North Kent College

RATIONALEWe previously showed a comprehensive computer guided-consultation (containing prompts developed from NICE guidelines) in COPD primary care was feasible without specialist training, while preserving the autonomy of clinical decision making. The pilot study based on COPD primary care register, 88% had a proposed management change and 29% of patients had a diagnostic revision. We have re-examined the impact in real life to determine if this is repeated.MethodsWe report on review of 2000 patients drawn from COPD registers across 78 practices. 459 (23%) did not have COPD based on spirometry. 1541 with COPD, had a mean (SD) age of 69.4 (9.8) yrs, 903 (58.6%)male, 1407 (91.6%) had been smokers and 597 (38.4%) were current smokers. The mean (SD) FEV1 was 1.48 (0.56) with a mean FEV1 percent predicted of 61.4 and a mean FEV1/FVC ratio of 52.4. The mean (SD) MRC score was 2.58 (0.9) and BMI was 27.0 (5.9).ResultsTreatment modifications were implemented across various interventions. Pharmacological recommendations included the addition of: Short-acting bronchodilator in 75/1541 (4.9%), and a long-acting bronchodilator (LAMA) in 78/1541 (5.1%). Long-acting beta agonist/inhaled corticosteroid combination (LABA/ICS) was added in 75 patients including 37 with only moderate disease. In 32 (1.8%) patients the recommendation was to discontinue various inhaled medication and in 28 (1.6%) patients these were LABA/ICS combinations. In addition, 28.8% of patients currently smoking, accepted referral for smoking cessation support. 38 patients had hypoxia, 10 already on oxygen, and 4/28 (14.3%) referred for oxygen assessment. 33.3% of eligible patients were referred to pulmonary rehabilitation. 77.5% required and were provided with a written educational pack, and a formal crisis management plan formulated for 49.3% cases. Inhaler technique was inadequate in 10.2% of patients and in part drove the prescribing changes.ConclusionUsing computer guiding consultation in real life practice resulted in substantial management recommendations and diagnostic revisions. COPD care can be improved, using computer guided consultation which enables non specialists to achieve it.

Sensations from nature provoke an emotional response from a particular motif around which a painting is constructed. Nature is not slavishly copied but the sensations are submitted to the necessity of making a picture in which the compositional elements are brought into unity over the whole surface to achieve stability. Within the stability there are local areas of dissonance to add a dynamic structure to the composition and to attract the gaze as the painting is examined by very rapid eye movements (saccades). Examples are given of a number of paintings by the author comprising two abstracts and four landscapes. Colours are heightened and usually highly saturated, so that they have an intense purity to express the emotions with greatest clarity and may not be imitative. Each colour is put down in relation to all other colours with consideration for their interrelationships and expressiveness. Painting is instinctive but has an underlying theoretical basis relying on the juxtaposition and displacement of complementary colours and of dissonant colour. In order to demonstrate the methodology of painting, two series of ‘progressive’ images are given that show the completion of two additional landscapes in six stages.

We present a series of early UVES/VLT high resolution spectra of the afterglow of GRB 030329 at redshift z=0.16867+-0.00001. In contrast to other spectra from this burst, both emission and absorption lines were detected. None of them showed any temporal evolution. From the emission lines, we determine the properties of the host galaxy which has a star formation rate (SFR) of 0.198 M_solar yr^-1 and a low metallicity of 1/7 Z_solar. Given the low total stellar host mass M_star=10^7.75+-0.15 M_solar and an absolute luminosity m_V=-16.37, we derive specific SFRs (SSFR) of log SFR/M = -8.5 yr^-1 and SFR/L = 14.1 M_solar yr^-1 L_*^-1. This fits well into the picture of GRB hosts as being low mass, low metallicity, actively star forming galaxies. The MgII and MgI absorption lines from the host show multiple narrow (Doppler width b=5-10 km/s) components spanning a range of v about 260 km/s, mainly blueshifted compared to the redshift from the emission lines. These components are likely probing outflowing material of the host galaxy, which could arise from former galactic superwinds, driven by supernovae from star forming regions. Similar features have been observed in QSO spectra. The outflowing material is mainly neutral with high column densities of log N(MgII)=14.0+-0.1 cm^-2 and log N(MgI)=12.3+-0.1 cm^-2.

