Term Relief Research Articles

Quality of Life After Palliative Treatment for Esophageal Carcinoma: A Longitudinal Prospective Comparison Between Stent Placement and Single Dose Brachytherapy

Background: Metal stent placement and single dose brachytherapy are commonly used treatment modalities for the palliation of inoperable esophageal carcinoma. We investigated generic and disease-specific health-related quality of life (HRQoL) after these palliative treatments. Methods: Patients with dysphagia from inoperable esophageal carcinoma were randomized to placement of a covered Ultraflex stent (n=108) or single dose (12 Gy) brachytherapy (n=101). We obtained longitudinal data on disease-specific (dysphagia score, EORTC OES-23, visual analogue pain scale) and generic (EORTC QLQ-C30, EuroQol scales) HRQoL at monthly home visits by a specially-trained research nurse. We compared HRQoL between the two treatments and analyzed changes in HRQoL during follow-up. Results: Dysphagia improved more rapidly after stent placement than after brachytherapy, but long term relief of dysphagia was better after brachytherapy. For generic HRQoL, there was an overall significant difference in favor of brachytherapy on several functional scales of the EORTC QLQ-C30 (role, emotional, cognitive and social) (p<0.05). Generic HRQol deteriorated over time on all functional scales of the EORTC QLQ C-30 and Euroqol scales, in particular physical and role functioning (-23 and -24 on a 100 points scale during 0.5 years of follow-up) in both treatment groups. This decline was more pronounced in the stent group. In contrast, except for the dysphagia and eating scales, no major changes during follow-up were seen for disease-specific HRQoL. Self-reported pain levels remained stable during follow-up in both treatment groups. Conclusions: Treatment with single dose brachytherapy gave better overall scores on HRQoL scales compared to stent placement for the palliation of esophageal cancer. Generic HRQol scales were more responsive in measuring patients' functioning and well-being during follow-up. Pain management was adequate during follow-up.

Compression therapy for treating stage I and II (Widmer) post-thrombotic syndrome.

Post-thrombotic syndrome (PTS) is a long-term complication of deep vein thrombosis characterised by chronic complaints, swelling, and skin changes in the affected limb. One in every three patients with deep vein thrombosis develops post-thrombotic complications within five years. To assess the effectiveness of compression therapy in patients with stage I and II post-thrombotic syndrome according to the classification of Widmer. Interventions of interest included elastic compression stockings and mechanical devices, compared with no intervention and with each other. The reviewers searched the Cochrane Peripheral Vascular Diseases Specialised Trials Register (last searched April 2003), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 1, 2003). In addition, journals, conference proceedings and bibliographies were hand searched. Personal contact with other investigators involved in the clinical area was sought to get information about missed or unpublished studies. Trials that evaluated compression therapy for stage I and II (Widmer) post-thrombotic syndrome. Primary outcomes were leg ulceration, or deterioration of post-thrombotic syndrome. There were no restrictions on date or language. One reviewer (DNK) assessed titles and abstracts for relevance. This was verified independently by a second reviewer (MWCS). Details of eligible studies were extracted and summarised using data extraction sheets. Data extraction was undertaken by one reviewer (DNK) and verified by a second reviewer (MHP). Only two trials were identified that addressed physical treatment of post-thrombotic syndrome. Both trials were initiated by the same group of investigators. A cross-over study lasting two months compared low and high pressure with intermittent compression units for severe post-thrombotic syndrome. This showed a beneficial effect of higher pressures. The second study, in patients with mild to moderate post-thrombotic symptoms, showed no effect of elastic compression stockings (30-40 mm Hg at the ankle region) when compared to 'placebo' stockings that were one to two sizes too large. There is some evidence of a beneficial effect of intermittent pneumatic compression units, but the study was too small and of too short a duration to draw strong conclusions. Further research is needed in order to assess whether intermittent pneumatic compression units give long term reduction and relief of the symptoms caused by post-thrombotic syndrome, and prevent deterioration and leg ulceration. The use of elastic compression stockings to treat post-thrombotic syndrome cannot be supported on the basis of the currently available data.

