BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

Drugs and crime - making the connection: a discussion paper.

In this discussion paper, the author discusses the level of drug-related crime in Dublin. The author outlines the legislative framework as set out in the Misuse of Drugs Acts, 1977 and 1984 and the Misuse of Drugs Regulations, 1988. He also investigates the powers of investigation of the Gardai, and the situation in the courts and prisons when dealing with drug related offences. The author concludes with commentary on the current drug culture and some proposals for reform to tackle the growing drug problem

Drugs: the judicial response (continued from May issue).

This paper examines the difficulty in applying simple determinate sentences, except for those deserving of the highest possible punishment. It is argued that in sentencing what every court is aiming for is not uniformity of sentence, which is impossible, but of uniformity of approach. One of the problems addressed here is the scale of difference between a commercial dealer and the helpless addict. Also discussed are those sentenced as couriers, students, social suppliers of drugs and those supplying drugs for a third country. Suggestions are made for leniency for those who assist investigations. Finally it is suggested that rather than use simplistic legislative models that, for example, relate quantity of drugs to sentence, alternatives to imprisonment such as treatment should be considered

Drugs: the judicial response.

This article examines current trends where courts are used as deterrent weapons in the fight against crime, and the belief that addiction and dependency are the engines driving crime