A comparison of blood pressure control in hypertensive patients treated in hospital clinics and in general practice

Two thousand and twenty hypertensive patients of 45 years and over were treated and followed up for either 6 months, 12 months, 18 months or 2 years. Seventeen hundred and forty of these patients were seen in hospital outpatient clinics, 280 in general practice.

The patients followed in general practice had an average blood pressure of 182/111 mmHg prior to treatment. The blood pressure after follow-up for 18-24 months averaged 156/97 mmHg. The corresponding results for the patients followed in hospital clinics were 195/115 mmHg untreated and 150/92 mmHg after follow-up.

The untreated blood pressures were higher in the hospital patients (p < 0·001 for systolic, p < 0·05 for diastolic pressure) and the treated diastolic pressures at 18-24 months were lower in the hospital than the general practice group (p < 0·001). The hospital patients did not receive a greater variety of drugs but were prescribed them in higher doses. Blood pressure control was considered to be inadequate in many patients in both groups. At 18-24 months, 26 per cent of the general practice group had diastolic pressures of 105 mmHg or more, as had 13 per cent of the patients followed in the hospital clinics.

     

A cervical cytology campaign using a computerised age-sex register

The computerised age-sex register of the population attending a small health centre was used to generate invitations to women aged from 25 to 64 years to attend for a cervical smear. The campaign took place over about three months and was accompanied by appropriate publicity measures.

Replies were received from 80·7 per cent of those to whom invitations were sent. Of those who replied, 11·5 per cent refused the test and of those who accepted 7·6 per cent failed to attend. The cost of the campaign was about £2,280, or £2.71 for each of the 842 smears taken. Of the publicity measures used, posters appeared to be more effective than evening paper publicity or handbills.

Just over 70 per cent of the women in the target population had a cervical smear during the campaign or in the preceding three years. It is not possible from the available data to assess whether this coverage rate justifies the costs of the campaign.

     

Fatal illness in general practice

In an investigation of fatal illness during a 12-month period in a practice of 5,897 patients in Glasgow, 58 deaths (42 male, 16 female) were recorded. Malignant neoplasms and myocardial infarction in male patients of 50 years and over accounted for 27 (46·6 per per cent) of the deaths. Thirty (51·7 per cent) of the deaths took place in hospital. Fifteen (25·9 per cent) of the deaths were sudden. In patients dying in hospital of malignant, cardiac, and respiratory disease the duration of the terminal stay in hospital represented a small proportion of the total duration of the illness, the principal burden of their care falling upon their families and community resources.

In an integrated health service much yet remains to be accomplished in co-ordinating the efforts of hospital and community teams in caring for the fatally ill patient.

     

The natural history of angina in a general practice

An appreciation of the natural history of angina pectoris is important when deciding on the place of new and potentially dangerous forms of treatment. During 1950-1975, 268 patients with angina were diagnosed and followed up in my London general practice. The annual incidence, in adults over 40, was five per 1,000 and increased with age.

During the period of follow-up, half the patients died, an annual mortality of 4·6 per cent. However, among the survivors one third ceased to suffer anginal symptoms spontaneously and without specific therapy. Of those who continued to suffer from angina, in 71 per cent the condition was graded as minor, in 27 per cent as moderate, and in only two per cent were the attacks severe and disabling. Usually the angina was primary (77 per cent) and it was secondary, after myocardial infarction, in 23 per cent.

Of the 134 deaths, three quarters were from a cardiovascular cause. This group of angina patients had a 2:1 times greater observed, than expected, risk of dying (O/E ratio). The O/E mortality ratio fell progressively with age. It was highest in the 40-49 decade (4·0) and lowest in the over 80s, when the observed mortality rate was less than expected (0·9). The O/E mortality ratio was higher in men (2·3) than in women (1·7).

From this survey I conclude that angina does not have a uniformly bad prognosis, and that with the advent of beta-adrenergic blockers, the proportion considered for angiocardiography and aorto-coronary bypass grafting should be less than five per cent of all patients with angina.

     

Acute sore throat—diagnosis and treatment in general practice

This study tested how general practitioners diagnose streptococcal infection on clinical grounds alone, in patients who presented with sore throats.

Four hundred and fifty-two patients were admitted to the study. A clinical diagnosis, prognosis and follow-up was completed in each case and the clinical assessment was checked by throat swabbing at first contact and a week later.

The doctors were inaccurate in predicting streptococcal infection, but better than might be expected if prediction were a matter of pure guesswork. Colds and influenza implied negative prediction, tonsillitis a positive prediction, and pharyngitis was doubtful.

In this series negative prediction for pharyngitis was 85·2 per cent and positive prediction 31·5 per cent accurate. The equivalent figures for tonsillitis were 61·5 per cent and 38·9 per cent respectively. There was a general tendency to overpredict streptococcal infection which was most marked in acute follicular tonsillitis, but this led to few false negatives. The tendency to overpredict streptococci was most marked when the patient was an adolescent female.

There were differences between the urban and rural patterns. During the same period, influenza (and similar illnesses) was recorded less often in the country, whereas urban practitioners were more likely to predict streptococcal infection. Rural practitioners were more accurate in prediction because they were less prone to implicate streptococcal infection than their urban colleagues; there was a higher proportion of cases with proven streptococcal infection in the town and there is a disproportionately high number of adolescent females among the urban patients.