The importance of nicotinic acetylcholine receptors in schizophrenia, bipolar disorder and Tourette's syndrome.

As the prevalence of tobacco use has decreased, it has become clear that individuals with mental illness comprise a substantial portion of the remaining smokers. Seventy to eighty percent of patients with schizophrenia smoke and their smoking is established before their first psychotic episodes or the initiation of treatment. Many patients with schizophrenia, and approximately 50% of their first degree relatives have abnormalities in auditory sensory gating and/or smooth pursuit eye movements. These abnormalities are corrected by nicotine, and they appear to be transmitted as autosomal dominant traits. Evidence is accumulating that these abnormalities reflect genetic variations in nicotine receptor number and function, that may increase susceptibility for schizophrenia. Recent studies suggest that bupropion, added to treatment with an atypical antipsychotic, can enhance the likelihood of smoking cessation or reduction in patients with schizophrenia. The prevalence of smoking is also substantially increased among patients with bipolar disorder, perhaps especially so among those with psychotic features. Nicotine delivered by gum or transdermal patch can provide short term relief for exacerbations of Tourette's Syndrome, but its use is limited by frequent toxicity, primarily nausea.

Challenges and opportunities for humanitarian relief in Afghanistan.

Afghanistan is in the midst of a profound humanitarian crisis resulting primarily from long-standing armed conflict, a devastating drought, and massive population migration. The economy, government, and health care system are in shambles. Currently, as many as 5 million Afghans are in camps either as refugees in neighboring countries or as internally displaced persons within Afghanistan. Much of the rest of the population is in dire need of basic essentials such as food, water, shelter, and basic medical care. Those attempting to carry out humanitarian relief face many daunting challenges, such as reaching remote locations, coping with a dangerous security situation, and working with limited resources. However, there are opportunities in the short run to save many lives and substantially improve the plight of Afghans by carrying out appropriate and effective emergency relief programs. Over the long term, effective medical and public health relief efforts will be an essential part of rehabilitating and rebuilding this devastated country.

Electroconvulsive therapy for schizophrenia.

