Comparison of two bowel preparations for colonoscopy: sodium picosulphate with magnesium citrate versus sulphate-free polyethylene glycol lavage solution

OBJECTIVES: Adequate preparation of the bowel is essential for accurate colonoscopic examination. We compared colonic preparation with sodium picosulphate plus magnesium citrate (SPS-Mg) with sulphate-free polyethylene glycol electrolyte lavage (PEG-EL) solution before colonoscopy, for quality of bowel cleansing, patient discomfort, and side effects. METHODS: Sixty-eight consecutive patients were randomly assigned to receive either 3 sachets of SPS-Mg (16.5 g each) (n = 39) or 3 L of PEG-EL (n = 29) on the day before colonoscopy. Shortly before the procedure each patient was interviewed to determine the degree of discomfort (1 = none or mild, 2 = moderate, 3 = severe) and side effects. The quality of bowel cleansing was graded by a gastroenterologist who was unaware of the method of preparation (from 1 = poor to 4 = excellent). RESULTS: Of the 29 PEG-EL patients, four (14%) did not complete the preparation because of side effects. The degree of discomfort was significantly greater with PEG-EL (mean score, 2.3 +/- 0.7) than with SPS-Mg (mean score, 1.4 +/- 0.5; p < 0.01). Nausea and vomiting were significantly more common in the PEG-EL group (38% vs 13%; p < 0.05). Using intention-to-treat analysis, bowel cleansing proved to be significantly better with SPS-Mg than with PEG-EL (mean score +/- SD, 3.05 +/- 0.9 and 2.57 +/- 1.0, respectively; p = 0.036). CONCLUSIONS: Colonic preparation with SPS-Mg is better tolerated, associated with significantly fewer side effects, and results in higher quality bowel cleansing than preparation with PEG-EL.     

The adequacy of medical school education in musculoskeletal medicine

A basic familiarity with musculoskeletal disorders is essential for all medical school graduates. The purpose of the current study was to test a group of recent medical school graduates on basic topics in musculoskeletal medicine in order to assess the adequacy of their preparation in this area. A basic-competency examination in musculoskeletal medicine was developed and validated. The examination was sent to all 157 chairpersons of orthopaedic residency programs in the United States, who were asked to rate each question for importance and to suggest a passing score. To assess the criterion validity, the examination was administered to eight chief residents in orthopaedic surgery. The study population comprised all eighty-five residents who were in their first postgraduate year at our institution; the examination was administered on their first day of residency. One hundred and twenty-four (81 per cent) of the 154 orthopaedic residency-program chairpersons who received the survey responded to it. The chairpersons rated twenty-four of the twenty-five questions as at least important. The mean passing score (and standard deviation) that they recommended for the assessment of basic competency was 73.1 +/- 6.8 per cent. The mean score for the eight orthopaedic chief residents was 98.5 +/- 1.07 per cent, and that for the eighty-five residents in their first postgraduate year was 59.6 +/- 12 per cent. Seventy (82 per cent) of the eighty-five residents failed to demonstrate basic competency on the examination according to the chairpersons' criterion. The residents who had taken an elective course in orthopaedic surgery in medical school scored higher on the examination (mean score, 68.4 per cent) than did those who had taken only a required course in orthopaedic surgery (mean score, 57.9 per cent) and those who had taken no rotation in orthopaedic surgery (mean score, 55.9 per cent) (p = 0.005 and p = 0.001, respectively). In summary, seventy (82 per cent) of eighty-five medical school graduates failed a valid musculoskeletal competency examination. We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.     

Is there a relation between student lecture attendance and clinical science subject examination score?

OBJECTIVE: To determine whether there is a relation between lecture attendance and factual knowledge of obstetrics and gynecology, as measured by the National Board of Medical Examiners (NBME) clinical science subject examination. METHODS: We analyzed data on 197 students completing 8-week obstetrics and gynecology rotations from July 1, 1991 to June 30, 1992. Each student was expected to attend a weekly lecture series, and each completed the NBME clinical science subject examination at the end of the clerkship. Student attendance and board scores were correlated at the end of the academic year overall and by subgroups. Scores in the top and bottom 15% were defined as good and poor performance, respectively. RESULTS: A negative correlation (r = -0.1738, P = .0146) was found between percent absence and examination score. The odds ratio for poor performance was 5.48 (95% confidence interval 1.3-26.5; P = .015) for the subgroup of students with more than 30% absence compared to those without absences. Odds ratios for scoring in the upper 15th percentile were not significant. CONCLUSIONS: The negative correlation and the high odds ratio for poor performance suggest the value of monitoring attendance and identifying students at risk for poor performance (more than 30% absence). Lower absence rates did not predict performance.     

