England

The author considers that whilst nurse tutors teach theory, nurse practitioners go on nursing in the same way that they always have done. There appears to be a chasm dividing theory and practice. This paper describes an attempt to leap that chasm. The paper identifies the problem, inherent in the nursing process that creates such difficulties in its implementation. The nursing process alone does not provide an adequate framework for nursing practice. The paper then describes how the translation of theory into practice took place on a ward in Brighton General Hospital, Brighton, England. The barrier between theory and practice is highlighted, along with a description of how the problems this presents to ward staff were overcome. The author considers that the attribution of cause is a key concept in the problem-solving approach, since it generates the question — Why?— and therefore that attribution of cause must be a concept in any model of nursing that is being used to implement the nursing process. The paper provides an example of how nursing models may be adapted, at ward level, to guide everyday practice, whilst retaining the conceptual framework ofthe model. The inference of the paper is that such a process could be applied to other models resulting in a greater use of theory in everyday nursing practice.

The Mont Saint-Michel is a small, rocky tidal island in France located in a large bay at the mouth of the Couesnon.
The granite massif of Mont Saint-Michel is crowned with a medieval abbey. It's a table moutain; a remaining of a prehistoric petrified treetop.
Since 1898, the spire of the abbey church has a statue of Saint Michael that protrudes a hundred and seventy meters above the bay. The island is located about 1 kilometer from the coast near the town of Avranches in Normandy . It was originally a tidal island : it was accessible by land at low tidebut at high tide it was surrounded by water. Today a narrow bridge, with shuttle service, runs to the island. Mont Saint-Michel, with its pedestrian streets, is only accessible to pedestrians.

The first text about an abbey is the 9th-century Latin text Revelatio ecclesiae sancti Michaelis in monte Tumba written by a chanoine living at Mont Saint Michel or at the Cathédrale Saint-André d'Avranches. This text was written at a time of power struggle between Brittany and the County of Normandy against Francia as well as during canon law reforms by Roman emperors.

When Christianity expanded to the area, around the 4th century, Mont Tombe, the original name of Mont Saint Michel, was part of the Diocese of Avranches. By the middle of the 6th century, Christianity had a stronger presence in the bay. By this time, Mont Tombe was populated by religious devotees, hermits (probably some Celtic monks) supplied by the curé of Astériac, (Asterix) who took care of the site and led a contemplative life around some oratories. The hermits Saint Pair and Saint Seubilion dedicated one of the oratories to Saint Étienne, midway through the mont and one to Saint Symphorien, at the foot of the rock.

Saint Aubert
In 710, Mont Tombe was renamed Mont Saint Michel au péril de la Mer ("Mount Saint Michael at the peril of the sea) after erecting an oratory to Saint Michael by bishop Saint Aubert of Avranches in 708. According to the legend, Aubert received, during his sleep, three times the order from Saint Michael to erect an oratory on the Mont Tombe. The archangel was reputed to have left his finger mark on Aubert's skull. This skull is displayed at the Saint-Gervais d'Avranches basilica with such a scar on it.

This sanctuary should be, according to the archangel, a replica of the Gargano in Italy (from the 5th century). Aubert had a local religious artifact removed and instead a circular sanctuary built, made of dry stones. Around 708, Aubert sent two monks to get some artifacts from the Italian sanctuary Gargano (a rock with his foot print and a piece of tissue from the altar). During this mission, the March 709 tsunami is supposed to have destroyed the Scissy forest and turned the Mont into an island. On October 16 709, the bishop dedicated the church and put twelve chanoine there. The Mont-Saint-Michel was born.

The remains of the oratory were found in the chapel Notre-Dame-Sous-Terre. This sanctuary contained the tomb of Aubert and most likely the artifacts brought from Gargano. The chapel Notre-Dame-Sous-Terre is today under the nave of the abbey-church.

The first buildings became too small and under the Western Roman Empire multiple buildings were added. Charlemagne chose saint Michel as a protector of his empire during the 9th century and tried to have the place renamed Mont-Saint-Michel, but during the Middle Ages it was usually called Saint-Michel-aux-Deux-Tombes (Saint Michel with two tombs) (Mons Sancti Michaelis in periculo maris, in reference to Tombelaine).

