Behavioral preparation of patients for gastrointestinal endoscopy: information, relaxation, and coping style

The anterior insula and anterior cingulate cortex are associated with avoidance of dental treatment based on prior experience of treatment in healthy adults

Background

Fear concerning stressful medical or dental procedures is one of the major factors that distance patients from health care. Fear and avoidance of dental treatments can be shaped by a patient’s prior experience with receiving dental procedures or by imagining the procedures.

Methods

We performed two functional magnetic resonance imaging (fMRI) experiments to investigate the role of the anterior insula (aINS) and dorsal anterior cingulate cortex (dACC), which are both critical to threat perception, in dental avoidance. Dental avoidance based on both prior treatment experience and imagination was assessed using a customized questionnaire. In an fMRI task-based study, we investigated brain activation in 17 healthy participants when they viewed images depicting dental procedures that evoked a moderate degree of fear. Region-of-interest analysis was performed to assess the association between dental avoidance and aINS as well as dACC activation. In a resting state fMRI study, we investigated 18 healthy participants for the association between the intrinsic functional connectivity of the aINS and dACC and dental avoidance.

Results

We found that (1) the participants showed a higher activation of the right aINS and bilateral dACC when they viewed images of dental procedures compared with the brain activation observed when they viewed scrambled images (p < 0.05 corrected for small volume and family-wise error). (2) The avoidance ratings based on prior experience of dental treatment were significantly positively correlated with the activation in the right aINS (r = 0.67, p = 0.003), right dACC (r = 0.65, p = 0.005) and left dACC (r = 0.63, p = 0.007). (3) The intrinsic functional connectivity between the aINS and the orbitofrontal cortex was positively correlated with the avoidance ratings based on experience (uncorrected p < 0.001).

Conclusions

The findings highlight prior experience of dental treatment as a predominant factor in shaping patients’ avoidance behavior. Individual differences in threat perception may play a key role in the development of dental avoidance.

The effects of two educational interventions on knowledge and competence of nurses with regard to conveying gastroscopy-related information to patients

AIM

The study was to compare the effects of two different educational interventions on knowledge and competence of nurses regarding conveying gastroscopy-related information to patients.

BACKGROUND

Nurses play an important role in helping patients undergo gastroscopy and must be familiar with the procedure to provide related patient education.

DESIGN

A quasi-experimental study.

METHODS

This study in 2010 involved a pre-test and two post-tests. The experimental group (n=25) received a multimedia CD-ROM, and the comparator group (n=40) received a pocket booklet. The effects of the two educational interventions were measured using the Knowledge Test Gastroscopy Nursing Instruction Scale, the Self-Evaluation Gastroscopy Nursing Instruction Scale, and the Gastroscopy Nursing Instruction Learning Satisfaction Scale.

RESULTS

No overall significant difference in knowledge scores between the two groups was found, but subsequent post hoc analysis showed significantly higher scores in the experimental group than in the comparator group at week 6. A significant within-subjects effect of the self-evaluation gastroscopy nursing instruction scores from baseline-week 6 was dependent on the experimental group or the comparator group. There were significant between-subjects effects overall, at week 3 and at week 6.

CONCLUSION

Both educational interventions improved nurses' knowledge and competence in gastroscopy-related information. However, the CD-ROM-based intervention had long-term effects on knowledge and had short-term and long-term effects on competence.

A Person-Focused Analysis of Resilience Resources and Coping in Diabetes Patients

This study investigated the resilience resources and coping profiles of diabetes patients. A total of 145 patients with diabetes completed a questionnaire packet including two measurements of coping (COPE and Coping Styles questionnaires), and personal resources. Glycosylated hemoglobin (HbA(1c)) was also assessed. Resilience was defined by a factor score derived from measures of self-esteem, self-efficacy, self-mastery, and optimism. All of the maladaptive coping subscales were negatively associated with resilience (r's range from -.34 to -.56, all p's <.001). Of the adaptive coping subscales, only acceptance, emotional support, and pragmatism were positively associated with resilience. The upper, middle, and lower tertiles of the resilience factor were identified and the coping profiles of these groups differed significantly, with low resilience patients favoring maladaptive strategies much more than those with high or moderate resilience resources. Resilience groups did not differ in HbA(1c) levels; correlation coefficients of the coping subscales with HbA(1c) were explored. This study demonstrates a link between maladaptive coping and low resilience, suggesting that resilience impacts one's ability to manage the difficult treatment and lifestyle requirements of diabetes.