Obesity in childhood craniopharyngioma: relation to post-operative hypothalamic damage shown by magnetic resonance imaging

OBJECTIVE: To quantify the extent of hypothalamic damage after surgery for craniopharyngioma using magnetic resonance imaging (MRI) and to relate the findings to changes in body mass index (BMI). PATIENTS: Sixty-three survivors (36 males, 27 females) of childhood cramopharyngioma were treated surgically between 1973 and early 1994. METHODS: Cranial MRI was performed at a structured follow-up assessment 1.5-19.2 yr after the initial surgery. Hypothalamic damage was scored as 0 (no visible damage), 1 (intermediate), or 2 (severe). RESULTS: After surgery there was an increase in BMI standard deviation (SD) from diagnosis to study assessment in all but 7 patients. However, patients with MRI scores of 2 (n = 17) had a significantly greater increase in median BMI SD score at follow-up (+5.5 SD score), compared with +2.5 SD score and +1.1 SD score for patients with MRI scores of 1 or 0, respectively. Of the 17 cases with MRI scores of 2, 10 had a history of extreme weight loss or weight gain at presentation; preoperative neuroimaging demonstrated extensive hypothalamic infiltration by tumor in these cases. CONCLUSION: MRI gives sufficient anatomical definition to allow assessment of the extent of hypothalamic damage and, thereby, prediction of the patients most at risk for severe post-operative weight gain.     

Evaluation of medical students in radiology. Written testing using uncued multiple-choice questions

RATIONALE AND OBJECTIVES: Evaluation of uncued multiple-choice questions (UMCQ) was compared with traditional multiple-choice questions (MCQ) for assessing medical student performance during radiology electives. Methods for analyzing and improving the quality of UMCQ examinations are described. METHODS: The authors compared the performance of radiology medical students on similarly constructed MCQ and UMCQ tests. For the UMCQ examination, the reliability (coefficient alpha), standard error of measurement, item difficulty index, and corrected item-to-total test coefficient (point biserial correlation) were analyzed. RESULTS: Students' level of performance was lower on UMCQs (mean percent correct score = 68.9 +/- 10.2 standard deviation [SD]) than on MCQs (mean percent correct score = 75.6 +/- 12.4 SD). Coefficient alpha for the UMCQ format was .7690 (standard error of measurement mean = 4.89%). Analysis of the item difficulty index and point biserial correlation for each test item provided information for improving the quality of the UMCQ examination. CONCLUSIONS: Because the UMCQ measures students' abilities to recall critical information without providing cues, this format can be used to overcome some of the limitations of conventional MCQs. With simple computerization, analysis of UMCQ testing instruments provides important feedback to both the examinees and the examiner.     

A mammographic evaluation of the morphostructural variations of the breast during hormone-replacement therapy in the postmenopause

OBJECTIVE: To compare i.v. ketorolac with i.v. prochlorperazine as the initial treatment of migraine headaches in the ED. METHODS: A prospective, double-blind comparison study was performed, using a convenience sample of 64 patients suffering from migraine headaches presenting to the ED at a tertiary care university teaching hospital. Patients were randomly assigned to receive either 10 mg of prochlorperazine i.v. or 30 mg of ketorolac i.v.. Patients scored the severity of their headaches using a 10-cm visual analog pain scale. An initial mark was made on the scale at the time of entry into the study and later another mark was made on a new unmarked pain scale 1 hour after medication administration. Changes in pain scores within each treatment group and between groups were analyzed using the Wilcoxon rank sum test. RESULTS: Prior to treatment, the patients assigned to receive prochlorperazine had a median score of 9.2 cm (mean +/- SD pain score of 8.3 cm +/- 2.1 cm), while the patients receiving ketorolac had a median score of 9.0 (mean pain score of 8.4 cm +/- 1.7 cm). There was no significant difference between the pain scores of the participants in the 2 groups prior to treatment (p = 0.80). One hour after medication administration, the patients in the prochlorperazine group had a median score of 0.5 cm (mean 2.1 +/- 3.2 cm), while those patients receiving ketorolac had a median pain score of 3.9 (mean 4.0 +/- 3.3 cm). The decrease in pain score was significant for both groups of patients (p = 0.0001). The change in pain score for the patients in the prochlorperazine group (median 7.1) was significantly greater than the change in pain score for the patients in the ketorolac group (median 4.0; p = 0.04). CONCLUSION: Although both drugs were associated with a significant reduction in pain scores, benefit over a placebo agent was not tested. Furthermore, the patients who received prochlorperazine i.v. for migraine headaches had a statistically significant greater decrease in their pain scores than did those receiving ketorolac i.v.     