History of the abbey
Church of Saint Michel during 9th and 10th centuries
The Mont-Saint-Michel monks, during the first century of their institution, venerated the archangel Michael. The Mont became a place of prayer and study, but the stability period, known as the Neustria, during the reign of Charlemagne ended when he died. As the rest of Gaule was fighting invasions, religion and science found some welcoming in the diocese of Avranches and at the Mont-Saint-Michel.

At first, pilgrims kept coming to the Mont. After the Vikings captured the Mont in 847, the monks departed. But, as an island, it offered some protection for the local population and thus never stayed empty.

After the signature of the treaty of Saint-Clair-sur-Epte, Rollo (Gange-Hrólfr "Rollo" Ragnvaldsson de Normandie) started repairing the damages inflicted to the religious buildings. He generously financed the Mont and called back the monks displaced by the war, returning the Mont to its previous condition.

The wealth and support that the Mont suddenly obtained from Rollo started to fundamentally affect its inhabitants, taking them away from their solitary, religious life. After William I of Normandy took over his father's title as Duke of Normandy in 927, he expanded his support toward monasteries until his assassination in 932; but his wealth, from which they benefited, further exacerbated their mundane life style. Because of their generous contributions to the Mont, the Dukes of Brittany Conan 1st, who died in 992, and Geoffrey 1st, who died in 1008, were buried in the Mont as benefactors.

As a German historian recently remarked, for Germany Adolf Hitler was the “off-spring,” the outstanding legacy, of World War I, and no one doubts that.1 He himself started his political career in 1919 in the wake of a lost war and the crushing peace of Versailles. That treaty reduced Germany’s territory by 14 percent and its population by 6.5 million citizens. It created for Germany large minorities outside its new borders and for the time being an unlimited reparations liability.2 Hitler’s rise to dictatorship is unthinkable without the humiliation and misery that resulted for the German people out of their defeat. And still: was he bound to become the war’s nemesis in destroying the Weimar Republic? This article thus asks the question whether Hitler’s rise to power from Germany’s defeat to the proclamation of the Third Reich was inevitable. For that purpose the ways in which Germans tried to come to terms with their defeat and the war’s legacies will be discussed. As an illustration the article focuses on two highly popular political doctrines, both legacies of the war of its own—both in different ways denying the hopelessness of Germany’s military situation at the end of the war. These were: (1) the doctrine of the so-called “stab-in-the-back” (Dolchstoss); and (2) the doctrine of the so-called “war guilt lie” (Kriegsschuldlüge). At its conclusion, this analysis will raise the question as to whether Hitler’s exploitation of these two doctrines immediately led to his dictatorship.
(1) The stab-in-the-back doctrine first was foreshadowed, when, on October 3, 1918, the German government requested an armistice with the Allies and peace negotiations on the basis of the peace program that President Woodrow Wilson had propagated. To the German public this move was an absolutely shattering surprise. Until then the German High Command had failed to admit the increasing seriousness of Germany’s military position resulting from strategic overstretch and military exhaustion.3 Instead, all the public had perceived was that the German troops fighting in France had protected them against the direct experience of war and that in the East Germany's predominance extended as far as the Caucasus Mountains. How then could Germany’s bid be explained?4 Could it be that the million-fold sacrifice of lives had been in vain? The gap that throughout the war had yawned between far-flung popular hopes and the grim military reality thus deepened even further. Other, non military reasons, it was believed, must have been behind Germany’s sudden giving up. The German military command concealed what it had confessed to the political leadership in Berlin—that it feared German troops in France were on the verge of being routed. To avoid a public loss of face, it claimed that nonmilitary reasons lay behind Germany’s critical military situation. Ludendorff, the de facto highest commander of Germany’s troops, concocted an explanation by inventing the stab-in-the-back doctrine. Germany had sued for an armistice, he asserted in a confidential talk with his officers, because it had become impossible to continue the war. This was due to the “poison” of Marxist–Socialist propaganda that had undermined the soldiers’ resolution to go on fighting and made them “unreliable,” although the chances of a successful defense, if not victory, continued to be good.5 Ludendorff’s statement initiated a lengthy process of political onus shifting between military and civil authorities, between the Right and the Left, regarding the responsibility for the military disaster that was threatening their country.6
Actually, the antecedents of this doctrine went further back—well into the fall of 1916. At that point, under the impression of a precarious military situation during the battle of the Somme, the first doubts arose in Germany regarding the prospects of a victory. A heated controversy about the war’s purpose and Germany’s war aims broke out. The military leadership and the exponents of the nationalist right kept insisting that a total victory was indispensable that would ensure sizable annexations, improve Germany’s geopolitical position, and entail a reward for the sacrifices the German people had made. Significantly, it was also held that only the perspective of a total victory would maintain morale at home and at the front.7 The forces of the German Center and Left, not least Labor, on the other hand, pressed for a peace of accommodation based on a military tie as the only realistic way out of a war that Germany apparently could not win. The real reward of the war seemed to be liberal reforms in Prussia and the Empire.8 On July 19, 1917, a majority of the German Reichstag passed a resolution demanding just that.9 To the rightist die-hards this amounted to outright treason subverting the public morale. According to the Right, internal reforms could not be a substitute for military victory.10

