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Objective Neck pain is a common musculoskeletal disorder, but little is known about which individuals develop neck pain. This systematic review investigated factors that constitute a risk for the onset of non-specific neck pain. Design and setting A range of electronic databases and reference sections of relevant articles were searched to identify appropriate articles. Studies investigating risk factors for the onset of non-specific neck pain in asymptomatic populations were included. All studies were prospective with at least 1 year follow-up. Main results 14 independent cohort studies met the inclusion criteria for the review. Thirteen studies were assessed as high quality. Female gender, older age, high job demands, low social/work support, being an ex-smoker, a history of low back disorders and a history of neck disorders were linked to the development of non-specific neck pain. Conclusions Various clinical and sociodemographic risk factors were identified that have implications for occupational health and health policy. However, there was a lack of good-quality research investigating the predictive nature of many other variables.

The diagnosis and treatment of breast cancer can adversely affect quality of life. Here the aim was to determine the effects of reflexology on host defences and endocrine function in women with early breast cancer. Six weeks after surgery for early breast cancer, 183 women were randomly assigned to self-initiated support (SIS), SIS plus foot reflexology, or SIS plus scalp massage. Peripheral blood mononuclear cells and serum were isolated at T1 (6 weeks post surgery; baseline), T2 and T3 (4 and 10 weeks post completion of intervention, respectively). Lymphocyte phenotyping found that CD25(+) cells were significantly higher in the massage group compared with the SIS group at T3. The percentage of T cells, and more specifically the T helper subset expressing IL4, decreased significantly in the massage group compared with the SIS group at T3. This change was accompanied by an increase in the percentage of CD8(+) T cytotoxic cells expressing IFNγ in the massage group. Natural killer and lymphokine activated killer cell cytotoxicity measurements, serum levels of cortisol, prolactin and growth hormone, and flow cytometric assessment of their corresponding receptors all revealed no significant differences between the three groups of patients. This study provides evidence that the immunological balance of patients can be altered in a potentially beneficial manner by massage. The original trial was registered with the International Standard Randomised Controlled Trial Registry (ISRCTN87652313).

Purpose To conduct a pragmatic randomised controlled trial (RCT) to evaluate the effects of reflexology on quality of life (QofL) in women with early breast cancer. Patients and methods One hundred and eighty-three women were randomised 6 weeks post-breast surgery to self-initiated support (SIS) (comparator intervention), SIS plus reflexology, or SIS plus scalp massage (control for physical and social contact). Reflexology and massage comprised eight sessions at weekly intervals. The primary end-point was 18 weeks post surgery; the primary outcome measure was the Trial Outcome Index (TOI) of the Functional Assessment of Cancer Therapy (FACT-B) – breast cancer version. The secondary end-point was 24 weeks post surgery. Secondary outcome measures were the Hospital Anxiety and Depression Scale (HADS) and the Mood Rating Scale (MRS). Results At primary end-point, massage, but not reflexology, was significantly better than SIS on the TOI. Reflexology and massage were both better than SIS for MRS relaxation. Massage was better than reflexology and SIS for MRS easygoingness. At secondary end-point, reflexology, but not massage, was better than SIS on the TOI and MRS relaxation. There were no significant differences between reflexology or massage. There were no significant between group differences in HADS anxiety and depression. Self-reported use of out of study complementary therapies indicated that this was unlikely to have a significant effect on findings. Conclusions When compared to SIS, reflexology and massage have statistically significant, and, for reflexology, clinically worthwhile, effects on QofL following surgery for early breast carcinoma.

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

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

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.

Neck pain is one of the four most commonly reported musculoskeletal disorders in the UK. Little is known about which individual neck pain sufferer goes on to have recurrent, persistent or disabling neck pain. The development and persistence of non-specific neck symptoms are thought to be related to multiple factors. This systematic review investigated the prognostic factors that may constitute a risk for recurrent, persistent or disabling problems in patients who suffer from non-specific neck pain. It included prospective studies with a minimum of 1-year follow-up period and excluded cross-sectional and case-control studies. Nine studies were included. Eight were assessed as high quality and one as lower quality. This review found strong evidence of unfavourable outcome associated with older age, a longer duration of the current episode of neck pain, a previous history of neck problems, co-existing shoulder problems and other musculoskeletal disorders. There was conflicting evidence that baseline measures of pain and disability predicted outcome. There was strong evidence that regular exercise predicted a good outcome. This evidence about prognostic indicators can guide clinicians to provide advice or treatment which may help to prevent persistent neck problems. There is an absence of high-quality research investigating the predictive nature of psychological and sociodemographic factors. This has implications for clinical practice and research alike.

