Clustered randomised trial of an intervention to improve the management of asthma: Greenwich asthma study.

OBJECTIVES: To evaluate the effectiveness of an asthma resource centre in improving treatment and quality of life for asthmatic patients. DESIGN: Community based randomised controlled trial. SETTING: 41 general practices in Greenwich with a practice nurse. SUBJECTS: All registered patients aged 15-50 years. INTERVENTION: Nurse specialists in asthma who educated and supported practice nurses, who in turn educated patients in the management of asthma according to the British Thoracic Society's guidelines. MAIN OUTCOME MEASURES: Quality of life of asthmatic patients, attendance at accident and emergency departments, admissions to local hospitals, and steroid prescribing by general practitioners. RESULTS: Of 24 400 patients randomly selected and surveyed in 1993, 12 238 replied; 1621 were asthmatic of whom 1291 were sent a repeat questionnaire in 1996 and 780 replied. Of 24 400 patients newly surveyed in 1996, 10 783 (1616 asthmatic) replied. No evidence was found for an improvement in asthma related quality of life among newly surveyed patients in intervention practices compared with control practices. Neither was there evidence of an improvement in other measures of the quality of asthma care. Weak evidence was found for an improvement in quality of life in intervention practices among asthmatics registered with study practices in 1993 and followed up in 1996. Neither attendances at accident and emergency departments nor admissions for asthma showed any tendency to diverge in intervention and control practices over the study period. Steroid prescribing rates rose steadily during the study period. The average annual increase in steroid prescribing was 3% per year higher in intervention than control practices (95% confidence interval -1% to 6%, P=0.10). CONCLUSIONS: This model of service delivery is not effective in improving the outcome of asthma in the community. Further development is required if cost effective management of asthma is to be introduced.

Asthma in Greenwich, UK: impact of the disease and current management practices.

A great deal of the care of patients with asthma takes place in general practices. The aim of the present study was to describe the impact of asthma in the community and to identify current asthma self-management practices. A two-part questionnaire survey was conducted in a random sample (23%; n=24,398) of persons aged 16-50 yrs, registered with one of the 41 general practices in Greenwich, London, UK. The two parts were: a screening questionnaire identifying persons with current asthma (defined as waking with shortness of breath in the last 12 months, attack of asthma in the last 12 months, or currently taking treatment for asthma); and an asthma questionnaire (completed by those with asthma) assessing quality of life, frequency of asthma symptoms, possession and use of self-management tools, and action in the event of an exacerbation of asthma. The crude response rate was 51%, but this may be an underestimate due to errors in the sampling frame. The prevalences of wheeze and asthma in the past 12 months were 26% and 14%, respectively. Among asthma patients: 43% reported symptoms occurring three or more times per week, and 20% were woken by asthma symptoms on three or more nights per week; most had asthma with a mild impact on quality of life; 26% used inhaled steroids on most days in the preceding month; 16% had a peak flow meter at home; and 7% had oral steroids available. Of the 44% of subjects with asthma, who could identify an exacerbation of asthma in the preceding 6 months: 19% had used a peak flow meter during the episode; 19% had changed their treatment without first being told to do so by a doctor; and 50% had sought urgent medical help. Smokers used less appropriate asthma management and subjects whose asthma had a severe impact on quality of life used more treatment and peak flow monitoring. In conclusion, the prevalence of asthma among adults in Greenwich, UK, has increased since a similar survey in 1986. Many people have fairly mild asthma and a smaller number have severe disease. Much remains to be done to promote appropriate strategies for self-management of asthma exacerbations.

A reliable method to retrieve accident & emergency data stored on a free-text basis.

Accident & Emergency (A & E) data on asthma-related attendances are useful for studies on the effectiveness of asthma interventions, and to determine the relationship of environmental factors to asthma and asthma epidemics. The final diagnoses made in the A & E departments are not usually coded when entered into hospital databases in the U.K., although the "presenting complaint' can be retrieved from the computerized Hospital Information & Support Systems (HISS), from a free-text attendance diagnosis field entered by the reception clerk when the patient arrives at the A & E department. The validity of this as an indication of the final diagnosis is unevaluated. The aim of this study was to measure the validity of the string "asth' in the A & E attendance diagnosis field for identifying patients attending the A & E departments of two hospitals for asthma-related conditions. A list of patients who attended the A & E department of two hospitals was retrieved from the HISS along with the attendance diagnosis field. If the attendance diagnosis field contained the text string "asth', mentioned wheeze or breathing problems, or the patients were referred by their GP without any diagnostic information entered on HISS, the records were selected for evaluation. The remaining attendances, which were not evaluated further, were attributed to another diagnosis based on the evidence of the recorded attendance diagnosis. The results indicated that the string "asth' in the attendance diagnosis field had a sensitivity of 80.3% (95% CI 75.1-85.5%) and a specificity of 96.7% (95% CI 95.6-97.8%) for a final diagnosis of asthma. It is concluded that free-text attendance diagnosis fields in hospital databases can be searched with suitable strings to obtain reliable data on attendance with asthma. As part of another investigation, the present authors attempted to retrieve a list of the attendances with asthma at the same two A & E departments at a time that was reportedly associated with an epidemic of asthma following a thunderstorm. On this occasion, the string "asth' proved to be significantly less sensitive. The possible reasons for this and the implications for using this method for identifying cases are discussed.