Results: Twenty five (58%) control patients died at home compared with 124 (67%) patients allocated to hospital at home. This difference was not significant; intention to treat analysis did not show that hospital at home increased the number of deathsat home. Seventy three patients ...

To examine the prevalence of depressive symptoms and suicidal ideation, their comorbidity, and associated risk factors in adolescence. A self-administered questionnaire was completed in class by students in three middle schools (grades 6 through 8) enrolling more than 3,200 students. Usable questionnaires were obtained from 2,614 (81.5%), of which 924 were Anglo and 1,354 were of Mexican origin Depression was measured using the 20-item Center for Epidemiologic Studies Depression Scale and suicidal ideation using four items on thoughts of death and suicide. The minority adolescents reported significantly higher crude prevalence rates of symptoms of depression and thoughts of suicide than their Anglo counterparts. Prevalence rates were highest for females of Mexican origin. There was a strong association between depression and suicidal ideation in both ethnic groups. Multivariate logistic regression analyses indicated significant correlates of depressive symptoms were suicidal ideation (adjusted odds ratio = 10.9), loneliness, and use of English, in that order. Significant correlates of suicidal ideation were depression (adjusted odds ratio = 10.6), loneliness, two-parent household, use of English, and being of Mexican origin. More than 80% of those with high ratings on suicidal ideation scored as depressed in both ethnic groups. Results are consistent with other studies suggesting rates of suicidal ideation among adolescents are in the 10% to 20% range, while rates of depressive symptoms are in the 35% to 50% range using standard caseness scores. Mexican-American youths appear to be at higher risk than Anglo youths, particularly for suicidal ideation. In addition, it appears that youths who are lonely are more likely to report higher rates of both depression and suicidal ideation. The data also indicate that youths who spoke only or mostly English reported lower rates of depression and suicidal ideation, suggesting that acculturation may play a role as well.

Despite their numerous similarities, Marranos in inquisitorial Spain and Recusants (and the so-called ‘Church Papists’), English Crypto-Catholics, in the wake of the English religious reforms, have rarely been studied concurrently. In this paper I will argue that secrecy was a central feature of the daily lives of both these minorities, and it helped them function as groups despite their internal diversity, experiencing a wide array of expressions of belonging. The elasticity of the groups’ religious practices clearly contributed to the rise of new forms of worship and to the creation of new ritual objects which could be validated by diasporic belief systems. As a consequence, beyond criticisms, these communities functioned as significant vectors of change in how their entire religious groups practiced their faiths. Ultimately, it appears that both Crypto-Jews and Crypto-Catholics existed as cohesive groups as much because their members shared religious practices as due to the diasporic culture of martyrdom.

Funding models influence provision and development of palliative care services. As palliative care integrates into mainstream health care provision, opportunities to develop funding mechanisms arise. However, little has been reported on what funding models exist or how we can learn from them. To assess national models and methods for financing and reimbursing palliative care. Initial literature scoping yielded limited evidence on the subject as national policy documents are difficult to identify, access and interpret. We undertook expert consultations to appraise national models of palliative care financing in England, Germany, Hungary, Republic of Ireland, New Zealand, The Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United States and Wales. These represent different levels of service development and a variety of funding mechanisms. Funding mechanisms reflect country-specific context and local variations in care provision. Patterns emerging include the following: Pr...