How does anger coping style affect glycemic control in diabetes patients?

BACKGROUND

Although various forms of anger have been found to influence the psychological and physical health in many chronic illness populations, little is known about the effects of anger in diabetes patients.

PURPOSE

Associations between anger coping style, diabetes-related psychological distress, and glycosylated hemoglobin (HbA1c) were examined in 100 diabetes patients.

METHOD

Participants completed the Problem Areas in Diabetes and Coping Styles questionnaires, and had HbA1c assessments at study entry (Time 1 = T1), six months (T2), and 12 months after T1 (T3).

RESULTS

Linear regression analyses revealed T1 anger coping associated with T3 HbA1c (beta = .22, p < .05), but T1 HbA1c did not associate with T3 anger coping (beta = .13, p = NS). After controlling for significant covariates (of gender, age, education, type and duration of diabetes), regression analyses revealed that T2 diabetes-related psychological distress partially mediated this association.

CONCLUSION

These results suggested that higher levels of anger coping may promote poorer glycemic control in diabetes patients by provoking greater diabetes-related distress. Areas of future research on this topic are discussed.

Impact of day-case gastroscopy on children and their families

BACKGROUND AND AIM

Increasing numbers of endoscopies are being carried out in children. The purpose of our study was to evaluate the provision of information about the admission and procedure and the functional and economic impact of day-case gastroscopy on children and their families.

METHODS

We administered a structured questionnaire to families of children undergoing elective gastroscopy, with daily follow up by telephone over the next 3 days.

RESULTS

One-hundred-and-three children were recruited. All had seen a consultant gastroenterologist (usually the proceduralist) prior to the endoscopy, who had obtained signed consent; 89% of families remembered receiving an explanation from the doctor carrying out the procedure. Nearly all (94%) described the information they received as adequate. However, only one-third of families recalled receiving an explanatory brochure and very few had toured the Day Surgical Unit or seen the complimentary video. Thirty percent were unhappy with the time spent at the Day Surgical Unit and an apparent failure to warn of possible delays, 8% felt that they were not given adequate information prior to discharge, and 39% of children failed to attend school the day after the procedure. Although tiredness or sleepiness was common, no correlation was found between the presence of symptoms and school absence. Complaints about the admission included overcrowding, lack of privacy, excessive noise, and failure to cater for adolescents. Fifty percent of parents took leave from work, but most manipulated work rosters and holidays so that costs to them and to the workplace were minimal.

CONCLUSION

Information provision about the procedure and admission appears to be adequate in most families of children undergoing day-case gastroscopy, but may be improved in some areas. Failure to remember elements of the consent and explanatory process is common. Minor morbidity is also common after the procedure.

The Effects of Concrete Objective Information and Relaxation on Maintaining Usual Activity During Radiation Therapy

PURPOSE/OBJECTIVES

To examine the effects of concrete objective information (COI) and relaxation instruction (RI) on patients undergoing radiation therapy, as well as the contribution of symptom uncertainty and body awareness to the intervention effects.

DESIGN

Three-group randomized trial. Assignment was stratified by cancer site. Data collectors were blinded to group assignments.

SETTING

University medical center radiation therapy department serving both urban and rural communities in the southeastern United States.

SAMPLE

76 adults having radiation with curative intent for gynecologic, head and neck, or lung cancer. Most were Caucasian and had in situ to stage II disease. Mean age was 55 years.

METHODS

COI and RI were delivered by tape recordings. Outcome measures were indicators of usual activities and emotions at treatment week 3 and two and four weeks post-treatment.

MAIN RESEARCH VARIABLES

Intervention group; social, household, and recreational activities; anxiety, depression, and anger; body awareness; and symptom uncertainty.

FINDINGS

Participants receiving either intervention reported more social activity during treatment. Those given RI who were high in body awareness reported more household activity during treatment. No effects were found regarding emotion. Symptom uncertainty partially explained COI effects.

