An international, open-label, randomised trial comparing a two-step approach versus the standard three-step approach of the WHO analgesic ladder in patients with cancer.

BACKGROUND: Worldwide, cancer pain management follows the World Health Organization (WHO) three-step analgesic ladder. Using weak opioids (e.g. codeine) at step 2 is debatable with low-dose strong opioids being potentially better, particularly in low- and middle-income countries where weak opioids are expensive. We wanted to assess the efficiency, safety and cost of omitting step 2 of the WHO ladder. PATIENTS AND METHODS: We carried out an international, open-label, randomised (1 : 1) parallel group trial. Eligible patients had cancer, pain ≥4/10 on a 0-10 numerical rating scale, required at least step 1 (paracetamol) of the WHO ladder and were randomised to the control arm (weak opioid, step 2 of the WHO ladder) or the experimental arm (strong opioid, step 3). Primary outcome was time to stable pain control (3 consecutive days with pain ≤3). Secondary outcomes included distress, opioid-related side-effects and costs. The primary outcome analysis was by intention to treat and the follow-up was for 20 days. RESULTS: One hundred and fifty-three patients were randomised (76 control, 77 experimental). There was no statistically significant difference in time to stable pain control between the arms, P = 0.667 (log-rank test). The adjusted hazard ratio for the control arm was 1.03 (95% confidence interval 0.72-1.49). In the control arm, 38 patients (53%) needed to change to a strong opioid due to ineffective analgesia. The median time to change was day 6 (interquartile range 4-11). Compared to the control arm, patients in the experimental arm had less nausea (P = 0.009) and costs were less. CONCLUSION: This trial provides some evidence that the two-step approach is an alternative option for cancer pain management.

Application of Variable Life Adjusted Display (VLAD) to risk-adjusted mortality of esophagogastric cancer surgery.

PURPOSE: In the new era of revalidation, there is an increasing need to measure surgical outcome objectively. We apply a graphical method, the Variable Life Adjusted Display (VLAD), to esophagogastric resection for malignancy. This technique charts the cumulative difference between expected and actual risk-adjusted mortality over time, allowing observation of performance trends irrespective of case-mix. METHODS: P-POSSUM was applied retrospectively to 182 consecutive patients who underwent resection for esophageal or gastric malignancy in a district general hospital. The primary outcome measured was 30-day mortality. RESULTS: A total of 168 patients were eligible for inclusion, with a median age of 68 years. The overall 30-day mortality rate was 4.2% compared with 7.1% as predicted by P-POSSUM. The resulting VLAD plot demonstrates an upward trend of better than predicted surgical performance. CONCLUSIONS: VLAD has been hereby applied to esophagogastric surgery and has graphically demonstrated risk-adjusted trends in a single general surgeon's performance. For qualitative comparative purposes, including recertification, VLAD is judged to be a simple, directly interpretable, and useful technique for monitoring surgical performance.

Reprinted article "The fate of the claudicant--a prospective study of 1969 claudicants".

A prospective study of 1969 patients with intermittent claudication receiving placebo medication for a minimum of 1 year is reported. Patients were carefully monitored and only four patients were lost to follow-up. Annual mortality was 4.3%. Thirty-six patients developed a definite myocardial infarction, 27 a major stroke, 32 required a major amputation and 111 required surgical or radiological intervention for deteriorating ischaemia of the leg. The entry characteristics of the patients were analysed as a predictor of serious cardiovascular events. The most sensitive predictors of total mortality were age, history of coronary heart disease and an ankle/arm pressure ratio below 0.5. Of the laboratory measurements performed only the initial white cell count was a significant predictor of myocardial infarction, stroke and vascular deaths.

Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results.