The aim of the present study was to investigate predictors of treatment outcome for Post-traumatic Stress Disorder (PTSD) after treatment completion and at 15-months follow-up (n = 48), in a trial of Eye Movement Desensitisation and Reprocessing (EMDR) versus Imaginal Exposure and Cognitive Restructuring (E+CR). Factors associated with treatment outcome were investigated using regression analyses with the mean change scores in three assessor and self-rated PTSD symptomatology measures, including the Clinician-Administered PTSD Scale (CAPS), the Impact of Events Scale (IES) and the PTSD Symptom Checklist (PCL) from pre- to post-treatment and pre-treatment to follow-up as the dependent variables and demographics, trauma, clinical and personality measures as independent variables. Irrespective to outcome measures and assessment points it was found that four variables were able to predict significantly treatment outcome. These included baseline PTSD symptomatology, number of sessions, gender and therapy type. Overall, our results showed that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome, as significant predictors were found to be sample-specific and outcome measure-specific. Clinical relevance of the present results and directions for future research are discussed.

Cognitive behaviour therapy (CBT) for generalized anxiety disorder produces variable results. It would be valuable to identify which patients respond well to brief CBT and whether increased intensity of therapy improves outcome for those with a poor prognosis. This clinical effectiveness study was designed to address these issues using a prognostic index developed from earlier research. Suitable patients were given five sessions of CBT if they had a good prognosis and either 9 or 15 sessions of CBT if they had a poor prognosis. There was no evidence that increasing the intensity of therapy for poor prognosis patients improved outcome and 60% remained cases at 6 month follow-up. In contrast, only 12% of good prognosis patients remained cases at follow-up despite receiving only brief therapy. Patient characteristics are a more powerful influence on outcome than the length of therapy. Prognostic indices may have an important place in routine clinical practice. Copyright © 2004 John Wiley & Sons, Ltd.

Panic disorder and agoraphobia is a prevalent clinical condition which places heavy demands on treatment resources in primary care. The efficient delivery of evidence-based psychological treatment for this disorder is therefore important. Previous research has investigated both individual and group treatment formats for cognitive behaviour therapy (CBT) for panic disorder and agoraphobia. These two modalities of treatment delivery are, however, rarely compared within the same study format. Also little is known of patients' preferences regarding treatment delivery formats. The present study investigated the relative efficacy of a group treatment CBT and an individual treatment CBT in comparison with a waiting list control group in the treatment of panic disorder with or without agoraphobia in primary care. Ninety-seven patients suffering from DSM-IV panic disorder with or without agoraphobia were randomly allocated to receive either group CBT, individual CBT, or waiting list control. All patients were seen by the same therapist and all received an identical treatment manual. Treatment response was measured by blind assessor, therapist and patient-rated measures of anxiety, depression, and agoraphobic avoidance, and was analysed in terms of both traditional statistical significance and clinical significance of outcome. At treatment end-point, in terms of traditional statistical significance, both the group and individual CBT were significantly superior to waiting list control but did not differ significantly from each other. When clinical significance of outcome at treatment end-point was considered, individual CBT showed a significant advantage over both group CBT and waiting list control. At 3-month follow-up, however, the individual CBT treatment group showed significant superiority to the group CBT treatment on clinical significance of outcome on one outcome measure only. This was principally due to a reduction in the proportion of patients achieving criteria of clinically significant change in the individual CBT treatment group over the 3-month follow-up period. When given a free choice of group or individual CBT at the end of the waiting list period, the overwhelming majority (95%) of the waiting list patients chose individual CBT. The implications of these findings for future research and for wider clinical practice are discussed. Copyright © 2004 John Wiley & Sons, Ltd.