Testing the raters: inter-rater reliability of standardized anaesthesia simulator performance

PURPOSE: Assessment of physician performance has been a subjective process. An anaesthesia simulator could be used for a more structured and standardized evaluation but its reliability for this purpose is not known. We sought to determine if observers witnessing the same event in an anaesthesia simulator would agree on their rating of anaesthetist performance. METHODS: The study had the approval of the research ethics board. Two one-hour clinical scenarios were developed, each containing five anaesthetic problems. For each problem, a rating scale defined the appropriate score (no response to the situation: score = 0; compensating intervention defined as physiological correction: score = 1; corrective treatment: defined as definitive therapy score = 2). Video tape recordings, for assessment of inter-rater reliability, were generated through role-playing with recording of the two scenarios three times each resulting in a total of 30 events to be evaluated. Two clinical anaesthetists, uninvolved in the development of the study and the clinical scenarios, reviewed and scored each of the 30 problems independently. The scores produced by the two observers were compared using the kappa statistic of agreement. RESULTS: The raters were in complete agreement on 29 of the 30 items. There was excellent inter-rater reliability (= 0.96, P < 0.001). CONCLUSIONS: The use of videotapes allowed the scenarios to be scored by reproducing the same event for each observer. There was excellent inter-rater agreement within the confines of the study. Rating of video recordings of anaesthetist performance in a simulation setting can be used for scoring of performance. The validity of the scenarios and the scoring system for assessing clinician performance have yet to be determined.     

Undergraduate training in primary health care: 6 years' experience at the University of Alicante

OBJECTIVE: To assess the opinion of medical students on the teaching offered in the Primary Care context (TOPC). DESIGN: Observational and crossover study. The assessment used an opinion questionnaire. PARTICIPANTS: 296 sixth-year medical students between 1987 and 1992. INTERVENTIONS: The TOPC consisted of four weeks stay in a Health Centre with an eminently practical programme. However this also included hour-long theoretical seminars on the most important Primary Care questions and the student's completion of a research project related to Primary Care. RESULTS: The students expressed satisfaction with the TOPC (average score of 4 out of 5). Moreover this satisfaction increased over the five years (from 3.7 to 4.6, p = 0.0001). They believed the TOPC to be useful (3.6 to 4.7, p = 0.0001) and relevant to their future professional activity (3.1 to 4.6, p = 0.0001). They thought that the tutors were very competent (4 out of 5, with no significant variation) and the Health Centres' teaching facilities suitable (3.8 to 4, with no significant variation). Finally, they considered that TOPC should become a compulsory undergraduate subject (3.9 out of 5). CONCLUSIONS: Medical students give a positive rating to the Primary Care teaching offered and believe it should be integrated into the Medicine syllabus as a compulsory subject.     

Performance of "standardized examinees" in a standardized-patient examination of clinical skills

