A recurrent nova super-remnant in the Andromeda galaxy.

The accretion of hydrogen onto a white dwarf star ignites a classical nova eruption1,2-a thermonuclear runaway in the accumulated envelope of gas, leading to luminosities up to a million times that of the Sun and a high-velocity mass ejection that produces a remnant shell (mainly consisting of insterstellar medium). Close to the upper mass limit of a white dwarf3 (1.4 solar masses), rapid accretion of hydrogen (about 10-7 solar masses per year) from a stellar companion leads to frequent eruptions on timescales of years4,5 to decades6. Such binary systems are known as recurrent novae. The ejecta of recurrent novae, initially moving at velocities of up to 10,000 kilometres per second7, must 'sweep up' the surrounding interstellar medium, creating cavities in space around the nova binary. No remnant larger than one parsec across from any single classical or recurrent nova eruption is known8-10, but thousands of successive recurrent nova eruptions should be capable of generating shells hundreds of parsecs across. Here we report that the most frequently recurring nova, M31N 2008-12a in the Andromeda galaxy (Messier 31 or NGC 224), which erupts annually11, is indeed surrounded by such a super-remnant with a projected size of at least 134 by 90 parsecs. Larger than almost all known remnants of even supernova explosions12, the existence of this shell demonstrates that the nova M31N 2008-12a has erupted with high frequency for millions of years.

A prospective trial of primary inguinal hernia repair by surgical trainees.

The main hypotheses were that the Lichtenstein inguinal hernia repair has a lower recurrence rate and similar incidence of chronic groin pain compared to sutured repairs when performed by surgical trainees. In a U.S. Veterans Administration Hospital, 150 primary hernia repairs were randomized to a Lichtenstein, McVay, or Shouldice repair. The Shouldice repair included a routine relaxing incision. First- and second-year residents, under the supervision of an experienced general surgeon, performed the procedure. Long-term follow-up was obtained in 81% of patients. Hernia recurrence rate was Lichtenstein 8%, McVay 10%, Shouldice 5% ( P>0.1) at 6-9 years follow-up. More patients had chronic groin pain following Lichtenstein repair (38%) than after Shouldice repair (7%) ( P<0.05). More information is needed on long-term groin pain following anterior mesh repair. The Shouldice inguinal hernia repair may have a role in open primary herniorrhaphy to decrease the risk of chronic groin pain.

Sequential thoracic metastasectomy prolongs survival by re-establishing local control within the chest.

OBJECTIVE: The value of sequential thoracic metastasectomies is unknown. We evaluate repeat metastasectomy for limited recurrences within the thorax. METHODS: From July 1988 to September 1998, 54 patients underwent 2 to 6 separate sequential procedures to excise metastases after recurrence isolated to the thorax. Kaplan-Meier survival and Cox modeling determined prognostic variables. RESULTS: Thirty-three men and 21 women, 22 to 76 years underwent 2 (100%, n = 54), 3 (50%), 4 (22%), or 5 to 6 (11%) metastasectomies. Fifty-four percent of patients had carcinoma, 35% sarcoma, 9% germ cell, and 2% melanoma. There were no operative deaths; all late deaths occurred from cancer. Median follow-up was 48 months. Cumulative 5-year survival from the second procedure was 57%. After the second, third, fourth, and fifth procedures, respectively, permanent control was achieved in 15 (27%) of 54 patients, 5 (19%) of 27, 1 (8%) of 12, and 0 of 7. Recurrence amenable to additional surgery occurred in 27 (50%) of 54, 12 (44%) of 27, 6 (50%) of 12, and 1 (17%) of 6. Mean hazard for the development of unresectable recurrence increased from 0.21 after the second procedure to 0.91 after the fifth procedure. The 5-year survival for the 27 patients undergoing only 2 metastasectomies was 60% (median not yet reached), 33% for the 15 patients undergoing only 3 metastasectomies (median 34.7 months), and 38% for the 12 patients undergoing 4 or more (median 45.6 months). From the time a recurrence was declared unresectable, patients had a 19% 2-year survival (median 8 months). CONCLUSIONS: Multiple attempts to re-establish intrathoracic control of metastatic disease is justified in carefully selected patients, but the magnitude of benefit decays with each subsequent attempt.

