Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial.

OBJECTIVE: To determine whether supported self management in chronic obstructive pulmonary disease (COPD) can reduce hospital readmissions in the United Kingdom. DESIGN: Randomised controlled trial. SETTING: Community based intervention in the west of Scotland. PARTICIPANTS: Patients admitted to hospital with acute exacerbation of COPD. INTERVENTION: Participants in the intervention group were trained to detect and treat exacerbations promptly, with ongoing support for 12 months. MAIN OUTCOME MEASURES: The primary outcome was hospital readmissions and deaths due to COPD assessed by record linkage of Scottish Morbidity Records; health related quality of life measures were secondary outcomes. RESULTS: 464 patients were randomised, stratified by age, sex, per cent predicted forced expiratory volume in 1 second, recent pulmonary rehabilitation attendance, smoking status, deprivation category of area of residence, and previous COPD admissions. No difference was found in COPD admissions or death (111/232 (48%) v 108/232 (47%); hazard ratio 1.05, 95% confidence interval 0.80 to 1.38). Return of health related quality of life questionnaires was poor (n=265; 57%), so that no useful conclusions could be made from these data. Pre-planned subgroup analysis showed no differential benefit in the primary outcome relating to disease severity or demographic variables. In an exploratory analysis, 42% (75/150) of patients in the intervention group were classified as successful self managers at study exit, from review of appropriateness of use of self management therapy. Predictors of successful self management on stepwise regression were younger age (P=0.012) and living with others (P=0.010). COPD readmissions/deaths were reduced in successful self managers compared with unsuccessful self managers (20/75 (27%) v 51/105 (49%); hazard ratio 0.44, 0.25 to 0.76; P=0.003). CONCLUSION: Supported self management had no effect on time to first readmission or death with COPD. Exploratory subgroup analysis identified a minority of participants who learnt to self manage; this group had a significantly reduced risk of COPD readmission, were younger, and were more likely to be living with others. TRIAL REGISTRATION: Clinical trials NCT 00706303.

Electromagnetic vortex fields, spin, and spin-orbit interactions in electron vortices.

Electron vortices are shown to possess electric and magnetic fields by virtue of their quantized orbital angular momentum and their charge and current density sources. The spatial distributions of these fields are determined for a Bessel electron vortex. It is shown how these fields lead naturally to interactions involving coupling to the spin magnetic moment and spin-orbit interactions which are absent for ordinary electron beams. The orders of magnitude of the effects are estimated here for ȧngström scale electron vortices generated within a typical electron microscope.

Comparison of positive lymph node ratio with an inflammation-based prognostic score in colorectal cancer.

BACKGROUND: Two prognostic scoring systems have been proposed in colorectal cancer: the pathologically based positive lymph node ratio (pLNR) and the inflammation-based modified Glasgow Prognostic Score (mGPS). This study compared these two scores with the tumour node metastasis (TNM) staging system in terms of cancer survival. METHODS: Between 2003 and 2005, 206 patients, of mean(s.d.) age 69·9(10·6) (range 40-95) years, underwent curative resection for colorectal cancer in two centres. Age, sex, primary tumour site and whether radio/chemotherapy was given were recorded in addition to the three scores (TNM stage, pLNR and mGPS). Univariable and multivariable analyses of overall survival were performed. RESULTS: Age, rectal cancer, TNM stage, pLNR and mGPS were significant factors in univariable analysis. On multivariable analysis, N category and tumour stage (I-III) were removed from the model, leaving pLNR and mGPS as independent predictors of overall survival: hazard ratio 1·51 (95 per cent confidence interval 1·24 to 1·84; P < 0·001) and 1·56 (1·18 to 2·08; P = 0·020) respectively. C-statistic analysis, used to compare pLNR and mGPS directly, found only pLNR to be significant (P < 0·001) CONCLUSION: This study found pLNR to be the superior prognostic scoring system in determining long-term survival in patients undergoing resection for colorectal cancer.

Understanding the experience of prophylactic bilateral mastectomy: a qualitative study of ten women.