Electroconvulsive therapy (ECT) involves the induction of a seizure (fit) for therapeutic purposes by the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp. The effects of its use in people with schizophrenia are unclear. To determine whether electroconvulsive therapy (ECT) results in clinically meaningful benefit with regard to global improvement, hospitalisation, changes in mental state, behaviour and functioning for people with schizophrenia, and whether variations in the practical administration of ECT influences outcome. Electronic searches of Biological Abstracts (1982-1996), EMBASE (1980-1996), MEDLINE (1966-2001), PsycLIT (1974-1996),SCISEARCH (1996) and the Cochrane Schizophrenia Group's Register (July 2001) were undertaken. The references of all identified studies were also inspected and authors contacted. All randomised controlled clinical trials that compared ECT with placebo, 'sham ECT', non-pharmacological interventions and antipsychotics, and different schedules and methods of administration of ECT for people with schizophrenia, schizoaffective disorder or chronic mental disorder. Studies were reliably selected, quality rated and data extracted. For dichotomous data, relative risks (RR) were estimated, with the 95% confidence intervals (CI). Where possible, the number needed to treat statistic (NNT) was calculated. Analysis was by intention-to-treat. Normal continuous data was summated using the weighted mean difference (WMD). Scale data was presented for only those tools that had attained pre-specified levels of quality. Tests of heterogeneity and for publication bias were undertaken. This review includes 24 trials with 46 reports. When ECT is compared with placebo or sham ECT, fewer people remain unimproved in the real ECT group (n=400, RR fixed 'not globally improved in the short term' 0.77 CI 0.6 to 0.9, chi-square 13.46 df=8 p=0.1). Removal of the one study with clearly heterogeneous results causes a change in the findings (n=380, 8 RCTs, RR fixed 0.83 CI 0.7 to 1.01), as does removal of a clinically heterogeneous trial (n=370, 8 RCTs, RR fixed 0.74 CI 0.6 to 0.9, chi-square 10.97 df=7 p=0.14). There was a suggestion that ECT resulted in less relapses than sham ECT (n=47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2), and a greater likelihood of being discharged from hospital (n=98, 1 RCT, RR fixed 0.59, CI 0.34 to 1.01). There is no evidence that this early advantage for ECT is maintained over the medium to long term. People treated with ECT did not drop out of treatment earlier than those treated with sham ECT (n=495, 14 RCTs, RR fixed 0.71 CI 0.33 to 1.52). Very limited data indicated that visual memory might decline after ECT compared with sham ECT (n=24, 1 RCT, WMD -14.0 CI -23 to -5); the results of verbal memory tests were equivocal. When ECT is directly compared with antipsychotic drug treatment (total n=419, 8 RCTs), results favour the medication group (n=175, 3 RCTs, RR fixed 'not improved at the end of ECT course' 2.18 CI 1.3 to 3.6). One small study suggested more memory impairment after a course of ECT combined with antipsychotics than with antipsychotics alone (n=20, MD serial numbers and picture recall -4.90 CI -0. 8 to -9), though this proved transient. When continuation ECT was added to antipsychotic drugs, the combination was superior to the use of antipsychotics alone (n=30, WMD Global Assessment of Functioning 19.1 CI 9.7 to 28.5), or CECT alone (n=30, WMD -20.3 CI -11.5 to -29.1). Unilateral and bilateral ECT were equally effective in terms of global improvement (n=78, 2 RCTs, RR fixed 'not improved at end of course of ECT' 0.79 CI 0.5 to 1.4). One trial showed a significant advantage for 20 treatments over 12 treatments for numbers globally improved at the end of the ECT course (n=43, RR fixed 2.53 CI 1.1 to 5.7). There is no evidence to clearly refute the use of ECT for people with schizophrenia. There is some limited evidence to support its use, particularly combined with antipsychotic drugs for those with schizophrenia who show limited response to medication alone. The research base for the use of ECT in people with schizophrenia is growing but, even after more than five decades of clinical use, is still inadequate.

'As required' medication regimens for seriously mentally ill people in hospital.

Drugs used to treat psychotic illnesses may take weeks to have an effect. Often, in the interim, additional, 'as required' doses of medication can be used to calm patients in psychiatric wards. 20 to 50% of people on acute psychiatric wards are written up for 'as required' doses of medication. In this situation, a doctor prescribes the frequency and upper limit of dose, and the drug is then given at the discretion of clinical staff. To compare the effects of 'as required' medication regimens with regular regimens of medication for the treatment of psychotic symptoms or behavioural disturbance, thought to be secondary to psychotic illness. This is in addition to any regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses. The reviewers searched the Cochrane Schizophrenia Group's register of trials (November 2001). This register is compiled by methodical searches of BIOSIS, CINAHL, Dissertation abstracts, EMBASE, LILACS, MEDLINE, PSYNDEX, PsycINFO, RUSSMED, Sociofile and is supplemented with hand searching of relevant journals and numerous conference proceedings. Relevant randomised control trials, involving hospital inpatients with schizophrenia or schizophrenia-like illnesses, comparing any regimen of medication administered for the short term relief of behavioural disturbance, or psychotic symptoms, to be given at the discretion of ward staff ('as required', 'prn') with fixed non-discretionary patterns of drug administration of the same drug(s). This is in addition to regular psychotropic medication for the long-term treatment of schizophrenia or schizophrenia-like illnesses where prescribed. The primary outcomes of interest were levels of disturbance, severity of psychiatric symptoms, dose of medication, and adverse effects. Studies were reliably selected, quality rated and data extracted. For dichotomous data, relative risks (RR) would have been estimated, with the 95% confidence intervals (CI). Where possible, the number needed to treat statistic (NNT) was to have been calculated. Analysis would have been by intention-to-treat. Normal continuous data were to have been summated using the weighted mean difference (WMD). Scale data were to have been presented for only those tools which had attained pre-specified levels of quality. Tests of heterogeneity and for publication bias were to have been undertaken. No randomised trials comparing 'as required' medication regimens to regular regimens of the same drug were identified. This common current practice has no support from randomised trials. Current practice is based on clinical experience and habit rather than high quality evidence. Current practice, therefore, outside of a well designed, conducted and reported randomised trial, is therefore difficult to justify.

