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Melanoma of the anorectum represents

Aim The Rapid Access Diagnosis and Remedy (RADAR) clinic combines 2-week wait (TWW) specialist consultation with ‘straight-to-test’ flexible sigmoidoscopy (FS) for left-sided ‘red-flag’ TWW criteria (excluding right-sided mass or iron-deficiency anaemia). The study aims were to determine the effectiveness of RADAR in differentiating colorectal cancer from benign disease and to evaluate the need for whole colonic investigation (WCI) following FS, in symptomatic patients. Method Prospectively collated data of all RADAR patients from November 2005 to November 2009 were analysed, excluding patients referred internally for a FS. The local histology database was later interrogated to detect any missed cancers. Results Of 1690 patients (729 men; median (range) age: 68 (18–96) years) assessed in RADAR, 84 were excluded. Colorectal cancer (CRC) was diagnosed in 117 (7.3%). Eighty-seven cancers were diagnosed on the day of attendance and a further 13 within a week (88.9% overall). Two patients after a cancer-free FS were found to have a right-sided CRC on WCI (0.24%) and one synchronous cancer was found. No patient with a cancer-free FS having a WCI was subsequently found to have CRC at a median of 35 (12–58) months. Conclusion Flexible sigmoidoscopy, in the context of an endoscopy unit TWW clinic, allows same-day diagnosis of most patients referred with left-sided symptoms, and immediate reassurance and treatment of most benign diagnoses. For these patients, the use of routine WCI following a cancer-free FS does not appear to be beneficial. Adopting this system would significantly reduce the number of barium enemas and colonoscopies currently performed.

Clinical and sub-clinical varicoceles are associated with infertility and abnormal sperm parameters. Percutaneous embolization is a minimally invasive, safe, outpatient method of treatment which is cost effective in comparison to surgery. This study is a retrospective review of embolization of the spermatic vein using stainless steel occluding spring coils, performed in 116 males from two infertility clinics. Follow-up results were complete in 87 patients of which 79 (91%) were successful both technically and clinically and all had sperm analysis performed both before and within 2 years after embolization. There was a highly significant increase in motility (mean 35% before, mean 46% after, p < 0.001). Sperm density showed a trend towards improvement, but only p < 0.10, and there was no significant change in semen volume or morphology. The partners of 29 men (33%) became pregnant in a total of 241 years of follow-up.

Hepatic epithelioid haemangioendothelioma (HEH) is a rare, low grade malignant neoplasm of endothelial origin which is difficult to diagnose and has a variable outcome. We review five HEH cases from our centre with the aim of identifying clinical predictors of outcome and various therapeutic options. A search was made on the WA Liver Transplant registry for cases with histologically confirmed HEH. Their medical records were reviewed. A literature search was conducted through Medline using terms to compare the results from this series with those of other series. Five patients were identified to have HEH. The mean age was 44.2years (range 34-53years). Four of five patients presented with dyspepsia and two patients had clinical evidence of portal hypertension with ascites. Two patients had radiologically diffuse disease and three patients had discrete nodular liver involvement. The mean duration from presentation of symptoms to diagnosis of HEH was 26.8months. Liver transplantation was performed in one patient with diffuse HEH who is alive with no disease recurrence at 3years. Three patients with radiologically stable disease followed with 6monthly surveillance imaging are currently alive and well. The median survival of all five patients was 5years (range 1.5-16years) at the time of follow up. These results support the role of surveillance alone for patients with focal and radiologically stable disease. Patients with diffuse HEH with hepatic decompensation should be considered for transplantation. However, numbers are small and an international registry is required to make firm comparisons.

We present a case of recurrent variceal bleeding due to subtotal occlusion of the splenoportal junction by a pancreatic carcinoma. This was effectively treated by transhepatic venous angioplasty and stenting.