A total of 105 patients with post-traumatic stress disorder (PTSD) were randomly allocated to eye-movement desensitization and reprocessing (EMDR) (n = 39) versus exposure plus cognitive restructuring (E + CR) (n = 37) versus waiting list (WL) (n = 29) in a primary care setting. EMDR and E + CR patients received a maximum of 10 treatment sessions over a 10-week period. All patients were assessed by blind raters prior to randomization and at end of the 10-week treatment or waiting list period. EMDR and E + CR patients were also assessed by therapists at the mid-point of the 10-week treatment period and on average at 15 months follow-up. Patients were assessed on a variety of assessor-rated and self-report measures of PTSD symptomatology including the Clinician Administered PTSD Scale (CAPS), the Impact of Events Scale (IOE) and a self-report version of the SI-PTSD Checklist. Measures of anxiety and depression included the Montgomery Asberg Depression Rating Scale (MADRS), the Hamilton Anxiety Scale (HAM-A) and the Hospital Anxiety and Depression Scale (HADS). A measure of social function, the Sheehan Disability Scale was also used. Drop-out rates between the three groups were 12 EMDR, 16 E + CR and five WL. Treatment end-point analyses were conducted on the remaining 72 patients. Repeated measures analysis of variance of treatment outcome at 10 weeks revealed significant time, interaction and group effects for all the above measures. In general there were significant and substantial pre–post reductions for EMDR and E + CR groups but no change for the WL patients. Both treatments were effective over WL. The only indication of superiority of either active treatment, in relation to measures of clinically significant change, was a greater reduction in patient self-reported depression ratings and improved social functioning for EMDR in comparison to E + CR at the end of the treatment period and for fewer number of treatment sessions for EMDR (mean 4.2) than E + CR (mean 6.4) patients. At 15 months follow-up treatment gains were generally well-maintained with the only difference, in favour of EMDR over E + CR, occurring in relation to assessor-rated levels of clinically significant change in depression. However, exclusion of patients who had subsequent treatment during the follow-up period diminished the proportion of patients achieving long-term clinically significant change. In summary, at end of treatment and at follow-up, both EMDR and E + CR are effective in the treatment of PTSD with only a slight advantage in favour of EMDR. Copyright © 2002 John Wiley & Sons, Ltd.

Panic disorder with or without agoraphobia is a prevalent clinical disorder which places heavy demands on treatment resources in primary care. The efficiency of delivery of psychological treatments for this disorder is therefore important. Previous research has focused on psychological treatments delivered with reduced therapist contact but methodological problems preclude firm conclusions. The present study investigated the relevance of therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia, taking account of previous methodological problems. One hundred and four patients suffering from DSM III-R panic disorder with or without agoraphobia were randomly allocated to receive cognitive behaviour therapy with either, ‘standard’ therapist contact, ‘minimum’ therapist contact or as a bibliotherapy. All patients were seen by the same therapist and all received an identical treatment manual. Treatment response, as measured by patient and therapist report scales of anxiety, depression, and agoraphobic avoidance, was analysed in terms of both traditional statistical significance and clinical significance of outcome. At treatment end-point the ‘standard’ therapist contact and ‘minimum’ therapist contact groups showed significant reductions pre- to post-treatment on all measures. Pre- to post-treatment reductions for the bibliotherapy group were significant on therapist- and patient-rated measures of anxiety only. The ‘standard’ therapist contact group was consistently significantly improved in comparison to the bibliotherapy group. Significant differences between the ‘standard’ and ‘minimum’ therapist contact groups were found on therapist-rated anxiety only. Assessment of clinical significance of treatment outcome showed further differences between treatment groups with the ‘standard’ therapist contact group showing the largest proportion of patients achieving clinically significant change on all measures both at treatment end-point and at 6-month follow-up. Copyright © 2000 John Wiley & Sons, Ltd.

Recent discussion has emphasized the importance of assessments of clinical significance of outcome in treatment outcome studies. Several methods exist to assess clinical significance, one of which is the use of global ratings of outcome. This study reports the use of such measures in a treatment outcome study investigating pharmacological and psychological treatments for panic disorder and agoraphobia in primary care. Outcome is reported in terms of global ratings of symptom severity and of change in symptoms following treatment, completed by the psychologist, referring General Practitioners (GPs) and patients. Treatments involving cognitive behaviour therapy showed greater efficacy than those employing pharmacological treatments alone. Considerable agreement was demonstrated between psychologist and patient ratings. Such agreement was much less obvious for ratings completed by referring GPs. Possible reasons for this are advanced.

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.