CONCLUSIONS

The findings provide additional support for the effectiveness of COI in helping patients to maintain more of their usual activities during radiation therapy. Instruction in progressive muscle relaxation also may help in maintaining activities.

IMPLICATIONS FOR NURSING

COI helps patients to cope with treatment by reducing their uncertainty about symptoms. RI effects may vary by activity type and awareness of usual body sensations.

The effect of an information brochure on patients undergoing gastrointestinal endoscopy: a randomized controlled study

OBJECTIVE

The aim of the present study was to test the potential beneficial effects of an information brochure on undergoing a gastrointestinal endoscopy for the first time. The information provided was based on self-regulation theory, and patients could restrict themselves to reading the summary only.

METHODS

Patients were randomly assigned to an experimental group receiving the brochure at least 1 day before the gastroscopy (N=47), or to a control group not receiving the brochure (N=48).

RESULTS

The results show that all experimental subjects, except one, fully read the brochure. Those receiving the brochure experienced less anxiety before the gastroscopy and, afterwards, they reported greater satisfaction with the preparation for it. With regard to coping style there were some small moderating effects into the direction expected: low blunters (those not seeking distraction under impending threat) as compared to high blunters showed extra reduced anxiety after reading the brochure. They also tended to read the brochure more often. High monitors (those seeking information under impending threat) receiving the brochure showed reduced anxiety during the gastroscopy as compared to low monitors (tendency).

CONCLUSION

We conclude that providing patients with the developed brochure constitutes an efficient, beneficial intervention.

PRACTICE IMPLICATIONS

The brochure could easily be implemented in standard practice without the necessity to take the patient's coping style into account.

Stress-reductive effects of information disclosure to medical and psychiatric patients

Informed consent has become a central part of medical decision-making. It is based on disclosure of medical information to support patients' rights for autonomous decision-making from a legal point of view. However, information disclosure may also benefit patients. Research indicates that information disclosure reduces stress among patients and that the more patients desire relevant information, the more stress-reductive information disclosure may be. In psychiatry, too, studies have shown that educating psychiatric patients may not necessarily reduce compliance or increase relapse rate. These findings are in line with patients' desires and their legal right to know their own medical matters. It has long been believed that patients, be they psychiatric or non-psychiatric, should be protected and not given information that would potentially cause distress or harm to them. However, patient's competency may be a function of the physicians' efforts to make patients understand necessary information. Therefore, a patient's right to give informed consent leads to a physician's duty to disclose individually tailored information understandable to patients.

Music during bronchoscopic examination: the physiological effects. A randomized trial

BACKGROUND

Patients scheduled for bronchoscopic procedures are often anxious and frightened. Reduction in the state of anxiety during an invasive procedure may prevent some possible complications. Music has been proposed as a safe nonpharmacological antianxiety intervention.

OBJECTIVE

We followed up physiological indicators of anxiety (blood pressure, heart rate) during bronchoscopic examination to determine the effect of music on the level of anxiety.

METHODS

Two hundred adult patients were included in the study. Blood pressure, heart rate, procedures performed during bronchoscopy and duration of examination were monitored. Patients' overall feelings during the procedure were rated from 0 (without unpleasant feelings) to 10 (unbearable). All patients used the Visual Analogue Scale (VAS).

RESULTS

Two hundred adult patients referred for bronchoscopy were included in the study: 93 patients received music during the procedure and 107 served as control. There were no significant differences between the two groups in terms of age, sex, indications for bronchoscopy, procedures performed during bronchoscopy, duration of the examination and patients' subjective perception of the procedure. The mean hart rate, systolic and diastolic blood pressures were significantly lower in the music group compared to the control group.

CONCLUSIONS

Our findings suggest that the application of music reduces anxiety during bronchoscopic examination as physiological indicators of anxiety, the mean heart rate, systolic and diastolic blood pressures, were significantly lower in the music group.

Relaxation techniques for reducing pain and anxiety during screening mammography

OBJECTIVE

The purpose of this study was to determine whether listening to a relaxation audiotape before and during mammography decreases subjective reports of pain and anxiety.

CONCLUSION

Listening to a relaxation or music audiotape before and during mammography does not reduce subjective reports of anxiety or pain. Women undergoing screening mammography report minimal levels of distress.

