, Fear of being 'done to', Fear of not having a voice in decision making and Fear of being abandoned and alone. One further theme was generated by the women and supported by the reports included the meta-synthesis: Fear about my body's ability to give birth. Two further themes were generated by the consultant midwives and were present also in the meta-synthesis: Fear of internal loss of control and Terrified of birth and not knowing why. CONCLUSIONS: Ten key elements in women's FOC were identified. These can now be used to inform development of measurement tools with verified content validity to identify women experiencing FOC, to support timely access to support during pregnancy.

Can community midwives prevent antenatal depression? An external pilot study to test the feasibility of a cluster randomized controlled universal prevention trial.

BACKGROUND: Repeated epidemiological surveys show no decline in depression although uptake of treatments has grown. Universal depression prevention interventions are effective in schools but untested rigorously in adulthood. Selective prevention programmes have poor uptake. Universal interventions may be more acceptable during routine healthcare contacts for example antenatally. One study within routine postnatal healthcare suggested risk of postnatal depression could be reduced in non-depressed women from 11% to 8% by giving health visitors psychological intervention training. Feasibility and effectiveness in other settings, most notably antenatally, is unknown. METHOD: We conducted an external pilot study using a cluster trial design consisting of recruitment and enhanced psychological training of randomly selected clusters of community midwives (CMWs), recruitment of pregnant women of all levels of risk of depression, collection of baseline and outcome data prior to childbirth, allowing time for women 'at increased risk' to complete CMW-provided psychological support sessions. RESULTS: Seventy-nine percent of eligible women approached agreed to take part. Two hundred and ninety-eight women in eight clusters participated and 186 termed 'at low risk' for depression, based on an Edinburgh Perinatal Depression Scale (EPDS) score of <12 at 12 weeks gestation, provided baseline and outcome data at 34 weeks gestation. All trial protocol procedures were shown to be feasible. Antenatal effect sizes in women 'at low risk' were similar to those previously demonstrated postnatally. Qualitative work confirmed the acceptability of the approach to CMWs and intervention group women. CONCLUSION: A fully powered trial testing universal prevention of depression in pregnancy is feasible, acceptable and worth undertaking.

Self-hypnosis for intrapartum pain management in pregnant nulliparous women: a randomised controlled trial of clinical effectiveness.

OBJECTIVE: (Primary) To establish the effect of antenatal group self-hypnosis for nulliparous women on intra-partum epidural use. DESIGN: Multi-method randomised control trial (RCT). SETTING: Three NHS Trusts. POPULATION: Nulliparous women not planning elective caesarean, without medication for hypertension and without psychological illness. METHODS: Randomisation at 28-32 weeks' gestation to usual care, or to usual care plus brief self-hypnosis training (two × 90-minute groups at around 32 and 35 weeks' gestation; daily audio self-hypnosis CD). Follow up at 2 and 6 weeks postnatal. MAIN OUTCOME MEASURES: Primary: epidural analgesia. Secondary: associated clinical and psychological outcomes; cost analysis. RESULTS: Six hundred and eighty women were randomised. There was no statistically significant difference in epidural use: 27.9% (intervention), 30.3% (control), odds ratio (OR) 0.89 [95% confidence interval (CI): 0.64-1.24], or in 27 of 29 pre-specified secondary clinical and psychological outcomes. Women in the intervention group had lower actual than anticipated levels of fear and anxiety between baseline and 2 weeks post natal (anxiety: mean difference -0.72, 95% CI -1.16 to -0.28, P = 0.001); fear (mean difference -0.62, 95% CI -1.08 to -0.16, P = 0.009) [Correction added on 7 July 2015, after first online publication: 'Mean difference' replaced 'Odds ratio (OR)' in the preceding sentence.]. Postnatal response rates were 67% overall at 2 weeks. The additional cost in the intervention arm per woman was £4.83 (CI -£257.93 to £267.59). CONCLUSIONS: Allocation to two-third-trimester group self-hypnosis training sessions did not significantly reduce intra-partum epidural analgesia use or a range of other clinical and psychological variables. The impact of women's anxiety and fear about childbirth needs further investigation.

Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care.

BACKGROUND: To test whether receiving care from a health visitor (HV) trained in identification and psychological intervention methods prevents depression 6-18 months postnatally in women who are not depressed 6 weeks postnatally. METHOD: The study was a prospective cluster trial, randomized by GP practice, with follow-up for 18 months in 101 primary care teams in the Trent area of England. The participants were women scoring <12 on the postal Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks postnatally (1474 intervention and 767 control women). Intervention HVs (n=89, 63 clusters) were trained in identifying depressive symptoms using the EPDS and face-to-face clinical assessment and in providing psychologically orientated sessions based on cognitive behavioral or person-centered principles. The control group comprised HVs (n=49, 37 clusters) providing care as usual (CAU). The primary outcome measure was the proportion of women scoring ≥ 12 on the EPDS at 6 months postnatally. Secondary outcomes were mean EPDS score, Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) score, State-Trait Anxiety Inventory (STAI), 12-item Short Form Health Survey (SF-12) and Parenting Stress Index Short Form (PSI-SF) scores at 6, 12 and 18 months. RESULTS: After adjusting for individual-level covariates, living alone, previous postnatal depression (PND), the presence of one or more adverse life events and the 6-week EPDS score, the odds ratio (OR) for EPDS ≥ 12 at 6 months was 0.71 [95% confidence interval (CI) 0.53-0.97, p=0.031] for the intervention group (IG) women compared with the control (CAU) group women. Two subgroups were formed by baseline severity: a 'subthreshold' subgroup with a 6-week EPDS score of 6-11 (n=999) and a 'lowest severity' subgroup with a 6-week EPDS score of 0-5 (n=1242). There was no difference in psychological effectiveness by subgroup (interaction term: z=-0.28, p=0.782). CONCLUSIONS: This study provides new evidence of a universal, enduring preventive effect for depression in women who screen negative for depression postnatally.

Relationships between attachment, appraisal, coping and adjustment in men and women experiencing infertility concerns.

BACKGROUND: Attachment style may influence distress and relationship satisfaction in infertile couples. Appraisal and coping have also been linked to adjustment to infertility and may be related to attachment patterns. The study examined these associations in men and women around the time of attending initial appointments at fertility clinics. METHODS: Attachment, appraisal, coping, general well-being, infertility-related stress and relationship satisfaction questionnaires were completed by 98 women and 64 men. Data were analysed by gender comparisons, correlations and path analysis. RESULTS: Attachment anxiety was associated with well-being in women via appraisal of infertility as a loss and use of self-blame and avoidance (SBA) coping. Attachment anxiety was also linked with infertility-related stress through SBA. In men, attachment anxiety was associated with well-being and infertility-related stress again via SBA coping. Attachment anxiety and avoidance were related to lower relationship satisfaction in women, whereas only the former was important for men. CONCLUSIONS: Attachment patterns link to couples' relationship satisfaction and are associated with adjustment via appraisal and coping. Identification of such patterns may assist in identifying need and tailoring cognitive interventions to individuals. Participants were mainly white and well-educated, and wider generalization cannot automatically be assumed.

Preoperative anxiety and postoperative satisfaction in women undergoing elective caesarean section.