The scientist's world.

This paper describes the features of the world of science, and it compares that world briefly with that of politics and the law. It also discusses some "postmodern" trends in philosophy and sociology that have been undermining confidence in the objectivity of science and thus have contributed indirectly to public mistrust. The paper includes broader implications of interactions of government and science.

Sun avoidance practices among non-Hispanic white Californians.

This study measures self-reported sun avoidance practices, use of protective clothing, and use of sunscreen among 4,749 non-Hispanic white adults living in households in California. Data are from the California Behavioral Risk Factor Survey, a population-based telephone survey of health behaviors and attitudes. The average respondent spent at least 15 minutes in the sun on 21.4 days out of the last 30 days. Regular use of protective clothing was reported by 30.7%, regular use of sunscreen by 22.2%, and regular sun avoidance by 17.1% of the respondents. Results varied by month, gender, skin tone, age, education, and presence of children in the household. Health strategies should target younger adults (especially men), households with children and adults with less than a high school education. Because of relatively low rates of sun avoidance behaviors overall, a general population campaign also is warranted.

Psychological distress associated with waiting for results of diagnostic investigations for breast disease.

This paper presents the results of a multi-method research project investigating the psychological distress associated with waiting for results of diagnostic investigations in a delayed-results breast clinic. A cohort of 126 women completed standardized psychometric instruments to assess anxiety, mood and coping over 3 days. Semi-structured interviews were conducted with 20 respondents. The findings indicate that waiting sustained but did not exacerbate psychological distress. Peri-diagnostic anxiety, depression, uncertainty and confusion were associated with anxiety levels immediately following triple assessment. Women leaving the clinic with low anxiety retained this composure throughout the peri-diagnostic period. Those in the moderate and high anxiety groups recorded sustained anxiety, depression, uncertainty and confusion, with mean scores comparable to and exceeding those reported by psychiatric out-patients. Coping during the waiting period was typically accomplished by emotion-focused strategies. Qualitative data suggested the delayed-results clinic structure may facilitate psychological preparation for test results.

The conceptual structure of the integrated exposure uptake biokinetic model for lead in children.

The integrated exposure uptake biokinetic model for lead in children was developed to provide plausible blood lead distributions corresponding to particular combinations of multimedia lead exposure. The model is based on a set of equations that convert lead exposure (expressed as micrograms per day) to blood lead concentration (expressed as micrograms per deciliter) by quantitatively mimicking the physiologic processes that determine blood lead concentration. The exposures from air, food, water, soil, and dust are modeled independently by several routes. Amounts of lead absorbed are modeled independently for air, food, water, and soil/dust, then combined as a single input to the blood plasma reservoir of the body. Lead in the blood plasma reservoir, which includes extracellular fluids, is mathematically allocated to all tissues of the body using age-specific biokinetic parameters. The model calculation provides the estimate for blood lead concentration for that age. This value is treated as the geometric mean of possible values for a single child, or the geometric mean of expected values for a population of children exposed to the same lead concentrations. The distribution of blood lead concentrations about this geometric mean is estimated using a geometric standard deviation, typically 1.6, derived from the analysis of well-conducted community blood studies.

Ischemic heart disease and stroke mortality in African-American, Hispanic, and non-Hispanic white men and women, 1985 to 1991.

