Objectives: To investigate whether there are inter-arm blood pressure differences that are of clinical importance to general practice. Design and setting: Pragmatic study with randomised order of use of left or right arm carried out in routine surgeries in an inner city and suburban general practice. Subjects: There were 237 patients presenting opportunistically for blood pressure measurement to a nurse or general practitioner. Main outcome measures: 95% limits of agreement between measurements on the left and right arm and bias between arms. Results: Large inter-arm blood pressure differences exist reflected in wide 95% limits of agreement; ؊16

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SummaryBackground: Exacerbations are now an important clinical variable for research into, and management of, chronic obstructive pulmonary disease (COPD). Emphasis is usually on reductions in the incidence of exacerbations and their impact on quality of life. For such research to be useful and comparable there needs to be a clearly defined understanding of what is meant by the term 'exacerbation'. The aim of this study was to explore the notion of COPD exacerbations from the viewpoint of patients who had recently suffered an exacerbation. Methods: Using principles from grounded theory we conducted semi-structured, in-depth interviews with 23 volunteers from Denmark, the Netherlands and the UK who were identified as having had a COPD exacerbation. Interviews were recorded locally and translated into English for analysis. Notable themes were identified for each informant and their occurrences compared. Results: Patients' reasons for consulting fell into four categories: 'frightening change'; 'change in sputum colour'; 'gradual deterioration'; and 'opportunistic diagnosis'. Most patients consulted frequently about their COPD, but did not afford their exacerbations the same degree of prominence as healthcare professionals (HCPs). Conclusions: These data provide a new way of thinking about COPD exacerbations, offering a greater understanding and classification of the reasons underlying the decision of COPD patients to consult with HCPs. They suggest that the patient perspective of exacerbations is more complex than previously thought. These findings could be applied to clinical practice and research, facilitating focussed decisions on COPD management.

The links between deprivation, poverty and ill health are well known, but many people with significant health problems do not claim welfare benefits to which they are entitled. Accessing advice within primary health care may be one way of tackling this problem. The aim of this development project was to develop and evaluate over a 3-year period a welfare rights advice and information service that would not only complement the work of the primary health care team, but also target those patients who were most in need. The service was developed using an action research approach. Three models were used with different primary health care teams. The evaluation consisted of both qualitative and quantitative elements. The qualitative study used semi-structured one-to-one interviews with 11 patients who consented to be contacted, two Citizens' Advice Bureau workers and 26 primary health care team members from 10 general practices in Gateshead covering a wide range of practices and patients (approximately 73 000) from all socioeconomic groups, and additional focus group interviews with three further primary health care teams. Quantitative data were collected by the Citizens' Advice Bureau on 683 patients and benefits received. A welfare rights service with an attached Citizens' Advice Bureau worker was seen as beneficial by the primary health care team. The work of the primary health care team was complemented by the CAB worker's additional expertise. Many patients entitled to benefits who would not otherwise have sought advice from a Citizens' Advice Bureau worker were referred by primary health care team members. It was found that targeting people unable to access the surgery reached those most in need in the project group. For those referred, a cumulative total of £1 641 865 was gained during the lifetime of the project. Many patients were referred and as a result received benefits. Optimum use of the service was achieved by restricting the service to the housebound. The use of a dedicated telephone line appeared to maximize the use of the workers' time, and also made few demands on the time of the primary health care team.