How integrated are services for patients with chronic obstructive pulmonary disease? Perceptions of patients and health care providers.

Chronic obstructive pulmonary disease (COPD) is a common cause of hospital readmissions worldwide. Outcomes for COPD patients improve if care is more integrated. COPD patients and their health care providers at a district hospital and community health service were interviewed about their perceptions of integration of care. Patients were confused about provider roles, had little understanding of their disease, had difficulty accessing services and did not have COPD action plans. Health care providers espoused integration of COPD care. Care was reasonably well integrated in the hospital. Integration of care was compromised in the community because COPD patients went to the emergency department when symptoms became unmanageable, while only attending their GPs for routine booked appointments. Integration could be improved if health care providers spent more time with patients, promoting understanding of the disease, supporting self-management and liaising with other providers. Patients would benefit from an action plan and additional support. Potentially preventable COPD admissions will continue without action to improve integration of community services and patients' understanding of their condition.

Reduction of nitrogenase Fe protein from Azotobacter vinelandii by dithionite: quantitative and qualitative effects of nucleotides, temperature, pH and reaction buffer.

Oxidized Fe protein from Azotobacter vinelandii (Av2(0)) was reduced by dithionite (DT) in the absence and presence of nucleotides, over the temperature range 10-40 degrees C, over the pH range 7-8, and in various buffers--inorganic phosphate, TES, HEPES, and Tris. The reduction of each species of Fe protein--Av2(0), Av2(0)(MgATP)2, and Av2(0)(MgADP)2--was resolved into at least three exponential phases, with relative amplitudes of each phase varying over the range of experimental conditions, suggesting a dynamic population shift of kinetically distinct species. The rapid phase of Av2(0) reduction predominated at low temperature and pH, and in Tris buffer; rapid Av2(0)(MgATP)2 reduction was favored at high temperature and pH, and in phosphate buffer; and Av2(0)(MgADP)2 reduction was favored under more physiologically relevant conditions of 20 degrees C, pH 7.5, and in phosphate buffer. The rates of reduction of Fe protein species did not change with buffer, but temperature and pH do have an effect on the rates. With the appropriate constants, an empirically derived equation estimates the rate of Fe protein reduction at any temperature and pH within the limits 10-40 degrees C and pH 7-8, for a given species of Fe protein, and a given phase of the reaction. At 23.0 degrees C and pH 7.4, the rate of the dominant phase of Av2(0) reduction is 1.9 x 10(8) M(-1) s(-1). Under the same conditions, the rates of the two dominant phases of Av2(0)(MgATP)2 reduction are 1.2 x 10(6) and 1.5 x10 (5) M(-1) s(-1); and the rate of the dominant phase of Av2(0)(MgADP)2 reduction is 3.5 x 10(6) in M(-1) s(-1). Thermodynamic activation parameters for each phase of reduction were calculated. No breaks in the Arrhenius plots for any Fe protein species were observed.

Low-cost therapeutic agents. Uses and abuses.

The past quarter century has seen a transformation of the pharmaceutical industry from blind empiricism to the design of drugs to act as agonists or antagonists at specific receptor sites. As truly effective technology, many have led to marked savings in cost. Savings have been achieved when therapeutic drugs, often highly specific, can be substituted for surgery and other invasive procedures and when therapeutic drugs can be used to prevent illness and the need for treatment. Further savings are achieved with the reduced prescription of ineffective drugs. It is estimated that therapeutic drugs and vaccines contribute about half of medicine's contribution to increased life expectancy and improved quality of life in this century at about 7% of national expenditures for medical care in the United States.

Ivan Illich and the pursuit of health.

Fifty years ago, when medicine had relatively few effective treatments to offer, its value was unquestioned. Twenty-five years ago clinicians had become concerned that treatment could sometimes do harm and McKeown published epidemiological evidence claiming that medicine did little good. This state of affairs was used by Illich to bolster his crusade against technology in general. Today it is clear that medicine now makes a large contribution to health. But doubts still exist and alternative pathways to health are continually exhorted. Large-scale efforts at behavioural modification, encouraging the adoption of healthier lifestyles, have been largely unsuccessful. Social activists now argue that funds should be diverted from medical care to social programmes that, they claim, might contribute more to health. While it is true that health is strongly associated with socio-economic status (income, education and occupation), there is little sense of how best to reallocate scarce resources so as to improve the health impact of social and economic programmes. Social reform is not a substitute for medical care. Rather, our social environment is a second, important but quite separate, determinant of health and well-being.

Freedom, responsibility, and health.

Freedom and responsibility, how much of each and how they are balanced, have profound implications for our personal lives and for our work. The health of a population and its achievement in the workplace are enhanced when individuals have some freedom and some responsibility, but not too much of either, and when civil associations of individuals rather than individuals acting alone are the essential social units. The consistent association of social contacts with health and productivity provides strong support for the premise that intimate relationships are the focus around which people's lives revolve. Membership of a "social network" may be merely conforming to a reigning social norm, and this could mean having to pay an important price in the loss of creativity associated with individualism. But social conformity should not prevent individuals from going their own way, and it should be possible to combine the luxury of individuality with an active life in civic affairs. Less than complete freedom may fall short of existential utopia, but it may be best for our health and wellbeing.

Medicine matters after all.

The extraordinary increase in life-expectancy that occurred early in this century has been attributed largely to non-medical factors. Life-expectancy has continued to rise, and medical care can now be shown to make substantial contributions. Three of the seven years' increase in life expectancy since 1950 can be attributed to medical care. Medical care is also estimated to provide, on average, five years of partial or complete relief from the poor quality of life associated with chronic disease. The association of social factors with health is well-known, but except for occupation, it is not known how they might act or whether they are proxies for some other yet to be identified factor.

Improving health: measuring effects of medical care.

The impact of medical care on the quality and length of life of the population has been poorly documented. The rapid growth of evidence of efficacy of therapy for individual medical conditions now offers the opportunity to create an inventory of benefits. A method for creating such an inventory is described, as is its application to a selection of condition-treatment pairs, chosen for their high incidence of prevalence, their serious outcomes, and the demonstrated efficacy of their treatment. An aggregate effect of medical care on life expectancy is found to be roughly five years during this century, with a further potential of two years. Although there is no overall index of quality of life analogous to life expectancy, our inventory demonstrates the enormous burden of pain, suffering, and dysfunction that afflicts the population for which medical care can provide a large measure of relief.

The herpes-specific immune response of individuals with herpes-associated erythema multiforme compared with that of individuals with recurrent herpes labialis.

Infection with herpes simplex virus (HSV) is the most common precipitating factor in the development of erythema multiforme (EM). It is not known why only a few of the many individuals who experience recurrent HSV infection also develop herpes-associated EM (HAEM), although a difference in the HSV-specific immune response has been postulated. The purpose of this study was to compare the HSV-specific immune response of individuals with HSV infection alone with that of individuals with HAEM. There were 21 patients in each of the two groups. Four parameters of the HSV-specific immune response were examined: (1) anti-HSV IgG titers were measured by ELISA; (2) antibody neutralization was assessed using a plaque assay; and (3) antibody-dependent complement-mediated cytotoxicity, and (4) antibody-dependent cellular cytotoxicity were investigated using a previously described in vitro HSV-specific cytotoxicity assay. No statistically significant differences were detected between the two patient groups. Thus, a difference in these HSV-specific immune mechanisms does not explain the development of HAEM in some individuals with recurrent HSV infection.