Electronic patient record systems serve many purposes for many different kinds of users. Four case studies are reported of the use made by health-care staff of electronic patient record systems that supported healthcare pathways. The results demonstrate that the systems fit the purposes of strategic and managerial users of the record, but they are problematic as tools for use by the frontline staff delivering care. As a result, these staff frequently resort to workarounds to accomplish their work goals. An analysis of the design processes that created these systems shows that the specification of the systems was based on strategic and managerial requirements and there was no formal assessment of the needs of frontline users. Efforts to address the needs of frontline staff in the provisions of electronic systems were most often made after the main system was implemented.

The train crash that occurred in London in 1999 resulted in 31 dead and almost 300 injured persons. Mobilized resources allowed for the application of normal treatment principles. Available resources were in excess of what was needed. The procedures implemented were judged as adequate. Responses followed the management plan formulated over many years and experiences. The rotating command procedures used worked well. Multiple communications systems were used, including landline telephones, mobile telephones, and radios. Plans should include caring for both adults and children. Well-planned psychosocial services and functional compute services are essential components.

WALSH K, VARNES N, OSMOND C, STYLES R, COGGON D. Occupational causes of low-back pain. Scand J Work Environ Health 1989;15:54-59. Associations between occupational activities and low-back pain (LBP) were examined in a retrospective postal survey of 545 randomly ...

Background: Shoulder pain is a very common presentation in primary care. Evidence of benefit for subacromial corticosteroid injection is inconclusive and confined largely to studies with short follow-up. We plan a large, definitive, primary-care-based trial to determine efficacy and safety in patients with rotator cuff tendinopathy, and conducted a pilot trial to explore feasibility. Methods: Six general practitioners (GPs) from Oxfordshire, UK underwent update training in assessing painful shoulders and injecting the subacromial space. Each then recruited patients aged 35 to 74 years from primary care complaining of shoulder pain lasting no more than 6 months. Eligible participants were randomized to receive either methylprednisolone acetate 40 mg with lidocaine 1% (total volume 1 ml), or lidocaine 1% alone (total volume 1 ml), injected into the subacromial space. The participants were blinded to treatment allocation. Feasibility outcomes were rates of recruitment, withdrawal, adherence to the protocol, completeness of follow-up, and success of patient masking. Clinical outcomes were the Oxford Shoulder Score (OSS) at baseline and at 4 and 12 weeks, and responses to three satisfaction questions at 2, 4 and 12 weeks. Outcome data were collected by postal questionnaires. Results: A total of 40 participants were randomized (80% of the target 50 participants) over 26 weeks giving an overall recruitment rate of 1.5 participants per week. Rates of follow-up were maintained to a high level for the full 12 weeks. Four participants requested a 'rescue' corticosteroid injection but no patients withdrew. The trial GPs gave high scores for their confidence that the patient had remained blinded to treatment allocation during the procedure. The OSS at 4 and 12 weeks and the responses to the satisfaction questions are reported. Conclusions: It is feasible to recruit participants with shoulder pain in the primary care setting for a blinded, randomized trial of corticosteroid injection. Online randomization of participants from the practice is also feasible, and postal questionnaires provide an effective means of gathering outcome data in this area of study. The lessons learned from this pilot will usefully inform the design of a large, definitive efficacy trial in primary care.

I have three concerns about the description of central venous catheterization in the video by Graham et al.(May 24 issue). 1 First, it is misleading to describe the risk of hemothorax as “not applicable” when the internal jugular approach is used, since hemothorax is a known ...

