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 measuresThe 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. IntroductionSelf management has a well established evidence base for asthma and has been actively investigated as a useful strategy for patients with chronic obstructive pulmonary disease (COPD), with a growing evidence base for beneficial and unhelpful practices.1-3 It aims to develop patients' coping skills to maintain as active a lifestyle as possible, promote correct use of drugs, and encourage the early identification of increasing symptoms heralding an exacerbation, so that these can be treated early. Early treatment of exacerbations has been shown to reduce morbidity and effect on quality of life. 4 Case management is a related technique for the support of patients with chronic disease, concentrating on the provision of support by health professionals so that patients can obtain prompt and appropriate a...

Physiotherapists have a key role to play in promoting exercise to prevent falls in services for people with intellectual disabilities. This evaluation suggests positive outcomes for these clients to reduce or prevent further falls.

THE OPERATION of high ligation and retrograde injection of tlle saphenous vein has become the treatment of choice in those cases of varicose veins showing evidence of retrograde flow. This appears to be a rational method for, in the presence of incompetent valves, the weight of the column of blood from the femoral ring to the ankle interferes with venous return in the lower leg, and leads to pooling of blood in the large varicose veins.It appears to be the belief of the occasional operator that this is a simple, easily carried out procedure, free from hazard. Consequently, the operation is widely practised by inexperienced surgeons and hospital internes.As miiight be expected unfortunate results are occurring with increasing frequency. The purpose of this paper is to report 21 such cases, and, from a study of the results, to offer suggestions which might decrease the incidence of complications. It is quite obvious that minor surgical complications, such as haematomata and infections, will occur in a percentage of these cases depending on the care and skill with which the operation is carried out. However, we wish only to discuss the serious disasters such as occlusion of the artery by operative trauma, deep femoral phlebitis, and, perhaps, those more frequently unfavorable results due to damage caused by sclerosing solutions. It should also be mentioned that all these adverse results happened not only to occasional, or junior, operators, but also to senior surgeons of great experience and high standing. The operation of ligation of the great saphenous at the saphenofemoral junction miiay be difficult in an obese individual with a thinned out varix near the terminal portion, especially if, due to previous phlebitis and periphlebitis, firm adhesions are present. The varix is easily torn, or one of the large branches nmay escape the ligature. It shotuld be appreciated that very little pressture is reqluired to stol) this flowxr of blood but, at the momnenit, the unexpecte(l severity of the bleeding uipsets tlle calmii of the suirg,eon anid uincontrolled clanmpincg resuilts inl injurly to the deep felno-al vein, the artery or the nerve. Case 1.-Wlhile freciiig a large varicose saphenious vein a large tributary was torni near the terminal portioni. Kelly clamps were hurriedly applied which, oln later inlvestigation, proved to have included the femoral vein necessitating its ligation. When last seen some months later marked oedema of the leg was present. This patient, a soldier, had to be re-categorised and returned to base duties. On discharge he was found to he plensionlal)le because of this l)erinanent disal)ility. 426

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