PURPOSE: As a first step in testing the utility of using trained "standardized examinees" (SEs) as a quality-assurance measure for the scoring process in a standardized-patient (SP) examination, to test whether medical residents could simulate students in an SP examination and perform consistently to specified levels under test conditions. METHOD: Fourth-year students from the Baltimore-Washington Consortium for SPs participated in a National Board of Medical Examiners Prototype Examination of clinical skills consisting of twelve 15-minute student-patient encounters in 1994-95. For this examination, internal medicine residents were trained to act as ordinary candidates and to achieve target scores by performing to a set level on specific checklist items used by SPs for recording interviewing, physical-examination, and communication skills. The "strong SEs" were trained to score 80% correct on six of the examination's 12 cases (study cases), and the "weak SEs" were trained to score 40% correct on the same six cases. The strong and weak SEs' checklist scores on the study cases were compared through independent, two-tailed t-tests. When there was less than 85% agreement on specific checklist items in each case between the SE training and the SP recording, videotapes of the cases were reviewed; in such cases an SE's performance was the final score agreed upon after review. RESULTS: Seven SEs took the SP examination and were not detected by the SPs. There was a total of 84 discrepancies between predicted and recorded checklist scores across 659 checklist items in 40 encounters scored by the SPs. After correcting the discrepancies based on videotape review, the estimated actual mean score was 77.3% for the strong SEs and 44.0% for the weak SEs, and was higher for the strong SEs in each study case. The overall fidelity of the SEs to their training was estimated to be 97%, and the overall SP accuracy was estimated to be 91%. The videotape review revealed 47 training-scoring discrepancies, most in the area of communication skills. CONCLUSION: This study suggests that SEs can be trained to specific performance levels and may be an effective internal control for a high-stakes SP examination. They may also provide a mechanism for refining scoring checklists and for exploring the validity of SP examinations.     

Dental sealants: prevalence and need in U.S. military recruits

From February to June in 1996, there were 47,800 students for health examination in Taichung City, Taiwan. The population consisted of the first and fourth graders of primary schools and the first grader of junior high schools. We selected 3,452 healthy students for further study by two stage sampling. In this report, 52.5% of the students were boys, and 47.5% of the students were girls. The mean age of students was 9.9 +/- 2.4 years. Girls at age 7 and age 10 had higher activity of alkaline phosphatase than boys at the same age. The peak of alkaline phosphatase activity in girls occurred at age 10. Alkaline phosphatase activity was significantly related to weight-length index by multiple regression analysis (p < 0.05). Although clinical application as an obesity factor still needs further investigation, in the future it may be well to routinely check this enzyme when assessing childhood obesity.     

Relationship between self-rated functional status and psychosocial stress in patients suffering from rheumatoid arthritis

BACKGROUND: To assess relationship between psychosocial factors and self-rated functioning in rheumatoid arthritis (RA). METHODS: In 66 RA patients (mean age +/- SD = 50.8 +/- 12.6 years, women 49 (74%), illness duration mean +/- SD = 13.4 +/- 10.5 years) aspects of developmental psychosocial stress thought to influence human behavior were assessed in an in depth interview using structured biographical history. Furthermore evaluation included Trait anxiety, global functional status according to the ACR criteria, radiological staging of illness and patients' self-ratings of functioning obtained by the Health Assessment Questionnaire (HAQ). Bivariate correlations were performed using psychosocial and somatic factors and self-rated functional status. RESULTS: Scores of developmental psychosocial stress significantly correlated with interviewers scoring of nurture (r = -0.722, p < 0.001) indicating good internal consistency of interview data. Significant correlations were found between patients' scoring of functional status (HAQ) and (i) ACR criteria (r = 0.490, p < 0.0001) and (ii) score of Trait anxiety (r = 0.367, p < 0.003). There was no significant correlation between developmental psychosocial stress and HAQ score. CONCLUSION: Developmental psychosocial stress does not significantly contribute as to how RA patients perceive their functional ability. In a proportion of RA patients self-rated functional status may depend on the patients disposition (e.g. neuroticism) probably promoting impaired illness behavior (e.g. regressive tendencies) which should be considered in assessing treatment procedures.     

Benzophenanthridine alkaloids of Chelidonium majus; II. Potent inhibitory action against the growth of human keratinocytes

OBJECTIVE: To determine whether the neonatal chest radiograph (CXR) at 28 days in very low birthweight (VLBW) infants who develop chronic neonatal lung disease (CNLD) predicts oxygen therapy duration or CXR abnormalities in early childhood. Also, to assess the inter-observer reliability of the radiologists scoring the CXR. METHODOLOGY: Clinically well survivors of CNLD (n = 46) had neonatal CXR scored (mean age 28.5 days) and compared with current CXR (mean age 40 months). The CXR were scored independently and 'blindly' by two paediatric radiologists using a standardized scoring system (range 0-10). RESULTS: There was no correlation between neonatal CXR scores and current CXR scores for either radiologist. There was no association between CXR severity scores and duration of oxygen therapy for either neonatal or current CXR. Radiologist A scored the current CXR significantly more abnormal than radiologist B [medians (range): 3 (1-6) vs 1 (0-5), P < 0.001] with reasonable correlation (r = 0.593, P < 0.005) but worse than chance agreement (kappa = -0.034). The median scores for the neonatal CXR were similar [1.5 (0-8) vs 2 (0-8), P = 0.789] and again there was good correlation (r = 0.760, P < 0.0005) although poor individual agreement (kappa = 0.243) between radiologists. CONCLUSIONS: Follow-up CXR abnormalities in VLBW infants with CNLD are usually minor and are not predictive of the duration of oxygen therapy that will be required nor of the CXR appearance in early childhood. Considerable inter-observer variation exists in the interpretation of the CXR in CNLD.     