Prolonged clearance of microfilaraemia in patients with bancroftian filariasis after multiple high doses of ivermectin or diethylcarbamazine.

In a double-blind trial on 37 asymptomatic microfilaraemic subjects (minimum 400 microfilariae [mf] per mL) with Wuchereria bancrofti infection, the safety, tolerability and macrofilaricidal efficacy of 12 fortnightly doses of ivermectin, 400 micrograms/kg (ivermectin group), was compared with 12 fortnightly doses of diethylcarbamazine (DEC), 10 mg/kg (DEC group), over a period of 129 weeks after treatment. A control group (LDIC group) was treated with low dose ivermectin to clear microfilaraemia, for ethical reasons. Both ivermectin and DEC in high multiple doses were well tolerated and clinically safe. Macrofilaricidal efficacy was assessed by prolonged clearance of microfilaraemia, appearance of local lesions, and reduction of circulating W. bancrofti adult antigen detected by an antigen capture enzyme-linked immunoassay based on the monoclonal antibody AD12. Mf counts fell more rapidly after ivermectin than after DEC, but low residual mf levels were equivalent in these groups after week 4. Conversely, filarial antigen levels fell more rapidly after DEC than after ivermectin, but low residual antigen levels in these groups were statistically equivalent at all times beyond 12 weeks. Mild, self-limited systemic reactions to therapy were observed in all 3 treatment groups. Local reactions, such as development of scrotal nodules, were observed in several subjects in the DEC and ivermectin groups. These results suggested that high dose ivermectin and DEC both had significant macrofilaricidal activity against W. bancrofti, but neither of these intensive therapeutic regimens consistently produced complete cures. Thus, new drugs or dosing schedules are needed to achieve the goal of killing all filarial parasites in the majority of patients.

On an infection of a human eye with Parastrongylus (= Angiostrongylus) sp. in Sri Lanka.

A metastrongyle worm extracted from the anterior chamber of the right eye of a patient in Sri Lanka belongs to the genus Parastrongylus and probably to a yet undescribed species, related to P. cantonensis well known to infect man. It is mostly a parasite of rodents, wandering in man and unadapted to this host. Evidence for this lack of adaptation are that the specimen is undergoing necrosis (teratological specimen) and is located in an organ with little immunological defences.

Locally acquired cutaneous leishmaniasis in Sri Lanka.

Cutaneous leishmaniasis in a Sri Lankan, who had not left the country, is reported. The diagnosis was confirmed by detecting the parasite in smears under microscopic examination. This is the first case report of locally acquired leishmaniasis in Sri Lanka.

Comparative efficacy of single dose anthelmintics in relation to intensity of geohelminth infections.

The efficacy of a single dose of albendazole 400 mg, levamisole 2.5 mg/kg, mebendazole 500 mg, mebendazole 200 mg and pyrantel pamoate 10 mg/kg was evaluated in relation to the intensity of infection of Ascaris lumbricoides, Necator americanus and Trichuris trichiura. The study group comprised 667 3 to 12 year old children from poorer segments of the community. All 5 treatments produced high egg reduction rates ranging from 95.9% to 99.7% and substantial cure rates for Ascaris infection; the differences observed in the 5 treatment groups were not significant (p greater than 0.05). Although all treatment groups were effective against Necator, the number of patients was too small to draw useful conclusions. In Trichuris infections, although higher cure rates were obtained in light compared to heavy infections, the results were uniformly poor in all treatment groups. The few side effects encountered were mild and did not require any intervention.

Cutaneous leishmaniasis in Sri Lanka. An imported disease linked to the Middle East and African employment boom.

Cutaneous leishmaniasis acquired by two Sri Lankan nationals while they were employed in Iraq and Northern Nigeria respectively constitutes examples of an imported disease related to the 'Middle East and African employment boom'. In both cases the diagnoses were confirmed by demonstrating the parasites in smears from the lesions and in tissue sections, and by culturing the parasites in vitro. Since leishmaniasis, neither visceral nor cutaneous is prevalent in Sri Lanka the risks of 'introduced' diseases is discussed here in the context of these two cases.

Microfilariae of Brugia pahangi in the blood of cats have variable levels of feline IgG on their sheaths.

Feline IgG was found on the sheath of microfilariae (mf) of Brugia pahangi isolated from the blood of cats. Gamma heavy chains, both light chains, and the Fc and F(ab')2 portions of IgG were present, suggesting that the molecule is intact. The amount of IgG on the sheath was variable and the younger the mf the less IgG was present on their sheaths. Possible functions of this adherent layer of host protein are considered.

Congenital malaria due to Plasmodium vivax: a case report from Sri Lanka.

A case of Plasmodium vivax malaria in an eight-week-old infant in Colombo is documented, with epidemiological and circumstantial evidence which strongly supports a transplacental route of infection. The malarial antibody levels detected by the indirect fluorescent antibody technique in both mother and child are discussed in terms of the present epidemiological pattern of malaria in the country. We also comment on the species incidence of congenital malaria, this case being the first caused by P. vivax in Sri Lanka, despite this species being more prevalent than P. falciparum which has been reported in six previous cases of congenital malaria in Sri Lanka.