Objective: to develop consensus guidelines for management of delirium and to assess their effectiveness in improving the outcomes and process of care in delirium. Method: guidelines for delirium were developed following a literature search and a formal multidisciplinary consensus process using a two-stage Delphi technique. The process and outcomes of patients with delirium were then observed in a ' before' (211 patients) and an ' after' study (125 patients). Three levels of intervention were made in the ' after' study. (i) Feedback of baseline data only (low intensity intervention). (ii) As in (i), but also formal distribution of the guidelines to nurses and doctors (medium intensity intervention). (iii) As in (ii), but in addition the guidelines were reinforced with teaching sessions for the nurses and doctors (high intensity intervention). Setting: older people (aged over 65 years) with delirium admitted to acute medical or acute elderly care wards in Wve district general hospitals in England. Results: only in the high intervention group was there an improvement in process and outcome of care, but this failed to reach statistical signiWcance. Conclusion: delirium is a poorly managed condition in older people and guidelines alone fail to improve the process and outcomes of care.

This paper's main contention is that some basically methodological developments in science which are apparently distant and unrelated can be seen as part of a sequential story. Focusing on general inferential and epistemological matters, the paper links occurrences separated by both in time and space, by formal and representational issues rather than social or disciplinary links. It focuses on a few limited aspects of several cognitive practices in medical and biological contexts separated by geography, disciplines and decades, but ...

The reluctance of physicians to use estrogens in women with hormone responsive disorders is a tragic result of the 2002 WHI study. Although their hostility to estrogen therapy antedated these studies, the flawed data is now used as justification for the denial of estrogens for treatment of low bone density and various types of hormone responsive depression in women. Estrogens

Aim: To investigate whether children with autistic spectrum disorder (ASD) have bowel symptoms consistent with underlying enterocolitis. Methods: Information on children's stool patterns and gut symptoms collected by questionnaire at 4 weeks and at 6, 18, 30 and 42 months of age were available for

A historical review is presented of the link between Ludwig Wittgenstein, considered the most important philosopher of the 20 th century, and medicine, particularly neurology and psychiatry. Wittgenstein worked as a porter at Guy's Hospital in London, and then as a technician at the Royal Victoria Infirmary in Newcastle. He wrote about his important insights into language, and neuroscience. It has been suggested that he had Asperger syndrome and a possible movement disorder (mannerisms).

Objective Poor condition at birth may impact on IQ, although its effect on other measures of neurodevelopment is unclear. The authors' aim was to determine whether infants receiving resuscitation after birth have reduced scores in measures of attention, memory and language skills or the need for educational support at school even in the absence of clinical encephalopathy. Methods Three groups of term infants were identifi ed from the Avon longitudinal study of parents and children: infants resuscitated at birth but asymptomatic for encephalopathy (n=612), infants resuscitated who developed symptoms of encephalopathy (n=40) and the reference infants who were not resuscitated and had no further neonatal care (n=8080). Measures of attention, language, memory and the need for educational support were obtained for children between 8 years and 11 years. Test results (standardised to a mean of 100 and SD of 15) were adjusted for clinical and social covariates. Missing covariate data were imputed using chained equations. Results Infants asymptomatic after resuscitation had similar scores to those not requiring resuscitation for all measures while infants who developed encephalopathy had lower working memory (−6.65 (−12.34 to −0.96)), reading accuracy (−7.95 (−13.28 to −2.63)) and comprehension (−9.32 (−14.47 to −4.17) scores and increased risk of receiving educational support (OR 6.24 (1.52 to 26.43)) than infants thought to be well at birth, although there was little evidence for an association after excluding infants who developed cerebral palsy. Conclusions The authors found no evidence that infants who were resuscitated but remained well afterwards differed from those not requiring resuscitation in the aspects of neuropsychological functioning assessed in this study. Infants who developed neonatal encephalopathy had evidence of worse functioning, particularly in language skills and were more likely to receive educational support at school.

The functional anatomy of Chinese character processing was investigated using fMRI. Right-handed Mandarin-English bilingual participants made either semantic or perceptual size judgements with characters and pictures. Areas jointly activated by character and picture semantic tasks compared to size judgement tasks included the left prefrontal region (BA 9, 44, 45), left posterior temporal, left fusiform, and left parietal regions. Character processing produced greater activation than picture processing in the left mid and posterior temporal as well as left prefrontal regions. The lateral occipital regions were more active during picture semantic processing than character semantic processing. A similar pattern of activation and contrasts was observed when English words and pictures were compared in another set of bilingual participants. However, there was less contrast between word and picture semantic processing than between character and picture processing in the left prefrontal region. When character and word semantic processing were compared directly in a third group, the loci of activation peaks was similar in both languages but Chinese character semantic processing was associated with a larger MR signal change. The semantic processing of Chinese characters, English words, and pictures activates a common semantic system within which there are modality-specific differences. The semantic processing of Chinese characters more closely resembles English words than pictures.