One hundred and ninety patients meeting DSM-III-R criteria for panic disorder with or without agoraphobia were randomly allocated to (a) Fluvoxamine, (b) placebo, (c) Fluvoxamine + cognitive behaviour therapy, (d) placebo + cognitive behaviour therapy, or (e) cognitive behaviour therapy alone. Patients were treated over 13 weeks and all participated in nine sessions plus follow-up at 6 months. Numbers in each group were as follows—(a) Fluvoxamine: entered n = 36, completed n = 29, attended follow-up n = 23; (b) placebo: entered n = 37, completed n = 28, attended follow-up n = 21; (c) Fluvoxamine + cognitive behaviour therapy: entered n = 38, completed n = 29, attended follow-up n = 24; (d) placebo + cognitive behaviour therapy: entered n = 36, completed n = 33, attended follow-up n = 30; (e) cognitive behaviour therapy: entered n = 43, completed n = 30, attended follow-up n = 28. A balance across treatments for therapist contact was attempted. A fixed-dose medication regimen was used with patients taking 150mg Fluvoxamine per day. A range of process and outcome measures both therapist- and patient-rated was used. Outcome at treatment end point and at 6-month follow-up was assessed in terms of both statistical and clinical significance and revealed that all active treatments showed improvement over time. This improvement was better preserved over follow-up in those groups receiving cognitive behaviour therapy (Groups c, d, and e) with these groups showing larger proportions of patients continuing to achieve predetermined criteria of clinically significant change on the Hamilton Anxiety Scale, Kellner and Sheffield Symptom Rating Test, and the Fear Questionnaire-Agoraphobia Scale at 6-month follow-up than those of the medication-alone groups (Groups a and b). The largest and most consistent treatment gains were evidenced by the cognitive behaviour therapy (Group e) and the Fluvoxamine + cognitive behaviour therapy (Group c) groups, with the latter showing these gains 2 weeks earlier in treatment, at Day 28 rather than Day 42.

Evidence supports exercise-based interventions for the management of neck pain, however there is little evidence of its superiority over usual physiotherapy. This study investigated the effectiveness of a group neck and upper limb exercise programme (GET) compared with usual physiotherapy (UP) for patients with non-specific neck pain. A total of 151 adult patients were randomised to either GET or UP. The primary measure was the Northwick Park Neck pain Questionnaire (NPQ) score at six weeks, six months and 12 months. Mixed modelling identified no difference in neck pain and function between patients receiving GET and those receiving UP at any follow-up time point. Both interventions resulted in modest significant and clinically important improvements on the NPQ score with a change score of around 9% between baseline and 12 months. Both GET and UP are appropriate clinical interventions for patients with non-specific neck pain, however preferences for treatment and targeted strategies to address barriers to adherence may need to be considered in order to maximise the effectiveness of these approaches.

This study investigated the relationship between neck pain and upper limb disability in patients with non-specific neck pain (n = 151) recruited from physiotherapy departments in the United Kingdom. Baseline neck pain/disability was measured using the Northwick Park Neck Pain Questionnaire (NPQ). Baseline upper limb disability was measured using the Disabilities of Arm, Shoulder, Hand questionnaire (DASH). A range of baseline psychosocial variables were measured as potential confounding variables. Pairwise analysis revealed a positive correlation between NPQ score and DASH score (Pearsons’ r = 0.799, p < 0.001). After adjusting for potential confounding variables, stepwise linear regression indicated that increasing upper limb disability was predicted by two baseline variables: higher NPQ scores (B = 0.743) and lower pain self efficacy (PSE) scores (B = −0.489) {R2 = 0.713; n = 100, p < 0.001}. This study provides preliminary evidence that patients with severe neck pain/disability also report severe upper limb disability. The relationship between neck pain/disability and upper limb disability was mediated by PSE. Clinically, the presence of severe neck pain or low PSE should direct clinicians towards an assessment of upper limb function. In these cases upper limb disability may need to be addressed as part of the neck management process.

This paper presents a comparison of the component profiles of the Four Systems Anxiety Questionnaire (FSAQ), Three Systems Anxiety Questionnaire (TSAQ) and cognitive Somatic Anxiety Questionnaire (CSAQ) for agoraphobia, social phobia, simple phobia, generalized anxiety disorder, panic disorder and obsessional—compulsive disorder patient groups. The relationship between cognitive and affect components of the FSAQ for each diagnostic group is presented with special regard to the obsessive—compulsive group. Results indicate that the FSAQ is sensitive to differential loadings of each of the anxiety diagnostic groups. In addition the obsessional—compulsive group produced a significantly higher cognitive than affect component and this difference was greater than for the other diagnostic groups. The clinical relevance of the FSAQ as an assessment measure is discussed.

