Some medical syndromes encountered in nineteenth-century French literature.

The medical content of a hundred selected French novels written between 1815 and 1914 has been examined. These books reflect contemporary public interest in medicine and disease. By means of translated quotations, the spectrum of diseases common at the time, including conditions nowadays rarely or never observed, such as smallpox and diphtheria, are graphically described, along with the effects of treatment of syphilis with mercury and the ravages of tuberculosis including lupus vulgaris. Some diseases which were not understood in the nineteenth century such as cretinism due to iodine deficiency may be recognised by the modern reader while other illnesses, convincingly described, are now unidentifiable. In the novels one can trace the transition from the humoral theory of disease to modern diagnoses and the advent of surgery and its complications. These extracts complement textbooks of the history of medicine by third-party depiction of the observed impact of disease upon the individual.

Patients' perceptions of primary health care in an inner-city practice.

BACKGROUND: The 1978 Alma Ata declaration by the World Health Organization emphasized the importance of primary health care, which includes social services and participation, as well as primary medical care. In the UK, primary medical care is based on general practice, increasingly working from purpose-built premises with primary care teams. However, this does not usually include social services or involve patient participation. Both general practice and social services are undergoing reorganization as separate entities, with little emphasis on intersectoral collaboration. OBJECTIVES: We aimed to assess patients' perceptions of primary health care in an inner-city practice in terms of primary medical care, social services and participation. METHODS: Perceptions of medical and social services, together with levels of satisfaction and patient participation, were assessed by self-completed questionnaires for 248 patients attending an inner-city health centre and by 74 home interviews for those who had requested house calls. RESULTS: Patients were more satisfied with primary medical care than with other aspects of primary health care, such as housing. Older patients at home were less satisfied with primary medical care and more satisfied with social services than younger patients attending the health centre. Physiotherapy, chiropody and pharmacy were the services most requested at the health centre. A domiciliary pharmacy, help with hearing aids and a social worker at the health centre were the main requests by older patients at home. CONCLUSIONS: Medical and social services at primary care level should have coterminous boundaries based on general practice populations, ideally with access through multipurpose health centres.

5-Fluorouracil related toxic myocarditis: case reports and pathological confirmation.

This report describes two cases of cardiotoxicity associated with the use of 5-fluorouracil (5-FU) in the treatment of neoplastic disease, and reviews the literature to date. The manifestations of cardiac toxicity were significant ventricular dysfunction during continuous infusion of 5-FU, accompanied by symptoms resembling cardiac ischemia in one case and irreversible cardiogenic shock in another. Detailed cardiac investigations and pathological findings provide convincing evidence that the development of acute myocarditis is the likely mechanism of 5-FU cardiotoxicity, rather than coronary insufficiency as has commonly been postulated. Although cardiotoxicity as a complication of 5-FU therapy remains rare, recognition of this entity is important as it may lead to serious hemodynamic compromise and may recur with drug rechallenge.

The provision and use of medical services during the 1991 World Student Games in Sheffield.

This paper describes the provision and use of medical services organized by Sheffield during the World Student Games in 1991. A descriptive study of medical and physio-therapy records, together with minor incident logs and hospital referrals, was carried out. It was found that 571 medical records and 357 physiotherapy records were completed, of which 83 per cent were generated at the Games Village. The majority of patients were competitors, although team officials accounted for a disproportionate number. Most physiotherapy requests were for sports injuries, whereas this was not so for medical cases. Twenty-five per cent of medical records and 40 per cent of physiotherapy records were for recurrent conditions which had started before arrival. Athletics and football accounted for the greatest number of records per competitor. During the Games, 82 patients were referred to hospital, of whom only 12 were admitted. The largest group of hospital referrals was for dental treatment, and the next largest was for minor trauma. A total of 1089 minor incidents were recorded, mainly at the competition venues and in the Physiotherapy Room at the Games Village. In addition, the Red Cross and the St John Ambulance Association attended to 330 people during the Games. The smallest national teams tended to make most demands on services, probably because the larger teams were accompanied by their own medical and physiotherapy staff. It is concluded that the main demands for medical services at the World Student Games were for general practice and physiotherapy at the Games Village, and for first aid at competition venues.(ABSTRACT TRUNCATED AT 250 WORDS)

Practice organization before and after the new contract: a survey of general practices in Sheffield.

In order to assess the effects of the new contract on practice organization, all general practices in Sheffield were surveyed just before the new contract came into effect in April 1990, and again one year later. Of the 120 practices, 57% responded in 1990 and 61% in 1991, with 47% responding in both years. There were significant increases in the mean number of clinics and employed staff for the practices responding to both questionnaires and in the proportion of these practices which had a computer. These changes represent a response to the incentives and stated aims of the new contract.

Workload of general practitioners before and after the new contract.