To explore the treatment effect of EGb 761((R)) (EGb) in Alzheimer's disease depending on baseline severity.We applied stratification to the intent-to-treat data set collected during a 52-week, randomized, double-blind, placebo-controlled, parallel-group, multicenter study with 120 mg of EGb, using cutoff points of 23 and 14 for the Mini-Mental State Examination (MMSE) score. Outcome measures used were the cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-Cog) and the Geriatric Evaluation by Relative's Rating Instrument (GERRI).In the severity stratum 1 (MMSE23), the placebo group did not show significant changes, while the EGb group improved significantly by 1.7 points on the ADAS-Cog and by 0.09 points on the GERRI. In the severity stratum 2 (MMSE24), the placebo group worsened by 4.1 points on the ADAS-Cog and 0.18 points on the GERRI, whereas the EGb group showed 60% less decline on the ADAS-Cog (treatment difference of 2.5 points) and no change on the GERRI (treatment difference of 0.25 points). The most severely impaired subgroup (MMSE15) showed slightly more pronounced worsening for both treatment groups. However, in comparison to placebo, EGb induced virtually the same magnitude of effect as was observed in the entire stratum 2.The results of this retrospective analysis indicated that a treatment effect favorable to EGb could be observed with respect to cognitive performance (p = 0.02) and social functioning (p = 0.001) regardless of the stage of dementia, whether mild or moderately severe. However, the relative changes from baseline measured at endpoint depended heavily on the severity at baseline. Improvement was observed in the group of patients with very mild to mild cognitive impairment, while in more severe dementia, the mean EGb effect should be considered more in terms of stabilization or slowing down of worsening, as compared to the greater deterioration observed with placebo.

Sexual dysfunction has long been noted as both a symptom of depressive illness and as a side effect of many of the medications used to treat depression. Although most people suffering from a major depressive illness would like to be sexually active, half experience a decrease in desire or sexual performance. Antidepressant medications often interfere with several parts of the sexual response. This review compares data from different types of research into the effect of antidepressant medications on the sexual response: case reports, chart reviews, and single- and double-blind studies with and without active control medications. From this review, it is clear that antidepressants of most classes interfere with human sexual functioning, with the notable exceptions of bupropion and nefazodone.

We report the results of a double-blind study comparing the efficacy and safety of low-dose (10-50 mg) and high-dose (20-100 mg) ranges of gepirone-extended release (ER) and placebo in 145 outpatients with major depressive disorder. At multiple time points and endpoint (Week 6), statistically significant reductions in Hamilton Rating Scale for Depression (HAM-D) scores were recorded for high-dose gepirone-ER compared to placebo. Analysis of the 17-item HAM-D and 28-item HAM-D scores indicated a relatively early onset of antidepressant efficacy with statistically significant results at treatment Weeks 1, 2, 4, and 6. A rapid response was evident in the high-dose group, beginning at Week 1 (p.05). The most frequently reported adverse experiences were headache, nausea, dizziness, and insomnia. The results indicate that gepirone-ER is clearly superior to placebo in terms of antidepressant efficacy. When used at higher doses, gepirone-ER appears to be efficacious, safe, and well-tolerated in depressed out-patients.

A multisite, double-blind, placebo-controlled study was made of 177 patients with the diagnosis of generalized anxiety disorder. After a 1-week placebo lead-in, they were randomized to 4 weeks of treatment by placebo or one of two doses of a novel, nonsedating compound that had demonstrated reduction of fear-avoidance behavior in animals. Efficacy was not demonstrated at a significant level. A further analysis of 142 patients who completed the treatment was undertaken to test the hypothesis that efficacy might be demonstrated by the single-rater procedure (SRP), which eliminates interrater error variance. The 80 patients who were examined by the same clinical rater for all six visits were compared with the 62 patients who had the multiple-rater procedure (MRP), ratings by two or more clinicians sequentially over the six visits. A two-way analysis of variance showed significantly greater discrimination of placebo and drug for the MRP group. The results provided no support for the frequent preference for the SRP. The MRP may include less psychotherapeutic interaction with the patient and less researcher bias in ratings.