Preparing patients for gastrointestinal endoscopy: the influence of information in medical situations

The effects of the provision of information were tested in a sample of patients who underwent a gastrointestinal endoscopy for the first time (N=260). On the basis of their Threatening Medical Situation Inventory (TMSI)-monitoring score these patients were divided in high monitors versus low monitors. On the basis of the existing literature each group received the type of information that was considered most beneficial with regard to their coping style, and each group was compared with a control group receiving standard care (the usual information plus coaching by a nurse). Dependent variables were anxiety at different points in time, heart rate and skin conductance, pain, experience of the procedure, course of the procedure, duration of gagging, and satisfaction with the information provided. Unexpectedly, it turned out that high monitors did not profit by extensive information when compared with high monitors receiving standard care. Also for low monitors their minimal informational intervention did not exceed the effects of standard care. In the discussion, four factors possibly responsible for these results were elaborated. It is concluded that reservedness is required in providing (too) extensive information to patients who ask for this. Furthermore, considering the rather unpredictable and uncontrollable course of a gastrointestinal endoscopy, coaching by a nurse remains a valuable type of support.

A qualitative evaluation of information leaflets for gastroscopy procedure

Written information sent to patients prior to diagnostic gastroscopy is an important part of the process of informing and preparing them for the procedure. Yet there is ample evidence in the literature that information leaflets do not measure up to the required standard. In this study, information leaflets from a random sample of seven hospitals in Northern Ireland that carried out gastroscopy as a day procedure were evaluated using a checklist of items recommended by the British Society of Gastroenterology (BSG) for inclusion in leaflets for patients undergoing diagnostic gastroscopy. The results showed that the number of written materials sent to patients prior to the procedure varied between units. There were inconsistencies in the information given by the same unit, and overall, there was a lack of vital information in most of the leaflets. Some of the information was confusing and ambiguous. The potential risk of the procedure was explained in only one of the leaflets. Patients' right to choose to have a mild sedative was not made clear in most of the leaflets. More should be done to address these gaps and inconsistencies in the written information provided to patients prior to gastroscopy.

Children's knowledge, anticipatory anxiety, procedural distress, and recall of esophagogastroduodenoscopy

BACKGROUND

This study evaluates the relations among children's knowledge of esophagogastroduodenoscopy (EGD) and anticipatory anxiety, procedural distress, and the nature of postprocedural recall and evaluations.

METHODS

One hundred patients, aged 8 to 17 years, completed self-report measures of knowledge and anxiety before EGD. Parents completed a self-report measure assessing how they prepared their children. Nurses and trained observers completed observational ratings of distress. Children's recall and evaluation of the procedure were assessed by self-report 1 hour after the procedure and by telephone that evening.

RESULTS

Most children knew about the major components of EGD. Children with greater knowledge experienced less distress and reported that they would be less anxious and upset when undergoing future EGDs. Children with greater anticipatory anxiety exhibited more procedural distress. Children's distress varied by the phase of the procedure. Children who were more distressed during intravenous line insertion experienced greater distress during esophageal intubation and the endoscopic examination. Approximately 20% of patients reported at least some memory of the procedure even at the end of the day. Children with greater recall reported greater aversion and a more negative attitude toward future EGDs.

CONCLUSIONS

This study provides information about children's distress during EGD and the effects of conscious sedation on patients' memories and attitudes toward future procedures. The study indicates that preparation before EGD may reduce patient distress.

Information and its impact on satisfaction among surgical patients

This study investigates the association between patient characteristics, reported problems with obtaining information and global evaluations of care among surgical patients. Using data from a large scale study of hospital care, a factor analysis of 30 information-relevant items was conducted with data from a sample of 3602 surgical patients; and correlation and multiple regression analyses were conducted to identify the relationships among information, patient characteristics and global evaluations of care. Path analysis was also used to determine the extent to which perceived control mediates the information evaluation relationship. Four information factors were identified: surgical information, recovery information, general information and sensory information, and each was significantly related to global evaluations. Desire for involvement interacted with information received in determining patients' evaluations; and partial support was found for perceived control as a mediator of the information evaluation link. The data indicate that the relationship between information and evaluations of quality is generalizable across patients, conditions and hospitals; and should be defined more broadly to include that which is given by a variety of providers. to family, and about medications and home recovery. Desire for involvement and perceived control must also be considered in understanding the value and impact of information.