OBJECTIVE: To assess changes in general practitioners' workload associated with the new contract introduced in April 1990. DESIGN: Weekly workload diary completed during four weeks in February-March 1990 and during the same period in 1991. SETTING: Sheffield, United Kingdom. SUBJECTS: All 300 general practitioners on Sheffield Family Health Services Authority list as principals in 1990 and 1991. MAIN OUTCOME MEASURES: Mean number of hours worked per week, number of patients seen each week, and mean time spent per patient. RESULTS: 181 (60%) general practitioners responded in 1990 and 163 (54%) in 1991. Of these, 18 (10%) were not working in 1990 and 14 (7%) in 1991. General medical service work increased during a "normal working week" from a mean of 38.6 hours a week in 1990 to 40.6 hours in 1991, and non-general medical service work decreased from 5.4 hours a week to 4.5 hours. Hours spent on call were similar before and after the contract. For the 99 general practitioners who responded in both years, time spent on general medical service duties increased significantly (40.5 h in 1990 v 42.5 h [corrected] in 1991; p = 0.033), mainly due to more time being spent in clinics. Significantly more patients were being seen in clinics (9 v 14; p = 0.001); the average time spent per patient remained at about 8 1/2 minutes during surgeries and 16 minutes for a home visit, and rose from 13 to 14 minutes for patients seen in clinics. The time spent on practice administration fell but not significantly. CONCLUSION: Since the new contract there has been a significant increase in general medical services work, mainly due to more patients being seen in clinics, with no reduction in the time spent per patient.

Sociocultural correlates of eating disorders among Asian schoolgirls in Bradford.

A survey of 204 south-Asian and 355 Caucasian schoolgirls was conducted in Bradford using the EAT-26 and the BSQ. At interview, seven Asian girls and two Caucasian girls met DSM-III-R criteria for bulimia nervosa, yielding a prevalence of 3.4% and 0.6% respectively. One Asian girl met DSM-III-R criteria for anorexia nervosa. Factor analyses of the EAT and BSQ supported their cross-cultural conceptual equivalence in this south-Asian population. Among the Asians, high EAT and BSQ scores were associated with a more traditional cultural orientation and not with greater Westernisation. It is probable that these findings reflect the cultural and familial difficulties faced by these Asian girls growing up in Britain.

Rheumatic disease in the Nuu-Chah-Nulth native Indians of the Pacific Northwest.

The Nuu-Chah-Nulth are a tribe of 2,300 Pacific Northwest native Indians. A retrospective study has identified 157 requiring referral to rheumatologists over 15 years. Rheumatoid arthritis (RA) was found in 23, systemic lupus erythematosus (SLE) in 8, sacroiliitis 5, and Reiter's syndrome 1. Overlap syndromes with combinations of RA, SLE, scleroderma and polymyositis were seen in 9. Other rheumatic disorders included osteoarthritis 10, soft tissue rheumatism 14, and musculoskeletal complaints of known etiology (trauma, infection, neoplasm) 12. The remaining 75 patients suffered from periodic weather dependent joint swelling (52) or polyarthralgia (23) which were sometimes accompanied by features of systemic connective tissue disease. These findings are compared with rheumatic disease in other North American Indians.

An interactive computerized protocol for the management of hypertension: effects on the general practitioner's clinical behaviour.

This paper reports an experimental study of general practitioners' use of an interactive computerized protocol for the management of hypertension, focussing particularly on the protocol's effects on doctors' clinical behaviour. Prior to its computerization a paper-based version of the protocol was used enabling a comparison of the alternative forms. Doctors' delivery of care was assessed from video recordings of 89 consultations and from the records made during these consultations. Comparisons were made of consultations conducted under control and experimental conditions. Use of paper and computer protocols resulted in significant improvements in the doctors' delivery of care, in terms of the range of verbal and physical examinations conducted and recorded. The protocol's effects were most marked when the computerized version was used. However, use of the computer protocol resulted in the recording of information on the non-occurrence of certain events which had not been explicitly elicited during the verbal examination; features of the design which were intended to encourage adherence to the protocol may have been inappropriate to the realities of a general practice consultation. The findings provide some useful insights for the design of future computerized protocols for the management of chronic conditions.

Anaphylactoid reactions during haemodialysis are due to ethylene oxide hypersensitivity.

Anaphylactoid reactions during haemodialysis are unusual, but increasingly recognised. It has recently been reported that there is a significant association between such reactions and the presence of IgE to albumin exposed to ethylene oxide (ETO). Review of the clinical features and epidemiology of dialysis anaphylaxis in the light of this new data suggests that these reactions are due to ETO hypersensitivity.

Spleen size in chronic renal failure.

To investigate the cause of clinically detectable splenomegaly, which is common in patients receiving regular haemodialysis, splenic volume was assessed by isotopic scanning using intravenously injected technetium-99m microspheres in 34 controls and 149 patients with chronic renal failure. Of the patients, 16 had never received dialysis, 10 were undergoing continuous peritoneal dialysis, 94 were undergoing regular haemodialysis, and 29 had undergone successful renal transplantation more than nine months previously. Mean splenic volume was increased only in the patients who were receiving haemodialysis. Splenic enlargement was probably not due to iron overload as it occurred in all patients who had received haemodialysis, 14 of whom had not received intravenous iron. No patient had had hepatitis. Splenic enlargement was probably related to the process of haemodialysis itself and may have been due either to red cell damage produced by haemodialysis or to an immunological reaction induced by a component of haemodialysis, possibly ethylene oxide.