Postoperative adhesions are a significant problem after colorectal surgery. However, the basic epidemiology and clinical burden are unknown. The Surgical and Clinical Adhesions Research Study has investigated the scale of the problem in a population of 5 million. Validated data from the Scottish National Health Service Medical Record Linkage Database were used to define a cohort of 12,584 patients undergoing open lower abdominal surgery in 1986. Readmissions for potential adhesion-related disease in the subsequent ten years were analyzed. The methodology was conservative in interpreting adhesion-related disease. In the study cohort 32.6 percent of patients were readmitted a mean of 2.2 times in the subsequent ten years for a potential adhesion-related problem. Although 25.4 percent of readmissions were in the first postoperative year, they continued steadily throughout the study period. After open lower abdominal surgery 7.3 percent (643) of readmissions (8,861) were directly related to adhesions. This varied according to operation site: colon (7.1 percent), rectum (8.8 percent), and small intestine (7.6 percent). The readmission rate was assessed to provide an indicator of relative risk of adhesion-related problems after initial surgery. The overall average rate of readmissions was 70.4 per 100 initial operations, with 5.1 directly related to adhesions. This rose to 116.4 and 116.5, respectively, after colonic or rectal surgery-with 8.2 and 10.3 directly related to adhesions. There is a high relative risk of adhesion-related problems after open lower abdominal surgery and a correspondingly high workload associated with these readmissions. This is influenced by the initial site of surgery, colon and rectum having both the greatest impact on workload and highest relative risk of directly adhesion-related problems. The study provides sound justification for improved adhesion prevention strategies.

The GIFT organization is one of the foremost European agencies in the education of, and in provision for, the exceptionally able. Within the UK it has a national and growing international reputation. Its activities range from in-school enrichment and extension courses for school students aged 4–18, age-specific residential weekend courses, week-long Summer and Easter Schools both at home and abroad, masterclass day-courses in various UK centres, the production of resources for the exceptionally able, and teacher in-service training. Most recently it has extended its brief to run courses for gifted undergraduates and graduates.

Abstract This is a report of the successful use of hypnotic suggestions aimed at encouraging self‐assertion and self‐acceptance in 51 children aged from 6–15 seen in a general medical practice with psychogenic enuresis or abdominal pain, school phobias, behavioural problems or chronic anxiety. All children treated were passive, timid and unassertive. The psychodynamics of passivity and of assertive therapy are discussed. Thirty‐nine children were rated at a two‐year follow‐up as completely recovered; twelve made no permanent improvement. The average total time spent on treatment was only one and a half hours so this approach to hypnotherapy may be of interest to general medical practitioners as well as child psychiatrists and therapists. Copyright © 1997 British Society of Experimental and Clinical Hypnosis

In this final chapter we’ll look at an example to show how the interpreter executes a command. I’ll also write down the full code, and describe a short interactive session using the interpreter. But first, let me state in more detail the subset of ABC that the interpreter can handle.

In view of the increasing interest now shown in the magnitude of the natural background radiation to which man is subjected, determinations have been made of the background counting rate of a Geiger-Muller tube in some hundreds of situations during the past three years. The counting rates have been determined by aural counting with a light-weight portable apparatus incorporating a G10H γ-ray tube with a chrome-iron cathode of effective length 11·8 cm. A standard error of between 5 and 10 per cent is achieved by this method. The counter, shielded from light by black paper and a canvas carrying bag, includes in its response some contribution from energetic β particles. A comparison with and without a 1 mm steel sheath indicated that in typical circumstances about two-thirds of the response above the cosmic-ray counting rate was due to hard γ radiation.