Fatigue Intervention by Nurses Evaluation - The FINE Trial. A randomised controlled trial of nurse led self-help treatment for patients in primary care with chronic fatigue syndrome: study protocol. [ISRCTN74156610]

Background: Chronic fatigue syndrome, also known as ME (CFS/ME), is a condition characterised primarily by severe, disabling fatigue, of unknown origin, which has a poor prognosis and serious personal and economic consequences. Evidence for the effectiveness of any treatment for CFS/ME in primary care, where most patients are seen, is sparse. Recently, a brief, pragmatic treatment for CFS/ME, based on a physiological dysregulation model of the condition, was shown to be successful in improving fatigue and physical functioning in patients in secondary care. The treatment involves providing patients with a readily understandable explanation of their symptoms, from which flows the rationale for a graded rehabilitative plan, developed collaboratively with the therapist. The present trial will test the effectiveness and cost-effectiveness of pragmatic rehabilitation when delivered by specially trained general nurses in primary care. We selected a client-centred counselling intervention, called supportive listening, as a comparison treatment. Counselling has been shown to be as effective as cognitive behaviour therapy for treating fatigue in primary care, is more readily available, and controls for supportive therapist contact time. Our control condition is treatment as usual by the general practitioner (GP). Methods and design: This study protocol describes the design of an ongoing, single-blind, pragmatic randomized controlled trial of a brief (18 week) self-help treatment, pragmatic rehabilitation, delivered by specially trained nurse-therapists in patients' homes, compared with nurse-therapist delivered supportive listening and treatment as usual by the GP. An economic evaluation, taking a societal viewpoint, is being carried out alongside the clinical trial. Three adult general nurses were trained over a six month period to deliver the two interventions. Patients aged over 18 and fulfilling the Oxford criteria for CFS are assessed at baseline, after the intervention, and again one year later. Primary outcomes are self-reported physical functioning and fatigue at one year, and will be analysed on an intention-to-treat basis. A qualitative study will examine the interventions' mechanisms of change, and also GPs' drivers and barriers towards referral

Anharmonic Evolution of the Cosmic Axion Density Spectrum

We present analytic solutions to the spatially homogeneous axion field equation, using a model potential which strongly resembles the standard anharmonic $(1-\cos N\theta)$ potential, but contains only a piece-wise second order term. Our exactly soluble model for $\theta(t)$ spans the entire range $[-\pi/N,\pi/N]$. In particular, we are able to confirm (i) Turner's numeric correction factors \cite{Turner} to the adiabatic and harmonic analytic treatments of homogeneous axion oscillations, and (ii) Lyth's estimate \cite{Lyth} valid near the metastable misalignment angle $\pi/N$ at the peak of the potential. We compute the enhancement of axion density fluctuations that occurs when the axion mass becomes significant at $T\sim 1$ GeV. We find that the anharmonicity amplifies density \mbox{f}luctuations, but only significantly for relatively large initial misalignment angles. The enhancement factor is $\sim$ (2,3,4,13) for $\theta_{\rm in}\sim (0.85,0.90,0.95,0.99)\times\pi$.Comment: 26 pages, 6 figures appended as a ps-file, Latex, DAMTP-94-21, VAND-TH-94-

Universal features in the growth dynamics of complex organizations

We analyze the fluctuations in the gross domestic product (GDP) of 152 countries for the period 1950--1992. We find that (i) the distribution of annual growth rates for countries of a given GDP decays with ``fatter'' tails than for a Gaussian, and (ii) the width of the distribution scales as a power law of GDP with a scaling exponent $\beta \approx 0.15$. Both findings are in surprising agreement with results on firm growth. These results are consistent with the hypothesis that the evolution of organizations with complex structure is governed by similar growth mechanisms.Comment: 4 pages, 7 ps figures, using Latex2e with epsf rotate and multicol style files. Submitted to PR

Topology and chiral symmetry breaking in SU(N) gauge theories

We study the low-lying eigenmodes of the lattice overlap Dirac operator for SU(N) gauge theories with N=2,3,4 and 5 colours. We define a fermionic topological charge from the zero-modes of this operator and show that, as N grows, any disagreement with the topological charge obtained by cooling the fields, becomes rapidly less likely. By examining the fields where there is a disagreement, we are able to show that the Dirac operator does not resolve instantons below a critical size of about rho = 2.5 a, but resolves the larger, more physical instantons. We investigate the local chirality of the near-zero modes and how it changes as we go to larger N. We observe that the local chirality of these modes, which is prominent for SU(2) and SU(3), becomes rapidly weaker for larger N and is consistent with disappearing entirely in the limit of N -> infinity. We find that this is not due to the observed disappearance of small instantons at larger N.Comment: 41 pages, 12 figures, RevTe

Firm heterogeneity and wages under different bargaining regimes : does a centralised union care for low-productivity firms?