BACKGROUND: The primary aim was to investigate whether preoperative anxiety in women undergoing elective caesarean section predicts postoperative maternal satisfaction with the process, perceptions of recovery, analgesic use or length of hospital stay. Other factors that might influence postoperative satisfaction were also explored. METHOD: In 85 women awaiting elective caesarean section, anxiety, social support and aspects of preparation were measured in the 24 hours preceding surgery. Maternal satisfaction and perceptions of recovery were assessed around the third postoperative day. Satisfaction with the preoperative information from the anaesthetist and postoperative pain relief were also measured at this time. Medical notes were used to gather information on analgesia use and length of hospital stay. RESULTS: Preoperative anxiety scores were comparable with those of general surgical/medical patients. Preoperative trait anxiety and state anxiety were inversely associated with postoperative maternal satisfaction. State anxiety was also inversely associated with better recovery. Preoperative anxiety was not associated with analgesic use or length of hospital stay. Linear regression analysis indicated the degree of satisfaction with information from the anaesthetist and perceived emotional support from the partner explained 52% of the variance in postoperative maternal satisfaction. CONCLUSION: Lower preoperative anxiety is associated with greater maternal satisfaction with elective caesarean section and better recovery. Information provided by anaesthetists and perceived emotional support are also of importance. It may be possible to identify women with high anxiety and facilitate satisfaction and recovery through providing additional supportive input.

The selective 5-HT1B receptor inverse agonist 1'-methyl-5-[[2'-methyl-4'-(5-methyl-1,2, 4-oxadiazol-3-yl)biphenyl-4-yl]carbonyl]-2,3,6,7-tetrahydro- spiro[furo[2,3-f]indole-3,4'-piperidine] (SB-224289) potently blocks terminal 5-HT autoreceptor function both in vitro and in vivo.

5-HT1 receptors are members of the G-protein-coupled receptor superfamily and are negatively linked to adenylyl cyclase activity. The human 5-HT1B and 5-HT1D receptors (previously known as 5-HT1Dbeta and 5-HT1Dalpha, respectively), although encoded by two distinct genes, are structurally very similar. Pharmacologically, these two receptors have been differentiated using nonselective chemical tools such as ketanserin and ritanserin, but the absence of truly selective agents has meant that the precise function of the 5-HT1B and 5-HT1D receptors has not been defined. In this paper we describe how, using computational chemistry models as a guide, the nonselective 5-HT1B/5-HT1D receptor antagonist 4 was structurally modified to produce the selective 5-HT1B receptor inverse agonist 5, 1'-methyl-5-[[2'-methyl-4'-(5-methyl-1,2, 4-oxadiazol-3-yl)biphenyl-4-yl]carbonyl]-2,3,6, 7-tetrahydrospiro[furo[2,3-f]indole-3,4'-piperidine] (SB-224289). This compound is a potent antagonist of terminal 5-HT autoreceptor function both in vitro and in vivo.

The behavioural effects of corticotropin-releasing factor-related peptides in rats.

The present study determined the behavioural effects of the corticotropin releasing factor (CRF)-related peptides, human/rat CRF (h/rCRF), ovine CRF (oCRF), sauvagine (SAUV), urotensin I (UT) and the recently discovered neuropeptide, rat urocortin (rUCN). All of the peptides dose-dependently increased motor activity in a familiar environment and reduced feeding in hungry rats. There was no apparent relationship between potency/affinity at CRF2 receptors and effects in these two tests. In a comparison of h/rCRF and rUCN upon discrete spontaneous behaviours, both peptides (3.0 microg i.c.v.) increased activity and grooming, induced a fore-paw tremor and reduced the incidence of motionlessness. However, h/rCRF reduced motionlessness to a greater extent and was a more potent inducer of defaecation, weight loss, oral movements and fore-paw tremor than rUCN. In the elevated X maze, both h/rCRF and rUCN (1.0 microg i.c.v.) had anxiogenic-like effects upon behaviour. In contrast, h/rCRF (1.0 microg i.c.v.), but not rUCN (1.0-10 microg i.c.v.) increased the startle response to an acoustic stimulus. In summary, all the CRF-related peptides increased motor activity and reduced feeding in rats in a similar manner and both rUCN and h/rCRF induced anxiogenesis. However, there were some behavioural differences between rUCN and h/rCRF which require further study. Further pharmacological investigation of the role of CRF receptor subtypes requires the use of subtype selective antagonists.

A computer-controlled apparatus for measuring and analysing myoclonic jerk activity in guinea pigs.

