Refinement: promoting the three Rs in practice.

Refinement of scientific procedures carried out on protected animals is an iterative process, which begins with a critical evaluation of practice. The process continues with objective assessment of the impact of the procedures, identification of areas for improvement, selection and implementation of an improvement strategy and evaluation of the results to determine whether there has been the desired effect, completing the refinement loop and resulting in the perpetuation of good practice. Refinements may be science-driven (those which facilitate getting high-quality results) or welfare-driven or may encompass both groups, but whatever the driver, refinements almost always result in benefits to both welfare and science. Refinements can be implemented in all aspects of animal use: improved methodology in invasive techniques, housing and husbandry, and even statistical analyses can all benefit animal welfare and scientific quality. If refinement is not actively sought, outdated and unnecessarily invasive techniques may not be replaced by better methods as they become available, and thus outdated information is passed down to the next generation, causing perpetuation of old-fashioned methods. This leads to a spiral of ignorance, leading ultimately to poor practice, poor animal welfare and poor-quality scientific data. Refinement is a legal and ethical requirement, yet refinements may not always be implemented. There are numerous obstacles to the implementation of refinement, which may be real or perceived. Either way, in order to take refinement forward, it is important to coordinate the approach to refinement, validate the science behind refinement, ensure there is adequate education and training in new techniques, improve liaison between users and make sure there is feedback on suitability of refinements for use. Overall, refinement requires a coordinated ongoing process of critical appraisal of practice and active scrutiny of resources for likely improvements. In the busy world of biomedical research, this process needs help. In order to develop these themes further, a workshop was held at the LASA Winter Meeting 2006, UK, to assist in identifying potential obstacles to refinement, and then to explore and develop strategies for overcoming these obstacles in key areas. A range of strategies appropriate to different circumstances was identified, which should facilitate the implementation of refinements.

Disease prevention and health promotion: a study of medical students and teachers.

All students at the Royal Free Hospital School of Medicine (n = 508) were surveyed on their self-reported smoking and drinking habits, attitudes to disease prevention and health promotion in general, attitudes towards the teaching of disease prevention and health promotion, and their perception of what was taught at the beginning of the 1993-1994 academic year (response rate 75.2%). The teaching staff (n = 271) were also surveyed on their attitudes towards the teaching of disease prevention and health promotion, and their perception of what was taught (response rate 74.2%). Seventeen per cent of the students reported they were current smokers and 81% drank alcohol. Four factors were extracted from the responses to the items on disease prevention and health promotion in general and these represented the importance of health, a patient-centred approach, patient responsibility and a doctor-centred approach. Clinical students and those who were older were more likely to have a 'patient-centred' approach to disease prevention and health promotion. Sixty per cent of clinical and 44% of pre-clinical teachers aimed to teach about disease prevention and health promotion. The topics reported by students as most likely to have been taught in detail are smoking and health, alcohol and health, immunization, and breast and cervical screening. However, all these topics were reported as having been taught in detail by less than 50% of the students. The majority of students and teachers believe that teaching about disease prevention and health promotion should be integrated into all years of the curriculum and all clinical firms. Teachers were significantly less likely than students to believe that students should learn more about disease prevention and health promotion, and that learning about prevention is as important as learning about diagnosis and treatment. We believe that, in order to build on the positive features highlighted in this study, agreed aims and objectives should be developed and teaching about disease prevention and health promotion should be integrated both horizontally and vertically throughout the curriculum.

Questionnaire for the identification of back pain for epidemiological purposes.

OBJECTIVES: To design a questionnaire for the identification and assessment of severity of back pain for epidemiological purposes, and gain preliminary experience of its use. METHODS: A group of specialists, experienced in the epidemiology and clinical assessment of back pain, designed the questionnaire, and tested it individually. It was also given cross sectionally by interview to a population of male coal mine workers. RESULTS: The questionnaire comprised a maximum of 12 questions on the presence, radiation, frequency, and severity of back pain with reference to difficulty with specific activities, interference with normal work, and absence from work. 471 coal miners answered the questionnaire (66% of those invited). 56% (265 men) of the responders reported pain or ache in the back during the previous 12 months, and the incidence of first ever attacks during the same period was reported to be 34%. 69% reported having had back pain at some time. The responses to the questionnaire were partially validated by comparison with certified sickness absence for two days or more attributed to back pain. In men who were symptomatic in the previous 12 months, for the question relating to absence from work because of back pain, the sensitivity was 82% and specificity was 84%. CONCLUSION: The questionnaire is easy to administer and generates clear cut data that could be useful for epidemiological or screening purposes. Preliminary, limited, studies of its validity are reasonably encouraging, although further validation is required. It is hoped that researchers will find the questionnaire useful, will extend its validation, and continue to develop it.

Adaptive computer education--more than "high-tech".