This paper studies the relationship between wages and the degree of firm heterogeneity in a given industry under different wage setting structures. To derive testable hypotheses, we set up a theoretical model that analyses the sensitivity of wages to the variability in productivity conditions in a unionsised oligopoly framework. The model distinguishes centralised and decentralised wage determination. The theoretical results predict wages to be negatively associated with the degree of firm heterogeneity under centralised wage-setting, as unions internalise negative externalities of a wage increase for low-productivity firms. We test this prediction using a linked employeremployee panel data set from the German mining and manufacturing sector. Consistent with our hypotheses, the empirical results suggest that under industry-level bargaining workers in more heterogeneous sectors receive lower wages than workers in more homogeneous sectors. In contrast, the degree of firm heterogeneity is found to have no negative impact on wages in uncovered firms and under firm-level contracts

Explanation and relations. How do general practitioners deal with patients with persistent medically unexplained symptoms: a focus group study

Contains fulltext : 80758.pdf (publisher's version ) (Open Access)BACKGROUND: Persistent presentation of medically unexplained symptoms (MUS) is troublesome for general practitioners (GPs) and causes pressure on the doctor-patient relationship. As a consequence, GPs face the problem of establishing an ongoing, preferably effective relationship with these patients. This study aims at exploring GPs' perceptions about explaining MUS to patients and about how relationships with these patients evolve over time in daily practice. METHODS: A qualitative approach, interviewing a purposive sample of twenty-two Dutch GPs within five focus groups. Data were analyzed according to the principles of constant comparative analysis. RESULTS: GPs recognise the importance of an adequate explanation of the diagnosis of MUS but often feel incapable of being able to explain it clearly to their patients. GPs therefore indicate that they try to reassure patients in non-specific ways, for example by telling patients that there is no disease, by using metaphors and by normalizing the symptoms. When patients keep returning with MUS, GPs report the importance of maintaining the doctor-patient relationship. GPs describe three different models to do this; mutual alliance characterized by ritual care (e.g. regular physical examination, regular doctor visits) with approval of the patient and the doctor, ambivalent alliance characterized by ritual care without approval of the doctor and non-alliance characterized by cutting off all reasons for encounter in which symptoms are not of somatic origin. CONCLUSION: GPs feel difficulties in explaining the symptoms. GPs report that, when patients keep presenting with MUS, they focus on maintaining the doctor-patient relationship by using ritual care. In this care they meticulously balance between maintaining a good doctor-patient relationship and the prevention of unintended consequences of unnecessary interventions

Endogenous technological change, innovation diffusion and transitional dynamics in a nonlinear growth model

This paper addresses capital accumulation and capital productivity change in an economy with endogenous technological change and floors and ceilings in activity. The properties of the resulting two-variable nonlinear differential equation system are studied in some detail. The welfare implications are also considered. When discrete lags are introduced, wide-ranging behaviour emerges, which includes convergence to a steady-state, catastrophes, hysteresis, limit cycles and chaos. Simulations illustrate the results. It is found that external shocks, such as the diffusion of innovations from elsewhere, do not just change the level of the steady-state equilibrium but also the dynamical properties of the paths of output and productivity

Group cognitive behavioural therapy for women with depression: pilot and feasibility study for a randomised controlled trial using mixed methods

<p>Abstract</p> <p>Background</p> <p>Group Cognitive Behavioural Therapy (CBT) may provide a means of improving mental health among people with depression but few studies have explored its effectiveness. Our aim was to examine the feasibility and acceptability of a randomised controlled trial of a group intervention based on CBT principles for women with depression in primary care.</p> <p>Methods</p> <p>Women aged 30 to 55 years were recruited and randomly assigned to either 12 weeks of the group intervention or usual care (control). The group intervention was based on a manual and used CBT and problem solving principles with weekly topics including raising activity levels, spotting and catching negative thoughts, problem solving and relaxation. Women were recruited from deprived areas of Bristol. The groups were run by facilitators with some experience and background in group work and one weeks training in use of the course manual. Assessments of mental health were made using measures including the PHQ-9. Follow-up was at 3 and 6 months after the intervention. Qualitative methods were used to support the design of the intervention and to help understand issues of acceptability and feasibility. Interviews were conducted with all participants at baseline and at 3 and 6 months although detailed qualitative analysis was based on a purposive sample of 20 participants at the 3 time points.</p> <p>Results</p> <p>Of the 86 participants assessed for eligibility, 52 were allocated to the intervention arm and 21 to the control group. The intervention was delivered according to the manual despite the limited training of the facilitators. The intervention was received favourably by participants and facilitators, with good attendance at sessions for those who engaged with the intervention. Follow up rates at 3 and 6 months for women in both the intervention and control arms were also good. The trial methodology used was appropriate and feasible.</p> <p>Conclusions</p> <p>This study showed that a randomised controlled trial of group CBT for women with depression is feasible and the intervention is acceptable, and may possibly prove to be effective in a larger trial. The cost effectiveness of group CBT for depression should be explored further in a full trial.</p> <p>Trial registration</p> <p><a href="http://www.clinicaltrials.gov/ct2/show/NCT00663078">NCT00663078</a></p