Chronic Pain: Management Strategies That Work

Chronic Pain: Management Strategies That Work

Laser supraglottoplasty for laryngomalacia: are specific anatomical defects more influential than associated anomalies on outcome?

Objective: To evaluate different CO2 laser procedures on children with various types of laryngomalacia and determine the role of associated anomalies on the outcome. Design: Retrospective chart review. Setting: Academic tertiary referral center. Patients: Twenty-three children who underwent laser supraglottoplasty for laryngomalacia between 1991 and 1998 at the UC Davis Medical Center. Interventions: CO2 laser vaporization of redundant supraglottic mucosa of the aryepiglottic fold, arytenoid, and the epiglottis, or modification of the latter, either individually or in combination, based on the obstructing anatomy. Outcome measures: Immediate, short term, intermediate and long term relief of respiratory symptoms, feeding difficulties, effect of associated anomalies on outcome, effect of specific anatomic obstructing site and surgical procedure performed on outcome, and the incidence of complications inherent to the procedure. Results: Children without associated anomalies invariably did very well, with 78% immediately resolving their respiratory symptoms and 100% within a week. Twelve of the 14 patients with unfavorable immediate results ( P<0.01) and all ten with short term unfavorable results ( P<0.05) had neurologic or anatomic associated anomalies. Seven patients, all with associated anomalies, were considered surgical failures ( P<0.05). These patients also had a significantly longer hospital stay ( P<0.01). The presence of associated anomalies was significant ( P<0.01) in determining surgical treatment of reflux or the need for an NG tube in treating feeding problems. The anatomic site of abnormality and the specific procedure performed did not affect the outcome. There were no serious complications inherent to this procedure. Conclusions: Laser supraglottoplasty, in its different modalities, is a safe and effective treatment for all types of laryngomalacia, but children with associated neurologic or anatomic anomalies will have a more complicated immediate and short term course, as well as a significant incidence of failure. Gastroesophageal reflux is an important associated condition that requires investigation in these patients, and in severe cases will merit surgical procedures to manage. The high incidence of associated neuromuscular anomalies suggests that this component has an important role in the etiology of laryngomalacia.

Electrical Stimulation of the Trigeminal Tract in Chronic, Intractable Facial Neuralgia

In this paper the treatment of patients with chronic, intractable trigeminal neuralgia by invasive electrical stimulation of the Gasserion ganglion is reviewed. Two different surgical techniques are employed in this treatment. Most frequently, a method similar to the traditional technique for percutaneous glycerol and radiofrequency trigeminal rhizolysis is used: a small percutaneous stimulation electrode is advanced under fluoroscopic control through a thin needle via the foramen ovale to the Gasserian cistern. Some neurosurgeons use an open surgical technique by which the Gasserian ganglion is approached subtemporally and extradurally, and the bipolar pad electrode is sutured to the dura. When percutaneous test stimulation is successful (at least 50% pain relief) the electrode is internalized and connected to a subcutaneous pulse generator or RF-receiver. Data from 8 clinical studies, including 267 patients have been reviewed. Of all 233 patients with medication-resistant atypical trigeminal neuralgia 48% had at least 50% long term pain relief. The result of test stimulation is a good predictor of the long term effect, because 83% of all patients with successful test stimulation had at least 50% long term relief, and 70% had at least 75% long term relief. Patients generally preferred this invasive method over TENS. The success rate in patients with postherpetic trigeminal neuralgia was very low (less than 10%). It is suggested that the likelihood of pain relief by electrical stimulation is inversely related to the degree of sensory loss. It is concluded that invasive stimulation of the Gasserian ganglion is a promising treatment modality for patients with chronic, intractable, atypical trigeminal neuralgia.