Background  Multidisciplinary and interprofessional working is currently a priority in health care policy, in caring for patients and in health professional education. Realising multidisciplinary approaches presents challenges in the context of changes in doctors' and nurses' roles and the increased emphasis placed on communication with patients. In communication in consultations, explanations are employed in the service of numerous activities, including decision making, diagnosis and physical examination, but they have been little studied.Setting  This paper presents findings from a comparative study of doctors' and nurses' communication with patients in multidisciplinary health care, focusing on diabetes in primary care.Methods  Video- and audio-recorded consultations were subjected to conversation analysis. Output from discussion groups with patient representatives and health professionals underwent qualitative analysis.Findings  Distinctive features of explanations in nurses' and doctors' consultations with patients were identified. These can be understood by reference to patterns of communication. Nurses' communication was mediated by patients' contributions; doctors' communication gave an overarching direction to the consultation as a whole. While nurses' explanations began from the viewpoint of a patient's responsibility and behaviour, doctors' explanations began from the viewpoint of biomedical intervention. Their consultations lent different opportunities for patients' involvement.Conclusion  Nurses' and doctors' communications each exhibit their own distinct features. Specification of these features, when considered in the context of a particular consultation activity such as explanations, allows both recognition of the distinct contributions each profession can offer and identification of ways of combining these to maximum effect. This has implications for policy, for practice and for interprofessional education.

Background Colonoscopy and fecal immunochemical testing (FIT) are accepted strategies for colorectal-cancer screening in the average-risk population. Methods In this randomized, controlled trial involving asymptomatic adults 50 to 69 years of age, we compared one-time colonoscopy in 26,703 subjects with FIT every 2 years in 26,599 subjects. The primary outcome was the rate of death from colorectal cancer at 10 years. This interim report describes rates of participation, diagnostic findings, and occurrence of major complications at completion of the baseline screening. Study outcomes were analyzed in both intention-to-screen and as-screened populations. Results The rate of participation was higher in the FIT group than in the colonoscopy group (34.2% vs. 24.6%, P<0.001). Colorectal cancer was found in 30 subjects (0.1%) in the colonoscopy group and 33 subjects (0.1%) in the FIT group (odds ratio, 0.99; 95% confidence interval [CI], 0.61 to 1.64; P = 0.99). Advanced adenomas were detected in 514 subjects (1.9%) in the colonoscopy group and 231 subjects (0.9%) in the FIT group (odds ratio, 2.30; 95% CI, 1.97 to 2.69; P<0.001), and nonadvanced adenomas were detected in 1109 subjects (4.2%) in the colonoscopy group and 119 subjects (0.4%) in the FIT group (odds ratio, 9.80; 95% CI, 8.10 to 11.85; P<0.001). Conclusions Subjects in the FIT group were more likely to participate in screening than were those in the colonoscopy group. On the baseline screening examination, the numbers of subjects in whom colorectal cancer was detected were similar in the two study groups, but more adenomas were identified in the colonoscopy group.

Breastfeeding prevalence in the United Kingdom is one of the lowest in Europe. The midwife provides feeding support for new mothers but research suggests that midwives&#39; knowledge of breastfeeding is limited. To discover the views of English midwives in relation to their breastfeeding support role. Qualitative design. Two maternity hospitals in Northwest England. Thirty midwives who cared for normal, healthy babies. Midwives were selected for interview using theoretical sampling principles from a pool of midwives who volunteered. Volunteers were accessed using a poster exhibited in relevant clinical areas. Data were collected using audiotaped, in-depth interviews and were analysed using constant comparison techniques. The study highlights that differing professional knowledge and beliefs about breastfeeding support created intense, mainly negative, emotions for these midwives. Irritation and despair was experienced with the greater emphasis placed on research, rather than practic...