Advances in technology have greatly broadened the range of occupational opportunities available to persons with disabilities. While technical devices help in making participation in computer-based work functions possible, a variety of strategies are required to help individuals with special needs prepare for, acquire, and maintain employment. The experience of the Centre for Adaptive Computer Education, a vocational training programme for adults with disabilities, highlights several strategies that have proven effective in helping persons with disabilities to access work training and employment. Techniques used to embrace a number of structural and behavioural approaches to training, including extended training time, individualized curricula, individual tutoring, stress management training, behaviour management, supportive counselling, and promotion in the workplace.

The contribution of general practice to medical education: expectations and fulfillment.

The aim of this study was to discover what students expected to learn during their fourth-year general practice attachment, to compare this with their GP tutors' expectations and to determine the extent to which the students' expectations were fulfilled. Questionnaires were used to gather this information; students completed them on the first and last days of the 4-week attachment and tutors shortly after the attachment. Students and their tutors had the highest expectations of the course in helping to raise awareness of the psychological and social aspects of ill health and develop clinical decision-making and management skills. At the end of the course students thought that they had gained most in these areas. Both students and tutors had lower expectations of the course helping to develop physical examination and practical skills and to improve knowledge in certain clinical areas. These were also rated lowest in terms of fulfillment. This study was carried out at a time when it is being suggested that more undergraduate teaching should take place in general practice and that this could include the teaching of practical skills and clinical subjects traditionally associated with hospital-based teaching. The results suggest that the expectations of students and GP tutors would need to be modified, as well as extra resources provided, if there is to be a shift in teaching towards the community.

Bronchoscopic cryotherapy for advanced bronchial carcinoma.

A prospective study was carried out to assess the value of bronchoscopic cryotherapy for palliation of inoperable bronchial carcinoma with bronchial obstruction. Symptoms, lung function, and chest radiographic and bronchoscopic findings were recorded serially before and after 81 cryotherapy sessions in 33 consecutive patients. Most patients improved in terms of overall symptoms, stridor, and haemoptysis and they had an overall improvement in dyspnoea. Objective improvement in lung function was seen in 58% of patients and the changes in lung function correlated with symptoms. Bronchoscopic evidence of relief of bronchial obstruction was seen in 77% of patients and 24% showed improvement in degree of collapse on the radiograph. There were no important complications. These results compare favourably with the results in published series of patients having laser therapy. It is concluded that bronchoscopic cryotherapy is valuable for the palliation of inoperable bronchial carcinoma.

Cardiopulmonary response to dynamic exercise after heart and combined heart-lung transplantation.

The exercise capacity and cardiopulmonary response to progressive dynamic exercise of eight healthy recipients of heart-lung transplants were compared with those of matched recipients of orthotopic cardiac transplants and normal controls. In both transplant groups the maximum workloads were lower than that in the normal group. The transplant recipients had higher pre-exercise heart rates and lower maximum heart rates than the normal controls. Ventilation during submaximal exercise was similar in the heart transplant group and the controls. The heart-lung group had an increased ventilatory response associated with lower end tidal carbon dioxide concentrations. Exercise capacity after combined heart-lung transplantation is similar to that after cardiac transplantation. Transplant recipients have an abnormal heart rate response during exercise related to cardiac denervation. The altered ventilatory response in heart-lung recipients may be the result of pulmonary denervation.

Occupational skin disease in hospital cleaning and kitchen workers.

Skin disorders were reported in 33% of catering staff and 35% of women cleaners who returned a questionnaire, and were employed in a large hospital. Hand dermatitis occurred in 15% of the caterers and 12% of the cleaners. In the majority, the dermatitis was irritant in origin and related to their wet work occupations. Cleaners had a high prevalence of jewellery dermatitis. Limited patch testing revealed a majority positive to nickel, but a third were negative, indicating that jewellery reactions often but not invariably predict nickel sensitivity. Few subjects were atopic, but some psoriatic patients with hand problems were encountered. Most workers were able to carry on in their occupations despite having hand dermatitis.

Epidemiologic study of back pain in miners and office workers.

Cross-sectional studies of miners at a Scottish colliery and workers in an administrative office were done to investigate the prevalence of back pain among them and to compare prevalence of pain with type of job. Sixty-two percent of the invited miners and 71% of the office workers participated. More than two thirds of the miners and more than one half of the office workers who participated reported back pain at some time in their lives. No relationship was detected between present job and back pain among the miners, except for a suggestion that recent first attacks of pain were more common in face workers and underground transport workers than in other men. These results confirm that back pain is a common problem in both miners and office workers.

Respiratory ill health among coal miners and telecommunication workers in south Wales.

