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The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).46 U.S. and Canadian hospitals.Patients aged 50 years or older undergoing hip fracture surgery.Spinal or general anesthesia.Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.Missing outcome data and multiple outcomes assessed.Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.Patient-Centered Outcomes Research Institute

Summary Engaging patients—defined broadly as individuals with lived experience of a given condition, family members, caregivers, and the organisations that represent them—as partners in research is a priority for policymakers, funders, and the public. Nonetheless, formal efforts to engage patients are absent from most studies, and models to support meaningful patient engagement in clinical anaesthesia research have not been previously described. Here, we review our experience in developing and implementing a multifaceted patient engagement strategy within the Regional Versus General Anesthesia for Promoting Independence After Hip Fracture (REGAIN) surgery trial, an ongoing randomised trial comparing spinal vs general anaesthesia for hip fracture surgery in 1600 older adults across 45 hospitals in the USA and Canada. This strategy engaged patients and their representatives at both the level of overall trial oversight and at the level of individual recruiting sites. Activities spanned a continuum ranging from events designed to elicit patients' input on key decisions to longitudinal collaborations that empowered patients to actively participate in decision-making related to trial design and management. Engagement activities were highly acceptable to participants and led to concrete changes in the design and conduct of the REGAIN trial. The REGAIN experience offers a model for future efforts to engage patients as partners in clinical anaesthesia research, and highlights potential opportunities for investigators to increase the relevance of anaesthesia studies by incorporating patient voices and perspectives into the research process.

Recent literature has reported as high as a 42 per cent recurrence rate after laparoscopic paraesophageal hernia repair (LPEHR). We report long-term follow-up in a cohort of patients undergoing LPEHR at Vanderbilt University. Thirty-one patients underwent attempted LPEHR between September 1993 and May 2000. Six of 31 patients (19%) were converted to an open procedure and were excluded from the study. All patients had complete excision of the sac, primary closure of the crura, and an antireflux procedure. An Institutional Review Board-approved follow-up barium esophagram was performed at a mean of 25 months postoperatively. Three experienced laparoscopic surgeons (K.S., M.H., and W.R.) collectively reviewed the esophagrams for evidence of recurrence. The mean age of patients was 61 years (range 41–92). There were six males and 19 females. Fifteen of 25 patients (60%) returned for an esophagram. Only one of 15 patients (7%) had a recurrent paraesophageal hernia. However, five of 15 patients (33%) had herniated an intact wrap 2 to 4 cm above the diaphragm. The patient with a true paraesophageal hernia recurrence returned with symptoms of dysphagia. Two of the five patients (40%) with a herniated wrap complained of heartburn, which was controlled with a proton pump inhibitor. All other patients were asymptomatic. Our recurrence rate of true paraesophageal hernias after LPEHR is low (7%) and compares with that reported in the literature for open repairs. However, 33 per cent of the patients in this study were found to have a herniated wrap. Because there is no risk of strangulation we have not operated on any of these patients. LPEHR is our procedure of choice for Type II and III hiatal hernias with good symptom relief and a low true recurrence rate.

Mary McCarthy had, and has, a formidable reputation in American intellectual life. Brilliant, beautiful, much feared for her biting wit, she is a major figure in the histories of her time and in the biographies of her friends, lovers, and enemies – notoriously unstable categories. She was, with her great friend, Hannah Arendt, a certain archetype of the independent and engaged intellectual. Although she began life as a member of the provincial Seattle upper middle class, and in her final years she constructed a life in Maine not remote from the ideals of that class, its constraints, and decorous pleasures, in her youth and early maturity she lived a myth of New York bohemia: poverty-stricken, promiscuous, politically of the Left. Such is her image. It is not an inaccurate story. It is merely incomplete. For during much of that time, for fifteen or twenty years, her milieu was defined not so much by the culture of the Left, as by that of the Central Intelligence Agency (CIA). Not that she was an official of the Agency; nor was it that she was one of those – like Arthur Schlesinger or Philip Rahv – who were more or less associated with it. She simply lived in a cultural matrix saturated with its influence, where she published in its journals, attended its conferences, stayed in the homes of those who were in its employee or who were members of the families of CIA officials. It is not, or should not be, controversial that such circumstances had an influence on her thought and work as it had on the thought and work of her contemporaries.