Medroxyprogesterone acetate (MPA) was administered as a depot injection to two adult male dogs. One was injected with 75 mg as a depot injection once a month for 2 months and the other with 50 mg at 2-weekly intervals for 1 month, followed by 100 mg at 2-weekly intervals for a further 2 months. Two other male beagles were given gonadotrophin-releasing hormone (GnRH) agonists (nafarelin derivative no. 49947 and nafarelin acetate) at a dose of 50 micrograms day-1 for either 22 or 23 days. The profiles of luteinizing hormone (LH) and testosterone were monitored before and during the treatment periods, and changes in the dogs' testes, epididymides and prostate glands were determined post mortem. In the MPA-treated animals, LH was suppressed for only very brief periods. In contrast, in the dogs treated with GnRH agonist, LH and testosterone concentrations were suppressed for most of the treatment period. In the MPA-treated animals, histological changes were seen mainly in the head of the epididymis, and in the acrosome region of the spermatozoa still present in this region of the male reproductive tract. The acrosome, instead of being closely applied to the sperm head, was in contact only in the most anterior areas, with the remainder forming a fan-like projection, indicating increasing detachment from the sperm head. In the dogs treated with GnRH agonist there was clear evidence of cessation of normal spermatogenesis in most of the seminiferous tubules. Changes in the histology of the head of the epididymis were similar to (but more profound than) those found in the dogs treated with MPA. Seminal changes were demonstrated in ejaculates collected during the latter stages of the treatment period.

The study extends work in informative labeling, fear appeals, and negative information effects. Respondents were given two labels from two packages, one of which contained the experimental treatment. Warning strength was manipulated at three levels: weak, medium, and strong. The data show that, unlike labels on prescription medications, non-prescription warning labels tend to discourage use of the product. Results have implications for information theorists, marketers, and public policy makers.

Estazolam, a triazolobenzodiazepine with an intermediate elimination half-life, has been shown previously to be an effective and safe hypnotic in insomniacs without concomitant psychiatric illness. Our study of the efficacy of estazolam in patients with insomnia associated with generalized anxiety disorder began when 108 patients meeting criteria for generalized anxiety disorder (mean total score of Hamilton Rating Scale for Anxiety [HAM-A] = 22.0 +/- 3.1 [SD]) and insomnia were given single-blind placebo for 7 nights. Nine patients whose anxiety and/or insomnia improved were dropped as placebo responders. The remaining 99 patients were randomly allocated (1:1) to double-blind treatment with either estazolam 2.0 mg or matching placebo for 7 nights. Hypnotic efficacy, as determined by patient-completed sleep questionnaires, was statistically significant for estazolam 2.0 mg versus placebo for all sleep indices (p less than 0.01). Patients treated with estazolam 2.0 mg showed significantly greater improvement in anxiety than those receiving placebo on the mean total score of HAM-A ([placebo, -3.4; estazolam, -7.1; p less than 0.001] and without the insomnia item [placebo, -2.7; estazolam, -5.5; p less than 0.001]). Anxiety scores on the State-Trait Anxiety Inventory showed greater improvement in the estazolam group, but without statistical significance (p = 0.237). Estazolam 2.0 mg is an effective hypnotic in patients with generalized anxiety disorder and appears to have a favorable anxiolytic action.

Summary Participant modelling, a behaviourally-orientated treatment technique, is an effect method of treating phobias associated with minor medical procedures or apparatus such as needles or intravenous catheters. The steps in this technique are described and two cases of severe needle phobias successfully treated with participant modelling are presented to illustrate further its application.

Ten children developed intussusception after laparotomy. The bowel obstruction caused by the intussusception was evident within 8 days of major laparotomy in 8 children and within 39 days in the other two. It developed after the usual postoperative laparotomy ileus, and did not respond to normal non-operative treatment not even to a barium enema. There was one palpable abdominal mass and no rectal bleeding. Only at surgery was the correct diagnosis made. Eight of 10 intussusceptions affected only the small-bowel; most of them were ileoileal, but 2 were ileocolic. Seven of the 10 intussusceptions needed only manual reduction. Postoperative recovery was uneventful.

Stumpy is a new chondrodystrophic mutant in the mouse. The condition is inherited as a fully penetrant Mendelian recessive, and is not allelic with brachymorphic, achondroplasia, or stubby-three similar, previously described mutants. No chromosomal position has yet been assigned to the gene. Phenotypically, stumpy mice are chondrodystrophic dwarfs with all cartilage-formed bones in the skeleton affected. The condition differs from the usual chondrodystrophy described in mice in that proximal elements in the limbs are affected more than distal ones.