Pulsus paradoxus: an objective measure of severity in croup

We used a noninvasive monitor of arterial pressure to determine the utility of pulsus paradoxus (PP) as an objective severity measure in croup. We performed a prospective, blinded comparison of PP in children with croup versus healthy control subjects, analyzed the relationship between PP and Westley croup score (WCS), and observed the effect of racemic epinephrine (RE) on PP and WCS in a subgroup of patients with severe croup. The PP and WCS were measured at presentation and in severe patients after treatment with RE. Mean PP was 6.1 +/- 1.8 (SD) mm Hg (n = 29) in control subjects compared with a mean of 17.8 +/- 11.2 (SD) mm Hg (n = 28) in patients with croup (p < 0.00001). There was significant concordance between baseline WCS and PP (Spearman's rho: 0.68; p = 0.0001). The mean decrease in PP after RE was 7.5 +/- 11.8 (SD) mm Hg (p = 0.05; n = 12). The magnitude of decrease in PP after RE has significant concordance with the concurrent decrease in WCS (Spearman's rho: 0.73; p < 0.007). PP is elevated in children with croup, and the magnitude of elevation correlates with severity as measured by the WCS. PP may have utility as a research tool to objectively measure the severity of upper airway obstruction in croup.     

The effectiveness of a new method for assessing induration

OBJECTIVE: To examine the correlation among the National Board of Medical Examiners subject examination, the US Medical Licensure Examination step 1 scores, and grade point average and to determine if poor performance could be predicted by the US Medical Licensure Examination step 1 score and grade point average. METHODS: The subject examination scores of 148 third-year medical students were compared with their US Medical Licensure Examination step 1 scores and grade point averages. Scores below the 20th percentile were defined as poor performance. RESULTS: There was a significant correlation between the US Medical Licensure Examination score and the subject examination score (r = .6, P < .001). The correlation with grade point average was also significant (r = .57, P < .001). CONCLUSION: The US Medical Licensure Examination step 1 performance, grade point average, and performance on the subject examination are all correlated. However, use of the US Medical Licensure Examination step 1 scores and grade point averages to identify all students at risk was associated with a high false-positive rate at our institution.     

Birth cohort differences in self-esteem, 1988–2008: A cross-temporal meta-analysis.

Three meta-analyses find increases over the generations in Rosenberg Self-Esteem scale (RSE) scores between 1988 and 2008 among American middle school (d = 0.78, n = 10,119), high school (d = 0.39, n = 16,669), and college students (d = 0.30, n = 28,918). The changes are consistent with an increasing emphasis on self-worth in American culture and, for high school students, with small increases in academic competence over time. College students' scores change only when the RSE is administered with a 4-point Likert scale with no midpoint. By 2008, a score of 40 (perfect self-esteem) was the modal response of college students, chosen by 18% of participants; 51% scored 35 or over. Given these shifts in responses, the possibility of revising the RSE is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Using self-efficacy in assessing self-care to the IDDM patients

The purpose of this study was to test an Self-Efficacy Scale for IDDM patients to assess their self-care performances. Data were collected by convenience sampling method from 72 patients with IDDM at southern Taiwan from February 5 to June 15, 1995. Two instruments were used in this study: the Insulin Management Diabetes Self-Efficacy Scale (IMDSES) and Diabetes Self-Care Scale. The following results were obtained. 1. Subjects had average levels of self-efficacy. The IMDSES Scale total mean was 70.59 (SD = 16.59). The highest and the lowest mean in all IMDSES subscales were blood sugar monitor (76.29, SD = 16.37) and the foot care (63.37, SD = 26.92) respectively. 2. Subjects had average levels of self-care. The Diabetes Self-Care Scale total mean was 68.80 (SD = 18.45). The highest and the lowest mean in all Diabetes subscale were insulin adjustment (75.01, SD = 20.22) and the foot care (61.07, SD = 27.70) 3. There was a strong correlation between the IMDSES Scale and the Diabetes Self-Care Scale (r = 0.94, p < 0.01). In addition, there were significant Pearson correlations between each of the all Diabetes Self-Efficacy subscales and their related Self-Care subscales (r = 0.93 approximately 0.62, p < 0.01). These results supported the theoretical perspective of Bandura's self-efficacy. Individual with higher levels of self-efficacy were better able to manage their diabetes self-care. Implications of these findings for nursing practice and research are discussed.     