Upper gastrointestinal endoscopy: are preparatory interventions effective?

BACKGROUND

This study was designed to examine the effects of preparatory cognitive and behavioral information on self-confidence, anxiety, and negative affect elicited by an impending upper gastrointestinal endoscopy.

METHODS

Forty-eight male and female out-patients, between 18 and 65 years of age, scheduled for a first-time, non-emergency, endoscopic examination were randomly assigned to receive one of four experimental interventions: cognitive, behavioral, combination, or attention-control. Measures of self-reported anxiety and self-reported self-confidence were obtained.

RESULTS

Cognitive and combination intervention subjects were statistically younger than behavioral and attention-control subjects. A credibility assessment revealed that subjects who were taught visualization used it during their procedure. Results indicated that subjects in the cognitive and combination interventions experienced significant reduction in anxiety and increase in self-confidence from pre- to post-intervention. Self-confidence did not increase for subjects receiving the behavioral-only or the attention-control interventions.

CONCLUSION

The results of this study show that preparatory information in general is effective in reducing anxiety and in increasing self-confidence before an upper gastrointestinal endoscopy. Results suggest that teaching subjects visualization before a procedure increases their use of visualization during a procedure.

Influence of coping style and precolonoscopy information on pain and anxiety of colonoscopy

BACKGROUND

This study assessed the relationship between patient coping style, precolonoscopy information, and anxiety and pain associated with colonoscopy.

METHODS

Eighty consecutive adult patients undergoing initial colonoscopy were classified into two groups on the basis of coping style: information seekers or information avoiders. All were given standardized information about colonoscopy. Half of each group was randomly assigned to receive additional sensory information describing what they could expect to feel. Self-report, physiologic, and behavioral indices of anxiety and pain were measured.

RESULTS

Patients given information congruent with coping style experienced significantly less self-report anxiety immediately after the information intervention and spent less time in recovery. In contrast, patients given information not congruent with coping style maintained their pre-intervention anxiety level. Patients given information congruent with coping style scored lower on behavioral indices of pain, but there were no differences with respect to patient perception of pain or the dosage of sedative drugs. Most patients reported that the bowel preparation was the most distressing part of the colonoscopy.

CONCLUSIONS

Assessment of coping style and provision of congruent information reduces anxiety, recovery time, and observed behavioral indices of pain of colonoscopy but has no effect on sedation dose or patient perception of pain.

Educating interventional radiology personnel in nonpharmacologic analgesia: effect on patients' pain perception

RATIONALE AND OBJECTIVES

The purpose was to evaluate the effects on patients' pain perception of educating interventional radiology personnel in nonpharmacologic analgesia.

MATERIALS AND METHODS

Ninety-six patients undergoing lower-extremity arteriography or percutaneous nephrostomy were asked to rate the pain they experienced during the procedure on a scale of 0 to 5 (0 = no pain, 1 = mild pain, 2 = moderate pain, 3 = severe pain, 4 = very severe pain, 5 = worst pain possible). Patients were studied at two baseline sessions (baseline 1, December 1993 to August 1994, n = 15; and baseline 2, September 1995 to January 1996, n = 11) and after the staff underwent one of two training sessions (posttraining 1, January 1995 to July 1995, n = 34; posttraining 2, January 1996 to April 1996, n = 36). Training targeted nurses and technologists and included rapport skills, correct use of language and suggestions, distraction, relaxation training, and self-hypnosis. Data were evaluated with analysis of variance for repeated measures.

RESULTS

The mean pain scores reported after training were lower (1.48) and matched an "acceptable" pain score of 1.52 more closely than those reported under baseline conditions (2.54, P = .001). There was a tendency toward reduced use of intravenously administered agents for conscious sedation after training. There were no statistically significant differences in the pain scores between patients who underwent arteriography and patients who underwent nephrostomy overall (1.76 and 1.78, respectively), at baseline (2.58 and 2.43, respectively), and after staff training (1.49 and 1.42, respectively).