Guinea pigs respond to 5-hydroxytryptophan (5-HTP) with a complex behavioural syndrome which includes distinctive whole-body jerks (myoclonic jerks). These are species-specific, involve all major muscle groups, are highly rhythmic and can occur with relatively high frequency (1-2/s). Current methods of quantifying the response, which rely on observer ratings are unsatisfactory. We report the development of a fully automated, PC-based system for detecting and analysing myoclonic jerks. Floor-mounted accelerometers generate a movement signal and detection is performed by an algorithm based on a detailed analysis of the topography of myoclonic jerk responses. The system can monitor the output from 10 purpose-built test enclosures and it provides for pseudorandom treatment allocation, flexible control of experimental parameters and automated data output to a spreadsheet which generates appropriate graphs, statistical summaries and data analysis. This robust response provides a useful means of exploring the role of novel 5-HT receptor subtypes in guinea-pig behaviour.

The role of 5-HT1D and 5-HT1A receptors in mediating 5-hydroxytryptophan induced myoclonic jerks in guinea pigs.

Systemic administration of 5-hydroxytryptophan (5-HTP) to guinea pigs causes species-specific, rhythmic, whole body jerks (myoclonic jerks), the frequency and amplitude of which were measured in an automated apparatus. The brain penetrant 5-HT1D receptor agonist 3-(2-dimethylaminoethyl)-4-chloro-5-propoxyindole hemifumarate (SKF 99101H) (3-30 mg/kg i.p.) and the selective 5-HT1A receptor agonist (+/-)8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT) (0.3-3 mg/kg s.c.) dose dependently potentiated the frequency and intensity of myoclonic jerks caused by 5-HTP (100 mg/kg). Cotreatment of guinea pigs with 8-OH-DPAT (3 mg/kg s.c.) and SKF 99101H (30 mg/kg i.p.), which were inactive when given alone, gave a marked myoclonic jerk response. Conversely, the myoclonic jerk response to higher doses of 5-HTP (150 mg/kg i.p.) was dose dependently blocked by the 5-HT1D receptor antagonist GR 127935 (N-[4-methoxy-3-(4-methyl-1-piperazinyl)phenyl]-2'-methyl-4'-(5-methyl-1 ,2,4-oxadiazol-3-yl)[1,1'-biphenyl]4-carboxamide oxalate) (ED50 0.32 mg/kg i.p.) and the selective 5-HT1A receptor antagonist WAY 100635 (N-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-N-(2-pyridinyl) cyclohexanecarboxamide trihydrochloride) (ED50 0.33 mg/kg i.p.). The response to 5-HTP (150 mg/kg i.p.) was also blocked by ritanserin (0.01-0.3 mg/kg i.p.). Our data therefore confirm previous reports concerning the effects of 5-HT2A/2C receptor blockade on 5-HTP induced myoclonic jerks and suggest that both 5-HT1D and 5-HT1A receptors play an important role in mediating this behavioural response.

Stimulation of 5-HT1B receptors causes hypothermia in the guinea pig.