We compare recent trends in ischemic heart disease (IHD) and stroke mortality in California among the 6 major sex-racial or -ethnic groups. Rates of age-specific and -adjusted mortality were calculated for persons aged 35 and older during the years 1985 to 1991. Log-linear regression modeling was performed to estimate the average annual percentage change in mortality. During 1985 through 1991, the mortality for IHD and stroke was generally highest for African Americans, intermediate for non-Hispanic whites, and lowest for Hispanics. Age-adjusted mortality for IHD declined significantly in all sex-racial or -ethnic groups except African-American women, and stroke rates declined significantly in all groups except African-American and Hispanic men. African Americans had excess IHD mortality relative to non-Hispanic whites until late in life, after which mortality of non-Hispanic whites was higher. Similarly, African Americans and Hispanics had excess stroke mortality relative to non-Hispanic whites early in life, whereas stroke mortality in non-Hispanic whites was higher at older ages. The lower IHD and stroke mortality among Hispanics was paradoxical, given the generally adverse risk profile and socioeconomic status observed among Hispanics. An alarmingly high prevalence of self-reported cardiovascular disease risk factors in 1994 to 1996, particularly hypertension, leisure-time sedentary lifestyle, and obesity, is a serious public health concern, with implications for future trends in cardiovascular disease mortality. Of particular concern was the growing disparities in stroke and IHD mortality among younger-aged African Americans relative to Hispanics and non-Hispanic whites.

Snoezelen and chronic pain: developing a study to evaluate its use (Part I).

Chronic pain can be devastating, it impinges upon the life of the sufferer, causing psychological, physical, social and financial problems, leaving the individual searching for an explanation and a cure. Although there are no major epidemiological studies to date, it has been suggested that the impact of chronic pain, not only to the patient, but also to society and the NHS is phenomenal, with loss of production and costs of treatments (Fordyce 1995). Specialists within the field of chronic pain have advocated the use of the multidisciplinary approach to deal with the problems and thus suggest the use of the pain management programme, which is designed to teach the patient coping strategies. Recently, however, there has been a call within the literature to identify the effectiveness of singular strategies, which may be equally as effective and less expensive (Keefe et al 1992). The purpose of these papers is to introduce one such strategy, which has been evaluated over the past four years in order to investigate the use of the sensory environment (Snoezelen) for the management of chronic pain. In part II of this paper, an evaluation of Snoezelen and chronic pain will be presented, along with the findings of an investigation into its use.

Use of the QSR.NUD.IST computer program to identify how clinical midwife mentors view their work.

This paper looks at the use of a computer program (QSR.NUD.IST) to analyse qualitative data. The data are derived from interviews with clinical midwife mentors as part of an evaluation of a midwifery educational programme. An account is given of the content analysis of the data with reference to the literature, and then the way the programme was used to analyse the data a second time. A description is given of the way this programme in particular functions using the textual data as an example. The use of computers in general for analysing qualitative data is discussed in terms of their advantages and disadvantages. The results of the study are described briefly showing how the mentors view their role and responsibilities.

Survey of post-operative patients' pain management.

Although effective pain treatment is available for both cancer-related pain and acute post-operative pain, many patients suffer unnecessarily. The aim of this study was to evaluate post-operative patients' pain management. A descriptive survey study was conducted in a 460-bed acute hospital in the southwestern part of Sweden. One hundred post-operative inpatients, on their second post-operative day, took part in the study. They were consecutively selected from six surgical wards. Data were collected using an interview questionnaire designed by the American Pain Society and analysed by descriptive and inferential statistics. At the time of the interview, 29 of the patients reported moderate to severe pain. Regarding the patients' worst pain experienced during the last 24 h, 79 of them reported moderate to very severe pain. Significant correlations were found between reported poor pain relief after pain medication and high intensity of pain both within the last 24 h and at the time of the interview. Eighty-three patients were satisfied with the way nurses treated their pain, while 64 patients were satisfied with the way physicians treated their pain. However, the higher the pain intensity experienced by the patients the less satisfied they were. The fact that patients do not know what kinds of relief are available may be one reason for the patients expressing satisfaction despite being in pain, another that the patients judge the kindness of the staff rather than their way of treating the pain. The field of pain management is rapidly changing requiring professional knowledge and experience in order to ensure pain management of good quality.

The effects of terminal illness on patients and their carers.