CONCLUSION

Interventional radiology personnel trained in nonpharmacologic analgesia methods can help reduce patients' pain perception during interventional procedures.

Predictors of patient cooperation during gastrointestinal endoscopy

We examined a number of patient variables, including three different scales of preprocedure patient anxiety, to determine which best predicted patient cooperation and satisfaction with gastrointestinal endoscopy. We prospectively evaluated 251 patients undergoing outpatient diagnostic esophagogastroduodenoscopy and colonoscopy under conscious sedation. All were given a questionnaire on arrival to our endoscopy center that included three measures of preprocedure anxiety: (a) a single question asking how anxious the patient was (termed "Anxiety I" scale); (b) a visual linear analog scale of anxiety; and (c) the Hospital Anxiety and Depression scale. Patient cooperation during the procedure was rated by the attending endoscopist. Patients were telephoned the next day to complete a questionnaire assessing their endoscopic experience. Logistic regression analysis was used to construct models for predicting which patients were most likely to have difficulty during their procedures from both the endoscopists' and the patients' standpoint. Statistical analysis identified three parameters that by themselves significantly correlated with patient cooperation during endoscopy: age (p = 0.008), Anxiety I scale (p = 0.03), and visual linear analog anxiety score (p = 0.02). When used together, age, type of procedure, and Anxiety I scale were the best predictors of patient cooperation from the standpoint of the endoscopist. Age, type of procedure, Anxiety I scale, and education level were the best predictors of satisfaction with endoscopy from the perspective of the patient. Good cooperation during endoscopy was associated with greater patient satisfaction.

A comparison of structured versus guided preheart catheterization information on mood states and coping resources

A rapid growth in outpatient surgical procedures has been necessary to help alleviate expensive health care costs. Because procedures, such as heart catheterization, require a short patient stay, preparatory information is often structured and delivered concisely. The purpose of this study was to determine if heart catheterization patients who receive guided precatheterization information had reduced stress compared with heart catheterization patients who received structured precatheterization information. Using a two-group pretest/posttest design, 89 subjects were randomly assigned to two different preparatory nursing interventions. Data were collected on outpatients' coping resources and mood states, which served as measures of stress. No significant differences in stress were found between the guided and structured preparatory information groups. The results indicated that a variety of approaches can be used to prepare patients for outpatient heart catheterization procedures.

Self-hypnotic relaxation during interventional radiological procedures: effects on pain perception and intravenous drug use

The authors evaluated whether self-hypnotic relaxation can reduce the need for intravenous conscious sedation during interventional radiological procedures. Sixteen patients were randomized to a test group, and 14 patients were randomized to a control group. All had patient-controlled analgesia. Test patients additionally had self-hypnotic relaxation and underwent a Hypnotic Induction Profile test. Compared to controls, test patients used less drugs (0.28 vs. 2.01 drug units; p < .01) and reported less pain (median pain rating 2 vs. 5 on a 0-10 scale; p < .01). Significantly more control patients exhibited oxygen desaturation and/or needed interruptions of their procedures for hemodynamic instability. Benefit did not correlate with hypnotizability. Self-hypnotic relaxation can reduce drug use and improve procedural safety.

The efficacy of preparation for surgery and invasive medical procedures

In this article, we review published research evaluating the effectiveness of preparation interventions for adult patients undergoing surgery or invasive medical procedures. This review is meant to assist practitioners in selecting or designing an intervention. In general, preparation interventions have been shown to be effective across a range of health outcomes. However, the relative efficacy of different strategies has been difficult to assess, as has the contribution of several patient variables to outcome. Considering interventions used prior to surgery, there is not a clear demonstration of effectiveness, in part because large numbers of outcome variables have been used. In contrast, the preparation intervention literature using adult patients facing invasive medical procedures has shown the relative superiority of modeling procedures and coping strategies. In this review, we consider methodological weaknesses in previous research, and make suggestions for improving future research.