Motor cortex stimulation for chronic neuropathic pain: a preliminary study of 10 cases

There is growing evidence to support the use of motor cortex stimulation (MCS) in the management of patients with chronic neuropathic pain. A prospective audit of ten patients using a modified staged technique for motor cortex implantation provides further evidence for the analgesic effectiveness of this technique. Ten patients suffering from phantom limb pain (n=3), post stroke pain (n=5), post traumatic neuralgia secondary to gunshot injury to the brain stem (n=1) and brachyalgia secondary to neuro-fibromatosis (n=1) were treated between November 1995 and February 1998. All ten patients had failed to respond to previous multiple pain therapies. Patients were evaluated pre and post-operatively by an independent pain specialist. The overall response rate was 50%, with 5/10 patients reporting short term relief (>50% pain relief) and long-term benefit in 4/5 of patients who initially responded to intermittent cortical stimulation (longest follow up 31 months after implantation). Of those patients who benefited two had post stroke pain, two phantom limb pain and one post-traumatic neuralgia. We conclude that motor cortex stimulation is an effective analgesic intervention in some patients with chronic neuropathic pain, but it is difficult if not impossible to predict those patients who may respond to treatment prior to implantation. Randomised controlled trials are now urgently needed to test the effectiveness of motor cortex stimulation under double-blind conditions.

Musculoskeletal and Acute Rheumatic Pain

Although the analgesic and anti-inflammatory properties of piroxicam have been well documented, the relatively slow onset of action of this nonsteroidal anti-inflammatory drug (NSAID) has somewhat reduced its role in the treatment of acute rheumatic and musculoskeletal disorders. To counter this disadvantage, piroxicam has been complexed with the cyclic oligosaccharide β-cyclodextrin, to form piroxicam-β-cyclodextrin. This new drug enhances the aqueous solubility of piroxicam, increases its rate of absorption, and results in more rapid achievement of therapeutic levels than occurs with standard piroxicam. Furthermore, clinical studies have shown that piroxicam-β-cyclodextrin is associated with an earlier onset of analgesic action than standard piroxicam, tenoxicam, naproxen and a number of other NSAIDs used to treat acute musculoskeletal and rheumatic pain, and that the agent has sustained efficacy in long term use. Thus, piroxicam-β-cyclodextrin is a suitable NSAID for the short term relief of acute pain and inflammation and for the long term management of chronic conditions such as osteoarthritis.

Nasal decongestants for the common cold.

The common cold is a major and recurrent cause of morbidity, affecting children and adults two or more times each year. Nasal congestion is its commonest symptom, and many therapies are marketed for its relief. There is no meta-analysis of controlled clinical trials on the effects of nasal decongestants for the common cold. To assess the efficacy of nasal decongestants at reducing the symptom of nasal congestion in adults and children with the common cold and to identify possible adverse effects associated with their use. MEDLINE, EMBASE and Current Contents were searched up to May 1999. Searching the Cochrane Acute Respiratory Infections Group's trials register, following the review citation trail from other references and contacting known principal investigators and pharmaceutical companies was also done. Randomised, placebo controlled trials of single-active oral and topical nasal decongestants in adults and children suffering from the common cold. Data were independently extracted by two reviewers (DT and LB). All outcomes variables were continuous. Subjective outcomes were normalised to a common scale and a weighted mean difference (WMD) was calculated. A standardised mean difference (SMD) was calculated for the objective outcomes. Four studies in adults, but none in children, fitted all inclusion criteria. There was a significant 13% decrease in subjective symptoms after decongestant compared with placebo. This was supported by a significant decrease in nasal airways resistance. Repeated doses of nasal decongestant were not significantly better than placebo at relieving symptoms of nasal congestion. A single dose of nasal decongestant in the common cold is moderately effective for the short term relief of congestion in adults, while there is no evidence available to show benefit after repeated use over several days. These medications are not recommended for use in young children with the common cold.

