Objective To assess how pressures from patients on doctors in the consultation contribute to referral and investigation.

Evidence suggests that atopic individuals may be predisposed to more severe rhinoviral colds coupled to a worsening of existing airway disease than those with asthma. The role of atopy and IgE levels, as well as their relationship to clinical disease expression have not been defined. We hypothesized that an allergic diathesis modulates rhinoviral colds and have initiated studies of normal, atopic and asthmatic subjects employing experimental rhinoviral infection, with measurements of symptom scores, viral shedding and cultures, albumin in nasal washes and serological responses. Twenty-two subjects (11 normal, 5 atopic, 6 atopic and asthmatic) participated and were inoculated with human rhinovirus serotype 16 (HRV 16). Measurements of neutralizing antibody and viral culture were performed at screening, pre-inoculation, during the cold and at 8-10 weeks convalescence. Daily symptoms were noted, nasal washes done, IgE measured and atopy was diagnosed by skin tests. Seventeen volunteers developed clinical colds as assessed by symptom scores, virus shedding was demonstrated (with positive culture) in all subjects and a fourfold or higher seroconversion occurred in 11/22. Neutralizing HRV antibody developed unexpectedly in 10 subjects between screening and inoculation and the presence of absence of this pre-inoculation antibody determined subsequent severity of colds in normal but not in atopic subjects. Atopic antibody positive individuals developed severe clinical colds that were independent of preinoculation antibody in contrast to normal subjects who developed mild colds in the presence of a neutralizing antibody (P = 0.01). Both atopic and normal antibody negative subjects developed severe colds.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective To assess the impact of leaflets encouraging patients to raise concerns and to discuss symptoms or other health related issues in the consultation. Design Randomised controlled trial. Setting Five general practices in three settings in the United Kingdom. Participants 636 consecutive patients, aged 16-80 years, randomised to receive a general leaflet, a depression leaflet, both, or neither. Main outcomes Mean item score on the medical interview satisfaction scale, consultation time, prescribing, referral, and investigation. Results The general leaflet increased patient satisfaction and was more effective with shorter consultations (leaflet 0.64, 95% confidence interval 0.19 to 1.08; time 0.31, 0.0 to 0.06; interaction between both − 0.045, − 0.08 to -0.009), with similar results for subscales related to the different aspects of communication. Thus for a 10 minute consultation the leaflet increased satisfaction by 7% (seven centile points) and for a five minute consultation by 14%. The leaflet overall caused a small non-significant increase in consultation time (0.36 minutes, − 0.54 to 1.26). Although there was no change in prescribing or referral, a general leaflet increased the numbers of investigations (odds ratio 1.43, 1.00 to 2.05), which persisted when controlling for the major potential confounders of perceived medical need and patient preference (1.87, 1.10 to 3.19). Most of excess investigations were not thought strongly needed by the doctor or the patient. The depression leaflet had no significant effect on any outcome. Conclusions Encouraging patients to raise issues and to discuss symptoms and other health related issues in the consultation improves their satisfaction and perceptions of communication, particularly in short consultations. Doctors do, however, need to elicit expectations to prevent needless investigations.

Objective To assess the effect of brief interventions during the "watchful waiting" period for hypertension. Design Factorial trial. Setting General practice. Methods 296 patients with blood pressure > 160/90 mm Hg were randomised to eight groups defined by three factors: an information booklet; low sodium, high potassium salt; prompt sheets for high fruit, vegetable, fibre; and low fat. Main outcome measures Blood pressure (primary outcome); secondary outcomes of diet, weight, and dietary biomarkers (urinary sodium:potassium (Na:K) ratio; carotenoid concentrations). Results Blood pressure was not affected by the booklet (mean difference (diastolic blood pressure) at one month 0.2, 95% confidence interval 1.6 to 2.0), salt (0.13; 1.7 to 2.0), or prompts (0.52; 1.3 to 2.4). The salt decreased Na:K ratio (difference 0.32; 0.08 to 0.56, P = 0.01), and the prompts helped control weight (difference 0.39 (0.85 to 0.05) kg at one month, P = 0.085; 1.2 (0.1 to 2.25) kg at six months, P = 0.03). Among those with lower fruit and vegetable consumption ( < 300 g per day), prompts increased fruit and vegetable consumption and also carotenoid concentrations (difference 143 (16 to 269) mmol/l, P < 0.03) but did not decrease blood pressure. Conclusion During watchful waiting, over and above the effect of brief advice and monitoring, an information booklet, lifestyle prompts, and low sodium salt do not reduce blood pressure. Secondary analysis suggests that brief interventionsparticularly lifestyle prompts-can make useful changes in diet and help control weight, which previous research indicates are likely to reduce the long term risk of stroke.

The association between diet and chronic obstructive pulmonary disease in subjects selected from general practice. L. Watson, B. Margetts, P. Howarth, M. Dorward, R. Thompson, P. Little. #ERS Journals Ltd 2002. ABSTRACT: It is unclear why some smokers develop chronic obstructive pulmonary disease (COPD) whilst the majority do not. Antioxidants found in food may protect against lung tissue injury, but previous epidemiological studies are inconsistent and do not focus on those most at risk of COPD, namely smokers. This case-controlled study measured the difference in dietary intake between smokers and exsmokers with and without COPD.Cases were patients w45 yrs of age with w10 pack-yrs of smoking, a forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) of ¡70% and a FEV1 of ¡80% of predicted. Controls were patients w45 yrs of age with w10 pack-yrs of smoking, a FEV1/FVC of w70% and a FEV1 w80% pred. Data were collected using validated questionnaires. Logistic regression analysis for an unmatched case-controlled study was performed.After controlling for other independent predictors of COPD, those with vegetable intake of o1 portion?day -1 (93 g) were less likely to have COPD, as were those consuming o1.5 portions?day -1 of fruit. This was not due to an overall reduction in food/calorie intake caused by the disease because: 1) adjusting for body mass index did not alter the estimates; 2) the effect was specific to fruit and vegetables, i.e. not other food groups; and 3) the estimates from incident cases were similar.In conclusion, fruit and vegetable consumption is inversely associated with chronic obstructive pulmonary disease and may explain why some smokers do not develop chronic obstructive pulmonary disease. Eur Respir J 2002; 20: 313-318.