Trends in the use of accident and emergency services by the homeless on the Wirral.

OBJECTIVE: To examine the use of accident and emergency (A&E) services by the homeless, with particular reference to the use of psychiatric services generated by this attendance. METHODS: A retrospective study of attendance registers at a large A&E department over an eight year period, during which there were 566 separate attendances by homeless patients out of a total of 421 237 adult attendances (1.3 per 1000). RESULTS: There was no significant change in rates of attendances over the eight year period (P = 0.41), in the broad demographic details of the groups, or in the use of psychiatric services. CONCLUSIONS: There has been no significant increase in the use of A&E services by homeless people in the population studied over the eight year period. Several possible explanations for this are given.

Dangerous monoamine oxidase inhibitor interactions are still occurring in the 1990s.

The clinical course is described of a 28-year-old woman who was severely ill following ingestion of a Do-Do tablet (which consists of ephedrine, caffeine and theophylline), 24 h after discontinuing phenelzine treatment. Signs and symptoms were delayed for 8 h after which she developed encephalopathy, neuromuscular irritability, hypotension, sinus tachycardia, rhabdomyolysis and hyperthermia. Her illness was complicated by pneumonia and adult respiratory distress syndrome (ARDS). The management of monoamine oxidase inhibitor (MAOI) toxicity, which can arise from interactions and overdoses, is discussed. It should be remembered that, despite the increase in use of alternative and safer antidepressants, MAOI interactions still occur and unless they are managed appropriately, are potentially fatal. Patients need to be warned that restrictions apply for up to 2 weeks after stopping the medication, and doctors need to be aware that serious interactions can occur in this time period.

Pressurised aerosol inhalers: the cost of misuse.

Bronchodilator aerosols, if used correctly, have many advantages over other therapies in patients with chronic airflow limitation caused by asthma or chronic bronchitis. The use of pressurized aerosol inhalers was examined in a district general hospital: of 57 patients on these inhalers, 39 were unable to use the inhaler effectively, and 23 had never received any advice on inhaler technique. A single demonstration of correct technique decreased the failures to 21 patients and, after two demonstrations, to ten. The cost of the misused inhalers in this relatively small population was 450 pounds, and obviously this figure escalates when the prescription for these inhalers is repeated monthly. It is also increased when the total numbers of misused inhalers in the country are accounted for. The cost in terms of finance, in these days of medical audit and drug budgets, and, more importantly, in terms of patient health, is unacceptable and can be avoided by repeated tuition of technique.