A meta-analysis of the situational interview: An enumerative review of reasons for its validity.

The premise underlying the situational interview (SI) is that intentions predict behaviour. The distinguishing characteristics of the SI include the depiction of a dilemma in the interview question, the use of an item scoring guide, and summative scoring of items to yield a total interview score. A meta-analysis of SI studies indicated that the weighted mean observed criterion-related validity of the SI is .35 (n?=?1010), and the mean corrected criterion-related validity is .47. An enumerative review of the literature revealed that the SI is applicable across a diversity of jobs, participants, performance criteria, and countries. The criterion-related validation evidence for the SI is explained in terms of content, construct, and incremental validity, freedom from interviewer biases, and practicality. The article concludes with a comparison of the SI to interviews that measure either past behaviours or future intentions where the interview question does not contain a dilemma or scoring guide, and performance dimensions rather than each individual item are scored. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exercise of young thoroughbred horses increases impact strength of the third metacarpal bone

OBJECTIVE: The aim of this study was to assess the frequency and severity of depressive symptoms, to determine the rate of depressive disorder, to explore possible reasons for the development of depressive symptoms and to examine the effects of depression in a group of human immunodeficiency virus (HIV)-positive patients. METHOD: HIV-positive patients attending an outpatient treatment facility were assessed by the research psychologist and completed a number of questionnaires: the Beck Depression Inventory (BDI); the Life Event Inventory (LEI); the Core Bereavement Item (CBI-17) questionnaire; and the Psychosocial Adjustment to illness Scale (PAIS). Patients scoring > or = 14 on the BDI were seen by the psychiatrist for further assessment, and where appropriate, diagnoses were made according to DSM-III-R criteria. RESULTS: One hundred and ninety-two patients participated in the study; 95 scored > or = 14 on the BDI and one-third of these were found to have a depressive disorder. Factors significantly predictive of a BDI score > or = 14 were: an LEI score > 77; a diagnosis of acquired immunodeficiency syndrome (AIDS); being on sickness benefits or a pension; no current relationship; and a past history of depression. Few differences were demonstrated between those with a depressive disorder and those with a BDI score > or = 14 but no diagnosis of depressive disorder. Both groups had high mean PAIS scores indicating significant illness effects in multiple areas of function. CONCLUSIONS: Depressive symptoms are common among patients with HIV infection. Few factors differentiate between patients with a depressive disorder and those whose depressive symptoms do not meet diagnostic criteria. Substantial disability is present in both groups.     

Multicentre randomised study of computerised anticoagulant dosage. European Concerted Action on Anticoagulation

BACKGROUND: The demand for anticoagulant treatment is increasing. We compared the benefits of computer-generated anticoagulant dosing with traditional dosing decided by experienced medical staff in achieving target international normalised ratios (INRs). METHODS: In five European centres we randomly assigned 285 patients in the stabilisation period and stabilised patients to the computer-generated-dose group (n=137) or traditional-dose group (n=148). Centres had a specialist interest in oral anticoagulation but no previous experience with computer-generated dosing. The computer program calculated doses and times to next visit. Our main endpoint was time spent in target INR range (Rosendaal method). FINDINGS: For all patients combined, computer-generated dosing was significantly beneficial overall in achieving target INR (p=0.004). The mean time within target INR range for all patients and all ranges was 63.3% (SD 28.0) of days in the computer-generated-dose group compared with 53.2% (27.7) in the traditional-dose group. For the stabilisation patients alone, computer-generated doses led to a non-significant benefit in all INR ranges (p=0.06), whereas in the stable patients the benefit was significant (p=0.02). INTERPRETATION: The computer program gave better INR control than the experienced medical staff and at least similar standards to the specialised centres should be generally available. Clinical outcome and cost effectiveness remain to be assessed.