As part of a large cross sectional epidemiological study of respiratory disease in coalminers, the respiratory health of miners in one colliery in south Wales has been compared with the health of nearby telecommunication (telecom) workers. The studies were carried out in 1981 and 1982. The answers to questionnaires on respiratory symptoms and results of lung spirometry indicate a much greater frequency of respiratory ill health among the miners than the telecom workers. The frequency of symptoms of chronic bronchitis among the current employees was 31% in the miners and 5% in the telecom workers, and these symptoms were reported as frequently by younger as by older miners. Reports of other respiratory symptoms showed similarly large differences between current miners and telecom workers. These differences were seen both within non-smoking and smoking groups. Comparisons of FEV1 with predicted values (several different predictions were used) confirmed that the differences in reported symptoms were accompanied by differences in lung function; of the order of 20% of current miners had an FEV1 less than 80% of predicted compared with 10% of current telecom workers. The excess of respiratory disease shown among these miners is not necessarily a consequence of the dust concentrations currently experienced underground, nor is the colliery necessarily representative of the coal industry generally. The findings, however, indicate the continued need for measures to improve the respiratory health of these men.

Study of lung function data by principal components analysis.

As a rational approach to the many lung function tests available, we have subjected the results of a battery of six lung function measurements made in 458 coalminers to the statistical technique of principal components analysis. By this means the six test results were reduced to three principal components without important loss of information. The first component appeared to represent lung size and the second the degree of airflow obstruction, and the third detected impairment of gas transfer factor in excess of that explained by the first two components. The values of the first principal component, used to select men with abnormal lung function, identified more younger men with functional abnormalities than a method based on comparison of observed and predicted values of forced expiration volume in one second. The values of the second and third principal components were used to classify types of functional abnormality. It is concluded that this statistical technique provides a sensitive method of identifying men with unusual lung function, particularly younger men, in a population and can be used to define and quantify different aspects of lung function.

Epidemiological study of the lung function of workers at a factory manufacturing polyvinylchloride.

A preliminary epidemiological study has been carried out to investigate a report that some men working in a factory manufacturing polyvinylchloride (PVC) had abnormally low values of the single breath diffusing capacity for carbon monoxide (TLCO). All monoxide (TLCO). All 265 present and past employees of the PVC factory were studied, together with 219 men from the workforce of a nearby foundry. Each man's TLCO was measured and a smoking history and detailed occupational history obtained. The distribution of standardised TLCO results from all persons examined was symmetrical and did not indicate an unexpectedly high proportion of men with having allowed for age, height, weight, and smoking habit, TLCO was associated with a history of working in the PVC factory before 1975 (when levels of vinylchloride monomers (VCM) were much higher than subsequently), and slightly associated with working in jobs where exposure to VCM was likely to have been highest. The men with low TLCO also tended to have smoked more heavily than controls. The relative importance of occupational factors and smoking in relation to low TLCO is not clear, but the results give some support to the hypothesis that work in the PVC factory before 1975 entailed exposure to a substance that caused impairment of lung function in a small number of men.

The value of a wide range of tests in the assessment of lung function in carcinoma of the bronchus.

Tests of forced ventilation, lung volume, transfer factor, flow-volume and arterial blood gas measurements were made on 209 patients before thoracotomy for carcinoma of the bronchus. The patients whom the surgeons subsequently considered to be unsuitable for operation had significantly poorer results in tests of forced ventilation than those who were selected for operation. There was little or no significant difference between these groups in respect of the RV, TLC, transfer factor and arterial blood gas measurements. There was no marked difference in the results of any of the measurements between those who developed complications and those who were complication free. It was therefore concluded that clinical assessment together with forced ventilation tests could not be bettered by adding further lung function tests, when these were interpreted as simple 'normal or abnormal'. However, more complex analysis of test findings, such as discriminant analysis, may be of more value.

The clinical features and management of pituitary apoplexy.

The clinical features and management of three patients presenting with pituitary apoplexy are described. They illustrate the difficulty of differentiating pituitary apoplexy from other acute neurologic conditions. One of the patients is the first reported case of pituitary apoplexy occurring in a histologically proved craniopharyngioma. Two of the cases reported were treated conservatively and recovered without seriouplexy as a neurosurgical emergency. The relationship between radiotherapy and pituitary apoplexy is discussed.

Effect of phenformin on gluconeogenesis from lactate and intracellular pH in the isolated perfused guinea pig liver.

Gluconeogenesis from lactate and hepatic cell pH (pHi) were measured in the isolated perfused livers of starved guinea pigs in the presence and absence of phenformin (phenethylbiguanide). The observed decrease in lactate consumption and glucose output in the presence of phenformin was associated with a fall in pHi. The fall in glucose output observed was considerably greater than accountable for by the decrease in lactate consumption. A possible mechanism for the pathogenesis of clinical lactic acidosis due to phenformin therapy is suggested.

Report of a family with inherited medullary carcinoma of the thyroid and phaeochromocytoma.

A family in which several members have medullary carcinoma and phaeochromocytoma is described. Four of the 5 patients in this family who had a phaeochromocytoma have died; in one of these the medullary carcinoma may have contributed to death but in general the thyroid cancers were slow growing. In our experience successful diagnosis and treatment of the phaeochromocytomas have presented the greatest challenge. The welfare of future generations with this syndrome would seem to depend upon regular clinical and biochemical surveillance of the individuals and expeditious diagnosis and treatment of their tumours, particularly the phaeochromocytomas.