Bipolar clavicular dislocation rarely occurs. Although referred to by several different names (panclavicular dislocation, bifocal clavicle dislocation, traumatic floating clavicle, and periarticular clavicle dislocation), knowledge regarding appropriate treatment of this condition is limited. Conservative therapy remains the gold standard in asymptomatic individuals. In younger individuals with higher functional demands, or individuals with persistent pain or instability, open reduction with internal fixation of the acromioclavicular joint has also proven successful. In situations with continued medial instability, internal fixation can be used at both the acromioclavicular joint and sternoclavicular joint. Chronic bipolar dislocation may require total claviculectomy, especially when chronic dislocation has led to nonviable acromioclavicular and sternoclavicular joint viability. This article presents a chronic case of bipolar dislocation treated by complete claviculectomy.

orking for the College Board or the Educational Testing Service (ETS) is an experience shared by many English teachers, usually in the form of participation in grading sessions for writing assessments or for the Advanced Placement tests. I thought that working on Pacesetter English would be something like that: wello .rganized, stro.ugly directed, intense, and short. It wasn't. It wasn't even at either the College Board or ETS. It was in a series of hotel conference rooms

In the following pages I will describe certain trends in the rhetoric and composition profession toward the teaching of writing as pure technique and argue that they are much more deeply rooted in the changing economic structure of our society, and have much more serious implications, than we usually realize. I find, in my work as chairman of a freshman composition program, that the growing importance of freshman composition within the university puzzles many observers. They ask why there is this sudden need for "remediation" on such a massive scale and often, without pausing for an answer, attribute it to a failure of the public schools, to lower standards in the schools fostered by the anarchic generation just now reaching the ranks of academic middle management. Although attractive, arguments of this kind cannot be completely supported. The purpose of freshman composition classes is not just remediation. Nor is the growth of college composition purely the result of a mysterious catastrophe devastating the nation's public school system. That system continues, by and large, to serve the purposes for which it was developed. Most public high schools, after all, are not supposed to be humanistic gymnasia. They never were. Of course a few high schools, usually private, were meant to provide a humanistic education for a small number of young people, preparing them for leading universities and for leading careers. These schools continue to function much as they always have, and their patron universities are not ill-served. It is pointless exaggeration, for instance, to claim that most freshman at Harvard or at Berkeley are illiterate. The problems these young people have with writing are those common among traditionally literate people. They tend to use an artificial, highly formal idiom that inhibits the expression of their ideas. The antidotes for this are well known and routine: Strunk and White, impromptu essays, all that ensemble so loved by editors and educators. On the other hand, most high schools in this country were, are, meant to teach their students enough to make it possible for them to find a place not in the universities, but in the labor force. In these schools teaching means the inculcation of habits of discipline as much as the impartation of knowledge. (This is symbolized by that interesting institution, study hall, which, as many of us remember, was a place of punishment as much as, if not more than, a sanctuary of juvenile scholarship.) This was the traditional division. Students from Manual Arts High School

It was a few days before the spring final examination for Composition 101. I was in my normal condition for the occasion: exhausted, nervous, and bored. It's hard to maintain all three of these at the same time, but I understand that night nurses and soldiers on guard duty are familiar with the required techniques. Olga Something was a CETA clerk with the County-I thought that was what she said-and wanted me to help with writing there. Oh yes, happy to, but a little busy right now, could you call back in ten days?

tion in its own right. Many of us have sought to define it as an academic discipline not only by its special area of study, but also by means of its specific methodology. Our area of study may be located between that of the psychology of learning and that of traditional literature. Our methodology is distinguished, on the one hand, from that of cognitive science by an emphasis on pedagogical application; on the other hand, crucially, it is distinguished from most literary studies by an interest in an empiricism modeled on that of the social sciences. We have followed the usual procedure of an emerging specialist community in making these distinctions. The practice of the natural sciences, especially that of mathematical physics, is exemplary for all disciplines which have as their goal the achievement of objective knowledge. The great prestige of the natural sciences and, to a lesser extent, that of the older social sciences has repeatedly influenced scholars in the humanities to pattern their research on scientific models. We have seen this, for instance, in linguistics and history. History is now virtually two disciplines, one humanistic, the other social scientific. Linguistics is emerging from a long period of consideration of exactly what is necessary for the founding of a science of language. It is developing as a model for a discipline that has, in large part, crossed the line from the humanities to the social sciences. The reasons for these changes are not confined to the requirements of the search for pure knowledge, but often

News From Nowhere is a complex work, requiring interpretation on many levels: literary-historical, biographical, political.' This essay will concentrate on the last of these. News From Nowhere is unusual among utopian romances in that it was intended to have a direct bearing on the political tactics of a group attempting to bring about the changes in society proposed by the text. This aspect of News From Nowhere can best be analyzed when it is considered not as a book, but in its original form, as a newspaper serial. In the following pages I will discuss William Morris's association with the Socialist newspaper Commonweal, then trace a debate about Anarchism which took place in its pages. This information will then be used as an introduction to an analysis of the political material in News From Nowhere. I hope to establish by this means that News From Nowhere was not merely an escapist utopian fantasy (although it was that too), but was, at least in part, a political act. I also wish by these reflections to add something to our knowledge of an interesting text, and of an important author, and perhaps to contribute some information to the discussion of the status of texts located on generic borderlines. An imaginative work serialized in a newspaper may differ in at least one crucial way from the book form of the same work: it can have a particular, time-bound context in the pages of the newspaper. This serves to focus interpretation immediately-at least for the original audience. News From Nowhere contains criticisms of certain tendencies in the emerging English revolutionary movement of the 1890s, especially those of the Anarchists. This layer of meaning, which would have been most important to the first audience of the tale-the readers of the Socialist League's newspaper Commonweal-was pointed to by the opening phrases of News From Nowhere, which they found on the front page of the January 11, 1890 issue of that paper