Treatment of Myofascial Pain

SUMMARYObjective: To review new, effective techniques and concepts in treatment [Tx] that have proven long-term results.Findings: The first goal is to instantaneously relieve pain, but recurrence can be prevented only by removal of the etiological factors. Treatment is ineffective unless it concentrates on the immediate cause of pain, which most frequently consists of tender spots [TSs], causing symptoms locally. Less frequent are trigger points [TrPs] that shoot pain into a distant area. Most effective Tx consists of “Needling and Infiltration of the Taut Band” [N&I of TB] with local anesthetic. Needling and infiltration is not limited to the TrP or TS itself, but extends over the entire TB including its attachment to bone. Such N & I mechanically disrupts the TB. Preinjection Block [PIB] is a new technique which prevents pain and sensitization caused by the penetration of the injecting needle into a sensitive area [TS or TrP]. There is no reason not to administer PIB routinely before each TrP injection. Paraspinous Blocks consist of spreading the anesthetic along the sprained supra/interspinous ligaments of the sensitized segment.Conclusions: Several studies documented that “N&I of TB” achieved long term relief of pain and normalization of tenderness, quantified by pressure algometry. Paraspinous block instantaneously alleviates pain by reducing activity of TrP/TSs, which often are a component of radicular sensitization. Paraspinous block may also relieve root compression often caused by paraspinal muscle spasm and TrPs.

A new visceral nociceptive pathway in the dorsal column: Anatomical and functional studies of pancreatic pain including the effects of limited dorsal column lesions in rats

Novel neuronal pathways carrying visceral nociceptive information through the dorsal column of the spinal cord have recently been described by our group. The clinical importance of these pathways is suggested by the effectiveness of a midline dorsal column lesion in the relief of pelvic visceral pain in cancer patients. Aims: To describe the neuronal pathways mediating pain from the pancreas and to study the effectiveness of dorsal myelotomy for the relief of pancreatic pain. Methods: Neuronal tract mapping was done after small iontophoretic injections of Phaseolus vulgaris-leucoagglutinin (PHAL, 2.5% in phosphate buffer; pH 8.0) around the central canal at 1'7 or S1 spinal segments. Acute pancreatitis was induced by glyoxydecholic acid (GDOC) injection into the pancreatic duct followed by six hourly intraperitoneal injections of caerulean (72mg total). Dorsal myelotomy was performed either at the C1 or T10 level. The above procedures were done in anesthetized rats. Body weight and behavior (locomotion, exploratory and grooming) was monitored. Results: The ascending neuronal projections from the T7 or S1 spinal cord regions ascend near the dorsal intermediate and dorsal midline septi of the dorsal column, respectively. These pathways terminated primarily in the cuneate and gracile nuclei, respectively, in the caudal medulla. Some terminal fibers were found throughout the brainstem primarily in midline structures such as the pontine reticular formation, periaqueductal gray, and the medial portions of the thalamus and hypothalamus. Limbic structures, including the supramammillary nucleus, the nucleus basaiis of Meynert, and the zona incerta also contained axonal terminals. Assessment of exploratory behavior in animals with acute pancreatitis revealed a significant decrease from controls. Normal rearing activity returned in animals after dorsal column lesions including the area near the dorsal intermediate septum. The long-term effects of dorsal myelotomy involving each of these dorsal column pathways was examined. Body weight and behavioral activity in animals with dorsal column lesions were not affected significantly at any time point through 30 weeks. Condnsions: These data demonstrate that pancreatic pain is transmitted via a dorsal column pathway. Further, a dorsal intermediate septum myelotomy may provide long term relief of such pain and is well tolerated. This research was made possible by full grant support from NIH NS 11255.