OBJECTIVE: To compare the long-term results of uterine artery embolisation (UAE) with surgery for women with symptomatic uterine fibroids. DESIGN: Pragmatic, open, multicentre, randomised trial. SETTING: Twenty-seven participating UK secondary care centres. SAMPLE: Women aged ≥18 years with symptomatic fibroids who were considered to justify surgical treatment. METHODS: In total, 157 women were randomised (in a 2:1 ratio): 106 to UAE and 51 to surgery (hysterectomy 42; myomectomy nine). MAIN OUTCOME MEASURES: Quality of life at 5 years, as assessed by the Short Form General Health Survey (SF-36). Secondary measures included complications, adverse events and the need for further intervention. RESULTS: There were no significant differences between groups in any of the eight components of the SF-36 scores at 5 years (minimum P = 0.45). Symptom score reduction and patient satisfaction with either treatment was very high, with no group difference. Rates of adverse events were similar in both groups (19% embolization and 25% surgery; P = 0.40). The 5-year intervention rate for treatment failure or complications was 32% (UAE arm) and 4% (surgery arm), respectively. The initial cost benefit of UAE over surgery at 12 months was substantially reduced because of subsequent interventions, with treatments being cost neutral at 5 years. CONCLUSIONS: We have found that UAE is a satisfactory alternative to surgery for fibroids. The less invasive nature of UAE needs to be balanced against the need for re-intervention in almost a third of patients. The choice should lie with the informed patient.

The effects of uterine artery embolisation and surgical treatment on ovarian function in women with uterine fibroids.

OBJECTIVE: The aim of this study was to evaluate and compare both ovarian function and menstrual characteristics following uterine artery embolisation (UAE) and surgery. DESIGN: Subgroup of women from a randomised controlled trial. SETTING: Gynaecology and radiology units in Scotland, UK. POPULATION: Ninety-six women from the randomised controlled trial comparing embolisation with surgery as a treatment for fibroids (REST), which recruited 157 patients (106 UAE; 51 surgery). METHODS: Seventy-three women undergoing UAE and 23 women undergoing surgery (with ovarian conservation) had serum follicle-stimulating hormone (FSH) measurements taken on day 3 of the menstrual cycle prior to treatment, and at 6 and 12 months post-treatment. Data on menstrual cycle characteristics was also collected. MAIN OUTCOME MEASURES: Ovarian failure, as defined by an FSH level of >40 iu/l, and change in duration of menses and length of menstrual cycle. RESULTS: There was no significant difference in the rate of ovarian failure at 12 months between UAE (11%) and surgical patients (18%) (P = 0.44). This finding was not influenced by age. The mean duration of menstrual flow decreased significantly, from baseline to 12 months, by 1.7 days (SD 3.8), (95% CI 0.8-2.6). There was no statistically significant change in mean cycle length at 12 months (0.7 days [SD 4.9]; 95% CI [-0.5, 1.9]). CONCLUSIONS: There is no evidence for UAE accelerating a deterioration in ovarian function at 1 year, when compared with surgery. UAE is associated with a decrease in the duration of menstrual flow at 1 year.

Randomized clinical trial comparing self-expanding metallic stents with plastic endoprostheses in the palliation of oesophageal cancer.

BACKGROUND: There is little evidence of the clinical and cost effectiveness of self-expanding metallic stents in the palliation of oesophageal cancer. The aims of this randomized trial were to evaluate the immediate and medium-term clinical outcomes following palliative intubation, examine patient quality of life, and evaluate costs and benefits from the perspective of the health service. METHODS: Fifty patients with inoperable oesophageal cancer were randomly allocated a metallic stent (n = 25) or plastic endoprosthesis (n = 25). Patients were followed up monthly until death. RESULTS: There was no significant difference in procedure-related complications or mortality rate between the two groups. There was a trend towards significance in favour of metallic stents with respect to quality of life and survival (median survival 62 versus 107 days for plastic prosthesis and metallic stent respectively). The cost of the initial placement of metallic stents was significantly higher than that of plastic endoprostheses ( pound 983 versus pound 296). After 4 weeks, cost differences were no longer significant. CONCLUSION: Metallic stents may contribute to improved survival and quality of life in patients with oesophageal cancer. Although initially more expensive, this cost difference does not last beyond 4 weeks. A larger trial involving approximately 300 patients would be required to detect a quality of life benefit of the magnitude observed in this trial.

Flame burn admissions and fire fatalities in Scotland with particular reference to the Strathclyde (Glasgow) region, and their prevention.

Scotland has the highest rate of fire fatalities in the UK. Nearly 50% of the population and fire deaths in Scotland are in the Strathclyde region. The data from the burns unit at Glasgow Royal Infirmary were studied to find the number of admissions due to flame burns and see how it compared with the fire deaths. During 1981-1993, amongst 2771 admissions to the burns unit, 1181 (43%) were due to flame burns and out of these flame burn victims, 69% were adults, 16% elderly and 15% children. The distribution of cases according to the total body surface area (TBSA) involvement was 866 (73%) with 1-15%, 165 (14%) with 16-30%, and 150 (13%) with > or =31% TBSA burns. The annual number of flame burn admissions declined during 1981-1993. In the Glasgow region 50% of the domestic fires leading to non-fatal burns or to death were started by misuse of smoking materials. Chip pan fires were responsible for 8% of admissions to the burns unit. The annual number of fire fatalities when reviewed for a longer period 1973-1995 also showed a decreasing trend. Further educational and legislative measures to prevent flame burns are discussed.