One hundred and one patients meeting the DSM III criteria for Generalised Anxiety Disorder were randomly allocated to Cognitive-Behaviour Therapy, Diazepam, Placebo, Cognitive-Behaviour Theraph + Diazepam, or Cognitive-Behaviour Theraph + Placebo, and treated over 10 weeks. Treatments were balanced for degree of psychologist / patient contact. A fixed dose medication procedure was used. A range of treatment process and outcome measures including psychologist assessor and patient self-report were used. Subsequent post-treatment pharmacological, psychological, and psychiatric treatments were recorded. Outcome measures at end of treatment and at six months follow-up revealed the superiority of all Cognitive-Behaviour Therapy treatments, especially Cognitive-Behaviour Therapy alone, and Cognitive-Behaviour Therapy + Diazepam. Diazepam was no more effective than Placebo. This may have been due to the use of a fixed low dosage regime for the DZ group. Cognitive-Behaviour Thrapy + Diazepam, and Diazepam groups showed no withdrawal symptoms or anxiety recurrence during graded withdrawal. However, the potential effectiveness of DZ and DZ + CBT may have been enhanced by the use of a flexible dose procedure with a higher maximum dose. All Cognitive- Behaviour Therapy groups revealed the lowest incidence of subsequent treatment interventions at six months follow-up.

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

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 (β = 0.379, P = 0.007) and extroversion (β = −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.

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. Copyright © 2007 John Wiley & Sons, Ltd.

Background In the context of finite health resources, encouraging self-management of chronic conditions is important. Indeed, it is a key priority in the UK. An increasing number of self-management programmes are becoming available. However, patients may not always choose to participate in them. Some will prefer a more directed or medically orientated treatment. The acceptability of self-management programmes for patients suffering from chronic pain is an important issue. Few measures exist that examine the process of change to a self-management approach. The Pain Stages of Change Questionnaire (PSOCQ) was evaluated for this purpose in the present study. Hypotheses were centred around criterion and construct validity of the PSOCQ. Methods A sample of pain patients was surveyed about their interest in participating in a lay-led self-management programme ('the Expert Patients Programme'). In addition, participants completed two psychometric measures: the Pain Stages of Change Questionnaire (PSOCQ) together with the Chronic Pain Acceptance Questionnaire (CPAQ). This is the first study as far as we are aware to examine these two scales together. The psychometric properties of the PSOCQ were examined. Analyses focused on the associations between the PSOCQ scores and interest in participating in the self-management programme. Further associations were examined between the PSOCQ and the Chronic Pain Acceptance Questionnaire. Results The results demonstrated qualified support for the PSOCQ, in particular the Contemplation sub-scale. There was a significant positive association between interest and likelihood of joining the self-management programme and contemplation scores. The action and maintenance sub-scales appeared to be measuring a unitary dimension. The associations between the PSOCQ and the Chronic Pain Acceptance Questionnaire were in the directions predicted. The limitations of the study were discussed. Conclusion The results showed some support for the PSOCQ as a potentially useful tool in assessing who may or may not be likely to join a self-management course.

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.

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.

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.

Rope has always been an important item in the marine environment. The transition from one type of construction to another, notoriously slow: for example, rope of both wire and fibre supplied to the S.S. ‘Great Britain’, launched in 1843 was of a similar type and quality to that which would be equally familiar to our mariners a century later. Many having experience in this latter period might recognize some similarity with the rope in use today but there have been substantial changes, and these changes have occurred not specifically because of any major breakthrough in rope design and production, although there have been very substantial advances in these sectors but because the detail of today's and tomorrow's applications have themselves changed. The paper examines a number of the major applications involving rope in the marine environment, and shows how rope characteristics must be recognised and wedded to the duty parameters if optimum performance is to be achieved.

