The purpose of the present study was to investigate whether criteria associated with assignment of asthma patients between general practice (GP) care alone, integrated care (shared between GP care and hospital clinic) or conventional specialist review could be identified, and whether outcomes for these patients differed over the next 12 months.Seven hundred and sixty four patients with a diagnosis of asthma and previously assigned to either integrated care or clinic care were reviewed after 1 year and reassigned. These patients were then followed for another 12 months and clinical data were collected over this time.After 12 months in clinic care or integrated care, assignment to integrated care was predicted by previous participation in integrated care (OR 2.94), patient preference for integrated care (OR 3.7), no admission (OR 1.56), fewer steroid courses during the previous year (OR 0.88) and nonattendance at review (OR 0.43) in the previous 12 months. Patient discharge to GP care was predicted by higher level of forced expiratory volume in one second (FEV1) (OR 1.49), lower number of GP consultations for troublesome asthma (OR 0.78), and nonattendance for review in the preceding year (OR 2.15). In the following 12 months, the three groups of patients differed significantly in hospital admissions (Discharged= 0.008; Integrated=0.12; Clinic=0.31), bronchodilators prescribed (Discharged=8.5; Integrated=10.2; Clinic=13.9), GP consultations (Discharged=1.3; Integrated=3.0; Clinic=4.1) and oral steroid courses (Discharged=0.62; Integrated=1.7; Clinic=2.4).Patients assigned to integrated care, clinic care or discharged to general practice care form three distinct patient populations differing retrospectively and prospectively in morbidity and admission risk. In particular, patients assigned to integrated care fall midway in risk and morbidity between those discharged or those retained in clinic care. These results suggest that integrated care provides general practitioners with a system of management for asthma patients, for whom they do not wish frequent specialist review but who they do not believe can safely be discharged to general practice care only. Eur Respir J., 1996, 9, 444-448 In medical systems which have two tiered patient care, (specialist out-patient clinics and general practice (GP) care) it is believed that specialist care allows greater costeffectiveness and the focusing of clinical expertise. However, it can be associated with gaps in communication between the specialist who sees the patient at regular intervals in an out-patient clinic and the GP, who sees the patient irregularly and at times of crisis with little knowledge of what is being provided in the specialist clinic. Shared care is intended to address these problems of communication and to offer patients care in general practice which has the support of specialist expertise. Shared care has been defined as "the joint participation of hospital consultants and general practitioners in the planned delivery of care for patients with ...

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It is rare to find two different causative organisms in a case of meningitis and of extreme rarity when one of these organisms is the tubercle bacillus. Neal (1924) reported her analysis of 1535 cases of meningitis, in which only six (0-32 per cent.) were due to mixed-organisms. All six cases were in children and included such organisms as the meningococcus, staphylococcus, b. paratyphosus B., haemolytic and non-haemolytic streptococcus, pneumococcus, and organisms of the b. coli group, but not the tubercle bacillus. An interesting case of mixed meningitis was described by Ravitch and Washington (1937) in a child whose blood culture grew meningococci and salmonella suipestifer. Both organisms were also cultured from the cerebrospinal fluid, but it was believed that the salmonella suipestifer had been introduced by blood contamination of the cerebrospinal fluid during lumbar puncture. Ashmun (1933) had five cases of mixed meningitis with pneumococci and streptococci present in the cerebrospinal fluid of all cases. In two cases the diplococcus catarrhalis was also present.

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