The selective, brain penetrant, 5-HT(1B/D) (formerly 5-HT(1D beta/alpha)) receptor agonist SKF-99101H (3-(2-dimethylaminoethyl)-4-chloro-5-propoxyindole hemifumarate) (30 mg/kg i.p.) causes a dose related fall in rectal temperature in guinea pigs which previous studies have shown to be blocked by the non-selective 5-HT(1B/D) receptor antagonist GR-127935 (N-[4-methoxy-3-(4-methyl-1-piperazinyl) phenyl]-2'-methyl-4'-(5-methyl-1,2,4-oxadiazol-3-yl) [1,1'biphenyl]-4-carboxamide oxalate). The present study shows that the hypothermic response to SKF-99101H is dose-dependently blocked by SB-224289G (1'-methyl-5-(2'-methyl-4'-[(5-methyl-1,2,4-oxadiazol-3-yl)bipheny l-4-yl]carbonyl)-2,3,6,7-tetrahydrospiro[furo[2,3-f]indole-3,4'-pi peridone] hemioxalate) (0.3-10.0 mg/kg p.o.) (ED50 3.62 mg/kg), which is the first compound to be described which is more than 60 fold selective for the 5-HT1B receptor over the 5-HT1D receptor. SB-216641A (N-[3-(2-dimethylamino) ethoxy-4-methoxy-phenyl] 2'-methyl-4'-(5-methyl-1,2,4-oxadiazol-3-yl)-(1,1'-biphenyl)-4-car boxamide hydrochloride) (0.6-20.0 mg/kg i.p.), which is somewhat less selective (30 fold) for the 5-HT1B receptor over the 5-HT1D receptor had a similar effect (ED50 4.43 mg/kg). The brain penetrant 5-HT1D selective receptor antagonist, BRL-15572 (4-(3-chlorophenyl)-alpha-(diphenylmethyl)-1-piperazineethanol+ ++ dihydrochloride) (0.3-100.0 mg/kg i.p.) was inactive. When administered alone neither BRL-15572 (0.1-10 mg/kg i.p.) nor SB-224289G (2.2-22 mg/kg p.o.) had an effect on body temperature. These data demonstrate that 5-HT1B (formerly 5-HT(1D beta)) and not 5-HT1D (formerly 5-HT(1D alpha)) receptors mediate the hypothermic response to SKF-99101H (30 mg/kg i.p.) in guinea pigs. The compounds described are useful pharmacological tools for distinguishing responses to 5-HT1B and 5-HT1D receptors.

Motivation to comply with infection control procedures.

This paper addresses the critical issue of motivating hospital staff to comply with standard infection control procedures. Previous psychological assessment of infection control knowledge, attitudes and behaviour has indicated that the reasons for non-compliance are very basic and reflect inter alia a low perception of the importance of the measures and a lack of motivation. It is argued that, although staff have a theoretical awareness of the value of complying with such procedures, in practice these seem to have a low priority. Compliance levels, therefore, are variable and generally of a low order. If recent advances in the fields of social psychology, behavioural psychology and clinical psychology could be imported to hospital medicine, they could have a dramatic impact in infection control. The Elaboration Likelihood Model, an effective theoretical approach to message-based persuasion, and the energizing effects of intrinsic and extrinsic motivational processes are defined. Finally, the implications of these concepts for persuasive intra-hospital communication in infection control are highlighted. They can provide a framework for developing effective infection prevention programmes.

Reducing the endoscopic workload: does serological testing for Helicobacter pylori help?

OBJECTIVE: Serological screening for Helicobacter pylori (H. pylori) in young (< or = 45 years) dyspeptic patients has been used to avoid oesophago-gastro-duodenoscopy (OGD). We used serology to identify seronegative and seropositive patients without sinister symptoms and combined approaches of avoiding OGD in both groups. We aimed to determine the reduction of OGD in this group. DESIGN: Prospective study on the treatment of 232 patients with dyspepsia. SETTING: Six hundred and fifty bed district general hospital serving rural Northamptonshire, UK. INTERVENTIONS: Two hundred and thirty-two patients referred by local general practitioners for OGD were offered serology. Symptom severity was scored using a questionnaire. One hundred and eleven seronegative patients received symptomatic treatment, 105 seropositive patients received triple therapy for 1 week. Sixteen patients with equivocal results were offered OGD. Patients were followed up after 6 months. MAIN OUTCOME MEASURES: Severity of dyspepsia symptoms and proportion of patients returning for OGD. RESULTS: Fifteen equivocal patients underwent OGD, one refused. Forty-six patients (33 seronegative, 13 seropositive) had persisting symptoms and underwent OGD. Mean symptom severity was reduced significantly in equivocal (P<0.01), seronegative (P<0.001) and seropositive (P<0.001) patients. Fewer seronegative patients were symptom-free at follow up compared to seropositive patients (n = 15 (16%) vs n = 48 (51%); P<0.001), 171 patients avoided OGD, a 74% reduction. CONCLUSIONS: Use of H. pylori serology in the management of young dyspeptic patients without sinister symptoms can reduce the OGD workload by 74%, decreasing the length of time that older patients, who are at greater risk of malignant disease, may have to wait for OGD.