Patients with acute and chronic central serous retinopathy (CSR) were studied by psychophysical and photochemical means to establish the extent of visual depression and to investigate the basis of rod dysfunction in this disorder. In acute disease with serous detachment of the retina, the loss of sensitivity attains 3 log units and parallels the height of retinal elevation as does its recovery with resolution of the episode. Immediately after resolution, there is a residual 0.5 log unit threshold elevation. In chronic disease, marked loss of function exists over areas of abnormal retinal pigment epithelium in the absence of clinically detectable serous detachment. Although rhodopsin levels are low in both acute and chronic CSR, this relative lack of visual pigment does not totally account for the functional deficits in either situation.

Combined Hamartoma of the Retina and Retinal Pigment Epithelium is a rare ocular condition that has occasionally been mistaken for a more sinister lesion. Although there are wide clinical variations within the spectrum of the disorder, they are characterised by a number of distinctive ophthalmoscopic and angiographic features.

1. The ouabain-insensitive Na efflux in barnacle muscle fibres is promptly stimulated by injection of cyclic GMP. The minimal effective injected concentration is found to be about 10(-7) M. This effect of cyclic GMP could not be mimicked by injecting 5'-GMP. 2. External application of ouabain (10(-4) M) to fibres not pretreated with ouabain during the stimulatory response to cyclic GMP causes some inhibition of the Na efflux indicating that cyclic GMP does not cause appreciable inhibition of the Na:K pump. 3. The magnitude of the stimulatory response to injected cyclic GMP depends on the external Ca2+ concentration, as well as pHe but not on the Na+, K+ or Mg2+ concentration. It also depends on pHi, since acidification of HCO3-containing ASW leads to a greater enhancement of the response to cyclic GMP than is observed with acidified HERPES-ASW. 4. Stabilization of myoplasmic pCa by injecting 100 mM-EGTA before or after cyclic GMP fails to alter the magnitude of the response to the nucleotide. Enrichment of the fibre with Mg2+ at the time of injection of cyclic GMP leads to a reduced response. No change in response, however, is seen when the internal free Mg concentration is suddenly reduced by injecting 0.05 M-pyrophosphate with cyclic GMP. 5. Injection of cyclic GMP-dependent protein kinase stimulatory modulator before cyclic GMP fails to enhance the response to the nucleotide. The same is true of the phosphodiesterase inhibitor protein. However pre-injection of 10(-2) M-papaverine enhances the response to a subsequent injection of 10(-3) M-cyclic GMP. 6. Injection of pure protein kinase inhibitor (1.6 x 10(-4) M) before 10(-3) M-cyclic GMP reduces the response to the nucleotide. 7. The argument is put forward that injected cyclic GMP stimulates the ouabain-insensitive Na efflux mainly by activating cyclic AMP-protein kinase rather than cyclic GMP-proton kinase.

On A4 paper, type a copy (1+1) of the following manuscript letter. Use fully-blocked style with full punctuation. Turn up three line-spaces between the date, the reference, the addressee and the salutation.

On A4 paper, type (1+1) the following letter from the General Manager. Type in fully-blocked style with open punctuation, but inset the small paragraph, also in block form. Note that the initials of the dictator are in capital letters and those of the typist in lower case.

Type a top copy and take two carbon copies, on A5 paper turned sideways, of the following standard Job Specification Form used by this Bureau.

LETTERS from this firm are typed in fully-blocked style. Open punctuation is used with no comma after either the salutation or the complimentary close. ‘For the attention’ line is typed in lower case letters and underlined but headings are in capital letters with no underlining. The firm’s name comes directly under the complimentary close, and after sufficient space for the signature the name of the signatory and his/her designation.

On A4 paper, type a copy of the following Agenda for a meeting of the General Purposes Committee.

MEMORANDA are typed on A5 paper. There is no central heading; four of the headings are blocked approximately 1/2cm from the ruled line, while the telephone extension and the date are spread across the page. The BBC prefers three spaces to be left after full stops, so remember to do this at the end of each sentence.

On A4 paper, type a copy of the following letter which gives the detailed letter layout designed to fit this Company’s headed notepaper. The three ‘dots’ referred to, printed on the stationery, line up with blocked headings; the dots will be obliterated by the typing of the first letter or figure. Note that the first line of the addressee is punctuated but the rest has no punctuation and that there are commas inserted after the salutation and complimentary close. Leave 9 line-spaces for the printed heading.

LETTERS from this firm are typed in blocked style on A4 paper, with the references to the right of the page. Open punctuation is used. The firm’s name comes directly under the complimentary close. ‘Our Ref’ consists of the initials of the sender, followed by the initials of the typist.