BACKGROUND Recommendations suggest that all patients with diabetes who use insulin should home test their blood glucose. Recommendations for those not using insulin remain contradictory. These recommendations are in part based upon the assumption that people with diabetes cannot make an accurate estimate. AIM To explore whether people with diabetes can accurately estimate their blood glucose levels and to assess which factors explain variability in these estimates. DESIGN A cross-sectional design. SETTING One general practice in Oxfordshire, UK. PARTICIPANTS One hundred and fifteen consecutive patients with diabetes attending a diabetic clinic were invited to estimate their blood glucose level prior to having it routinely measured. RESULTS One hundred and four patients made estimates. Of these, 45 (43.3%) underestimated their blood glucose, 18 (17.3%) overestimated, and 41 (39.4%) made guesses that fell into the range defined as accurate. Of those not using insulin (n = 85), 37 (43....

Despite increasing calls for shared decision making (SDM), the precise mechanisms for its attainment are unclear. Sharing decisions in mental health care may be especially complex. Fluctuations in service user capacity and significant power differences are particular barriers. We trialled a form of facilitated SDM that aimed to generate patients&#39; treatment preferences in advance of a possible relapse. The &#39;Joint Crisis Plan&#39; (JCP) intervention was trialled in four mental health trusts in England between 2008 and 2011. This qualitative study used grounded theory methods to analyse focus group and interview data to understand how stakeholders perceived the intervention and the barriers to SDM in the form of a JCP. Fifty service users with psychotic disorders and 45 clinicians participated in focus groups or interviews between February 2010 and November 2011. Results suggested four barriers to clinician engagement in the JCP: (i) ambivalence about care planning; (ii) percep...

A large proportion of non-communicable disease can be attributed to modifiable risk factors such as poor nutrition and physical inactivity. We present data on planning and transport practitioners&#x27; perceptions and responses to government public health guidance aimed at ...

Objective: No outcome measures specific to pulmonary hypertension (PH) currently exist. The aim of the study was to develop health-related quality of life (symptoms and functioning) scales and a quality of life scale that would allow comprehensive, accurate and valid patient-reported outcome assessment in clinical studies. Methods: The content of the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) was derived from qualitative interviews conducted with 35 patients. Item reduction was based on the analysis of responses to a postal survey (n=75) and patient interviews (n=15) designed to determine face and content validity. A final postal validation study (n=91) was performed to determine reproducibility and construct validity. Results: The questionnaire was well received by participants who found it to be relevant, comprehensible and quick and easy to complete. Rasch and factor analyses were conducted to ensure unidimensionality of the final CAMPHOR scales; Overall symptoms (made up of Energy, Breathlessness and Mood subscales), Functioning and Quality of life. The CAMPHOR scales had good internal consistency (a=0.90-0.92) and reproducibility (test-retest correlations=0.86-0.92). They also exhibited convergent, divergent and known groups validity. Conclusions: The CAMPHOR is a valuable new instrument for assessing patient-reported outcome in PH clinical trials and routine practice.

This article explores the age difference of marrying and divorcing couples, calculated by subtracting the wife&#39;s age from the husband&#39;s. Age difference is of interest in the study of families and partnership behaviour. It is also important because of its link with broader socio-demographic changes, such as population ageing, delayed fertility and the provision of care. The main finding is that between 1963 and 2005, the distribution of age differences for all marriages is very similar in each year to the distribution of age differences for the subset of couples who married in that year, but have since divorced. While there is some evidence of small variations in the proportion of marriages that end in divorce by age difference, there does not seem to be evidence of a strong association.

Recent changes in the English National Health Service (NHS) have introduced new complexities into the accountability arrangements for healthcare services. This commentary describes how the new organizational structures have challenged the traditional centralized accountability structures by creating a more dispersed system of governance for local health-care commissioners. It sets the context of discussions about accountability in the UK NHS and then describes the key changes in England following the implementation of the NHS reforms in April 2013. The commentary concludes that while there is increased complexity of accountability within a more decentralized and fragmented healthcare system, the government&#39;s goal of achieving increased local autonomy and greater control by general practitioners (GPs) will probably not be realized. In particular, the system will continue to have strongly centralized aspects, with increased regulation and central political responsibility.