Information effect on the perception of pain during electromyography

Pain during the performance of electromyography (EMG) is an important clinical problem because pain distresses the patient and can interfere with diagnostic accuracy. We hypothesized that anxiety and pain perception associated with EMG would decrease if patients received written material describing the EMG before examination. Forty-two subjects received written material and 30 did not. Information before the test significantly decreased pain perception for women during the nerve conduction studies (p = .008), but not during the needle examination. A similar effect was not identified for the men. Other results indicate that women perceive the test as more painful than do men, older subjects perceive more pain and experience greater anxiety than do younger subjects, and all subjects perceive greater pain during the performance of (concentric, bipolar) needle electromyography than during the nerve conduction studies.

Barium meal or endoscopy? A prospective randomized study of patient preference and physician decision making

This study examines the preference of 64 out-patients for either a barium meal or an upper gastrointestinal endoscopy. The sequence of the examinations was randomized to avoid order bias. An initial preference for a barium meal of almost two-to-one, with 53% having no preference, was changed after the investigations to a preference for endoscopy of two-to-one with 5% having no preference. The use of mild sedation and the skill of the endoscopist had a major impact on the patients' opinion of the endoscopic procedure, and on their choice of examination for any repeat study. There was little agreement between clinical diagnosis and the result of investigation, but clinicians tended to accept the reported result of the investigation, especially if the result was abnormal. Despite a change in diagnosis in 34 of 49 patients there was little change in management as a result of the investigations, supporting the view that young patients with dyspepsia may be managed with symptomatic treatment initially, and without investigation. This study lends further support to the view that endoscopy should be the investigation of choice in patients with persistent dyspepsia, especially those whose age or infirmity may make barium examination suboptimal.

Patient attitudes to sedation for diagnostic upper endoscopy

The presumed need for sedation in upper gastrointestinal endoscopy differs widely between countries and between endoscopists. Very little is known about patient attitudes and the factors that influence patient discomfort. We investigated all ambulatory patients scheduled for diagnostic upper GI endoscopy during a 4-month period (n = 1169) for their attitudes to sedation. One week before the examination they were asked whether they wanted sedation in addition to topical throat anesthesia. A brief description of the endoscopic procedure was given together with an explanation of presumed advantages and disadvantages of sedation. Only 399 patients (34.1%) wanted sedation. The two groups of patients were comparable as to age, gender, and previous experience of endoscopy. Of the 399 patients wanting sedative medication 54.2% were afraid of the diagnosis and 45.8% of the procedure. Male sex and young age were associated with a lower rate of preferring sedation. Patient discomfort during endoscopy was negatively correlated with age (r = -0.309; p = 0.000). Patients who had had more than one previous endoscopy had less discomfort than those without endoscopy experience (p = 0.0069). Men had less discomfort than women (p = 0.0014). The vast majority of our patients preferred 'a normal afternoon to endoscopy sedation'. Young women not previously endoscoped potentially benefit most from sedation.

Satisfaction with communication, medical knowledge, and coping style in patients with metastatic cancer

Interviews were conducted with 77 patients aged 19-84, admitted to a medical oncology ward for assessment and modification of treatment. Satisfaction with information provided about tests, symptoms and treatment was assessed, together with satisfaction with care in general, factual knowledge concerning cancer and other medical conditions, and anxiety. Habitual style of coping with stress by information-seeking vs avoidance was measured using the Miller Behavioral Style Scale. Satisfaction levels were generally high. Patients reporting the highest level of satisfaction with information were more avoidant in their coping style than the remainder, and were also less anxious. Factual knowledge about cancer was in contrast greater among patients who were less satisfied with communication. These patterns were not dependent on age or education. It is argued that satisfaction with communication in medical settings is not a simple function of communication skills and the provision of adequately structured information, but that patients' tendencies to cope with stress by seeking out or avoiding information need to be taken into account.

Review article: premedication and intravenous sedation for upper gastrointestinal endoscopy

Upper gastrointestinal endoscopy can be performed without intravenous sedation but the evidence suggests that, in the United Kingdom and United States, most patients and endoscopists prefer that some form of premedication is given. Intravenous diazepam or midazolam are used by the majority of endoscopists. In the UK, the ratio of diazepam to midazolam users is approximately 2:1, while in the USA more endoscopists are now using midazolam. Midazolam is approximately twice as potent as diazepam but, when allowance is made for this, there is probably little or no difference in the propensity of the two drugs to produce respiratory depression. The antegrade amnesic effect of midazolam is significantly superior to that of diazepam. A benzodiazepine/narcotic combination can achieve a smoother and more rapid induction with less gagging and choking, but the incidence of adverse outcomes--particularly respiratory depression--is increased significantly. Over 50% of the deaths that are associated with upper gastrointestinal endoscopy are due to cardiopulmonary problems. Hypoxia is very common if measured using non-invasive monitoring equipment, such as a pulse oximeter. Methods of preventing oxygen desaturation and thus, by inference, most cardiac arrhythmias associated with endoscopy are discussed, as is the role of flumazenil, the new benzodiazepine antagonist.