Prophylactic bilateral mastectomy represents a new and controversial cancer prevention strategy for women at high-risk of familial breast cancer, the psychosocial implications of which are yet to be fully explored. A qualitative methodology was therefore adopted to provide a discovery-orientated study of the perspectives of ten women who had undergone prophylactic mastectomy and the views of eight of their partners. Each participant was interviewed with the aim of exploring the personal experiences of surgery, factors associated with psychological adjustment and the impact on the family. Data were transcribed and systematically analysed using Grounded Theory. Themes emerging from participants' accounts formed seven significant categories that represented women's key experiences: (i) deciding; (ii) telling; (iii) experiencing surgery and recovering; (iv) maintaining womanliness; (v) processing the loss; and (vi) moving on. The importance of the social context in women's experience and difficulties of isolation/eliciting support were also highlighted: (vii) isolation and being supported. A core category of 'Suffering and countering multiple loss' considered central to women's experience, integrated the seven significant categories and provided further conceptualisation of women's experience. Implications for clinical practice are highlighted.

Failure to influence hypotension during spinal anaesthesia with a limb tourniquet.

Fourty patients undergoing total hip replacement under spinal anaesthesia were allocated randomly to have a thigh tourniquet inflated after exanguination of the leg not being operated on or to act as controls. Significant hypotension (systolic arterial pressure < 70 mm Hg) was treated with i.v. ephedrine in 6 mg boluses. There was no significant difference between the two groups with respect to systolic blood pressure or requirement of ephedrine, during the hour that the tourniquet was applied or the period immediately after the removal of the tourniquet.

Policy for controlling pain after surgery: effect of sequential changes in management.

OBJECTIVE: To observe the effects of introducing an acute pain service to the general surgical wards of a large teaching hospital. DESIGN: A study in seven stages: (1) an audit of current hospital practice succeeded by the sequential introduction to the general surgical wards of (2) pain assessment charts; (3) an algorithm to allow more frequent use of intramuscular analgesia; (4) increased use of local anaesthetic techniques of wound infiltration and nerve blocks; (5) an information sheet for patients about postoperative pain; (6) the introduction of patient controlled analgesia; (7) a repeat audit of hospital practice. Data were collected on each patient 24 hours after operation. SETTING: University Hospital of Wales, which has both district general and tertiary referral functions. PATIENTS: 2035 patients over nine months from all surgical specialties (excluding cardiac) at the hospital. General surgical operations were studied in detail and separated into major, intermediate, and minor for data collection. MAIN OUTCOME MEASURES: A change in the median visual analogue pain scores 24 hours after surgery for pain during relaxation, pain on movement, and pain on deep inspiration at each stage of the study. RESULTS: There was a reduction in median visual analogue scores during the study. The median (95% confidence interval) scores for pain during relaxation decreased from 45 (34 to 53) in stage 1 to 16 (10 to 20) in stage 7 for major surgical procedures. Pain on movement decreased from 78 (66 to 80) to 46 (38 to 48), and pain on deep inspiration decreased from 64 (48 to 78) to 36 (31 to 38). The reductions in median scores for intermediate and minor operative procedures showed similar patterns. CONCLUSIONS: The introduction of an acute pain service to the general surgical wards led to considerable improvement in the level of postoperative pain as assessed by visual analogue scores. Simple techniques of regular pain assessment and the more frequent use of intramuscular analgesia as a result of using an algorithm were particularly effective.

Is there still a place for prolonged bladder distension?

Over a 2-year period, 31 patients underwent prolonged hydrostatic bladder distension for benign and malignant bladder disease in this unit. Of these, 29 patients had benign functional disorders or bladder contracture, and in 2 patients hydrodistension was performed for complications of treatment for bladder neoplasia. Of the 29 patients with benign disease, 6 observed marked improvement and 8 some improvement in their symptoms, and 12 received no benefit. Patients with detrusor hypersensitivity fared better than those with detrusor instability or interstitial cystitis. A patient with malignant bladder disease died soon after the procedure as a result of a myocardial infarction. Problems attributed to the hydrostatic balloon catheter were responsible for 2 failures. The regional anaesthetic technique failed to provide adequate anaesthesia for hydrodistension in 9 procedures and limited the duration to 2 h in 13 others. Following recall of the perished balloon catheters by the manufacturer, and the introduction of continuous spinal anaesthesia, the number of technical failures has been reduced. This technique still has an important role to play in the relief of severe symptoms unresponsive to medical treatment, but it is important that ideal conditions are provided for hydrodistension in order to ensure maximum success, particularly when the alternative is major surgery.