Pre-existing cognitive impairment as a factor influencing outcome after cardiac surgery.

Conventional methodology to investigate cognitive impairment after coronary artery bypass graft (CABG) surgery leaves unclear the potential for pre-existing cognitive deficits to influence outcome. Individuals with pre-existing deficits may be more vulnerable to the effects of CABG, hence biasing the results of a typical prospective trial if account is not taken of their state. The present study examined the effect of pre-existing cognitive impairment upon cognitive outcome in 81 patients undergoing CABG. Patients performed the Stroop Neuropsychological Screening Test and other psychometric assessments prior to and at 6 days and 6 months after CABG. Those with pre-existing cognitive deficits were significantly more likely to display impairment at 6-day and 6-month follow-ups than were those without pre-existing deficits. Greater age and lower pre-morbid intelligence were also significant predictors of post-CABG deficit, confirming earlier findings. The results imply both that pre-existing cognitive impairments may render patients more vulnerable to post-operative deficits and that, in the absence of such pre-existing impairments, CABG surgery does not inevitably lead to later deficits. The study also replicated previous findings showing a similar influence of pre-existing depression upon emotional state after CABG. Overall, the results confirm the importance both of a patient's pre-existing cognitive and emotional states, and the methodology to assess them, in influencing outcome after cardiac surgery and the conclusions to be drawn as to the supposed adverse effects of the procedure.

Comparison of UK paediatric cardiac surgical performance by analysis of routinely collected data 1984-96: was Bristol an outlier?

BACKGROUND: Reports of high mortality after paediatric cardiac surgery at the Bristol Royal Infirmary, UK, led to the establishment of an independent public inquiry. A key question was whether or not the mortality statistics in Bristol were unusual compared with other specialist centres. To answer this question, we did a retrospective analysis of mortality in the UK using two datasets. METHODS: Data from the UK Cardiac Surgical Register (CSR; January, 1984, to March, 1996) and Hospital Episode Statistics (HES; April, 1991, to December, 1995) were obtained for all 12 major centres in which paediatric cardiac surgery is done in the UK. The main outcome measure was mortality within 30 days of a cardiac surgical procedure. We estimated excess deaths in Bristol using a random-effects model derived from the remaining 11 centres. Additionally, a sensitivity analysis was done and case-mix examined. FINDINGS: For children younger than 1 year, in open operations, the mortality rate in Bristol was around double that of the other centres during 1991-95: within the CSR, there were 19.0 excess deaths (95% interval 2-32) among 43 deaths; and in HES, there were 24.1 excess deaths (12-34) among 41 deaths recorded. There was no strong evidence for excess mortality in Bristol for closed operations or for open operations in children older than 1 year. INTERPRETATION: Our results suggest that Bristol was an outlier, and we do not believe that statistical variation, systematic bias in data collection, case-mix, or data quality can explain a divergence in performance of this size.

Intensive care management of head-injured patients in Europe: a survey from the European brain injury consortium.

OBJECTIVES: (a) to describe current practice in the monitoring and treatment of moderate and severe head injuries in Europe; (b) to report on intracranial pressure and cerebral perfusion pressure monitoring, occurrence of measured and reported intracranial hypertension, and complications related to this monitoring; (c) to investigate the relationship between the severity of injury, the frequency of monitoring and management, and outcome. METHODS: A three-page questionnaire comprising 60 items of information has been compiled by 67 centres in 12 European countries. Information was collected prospectively regarding all severe and moderate head injuries in adults (> 16 years) admitted to neurosurgery within 24 h of injury. A total of 1005 adult head injury cases were enrolled in the study from 1 February 1995 to 30 April 1995. The Glasgow Outcome Scale was administered at 6 months. RESULTS: Early surgery was performed in 346 cases (35%); arterial pressure was monitored invasively in 631 (68%), ICP in 346 (37%), and jugular bulb saturation in 173 (18%). Artificial ventilation was provided to 736 patients (78%). Intracranial hypertension was noted in 55% of patients in whom ICP was recorded, while it was suspected in only 12% of cases without ICP measurement. There were great differences in the use of ventilation and CPP monitoring among the centres. Mortality at 6 months was 31%. There was an association between an increased frequency of monitoring and intervention and an increased severity of injury; correspondingly, patients who more frequently underwent monitoring and ventilation had a less favourable outcome. CONCLUSIONS: In Europe there are great differences between centres in the frequency of CPP monitoring and ventilatory support applied to head-injured patients. ICP measurement disclosed a high rate of intracranial hypertension, which was not suspected in patients evaluated on a clinical basis alone. ICP monitoring was associated with a low rate of complications. Cases with severe neurological impairment, and with the worse outcome, were treated and monitored more intensively.