Premedication for upper gastrointestinal endoscopy

Premedication is not essential to endoscopy but patient tolerance is clearly improved and, thus, ease of examination. Although comparable results can be achieved through nonpharmacologic means, the time and effort involved precludes their widespread use. Despite near universal utilization of premedication in endoscopy, the associated risk is difficult to determine from the available literature. The reported data reveal nominal risk yet must be viewed as minimums. The ideal drug with predictable clinical effects, minimal postprocedure impairment, little respiratory compromise, and proven antagonist is not yet available. Although midazolam seems to represent an advance, recent emphasis on respiratory depression is particularly troublesome. Studies evaluating various agents have suffered from lack of quantitation of such parameters as patient tolerance, ease of examination, and postprocedure impairment. Development of proven standards for these parameters would have to occur before a definitive double-blind randomized trial could be undertaken. Suggested means of assessing these parameters are listed in Table I. Improvement in major morbidity would be difficult in light of its low incidence. As the search for the ideal drug continues, endoscopists must continue to use drugs whose full effects are incompletely understood. The ability to increase patient comfort must be balanced with the small, but ever present, risk of morbidity and mortality.

Uncertainty, coping, and distress following myocardial infarction: transition from hospital to home

The purpose of this study was to examine the influence of uncertainty in illness and use of coping methods on emotional distress and recovery following myocardial infarction. A longitudinal exploratory design with measures obtained at three times was used; multiple regression was used to analyze the data. Uncertainty explained a significant amount of the variance in emotional distress prior to hospital discharge (21%), and 1 (16%) and 4 (26%) weeks after discharge. Patients reporting greater uncertainty also reported more emotional distress. One week after discharge, coping behaviors significantly added to the variance explained in distress (27%). Greater use of emotive coping behaviors was associated with higher levels of emotional distress and accounted for the majority of the variance explained by coping behaviors (23%). The findings are discussed in terms of the nature of uncertainty in health care and future model development.

Coping with dental treatment: the potential impact of situational demands

Coping strategies and anxiety responding of dental patients were studied in order to test the generalizability of previous findings based on volunteer blood donors. State and trait coping measures were administered once, and a process coping scale was administered at three points throughout treatment. Self-report, behavioral observation, and psychophysiological measures of anxiety were sampled for the same periods as process coping. Findings included the replication of a negative relationship between avoidant coping and patient anxiety ratings. Fluctuations in coping were evident across periods, and impact of situational demands and constraints was introduced as an explanation for these variations. A method for direct assessment of coping consistency was introduced. On the basis of the replicable associations with anxiety measures, the ability to detect changes in coping within a situation, and the ability to provide direct evidence of coping consistency, the use of process methodology for coping assessment is encouraged.

Physiological and subjective stress responses in surgical patients

Autonomic responses, mood and psychological coping were assessed in two groups of orthopaedic patients during hospitalisation for major or minor surgery. Eight patients admitted for total hip replacement and seven patients undergoing knee arthroscopy were seen daily for two days before surgery until discharged from hospital. Mood and coping questionnaires were administered on each session, while pain, heart rate, blood pressure, skin conductance level, palmar sweat prints and forearm EMG were also recorded. Heart rate increased from pre- to post-operative assessments, while skin conductance and palmar sweating fell to low levels on the days immediately following surgery, returning to basal values only after several days. Self ratings of anxiety, fatigue, depression and pain were highest on the immediate post-operative days. Patients utilised the coping factors Rational Cognition and Behavioural Action to the greatest extent, but ratings on coping factors fluctuated little over the study period. The interrelations between these measures and possible explanations of the results are discussed.