A second survey of graduates of a traditionally black college of medicine.

To update and expand upon its 1975-76 survey of 729 graduates of seven classes, Howard University College of Medicine (HUCM) conducted a longer survey in 1985-86 of 1,985 graduates spanning 49 classes. Replies of the 728 respondents to the second survey confirm that HUCM's predominantly black alumni were continuing to provide patient care to a substantial number of poor blacks in urban areas. Fifty-six percent of all HUCM alumni were in primary care, compared with 46% of all alumni of U.S. medical schools who were in primary care. New findings included concerns about malpractice suits and physician impairment. Regarding physician supply in their own communities, 53% of respondents believed that there were too many physicians overall, but 63% believed there were too few black physicians. For the 1940-1969 graduates, loans financed 10% of their medical education, and indebtedness influenced the types of practice chosen by 4%; comparable figures for the 1970-1980 graduates were 25% and 11%.

Black student enrollment in US medical schools.

Blacks represent about 12% of the nation's population, but only 6% of the total medical school enrollment, 5% of medical school graduates, 5% of postgraduate trainees, 3% of physicians in practice, and 2% of medical school faculties. Addressing this underrepresentation of blacks in medicine not only is a matter of justice, equity, and national conscience but also has implications for the provision of quality physician care to this nation's minority and medically underserved populations. Black physicians are more likely to understand the cultural and social context of illness and disability among blacks and are also more likely to be able to communicate effectively with black patients. Black physicians are also more likely to practice in communities whose residents lack adequate access to medical care. An approach to addressing the problem of underrepresentation is proposed, consisting of activities at the precollege, college, and medical school levels.

Predicting academic performance at a predominantly black medical school.

A study was conducted by the authors that examined the validity of the Medical College Admission Test (MCAT), undergraduate grade-point average (GPA), and "competitiveness" of undergraduate college in predicting the performance of students at a predominantly black college of medicine. The performance measures used in the analysis consisted of course grades in all four years of medical school and scores on both Part I and Part II of the National Board of Medical Examiners (NBME) examinations. The predictive validities of the MCAT scores and undergraduate GPAs were found to be similar to those revealed in earlier studies conducted at predominantly white schools. Two exceptions to these similarities were found. First, the MCAT scores at the black school had a somewhat lower validity in predicting NBME examination scores than was the case at the other schools. Second, of the six MCAT subtest scores, Skills Analysis: Reading had the highest correlation with first-year grades, in contrast to results at the other schools. No differences between men and women were found in the validity of MCAT scores and the GPA. The competitiveness of the undergraduate college attended was found to contribute significantly to the prediction of all measures of medical school performance.

Subscriber suits: how to avoid them.

As HMOs and PROs become more significant elements of the health delivery system, they also become more likely targets for lawsuits. This article identifies twelve major liability risks of these organizations as well as those who provide services to HMOs and PPOs. Also presented are steps that can be taken to help protect against those risks.

Practice patterns of black physicians: results of a survey of Howard University College of Medicine alumni.

Over 600 Howard University medical alumni of seven representative classes graduating from 1955 to 1975 were surveyed by questionnaire in 1975 and 1976. Replies of the 252 black respondents confirm that these graduates are providing substantial care to blacks, the economically disadvantaged, and residents of the inner city. Survey findings reaffirm the necessity to train more black physicians and to provide data on current and future practice patterns. Comparisons are made between the practice patterns of earlier (1955 to 1970) and later (1973 to 1975) black graduates. A general bibliography of publications relevant to the practice patterns of black physicians is included.

Survey of graduates of a traditionally black college of medicine.

Over 700 Howard University medical alumni of seven representative classes graduating from 1955 to 1975 were surveyed by questionnaire in 1975-76. Replies of the 311 respondents confirm that this college of medicine has trained a substantial number of physicians who are providing care to blacks, the economically disadvantaged, and residents of inner city areas. Survey findings may also be useful in reaffirming the necessity for training more minority physicians, assessing the impact which the increasing number of minority physicians will have on health care delivery in this country, and suggesting the probable practice patterns of future minority graduates of U.S. medical schools.