Using routine data to complement and enhance the results of randomised controlled trials.

BACKGROUND: Randomised controlled trials (RCTs) are widely accepted as the best way to assess the outcomes and safety of medical interventions, but are sometimes not ethical, not feasible, or limited in the generalisability of their results. In such circumstances, routinely available data could help in several ways. Routine data could be used, for example, to conduct 'pseudo-trials', to estimate likely outcomes and required sample size to help design and conduct trials, or to examine whether the expected outcomes observed in an RCT will be realised in the general population. OBJECTIVES: The project was undertaken to explore how routinely assembled hospital data might complement or supplement RCTs to evaluate medical interventions: in contexts where RCTs are not feasible for defining the context and design of an RCT for assessing whether the benefits indicated by RCTs are achieved in wider clinical practice. METHODS: The project was based on the system of linked Scottish morbidity records, which cover 100% of acute hospital care episodes and statutory death records from 1981 to 1995. Three case studies were undertaken as a way of investigating the utility of these records in different applications. First, an attempt was made to analyse the link between the timing of surgery for subarachnoid haemorrhage (SAH) and subsequent outcomes (a question not easily susceptible to RCT design). A subsample was derived by excluding patients for which a diagnosis of SAH may not have been established or that may not have been admitted to a neurosurgical unit, and the data were assessed to attempt to inform the design of a trial of early versus late surgery. Transurethral prostatectomy (TURP), the second case study, has become the surgery of choice for benign prostatic hyperplasia without systematic assessment of its effectiveness and safety, and an RCT would now be considered unethical. However, there is a need to investigate long-term effects and the influence of co-morbidities on outcomes. A retrospective comparison of mortality and re-operation following either open prostatectomy (OPEN) or TURP was, therefore, undertaken. Patients for whom it was not possible to establish the initial procedure were excluded. The third case study compared coronary artery bypass grafting (CABG) with percutaneous transluminal angioplasty (PTCA) for coronary revascularisation. RCTs have been conducted in limited patient subgroups with short follow-up periods. A meta-analysis of RCTs could be augmented by routine data, which are available for large populations. This would allow assessment of subgroup effects, and outcomes over a long period. A subgroup of patients was therefore constructed for whom relevant routine data were available and who reflected the entry criteria for major RCTs, thus enabling a comparison between the results expected from this subgroup and those of the general population. RESULTS AND CONCLUSIONS: The uses of routine data in these contexts had strengths and weaknesses. The SAH study suggested a means of assessing outcomes and survival rates following haemorrhage, which could have value in informing the design of more precise trials and in evaluating changes in outcome following the introduction of new treatments such as embolisation. However, the potential of the data was not realised because their scope and content were insufficient. For example, lack of data on the time of onset of symptoms and patients' conditions at hospital admission made it difficult to establish the link between timing of surgery and the outcome, and there was insufficient information on patients' conditions at discharge to enable a comparison of outcomes. The prostatectomy study was able to address questions not answered by RCT literature because the large number of cases it included allowed exploration of subgroup effects. (ABSTRACT TRUNCATED)

A comparison of reports from referees chosen by authors or journal editors in the peer review process.

The aim was to analyse the peer review process by comparing reports produced by referees selected by journal editors, with those of referees selected by the authors of a scientific manuscript. Some 104 consecutive papers from the UK submitted to the British Journal of Surgery (BJS) were included. Of these, 102 were reviewed blind both by referees chosen by the journal editors, and referees chosen by the paper's principal author. Manuscripts were marked using a standard sheet for four basic aspects: originality, clinical/scientific importance, clarity and analysis; a final overall recommendation about possible publication was given. The time taken and the number of completed referee reports were similar in each group. Referees chosen by the BJS editors were more critical (scored higher) of the submitted articles. Mean scores for all domains were higher than for authors' referees, significantly for scientific importance (p = 0.009) and decision to publish (p = 0.029). In conclusion, reports produced by referees selected by BJS editors were more critical than those chosen by authors of the papers. Authors might argue that this reduced their chance of publication but constructive criticism might improve the final article and assist editors to make decisions about acceptance or rejection.

