A comparison of professionals' and patients' understanding of asthma: evidence of emerging dualities?

Despite an increase in the provision of services to patients with asthma, morbidity from the disease remains high. Recent research (outside asthma) has raised the possibility that patients may develop a conceptualisation of illnesses which is not entirely compatible with the prevailing biomedical view. This paper compares the way in which health care professionals and patients with asthma described various aspects of the illness, using an approach which considered the type of knowledge which might be used to construct the respective conceptualisations of asthma. A qualitative method is empliyed, using focus groups. Eight focus groups were convened, four of professionals and four of patients with asthma. Following the initial data analysis, the results were reviewed linguistically, with particular attention to the use of metaphor.The health care professionals and patients participating in this study agreed broadly in their explanations of the aetiology and drug treatment of asthma. The data suggest lack of congruence in the development of treatment strategies and locus of control. Health care professionals and patients in this study used linguistically different metaphors to represent the disease: the former more frequently used metaphors evoking on-going processes, the latter visualising the chest (in their use of metaphor) as a static container, emptying and filling throughout the course of the disease. Two commentaries from philosophical and anthropological literature are considered in order to offer theoretical accounts relevant to this interpretation. The data suggest an emerging duality in the approach to treatment plans, in the roles played by professionals and patients with asthma, and in the different types of knowledge used by professionals and patients to construct their respective working models of asthma.

A gun-cleaning "accident".

A case is presented in which the question of suicide is raised. Several pointers are outlined to help in this differentiation.

The physician healer: ancient magic or modern science?

The therapeutic role of general practitioners (GPs) is one that, over the years, has slowly diminished with the growing fashion for evidence-based medicine. However, it is clear that the art of healing and the strength of the doctor-patient relationship play a vital role in improving the well-being of patients. This is exemplified by the placebo effect, where the attitude of the doctor can make an appreciable difference to the psychological response of the patient who feels the need to be understood and listened to empathically. By maximizing the role of the physician healer, there is considerable scope for bridging the gap left by the impersonality of medical science, while at the same time increasing the GP's effectiveness.

Critical reading using the READER acronym by experienced general practitioners (G.P.s) and by G.P. registrars in southern and Northern Ireland.

The READER acronym describes a simple easily applied method of critical reading, an important skill for general practitioners (GPs). The aim of the study was to evaluate an abstract using the READER method, and to compare the appraisal by GP registrars in Southern Ireland with those of GP registrars in Northern Ireland and those previously recorded by experienced GPs at the Conference of Teachers of the Irish College of General Practitioners. General practice registrars (n = 41) in Southern Ireland participated in a critical reading workshop at which they appraised the abstract of a sample paper using the READER model for critical appraisal. A group of GP registrars (n = 10) in Northern Ireland, and experienced GPs (n = 35) at the Conference of Teachers of the Irish College of General Practitioners evaluated the complete paper using a similar methodology. There was no statistically significant difference between scores recorded by GP registrars in Southern Ireland and their Northern Irish counterparts, nor was there a statistically significant difference with experienced GP teachers. The READER model for critical reading provides GP registrars with a useful tool for critical evaluation of medical literature. GP registrars in Southern Ireland, Northern Ireland, and experienced GP's from the Conference of Teachers in Ireland recorded similar results and the study appraised, while dealing with an intervention in one practice in south west England, appeared relevant and applicable to participants from other locations in a different health care system.

Patients who do not receive continuity of care from their general practitioner--are they a vulnerable group?

BACKGROUND: Continuity of care is much valued by general practitioners but little is known about those patients who do not receive continuity of care. AIM: This study set out to identify and describe a group of patients who did not receive continuity of care from the general practitioner with whom they were personally registered. METHOD: A total of 110 patients (71 female and 39 male) were identified, who did not receive continuity of care, defined as four consecutive face to face consultations which did not take place with the doctor with whom they were registered. This group was compared with an age and sex matched control group who did receive continuity of care, using general practice records, for demographic characteristics, morbidity, relationship problems, number of 'difficult' consultations, failure to attend appointments, and use of an accident and emergency department and of open access clinics. RESULTS: Patients in the study group were more likely to be under the age of 65 years than all patients on the doctor's list. Study patients were more likely than control patients to be in social class 4 or 5 living in a council house. Patients in the study group were more likely than controls to be depressed. Women patients in the study group were more likely to suffer from vaginal discharge. Men patients in the study group were more likely to complain of non-cardiac chest pain. The study group had more marital problems, parent-child relationship problems, and problems involving violence in the family, as well as other relationship problems. Relationship problems included the relationship with the doctor, since a third of all the consultations in the study group were recorded as 'difficult', compared with 3% in the control group. The study group patients were more likely than controls not to attend appointments which they had made, to use the accident and emergency department repeatedly, and to have used other open access clinics. CONCLUSION: Lack of continuity of care is associated with some additional morbidity, an increased number of relationship problems, 'difficult' consultations, and non-attendances, and an increase in the use of open access clinics. The characteristics of this group of patients represent a syndrome which merits further study.

