Managing complex respiratory patients in the community: an evaluation of a pilot integrated respiratory care service.

INTRODUCTION: In the UK, there is significant variation in respiratory care and outcomes. An integrated approach to the management of high-risk respiratory patients, incorporating specialist and primary care teams' expertise, is the basis for new integrated respiratory services designed to reduce this variation; however, this model needs evaluating. METHODS: To evaluate an integrated service managing high-risk respiratory patients, electronic searches for patients with asthma and chronic obstructive pulmonary disease at risk of poor outcomes were performed in two general practitioner (GP) practices in a local service-development initiative. Patients were reviewed at joint clinics by primary and secondary care professionals. GPs also nominated patients for inclusion. Reviews were delivered to best standards of care including assessments of diagnosis, control, spirometry, self-management, education, medication, inhaler technique and smoking cessation support. Follow-up of routine clinical data collected at 9-months postclinic were compared with seasonally matched 9-months prior to integrated review. RESULTS: 82 patients were identified, 55 attended. 13 (23.6%) had their primary diagnosis changed. In comparison with the seasonally adjusted baseline period, in the 9-month follow-up there was an increase in inhaled corticosteroid prescriptions of 23.3%, a reduction in short-acting ß2-agonist prescription of 33.3%, a reduction in acute respiratory exacerbations of 67.6%, in unscheduled GP surgery visits of 53.3% and acute respiratory hospital admissions reduced from 3 to 0. Only 4 patients (7.3%) required referral to secondary care. Health economic evaluation showed respiratory-related costs per patient reduced by £231.86. CONCLUSIONS: Patients with respiratory disease in this region at risk of suboptimal outcomes identified proactively and managed by an integrated team improved outcomes without the need for hospital referral.

Re-evaluating Rudolf Laban's choreutics.

The choreutic conception of kinesthetic-motor space originally proposed by Rudolf Laban is given psychological validation through comparisons with similar conceptual models in spatial cognition and motor control research. Highly differentiated systems of reference are distinguished. Spatial paths are mentally represented as a series of locations linked into polygonal trajectories. Map-like images of the kinesphere' are structured with polyhedral networks. A fundamental practice consists of transforming spatial information with various operations (rotation, reflection, sizing, etc.). Loci are linked into spatial 'scales' which provide symmetrical solutions to geometric puzzles such as the traveling salesman problem and those devised by Hamilton (Icosian game) and Euler (Koenigsberg bridge problem). In the body these are considered to be prototypes for spatial paths used during adjustments of dynamic equilibrium. The choreutic conception of polyhedral body space is especially similar to the trajectory formation model. The choreutic principal of topological forms deflecting across various kinespheric nets is analogous to N. Bernstein's description of the "net of the motor field ... as oscillating like a cobweb in the wind." These commonalities indicate that further critical reviews of "choreutic laws" might be valuable in suggesting conceptual models and analytical tools for movement study in cognitive science.

Subjective organisation in the recall of abstract body movements.

Subjective organisation is a well known characteristic of verbal free recall in that items are recalled in groupings known as "chunks" or "clusters." This organisation is indicative of a memory strategy and has been used to derive the cognitive structure of particular areas of knowledge. Clustering might also occur in the free recall of body movements. Subjects attempted to learn unfamiliar abstract body movements over five learning and recall trials. Analysis showed that subjective organisation occurred and increased with additional recall trials. This extends the clustering effect to the free recall of body movements. It is suggested that this effect can be used to probe the cognitive structure of motor memory.

Tissue-invading ciliates associated with chronic colitis in a horse.

Ciliates resembling Polymorphella ampulla (Dogiel, 1929) were found in large numbers in the crypts and lamina propria of the caecum and colon of a one-year-old Thoroughbred gelding that had shown recurring bouts of chronic diarrhoea and weight loss over a 5-month period. A heavy burden of helminths, mainly cyathostomes (trichonemes) was present at post-mortem examination and no significant bacterial pathogens were recovered. It was considered that the Polymorphella (which is normally a commensal organism) had in this case assumed a secondary pathogenic role.

Effects of ketanserin on peripheral blood flow, haemorheology, and platelet function in patients with Raynaud's phenomenon.

Ketanserin, 40 mg b.i.d., or matching placebo were administered for 8 weeks each in a randomised double-blind crossover design to 23 patients with Raynaud's phenomenon. Ketanserin had no effect on Doppler arterial patency or blood flow at rest, 37 degrees C, 15 degrees C, or during recovery after cold challenge. Red cell deformability index and whole blood viscosity were not significantly affected by ketanserin treatment. In vivo bleeding time was prolonged on ketanserin (p less than 0.05) but beta-thromboglobulin and platelet factor 4 were unaffected. There was a nonsignificant decrease in platelet aggregation response to serotonin but no change at all with other aggregating agents on treatment with ketanserin.