Aims. To identify service models that provided care coordination for people with long-term neurological conditions in the UK. Background. The successful management of long-term neurological conditions needs sophisticated management across several health, social care and other service boundaries, as well as involvement of people with long-term neurological conditions and their support network. Yet, fragmentation of, and limited access to, support has been evident for over 20 years. Design. This study employed a mixed-method approach, including a systematic review, qualitative case studies and a quantitative national survey. This paper reports findings from the qualitative case study element of the research. Methods. In-depth (qualitative) case studies were conducted in six neurology 'service systems' in the UK representing geographic and demographic diversity. The research took place between November 2007-May 2008. The concept of 'continuity of care' was used as a framework for our case studies. Qualitative methods, including telephone and face-to-face interviews, were used to explore people's experience of continuity of care. Data were managed and analyzed using the Framework technique. Findings. Neurology nurse specialists were able to contribute to all elements of continuity of care for people with long-term neurological conditions. Conclusion. Their specialist knowledge about the condition and local services, flexibility, coordinating role, and their holistic and collaborative approach to practice, are key factors in nurse specialists promoting continuity of care. Nurse specialists exist in many different clinical areas and in many countries. Findings about the importance of their role in promoting continuity of care have important implications for UK and international policy and practice.

Background Short-term preoperative radiotherapy and total mesorectal excision have each been shown to improve local control of disease in patients with resectable rectal cancer. We conducted a multicenter, randomized trial to determine whether the addition of preoperative radiotherapy increases the benefit of total mesorectal excision. Methods We randomly assigned 1861 patients with resectable rectal cancer either to preoperative radiotherapy (5 Gy on each of five days) followed by total mesorectal excision (924 patients) or to total mesorectal excision alone (937 patients). The trial was conducted with the use of standardization and qualitycontrol measures to ensure the consistency of the radiotherapy, surgery, and pathological techniques. Results Of the 1861 patients randomly assigned to one of the two treatment groups, 1805 were eligible to participate. The overall rate of survival at two years among the eligible patients was 82.0 percent in the group assigned to both radiotherapy and surgery and 81.8 percent in the group assigned to surgery alone (P=0.84). Among the 1748 patients who underwent a macroscopically complete local resection, the rate of local recurrence at two years was 5.3 percent. The rate of local recurrence at two years was 2.4 percent in the radiotherapy-plus-surgery group and 8.2 percent in the surgery-only group (P<0.001). Conclusions Short-term preoperative radiotherapy reduces the risk of local recurrence in patients with rectal cancer who undergo a standardized total mesorectal excision.

The licensing of provincial surgeons and physicians in the post-Restoration period has proved an awkward subject for medical historians. It has divided writers between those who regard the possession of a local licence as a mark of professionalism or proficiency, those who see the existence of diocesan licences as a mark of an essentially unregulated and decentralized trade, and those who discount the distinction of licensing in assessing medical expertise availability in a given region. Such a diversity of interpretations has meant that the very descriptors by which practitioners were known to their contemporaries (and are referred to by historians) have become fragmented and difficult to use without a specific context. As David Harley has pointed out in his study of licensed physicians in the north-west of England, “historians often define eighteenth-century physicians as men with medical degrees, thus ignoring … the many licensed physicians throughout the country”. One could simi...

Across spoken languages, properties of wordforms (e.g. the sounds in the word hammer) do not generally evoke mental images associated to meanings. However, across signed languages, many signforms readily evoke mental images (e.g. the sign HAMMER resembles the motion involved in hammering). Here we assess the relationship between language and imagery, comparing the performance of English speakers and British sign language (BSL) signers in meaning similarity judgement tasks. In experiment 1, we found that BSL signers used these imagistic properties in making meaning similarity judgements, in contrast with English speakers. In experiment 2, we found that English speakers behaved more like BSL signers when asked to develop mental images for the words before performing the same task. These findings show that language differences can bias users to attend more to those aspects of the world encoded in their language than to those that are not; and that language modality (spoken versus signed) can affect the degree to which imagery is involved in language.