Genetic polymorphisms of cytochrome p4502E1 and susceptibility to alcoholic liver disease and hepatocellular carcinoma in a white population: a study and literature review, including meta-analysis.

AIMS: To investigate the associations between the Rsa I, Dra I, and Taq I genetic polymorphisms of cytochrome p4502E1 and susceptibility to alcoholic liver disease or to hepatocellular carcinoma. METHODS: DNA samples isolated from 61 patients with alcoholic liver disease, 46 patients with hepatocellular carcinoma, and 375 healthy controls were subjected to polymerase chain reaction amplification followed by digestion with the endonucleases Rsa I, Dra I, or Taq I. Meta-analysis was performed using data from previous studies of Rsa I polymorphism and the risk of alcoholic liver disease. RESULTS: No association was found between any of the three polymorphisms and susceptibility to hepatocellular carcinoma. The distributions of Rsa I and Dra I alleles among the patients with alcoholic liver disease were not significantly different from those among the control group. Meta-analysis of this data and previous data concerning Rsa I polymorphism and alcoholic liver disease risk failed to demonstrate any significant association between the two. However, the alcoholic liver disease group in this study showed a significantly lower frequency of the less common Taq I allele compared with the healthy control group (odds ratio, 0.33; 95% confidence interval, 0.12 to 0.78). CONCLUSIONS: Possession of the less common Taq I cytochrome p4502E1 allele is associated with reduced susceptibility to alcoholic liver disease. There is no existing evidence that the Taq I polymorphism is directly associated with altered alcohol metabolism, but it might be in linkage disequilibrium with as yet unidentified protective factors.

Comparing outcomes of percutaneous transluminal coronary angioplasty with coronary artery bypass grafting; can routine health service data complement and enhance randomized controlled trials?

AIM: To compare outcomes of percutaneous transluminal coronary angioplasty (PTCA) with coronary artery bypass graft surgery (CABG) for a population stemming from routinely collected data, in order to assess the merits of such data sources as a complement, and possible enhancement, to randomized controlled trial results. METHODS AND RESULTS: A population of Scottish patients were taken from a routine discharge summary and from this data source patients comparable to those from randomized controlled trial settings were identified. Between 1989 and 1995, 12 238 pseudo randomized controlled trial patients were identified from the routine data set, of which 3714 (30.3%) received PTCA and 8524 (69.7%) received CABG. The baseline characteristics of the pseudo randomized controlled trial and randomized controlled trial patients were similar. The evidence from both the randomized controlled trials and routine data indicate that for 1 year follow-up the risk of cardiac death and/or non-fatal myocardial infarction is not significantly different between the two treatment groups. CONCLUSION: The outcomes expected of PTCA and CABG following trial evidence have been realized in the routine data which are representative of a complete, non-selective population. Due to the size of the routine data set it would be possible to set up hypotheses for potential subgroup effects at the outset.

Oestrogen receptor status predicts local recurrence following breast conservation surgery for early breast cancer.

AIMS: To evaluate factors predicting locoregional recurrence in patients treated for early breast carcinoma by breast conservation surgery with or without radiotherapy. METHODS: A retrospective study of 256 patients was carried out, with special emphasis on the role of oestrogen receptor status. Other parameters studied included age, menopausal status, size of primary tumour, tumour type, axillary nodal status and adjuvant therapy. RESULTS: Multivariate analysis showed the following parameters to be independent predictors of locoregional recurrence. Radiotherapy (57% reduction in hazard, P = 0.004): expression of oestrogen receptors (52% reduction in hazard, P = 0.008); tamoxifen therapy (46% reduction in hazard, P = 0.023); tumour size (40% increase in hazard per cm, P<0.001). CONCLUSIONS: Within this study, lack of oestrogen receptor expression was a strong independent factor associated with a higher rate of locoregional recurrence. This may be of value in selecting a group of patients less suitable for breast conservation surgery.