Use of warfarin in non-rheumatic atrial fibrillation: a commentary from general practice.

Seven randomized trials published in the last six years have shown that warfarin reduces the risk of ischaemic strokes and death in patients with atrial fibrillation. The annual rates of major bleeding episodes in all these trials were low and, as a result, doctors in primary and secondary care are being encouraged to consider using warfarin for patients with atrial fibrillation unless there are obvious contraindications. However, the populations used in these studies were highly selected and rigorously monitored throughout the trial period to minimize the risk of bleeding in a way which probably could not be expected in routine primary care. Although the rates of major bleeding episodes were uniformly low, the rates of minor bleeding episodes were much higher and these could impact substantially on patients' views of the treatment and on the workload of the primary care team. Evidence is now at hand which allows the stratification of risk in patients with atrial fibrillation which should enable those who are at greatest risk to be considered for this form of treatment. Patients may develop risk factors over time which could render them unsuitable for continuation of warfarin therapy. The general practitioner is centrally placed to make the decision about initiating or continuing treatment or indeed stopping it. Several models for decision making in warfarin treatment from primary and secondary care are proposed.

Evaluation of an easy, cost-effective strategy for cutting benzodiazepine use in general practice.

AIM: This study set out to assess the effect of a letter from the general practitioner, suggesting a reduction in the use of benzodiazepines, and whether the impact of the letter could be increased by the addition of information on how to tackle drug reduction. METHOD: Two hundred and nine long-term users of benzodiazepines in general practice were divided into three groups: two intervention groups and a control group. The first intervention group received a letter from their general practitioner asking that benzodiazepine use be gradually reduced and perhaps, in time, stopped. The second intervention group received the same letter plus four information sheets at monthly intervals, designed to assist drug reduction: The mean age of the 209 people was 69 years (age range 34-102 years). RESULTS: After six months, both intervention groups had reduced their consumption to approximately two thirds of the original intake of benzodiazepines and there was a statistically significant difference between the intervention groups and the control group. Eighteen per cent of those receiving the interventions received no prescriptions at all during the six month monitoring period. CONCLUSION: The results indicate that a simple intervention can have a considerable effect on the use of hypnotic and anxiolytic drugs, even with a sample of elderly users.

Neutropenic enterocolitis. Two unusual cases with review of the literature.

Cases of neutropenic enterocolitis associated with Clostridium septicum infection have been reported with increasing frequency in the past decade. We report two such cases involving unusual hosts and briefly discuss possible pathogenetic mechanisms such as ischemia, mucosal damage related to chemotherapy and neutropenia, and immunosuppression. One case involved a young man with chronic Epstein-Barr infection who developed extensive gas gangrene of the right side of his trunk and thigh and who died within 12 hours of presentation to the emergency department. Diagnosis was only made at postmortem examination. The second, middle-aged patient was admitted with an acute abdomen shortly after he completed chemotherapy for pleural mesothelioma. A right hemicolectomy was performed, but the patient developed antibiotic-associated pseudomembranous colitis and died. These cases indicate that neutropenic enterocolitis may arise in a variety of underlying conditions and that prompt diagnosis and therapy will be required to salvage more patients with this disorder.

Laboratory investigation of deaths due to anaphylaxis.

To establish a useful laboratory protocol to investigate possible cases of fatal anaphylaxis, we measured mast-cell-derived tryptase levels and allergen-specific immunoglobulin E (IgE) antibody levels in sera obtained prior to or within 24 h after death from 19 anaphylaxis victims. Elevated serum tryptase levels (range = 12 ng/mL to 150 micrograms/mL) were found in nine of nine Hymenoptera sting fatalities, six of eight food-induced fatalities, and two of two reactions to diagnostic therapeutic agents. Tryptase levels were normal (less than 10 ng/mL) in 57 sequential sera obtained postmortem from six control patients. Tryptase could not be measured in pleural or pericardial fluids for technical reasons. Serum IgE antibodies were elevated in five of the nine Hymenoptera sting fatalities and in eight of the eight fatal food reactions; assays were unavailable for the two diagnostic/therapeutic agents. If elevated, the victim's serum IgE antibodies to food could be used to identify allergens in uneaten portions of foods consumed shortly before the anaphylactic event. IgE antibodies were moderately stable during storage in a variety of anticoagulants at room temperature for up to 11 weeks. Elevated mast-cell-derived tryptase levels in postmortem sera reflect antemortem mast cell activation and may be used as a marker for fatal anaphylaxis. If assays are available for IgE antibodies to relevant allergens, such assays provide evidence for antemortem sensitization; these assays may be modified to identify allergens in foods consumed by victims of food-induced anaphylaxis.