IgE against ethylene oxide-altered human serum albumin in patients who have had acute dialysis reactions.

Serum samples obtained from seven hemodialysis patients with immediate-type allergic reactions, from six hemodialysis patients without reactions, and from three nonatopic control subjects were analyzed for IgE against human serum albumin exposed to ethylene oxide (ETO-HSA). ETO is used to sterilize medical equipment like dialyzers that cannot withstand heat sterilization. IgE to ETO-HSA, measured by a polystyrene tube technique was found in six of seven dialysis reactor patients but in only one of six nonreactor patients (p less than 0.05 two-tailed Fisher's exact test). No control sera from three nonatopic individuals had antibody. The reactor patients had 2.0 +/- 8.0 ng (SD) of ETO-HSA bound per milliliter of serum, whereas nonreactor patients had 0.2 +/- 8.0 ng per milliliter bound (p less than 0.05 one-tailed Student's t test on log transformed values). We suggest that there is an association between the presence of IgE to ETO-HSA and immediate-type allergic reactions to dialysis in this group of patients.

Radiation-induced cerebellar chondrosarcoma. Case report.

The authors report a case of chondrosarcoma arising in the cerebellum 16 years after treatment of a cerebellar malignant astrocytoma by subtotal resection and irradiation. It is thought that the chondrosarcoma arising within the intracranial cavity was a probable consequence of previous ionizing radiation.

Water purification and the incidence of fractures in patients receiving home haemodialysis supervised by a single centre: evidence for "safe" upper limit of aluminium in water.

Between 1968 and 1980 fractures occurred in 56 of 284 patients treated by home haemodialysis in the Sheffield area for longer than one year. Patients sustained four times as many fractures while using dialysate prepared with water containing more than 1.0 mumol aluminium per 1 (2.7 micrograms/100 ml) than while using water containing a smaller concentration. When aluminium was removed from water by deionisation the incidence of fractures diminished during the next year and no patient developed dialysis encephalopathy. These findings show that 1.0 mumol/l is a safe maximum concentration of aluminium in water for use in home haemodialysis. It can be detected by the colorimetric aluminium analyses used by many water authorities. When financial resources are limited it is expedient to reserve aluminium analyses by electrothermal atomic absorption for plasma from patients receiving regular haemodialysis. Ingestion of aluminium hydroxide contributes significantly to the increased plasma aluminium concentration of these patients.

Selective C4 deficiency, systemic lupus erythematosus, and Whipple's disease.

A 45-year-old female with selective deficiency of C4 and systemic lupus erythematosus developed puzzling gastrointestinal and systemic symptoms in the last 6 months of her life. Extensive investigation of the gastrointestinal tract did not yield any diagnosis, and the patient died shortly afterwards. Autopsy revealed evidence of a typical Whipple's disease of the jejunum and lymph nodes. This association has not been previously described. The disease is reviewed with emphasis on its being an opportunistic infection in an immunosuppressed host with a complement deficiency and SLE.

Impact of continuous ambulatory peritoneal dialysis on treatment of renal failure in patients aged over 60.

Thirty eight patients aged over 60 with end stage renal disease were treated by continuous ambulatory peritoneal dialysis for up to three years. Most of these patients, because of their age or coexisting diseases, had been considered to be unsuitable for haemodialysis by the criteria used before the advent of continuous ambulatory peritoneal dialysis in 1980. Actuarial patient survival at one and two years was 72% and 61% respectively, and only two patients were permanently transferred to haemodialysis. Twenty one of the 23 survivors were fully rehabilitated, the remaining two being partially disabled but living at home. Continuous ambulatory peritoneal dialysis permits more liberal selection of patients with end stage renal disease for renal replacement treatment with excellent survival and rehabilitation and without overburdening scarce hospital haemodialysis facilities.

Splenic siderosis and parenteral iron dextran in maintenance haemodialysis patients.

The histological features of 40 spleens surgically removed from maintenance haemodialysis patients are reported. Twenty-four of the 40 (60%) showed massive iron loading and a significant direct correlation was found between iron loading and the amount of intravenous iron dextran administered. Since parenteral iron dextran appears to be a major factor in causing iron overload in haemodialysis patients its use as a method of iron replacement in these patients would appear inappropriate.

Genital oedema in patients treated by continuous ambulatory peritoneal dialysis: an unusual presentation of inguinal hernia.

Four patients receiving continuous ambulatory peritoneal dialysis presented with scrotal or labial oedema but no detectable cough impulse. Two of the patients later developed clinical evidence of inguinal hernia, and in the other two inguinal hernias were found at operation. These cases suggest that genital oedema occurring in a patient receiving continuous ambulatory peritoneal dialysis is a sign of a small inguinal hernia which may not be detectable clinically.