Influence of graft material on blood rheology and plasma biochemistry following insertion of an infrainguinal bypass graft.

BACKGROUND: Occlusive arterial disease causes alterations in blood rheology and levels of potential thrombotic and fibrinolytic mediators. The aim of this study was to investigate the effect of graft materials on these parameters in patients undergoing successful infrainguinal revascularization. METHODS: Some 186 consecutive infrainguinal grafts were observed for 12 months. Venous blood was sampled before operation and at 3, 6, and 12 months after surgery. Samples were assayed for thrombotic and rheological parameters. An area under the curve analysis was used to compare the effects of vein and synthetic grafting on these parameters in 99 patients whose grafts remained patent and free from stenosis. RESULTS: Plasma levels of fibrin degradation products were significantly higher in patients with synthetic grafts (n = 46) than in those with autogenous vein grafts (n = 53) (median 274 versus 150 ng/ml; P < 0.001). There were no significant differences in plasma fibrinogen or any other parameters between the two groups. CONCLUSION: Patients with a synthetic infrainguinal graft have a higher fibrin turnover than those with a vein graft. Further studies are required to determine whether this increase in fibrin turnover is an essential requirement to maintain patency of a synthetic infrainguinal graft.

Clinical, biochemical, and rheologic factors affecting the outcome of infrainguinal bypass grafting.

PURPOSE: The purpose of this study was to determine the effects of patient characteristics, blood rheology, and plasma biochemistry on the outcome of infrainguinal bypass grafting. METHODS: Blood rheology, plasma fibrinogen, cross-linked fibrin degradation products, von Willebrand factor (vWf) and other endothelial products, and clinical variables including smoking markers were determined before surgery in patients with 184 consecutive infrainguinal bypass grafts (90 vein, 94 synthetic grafts). RESULTS: Fifty (27%) graft occlusions and 17 (9%) deaths occurred within 1 year of surgery. On univariate analysis a poor outcome was associated with elevated preoperative plasma fibrinogen, fibrin degradation products, vWf, and platelet levels, reduced hemoglobin and systolic ankle pressure, a below-knee anastomosis, a decrease in patent calf vessels, and the presence of tissue necrosis (all p < 0.001). On multivariate analysis increased preoperative vWf levels were predictive of poor postoperative outcome (relative hazard for upper quartile versus lower quartile = 1.82), as were a low systolic ankle pressure (relative hazard = 2.51), presence of tissue necrosis (relative hazard = 2.73), and female sex (relative hazard = 1.9). None of the other variables studied was related to outcome. With a preoperative risk score derived from the results, graft patency rates within 3 months of surgery fell to less than 25% with risk scores in the upper quartile. CONCLUSIONS: Preoperative measurement of plasma vWf may enable more accurate prediction of the outcome of infrainguinal revascularization and when combined with other variables could assist in patient selection for these procedures. The association of vWf with graft occlusion supports a role for endothelial disturbance in graft occlusion.

Psychological support for patients undergoing breast cancer surgery: a randomised study.

OBJECTIVE: To evaluate the effect of support from a nurse specialising in breast care and a voluntary support organisation on prevalence of psychological morbidity after surgery for breast cancer. DESIGN: Prospective randomised study. SETTING: Three teaching hospitals in Glasgow with established breast clinics. SUBJECTS: 272 women aged less than 70 years undergoing surgery for breast cancer. INTERVENTIONS: Patients were randomly allocated to receive routine care from ward staff, routine care plus support from breast care nurse, routine care plus support from voluntary organisation, or routine care plus support from nurse and organisation. MAIN OUTCOME MEASURES: Prevalence of psychological morbidity as assessed by self rating scales: 28 item general health questionnaire and its subscales, and hospital anxiety and depression scale. Measurements were made at first postoperative clinic visit and at three, six, and 12 months after surgery. RESULTS: On each self rating scale, psychological morbidity tended to fall over the 12 month period. For each scale, scores were consistently lower in patients offered support from breast care nurse alone compared with the other groups, which were similar to each other. Differences were significant or nearly so: P values were 0.015 (28 item general health questionnaire), 0.027 (anxiety and insomnia), 0.072 (severe depression), 0.053 (somatic symptoms), 0.031 (social dysfunction), 0.093 (hospital anxiety), and 0.003 (hospital depression). CONCLUSION: Support from breast care nurse can significantly reduce psychological morbidity, as measured by self rating scales, in women undergoing breast cancer surgery.