5-HT 1D receptors mediate SKF 99101H-induced hypothermia in the guinea pig.

The selective, brain penetrant, 5-HT(1D) receptor agonist SKF 99101H (10-30 mg/kg i.p.) caused a dose-related fall in rectal temperature in guinea pigs which lasted longer than 2 h. Sumatriptan (1.0-100 mg/kg i.p.), a selective 5-HT(1D) agonist which does not penetrate the brain, did not produce hypothermia, suggesting that peripheral mechanisms are not critically involved in the response. The hypothermia induced by SKF 99101H (30 mg/kg i.p.) was dose-dependently blocked by the 5-HT(1D) receptor antagonists GR 127935 (0.01-1 mg/kg i.p.) and GR 125743 (0.01-3 mg/kg i.p.), confirming the role of 5-HT(1D) receptors. Mianserin (0.3-10.0 mg/kg i.p.) and granisetron (0.1-3.0 mg/kg i.p.) were inactive, suggesting that 5-HT(2A/2B/2C) or 5-HT( 3) receptors play no significant role in the generation of the hypothermic response. Nor was the hypothermia reversed by prazosin (0.03-1.0 mg/kg i.p.), idazoxan (0.03-1.0 mg/kg i.p.) or scopolamine (0.01-0.3 mg/kg i.p.), thereby excluding mediation by α(1)- and α(2)-adrenoceptors and muscarinic receptors. WAY 100635 (0.1-1.0 mg/kg) significantly potentiated the effect of SKF 99101H. The antagonists, when given alone, had no effect on body temperature, with the exception of prazosin (0.1 and 1.0 mg/kg). Three days of treatment with parachloroamphetamine (30 mg/kg i.p.) depleted forebrain 5-HT by ∼ 75% in frontal cortex, hypothalamus, hippocampus and striatum, but failed to alter the hypothermic response to SKF 99101H. The hypothermia is, therefore, unlikely to be mediated by 5-HT(1D) receptors located on 5-HT neurons. SKF 99101H-induced hypothermia in the guinea pig may serve as a useful model for investigation of centrally acting 5-HT( 1D) receptor antagonists.

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.

Premenstrual emotional changes in normal women: fact or fiction?

One hundred and eighteen women reported their experiences of symptoms on a daily basis. They were unaware that the study concerned the menstrual cycle. There was evidence of cyclic changes peaking premenstrually and menstrually for physical symptoms but psychological changes occurred randomly throughout the cycle. A possible explanation for the discrepancy between beliefs about the occurrence of symptoms and ratings of symptoms from daily reports is explored. This relies on the experience of random emotional fluctuations and differential patterns of attribution.

Miscarriage as a traumatic event: a review of the literature and new implications for intervention.

This review considers the psychological impact of miscarriage and follow-up care. A fifth of pregnancies end in miscarriage, and the experience leads to emotional consequences such as depression and anxiety, which may last for several months. Some have explored the focus of psychological morbidity and attempted to discover predictors of adjustment, but results are inconclusive. Grief has been identified as a feature of postmiscarriage distress, but trauma associated with the process of miscarriage has been neglected. Despite the recognized impact, there is dissatisfaction with professional emotional care, and there is no routine follow-up. There have been no controlled intervention studies with women who miscarry during early pregnancy, although anecdotal evidence suggests beneficial effects. Such studied have concentrated on loss, but perhaps future research should consider the whole experience of miscarriage. An intervention derived from trauma research has been suggested as a possible strategy for facilitating emotional adjustment and preventing longer term negative responses.