As part of a larger study, this paper describes the development and design of a project looking at the experiences of the relatives and carers of terminally ill patients in one health authority, as a replication of a similar study undertaken in another area. Following a description of the problems associated with studies into the problems of dying people and of the method used here, the results indicate that there are quite important effects on the household and carers, which include the problem of obtaining a diagnosis of terminal illness, and the actual process of dying. The study also highlights some of the effects of the terminal illness on the patients and their carers. In particular the results indicate that it was usually a spouse or the daughter who bore the brunt of the care, but that most preferred to retain their independence of the services as long as possible. Often, carers (and the patients) were not fully appraised that a terminal stage had been reached. Some doctors seemed reluctant (or found it difficult) to admit that such a stage had been reached. For many, the experience of dying was a very slow, distressing and often painful period, with serious limitations on their lifestyle imposed by the illness. A number of these limitations could have been reduced if earlier diagnosis had been made or if community nursing or social services had been called in sooner.

Evaluation of nursing process documentation.

Following the introduction of a nursing process and associated documentation in one hospital, an attempt was made to evaluate the effectiveness of the documentation as a record of the nursing process. Two questionnaires were developed, based on previous research in this field, one for the assessment of the documentation, and the other to assess the attitudes and practices of the ward sisters regarding its implementation. The findings indicated that, generally, the assessment phase of the process was poorly documented and that many psychological and social problems were not addressed as well as others. The interventions were relevant but contained little detail. The evaluation section was fair but updating and re-assessment where relevant were poor. Some sisters seemed to display a lack of understanding of the principles or the practice of the process, despite in-service education. Lessons to be learnt from the exercise are suggested.

The socioeconomic impact of chronic pain.

A concern with the socioeconomic effects of chronic nonmalignant pain, as well as the human aspects, inspired a search of the literature for evidence in this area. The review has identified three main areas of interest, socioeconomic statistics; pain prevalence in the community, and the quality of life issues. A selection of the literature is reviewed here under these headings, and the conclusion indicates possible areas for further work.

An international approach to master's-level preparation for clinical nurse specialists.

Nursing is seen as being increasingly a research-based profession with a developing knowledge base that demands a continuing programme of education. This is necessary to enable the practitioner to function with the level of expertise and skill required in today's health care systems. There have been repeated calls for and developments in the establishment of a higher-education approach to nursing, with degree courses for the advanced practitioner. It is also argued that in terms of the European perspective there are many commonalities in nursing and health care in Europe, and although cultural and national differences are important there can be advantages to nurses from different countries studying together. An example of a course which offers this European approach to higher education for nurses is described.

Nurses' provision of teaching and counselling on sexuality: a review of the literature.

Patients' sexual concerns and problems are a focus for nursing care. Research studies with nurses, patients and healthy adults support this assertion. However, investigations also identify that specific teaching, supporting and/or counselling interventions aimed at managing the effects of illness and treatment on sexual function are not provided most of the time. This discrepancy can be analysed by exploring factors that influence the nursing care behaviours: sex teaching and counselling. Investigators have studied the influence of the following five factors: (sexuality) knowledge and skills, attitude towards sexuality, opinion about professional role and tasks, comfort with sexuality, and participation in continuing education activities. Conflicting findings regarding the influence of these five factors upon teaching and counselling on sexuality are found. Predicted upon previous investigations, two specific areas for future investigations are identified. First is the need to clarify the definition and theoretical basis for the interventions of teaching and counselling on sexuality. Second, future investigations could place the problem within the context of theory which helps to explain (nursing) behaviour, such as the Theory of Reasoned Action.

Academic levels in nursing.

With the developments of new academic courses in nursing comes the need for a debate about educational levels. This paper offers a discussion of some of the issues involved in such a debate and draws upon data collected from professors of nursing in the United Kingdom, masters students in a Dutch college and from the American literature on the topic. The need to be able to distinguish between diploma, bachelors, masters and doctoral degrees is highlighted and various suggestions about how such distinctions may be made are offered.