A total system approach to sustainable pest management.

A fundamental shift to a total system approach for crop protection is urgently needed to resolve escalating economic and environmental consequences of combating agricultural pests. Pest management strategies have long been dominated by quests for "silver bullet" products to control pest outbreaks. However, managing undesired variables in ecosystems is similar to that for other systems, including the human body and social orders. Experience in these fields substantiates the fact that therapeutic interventions into any system are effective only for short term relief because these externalities are soon "neutralized" by countermoves within the system. Long term resolutions can be achieved only by restructuring and managing these systems in ways that maximize the array of "built-in" preventive strengths, with therapeutic tactics serving strictly as backups to these natural regulators. To date, we have failed to incorporate this basic principle into the mainstream of pest management science and continue to regress into a foot race with nature. In this report, we establish why a total system approach is essential as the guiding premise of pest management and provide arguments as to how earlier attempts for change and current mainstream initiatives generally fail to follow this principle. We then draw on emerging knowledge about multitrophic level interactions and other specific findings about management of ecosystems to propose a pivotal redirection of pest management strategies that would honor this principle and, thus, be sustainable. Finally, we discuss the potential immense benefits of such a central shift in pest management philosophy.

Symptomatic prescribing reappraised

At the University of Alberta we focus our history, examine pointedly, diagnose specifically, eradicate the cause, and educate the patient prophylactically. For completely ideal care we should also include (what was omitted from the dreamlike opening sequence) symptomatic treatment, the judicious management of distress. Until recently symptomatic treatment was virtually our entire stock in trade, but the profession prospered. Then science and serendipidity provided us with a range of specifics, and we began to dismiss other treatments as merely symptomatic and to note their capacity to obscure diagnosis or to cause dependence. I have seen calamities arising from thoughtless symptomatic prescribing and, because I am a fastidious academic, I shudder at the memory. Why, then, do I not shudder when I look at my own prescribing patterns and those of the senior professors who are my closest colleagues? Lorazepam is recommended for the short term relief of anxiety neurosis. Five years is commonplace at this centre, mostly not for anxiety neuroses. Diazepam should be discontinued after a few weeks at the most. Twenty five years does not raise an eyebrow round here. I draw a veil over amphetamines and congeners; symptomatic medicine thrives where you would least expect it. What happens …

Loss of Ganglion Cells and Marked Attenuation of Bowel Wall in Cecal Dilatation

Cecal dilatation may be encountered in volvulus, distal colonic obstruction, and colonic pseudo-obstruction. Our study attempts to determine whether the dilatation is related to loss of ganglion cells and bowel wall attenuation. The records and colonic pathology of 27 patients who had undergone resection of the right colon for obstruction at the Veterans Affairs Medical Center, Buffalo, New York, were reviewed. Patients with severe ischemic changes and bowel wall necrosis were excluded. The remaining 10 cases were all elderly males who had cecal dilatation associated with cecal volvulus (7 cases), distal obstruction (2 cases), and colonic pseudo-obstruction (1 case). The dilated ceca ranged in circumference from 12 to 35 cm with a wall thickness of 0.1 to 0.2 cm. Ganglion cells of the Auerbach's plexus were counted per 10 fields at 200× magnification in hematoxylin and eosin-stained sections. Adjacent nondilated segments were examined for comparison. The number of ganglion cells within the dilated segments was significantly lower (1 to 6 cells; mean of 2.8) than in adjacent nondilated segments (8 to 42; mean of 23). Both the muscularis mucosae and propria were markedly attenuated in the dilated segments. Since the parasympathetic tone is probably impaired given the loss of ganglion cells, it is conceivable that conservative measures alone may not provide long term relief from dilatation.