The majority of studies of primary anorexia nervosa have focused on adolescent females. Relatively little has been written on anorectic males, and there has been scarcely any documentation of the occurrence of this disorder in adult males. The present paper describes three cases of adult-onset primary anorexia nervosa in males. For each case, the history and diagnostic patterns are considered, followed by a discussion of the course of outpatient treatment. The therapy was multimodal and included elements of behavioral contingency management, cognitive therapy, and dynamic psychotherapy. Suggestions are made for future research.

Behaviour, vaginal cytology and plasma progesterone concentrations were monitored during oestrus in a group of 6 beagle bitches before intrauterine insemination with frozen semen. At intervals after insemination, the reproductive tracts were examined for evidence of conception, which occurred in 5 of the bitches. One pregnant bitch had received treatment with stilboestrol before insemination.

Ensuring patient compliance with instructions for medication continues to be a major problem. The authors report an experiment suggesting that warning labels promote compliance. In addition, other methods of improving compliance are discussed.

Two species of arctic phocid seals, the harp seal (Phoca groenlandica) and the gray seal (Halichoerus grypus), were studied during the 3-week period after birth of the young. This is a time of extremely rapid growth in the seal pup, particularly by the laying down of blubber, and terminates with the molt of the lanugo fur, with being weaned, and with the start of a pelagic diving habit. The adult seal undergoes parturition, lactation, and the initiation of the mating phase in this period. These various events require selective endocrine regulation for thermoregulation, metabolism, salt and water balance, hematopoiesis, and molt. Endocrine function was examined in the seals by plasma titers of the hormones triiodothyronine (T3), thyroxine (T4), cortisol, and aldosterone. Levels of T4, cortisol, and aldosterone were high in the neonate harp seal: 190, 53, and 225 ng/100 ml, respectively. At this time, a high rate of thermogenic metabolism utilizing brown adipose tissue in particular has been reported, suggesting this as a function for T4 and cortisol. Low plasma sodium levels were found in the newborn pups, requiring the action of aldosterone. Cortisol levels in the pup plasma declined after birth and then rose to a new peak by 3 weeks of age; T3 increased in concentration from birth, also to a peak at 3 weeks. Molt occurs at this time, and the pup is no longer nursing; two factors involving the action of both thyroid hormones and cortisol. Thyroid hormones were relatively elevated throughout the pupping period. A stimulatory effect on hematopoiesis is suggested. The source of the high levels of thyroid hormones in pup plasma may have been through nursing, high concentrations of T3 and T4 were found in the milk of lactating harp seals—3.73 ng T3/ml, 41 ng T4/ml. Adult male seals were marked by high plasma levels of cortisol, aldosterone, and T3. Enhanced lipolysis in the production of the fat-rich seal milk is suggested by elevated levels of T4 and cortisol in the plasma of lactating seals, as compared to those in females no longer nursing pups. The postnursing adult female harp seals generally had the lowest plasma concentrations of all four hormones examined—1.2 ng T3/ml, 25 ng T4/ml, 36 ng cortisol/ml, 30 ng aldosterone/100ml.

This study shows fluoxetine to be a potent anorectic agent in non-depressed clinically overweight individuals. It is as effective an anorexic compound as a currently available appetite control agent, benzphetamine, and highly significantly more effective than the placebo treatment. A relative lack of serious side-effects and a low abuse potential make it an interesting drug in the slim armamentarium of agents that are used to treat the overweight. If the lack of tolerance to the effects of this drug seen in the long-term studies of depression is confirmed in long-term studies of obese patients, fluoxetine may have a major part to play in the treatment of the obese patient where weight loss is medically indicated. This would include the morbidly obese, the type II diabetic, and the hypertensive patient. Although ideally behavior modification should accompany the drug treatment for obesity, clinical practice indicates that in many cases, patients will not follow through with the behavioral treatment. A strictly medical prescription of an acceptable pharmacologic agent like fluoxetine on a chronic or long-term basis may provide a new possibility for the treatment of these individuals.