The "cognitive process theory of writing," expounded by Linda Flower and John R. Hayes in the December, 1981 issue of College Composition and Communication and elsewhere, is attractive; as they argue, it improves on previous theories of composing by emphasizing the processes followed by the writer instead of describing "stages" in the completion of the product and by better accounting for the recursive nature of those processes through the use of a hierarchical rather than a linear description. But their casual reliance on unarticulated theories and an unsound methodology, while it does nothing to detract from our intuitive satisfaction with their conclusions, deprives them of any real support. Our acceptance of such work, if we accord it, will lead us away from, rather than toward, valid understanding of how writers write. Two facets of their work are particularly questionable: their theory of cognitive processes and their methodology for producing and analyzing protocols. Neither of these facets is new with Flower and Hayes. The cognitive processes they descry in writing are in large part those processes involved in purposive behavior. In discussing writing as a goal-directed activity, they rely on the concepts of goals, plans, and scripts developed by cognitive psychologists.1 But their discussion obfuscates much that is clear in their sources and thus seriously weakens their claims for the validity of their theory. Their methodology for psychological research dates from Plato and was made scientifically respectable in the nineteenth-century by Wilhelm Wundt, who named it introspection. But early and late critics of introspection have emphasized the limitations of the methodology, precisely as it is applied to the investigation of cognitive processes--limitations that Flower and Hayes ignore. In what follows we will discuss first the troublesome problems with their theory, and then pass on to the more serious problems with their methodology. In elaborating their model of the composing process, Flower and Hayes, especially in their most recent work, seem to ignore its status as a model and

There are many ways to get to Maryknoll. The way I took was to ride the Metro-North railroad to Ossining. At Ossining there were three or four cabs waiting for the train. Each accepted three or four passengers, and we all went off together, not, as it turned out, to Maryknoll, but to Sing Sing, which molders down along the railroad tracks, newer sections and older sections heaped together in what I gather must be the style of the region, in this case depicting an image of a century or more of industrialized punishment. After my fellow passengers left the cab with their gifts and visiting hour stories, the driver circled back to town, up the usual steep main street and out into a residential area on top of the bluffs overlooking the river. We passed the Chinese Imperial style residence of the Maryknoll priests, the retirement and nursing homes, then reached the center used by the Maryknoll sisters, a large complex of buildings that had once included a college. There are fewer Maryknoll sisters than there once were. Their colleges and hospitals have been closing not only in Ossining, but all over the world. Partly, this is simply because fewer women are joining the order. Partly, it is a matter of policy. The order no longer wishes to run institutions for people; it wishes to help people run their own institutions. All the rest of the day I sat in a small room near their library and listened to the nuns tell me stories of their years spent "accompanying" communities in the Third World. I was there to hear about their literacy work; they each told about how they went about it, about an educator they admired named Paulo Freire. All the stories were similar, though each had local particularities. In Panama, for instance, they had had a radio station that coordinated the schedules of literacy classes in a number of villages. They had had to leave when a priest was killed and the local bishop decided the sisters were in danger. In Tanzania they had helped women compile a cookbook, which was also a reading text. Now, of

THE WRITING PROGRAM I WILL BE DISCUSSING here began in the early seventies at a university which admits only those whose grades and test scores are in the upper twelve percent of graduating high school seniors in the state.1 The basic course was a two-quarter requirement for all incoming freshman. These students were quite likely to have produced writing which fit in well with the expectations of their high-school English teachers. They were students who would have readily adopted a version of what Richard Lanham has called "the official style." The founder of our program, Lowry Pei, now at Harvard University, saw that the problems that these students had with their writing were derived from their college prepatory training. They could write in the official style, but they had no style of their own. They could also repeat "official" ideas, but they had difficulty expressing their own thoughts, communicating their own perceptions of the world in a written language which corresponded with their personal voice. Consequently, Pei designed a program that stressed the writing of personal narratives. The program's instructors were given Peter Elbow's Writing Without Teachers and Ken Macrorie's Telling Writing as guides to transforming official styles into personal styles. Consistency of standards and content in the program was achieved not through the use of a syllabus or a uniform final examination, but through weekly meetings of the instructors and the other members of the program's staff. The instructors usually met with their students three times a week for regular classes and once every week or so individually. Writing assignments went from "What I Did Last Summer" to "My First Drug/Sexual/Political Experience." (These were often the same paper.) Many of the teaching assistants practiced charismatic teaching. One had a woodblock print of the Buddha with attendant Bodhisattvas. He said that the yellow