Cocaine babies: the scourge of the '90s.

Six cases of cocaine-related deaths of infants have covered the spectrum of potentially devastating effects. They include an intrauterine death of a 35-week-old fetus following acute maternal cocaine abuse; anoxic encephalopathy at birth with 3 months' vegetative survival from a similar episode; traumatic compression asphyxia in a 4-month-old; infectious cardiomyopathy with heart failure in a twin at age 21 months following maternal cocaine abuse at birth; malnutrition and dehydration in a 7-week-old during continuing cocaine abuse by the parents; and a teenage sibling's cocaine lacing of a baby milk bottle ingested by his 6-week-old brother. All the cases had positive toxicological screening for cocaine or metabolites or both in the mother at delivery or in the infant at birth, or both. There were no instances of sudden infant death syndrome (SIDS, or "crib death"). Pathologic and toxicologic, as well as birth, developmental, and social data are presented. An integrated medical, public health, law enforcement, and educational policy to prevent or at least ameliorate these tragic cases, now approaching epidemic proportions, has yet to be developed. A careful obstetrical history and examination of the mother, indication on the birth certificate of maternal drug abuse, and notification of health authorities (by birth certificate checking, among other ways) may send an early warning message to providers for intercession. Active ingestion/injection and passive inhalation by older children and teenagers require more intensive monitoring and aggressive interaction by pediatricians, social workers, school authorities, and employers.(ABSTRACT TRUNCATED AT 250 WORDS)

Fatal food-induced anaphylaxis.

Fatal food-induced anaphylaxis is rarely reported. In 16 months, we identified seven such cases involving five males and two females, aged 11 to 43 years. All victims were atopic with multiple prior anaphylactic episodes after ingestion of the incriminated food (peanut, four; pecan, one; crab, one; fish, one). In six cases the allergenic food was ingested away from home. Factors contributing to the severity of individual reactions included denial of symptoms, concomitant intake of alcohol, reliance on oral antihistamines alone to treat symptoms, and adrenal suppression by chronic glucocorticoid therapy for coexisting asthma. In no case was epinephrine administered immediately after onset of symptoms. Premortem or postmortem serum samples were available from six victims; in each case elevated levels of IgE antibodies to the incriminated food were demonstrated. Food-sensitive individuals must self-administer epinephrine promptly at the first sign of systemic reaction. Emergency care providers should be aware of cricothyrotomy as a life-saving procedure.

Synchronous triple malignant tumors of the lung. A case report of bronchial carcinoid, small cell carcinoma, and adenocarcinoma of the right lung.

The authors report a case in which a highly unusual, simultaneous occurrence of a peripheral small cell carcinoma and a central bronchial carcinoid in the right upper lobe and a peripheral adenocarcinoma in the right middle lobe was observed. This is the fourth case of triple lung cancer reported in the literature. The role of computerized tomography in disclosing multiple lung carcinomas and the significance of the concurrence of pulmonary small cell carcinoma and bronchial carcinoid are discussed.

In vitro susceptibilities of isolates from patients with Branhamella catarrhalis pneumonia compared with those of colonizing strains.

Branhamella catarrhalis has recently been recognized as an opportunistic respiratory pathogen. We tested 10 isolates recovered from patients with documented B. catarrhalis pneumonia and 15 colonizing isolates for their susceptibility to 19 antimicrobial agents and for their ability to produce beta-lactamase. Eight of ten disease isolates and 12 of 15 colonizing isolates produced a detectable beta-lactamase. The isolates that were negative for beta-lactamase were susceptible to all agents tested, including penicillin G. Although all strains were found to be susceptible to the majority of the newer agents by broth dilution testing, the most active new semisynthetic penicillin was azlocillin (MIC that inhibited 90% of strains, 0.5 micrograms/ml), and moxalactam had the greatest potency among the cephalosporins (MIC that inhibited 90% of strains, 0.06 micrograms/ml). Members of the first- and second-generation cephalosporins had only moderate activity. All disease isolates were susceptible to the aminoglycosides and to trimethoprim-sulfamethoxazole and resistant to vancomycin. The antibiotic susceptibilities of the disease isolates were not different from those of the colonizing strains. The results of standardized disk diffusion testing did not correlate well with those of dilution testing for penicillin or ampicillin. However, disk diffusion testing did predict susceptibility adequately for the remainder of the antibiotics tested.