A FRAMEWORK FOR ASSESSING THE IMPACT OF DISTRIBUTION FACTORS ON THE POTENTIAL EFFECTIVENESS OF INTERNATIONAL SHORT‐TERM HUMANITARIAN AID

Decisions on provision of international short term aid are often undertaken on an emotional, public relations driven basis. Such decisions may result in an inefficient and ineffective allocation of resources in terms of helping the most people at the lowest total cost. Using ideas from the marketing literature on the importance of distribution channels in effective and efficient delivery of non‐profit products and services, this paper addresses the issues of efficiency and effectiveness in allocation of short term relief aid. A framework is developed to assist decision makers in understanding how distribution factors might affect delivery of such aid.

Domiciliary oxygen cylinders: Indications, prescription and usage

Oxygen therapy for use in the home can be prescribed in two forms: oxygen concentrators are used to provide long term domiciliary oxygen therapy (LTOT), and oxygen cylinders are used to provide oxygen intermittently for relief of symptoms. In this study prescription and usage of oxygen cylinders in the home were assessed. All patients using oxygen cylinders at home in the London Borough of Tower Hamlets in October 1992 were studied. A questionnaire was sent to each patient; further information was obtained from a questionnaire to the general practitioner and from hospital notes where available. Patients with a diagnosis of chronic obstructive pulmonary disease (COPD) were visited at home to measure oxygen saturation levels (SaO2). The main outcome measures were the proportion of oxygen cylinder users who had undergone a full respiratory assessment and the number who might benefit from LTOT. There were 56 patients using oxygen intermittently, 77% with COPD of which 28% had an SaO2 < or = 92%. In these 56 patients 27% had not been assessed by a hospital physician for their chest disease, 58% used their oxygen at least once a day and on average these patients used three cylinders each per month. Most patients using oxygen cylinders at home have a diagnosis of COPD and use oxygen regularly for short term relief of breathlessness; many have not been assessed by a respiratory physician. Measurement of SaO2 suggested that a significant minority might benefit from LTOT and would certainly warrant further evaluation.

Long term results of endoscopic dilatation for corrosive oesophageal strictures.

Although dilatation is the treatment of choice for most patients with benign oesophageal strictures, there is little information on its efficacy and safety in corrosive oesophageal strictures. Of 123 adults with benign oesophageal strictures treated by endoscopic dilatation, 52 (42.3%) had strictures after corrosive ingestion and 39 (31.7%) had peptic strictures. Treatment was considered adequate if the oesophageal lumen could be dilated to 15 mm and there was complete relief of dysphagia. If dysphagia recurred after adequate initial dilatation, the stricture was dilated again up to 15 mm. Initial dilatation was adequate in 93.6% of patients with corrosive strictures and this success rate was comparable with that of the peptic stricture group (100%, p > 0.05). Long term success after adequate initial dilatation was studied in 36 patients with corrosive strictures (mean follow up 32.36 (17.12) months, range 6-60) and 33 patients with peptic strictures (mean follow up 36.32 (17.9) months, range 6-60). The mean (SEM) number of symptomatic recurrences per patient month during the total follow up period in the corrosive group was significantly higher than that in the peptic group (0.27 (0.04) v 0.07 (0.02), p < 0.001). The recurrence rate in the corrosive group, however, decreased over time, and after 12 months it was significantly (p < 0.001) lower than the recurrence rate in the first six months. After 36 months, the difference in the recurrence rate in the two groups was not significant (p > 0.05). Only nine oesophageal perforations occurred during a total of 1373 dilatation treatments (procedure related incidence 0.66%), and eight of these were in the corrosive stricture group. These patients were managed conservatively and subsequently strictures were dilated adequately in all. Endoscopic dilatation is safe and effective for short and long term relief of dysphagia in patients with corrosive oesophageal strictures.