     

Talking out of alcoholism: results from a survey of Alcoholics Anonymous in England and Wales

A national survey of Alcoholics Anonymous (AA) produced data on the way AA members talk about their experiences and the role this plays in achieving and maintaining sobriety. The survey was based on self-completion questionnaires given to one in four members attending meetings of a one in ten random sample of AA groups operating in England and Wales. Only 1·8 per cent of current members had never spoken at a meeting, while 62·5 per cent spoke regularly. Hearing other people's personal stories was felt by members to be the most useful part of AA meetings. At some time 81·9 per cent of members had told their own story and there was some relationship between dropping out and not telling personal stories. The great majority of those who had told stories reported changes in their content over time; 58·0 per cent of these changes involved a shift of emphasis from drinking to recovery. The results suggest that AA enables people to change the way they perceive and evaluate themselves. It enables them to talk themselves out of alcoholism.     

A study of bereavement in general practice

Forty six bereaved relatives were assessed by a general practitioner four to eight weeks after the bereavement. In 36 (78·3 per cent) the immediate reaction to bereavement was one of numbness or stupefaction; in seven (15·2 per cent) emotional relief occurred; and in three cases (6·5 per cent) there was no obvious immediate reaction. The numbness reaction was limited in duration to a week or less in 31 of the 36 instances.

At four to eight weeks after bereavement 29 (63·0 per cent) of the subjects continued to experience difficulty in coming to terms with their loss. Twenty subjects reported guilt feelings and a similar number expressed aggressive reactions. The bereaved subjects tended to increase their consumption of cigarettes and alcohol, while their appetite and weight tended to be reduced. Thirty six (78·3 per cent) of the subjects reported physical symptoms, notably headache, dizziness, generalised aches, and abdominal complaints.

The most prominent psychological features of bereavement were found to be: preoccupation with thoughts of the deceased, idealisation of the lost person, depressive mood, and loneliness.

The findings are discussed and reference made to the role of the family doctor in the management of bereavement reactions.

     

The accuracy of age—sex registers, practice medical records and family practitioner committee registers

This paper presents the results of a point prevalent evaluation of the comparative reliability and validity of age-sex registers, practice medical records and family practitioner committee (FPC) registers from five teaching practices. They all exhibited similar levels of acceptable accuracy for patient names, sex and age, but the distribution of wrong addresses varied greatly: practice medical records 3·9 per cent, age-sex registers 8·2 per cent and FPC registers 17·1 per cent. The presence of a patient entry in all three registers was associated with a high degree of probability (95·3 per cent) that this individual would be a bona fide practice patient. The register population inflation rates were FPC records 5·5 per cent, practice records 9·8 per cent and age-sex registers 10·6 per cent, but there were large variations between individual practices. A statistically significant contribution to inflation rates came from the age groups 0 to 1 and 21 to 40 (p<0·0005). The register population deflation rates were minimal. The significance of these findings is discussed and the need for practices to determine the accuracy of their individual age-sex registers is stressed. A convenient and economic method for so doing is suggested. We also suggest ways of making it easier to construct and use age-sex registers, since they can be a most versatile and useful aid to research in general practice.     

Converting medical records to A4 size in general practice

A procedure for converting the medical record envelopes now used in general practice to an A4-sized record folder is described. The average time for conversion was 20·2 minutes per record and the cost, excluding filing equipment, averaged 41·6 pence for each record. The average cost to the practice was reduced to 16·4 pence per record by the reimbursement of 70 per cent of the clerk's salary from the local Family Practitioner Committee.     

A labour-saving manoeuvre

Slow progress in the first stage of labour was treated in 792 mothers by digital dilatation. This manoeuvre is described. Partial dilatation was converted to complete dilatation in 94·4 per cent of all cases, the incidence of success being 90·0 per cent in primiparae and 96·0 per cent in multiparae. Difficulties are described, but serious complications were conspicuously absent.

The manoeuvre was helpful with mothers unable to resist premature bearing down, and especially valuable for reducing delay before applying forceps for fetal distress. The early perinatal loss of 20 (in the first 200 cases) was reduced to 3·3 (in the last 599 births) after a change of technique.

     

The prevalence and diagnosis of headache in an urban practice

During a six-month study, one person in every 24 of the practice population consulted us about headache. There were more than twice as many females as males, and the largest group of females was in the 20 to 40 year age group.

The majority of patients were managed entirely in the practice; only 10·4 per cent were investigated and four per cent were referred to hospital. The commonest cause was tension. Two patients had headaches due to serious pathology and one of these died.

     

Telephone messages received by seven general practices

Telephone calls were recorded in seven general practices in Aylesbury in a study of communications received from the hospitals, local health authority (L.H.A.), social services department, and other sources, but excluding calls from patients.

Analysis of 855 telephone calls revealed patterns of communication with the staff of the practices which have not previously been recorded. The general practitioners were central in communications from all sources except the local health authority, while calls to health visitors came overwhelmingly from the local health authority. Community nurses received only 36 (four per cent) of all the calls despite the interests expressed by hospital nursing staff in their responses to a postal questionnaire. A hypothesis is advanced to explain this discrepancy between interest and action.

     

Ten years' experience in general practice of dip-slide urine culture in children under five years old

Of 567 children under five registered with an industrial general practice over a 10-year period, 559 presented with symptoms of ill health in the first five years of life, and of these, 158 (27·9 per cent of those registered) had urine cultured using the dip-slide method. Thirty-four (12·3 per cent) girls and 23 (7·9 per cent) boys had at least one episode of significant bacteriuria. Two boys and three girls were found to have radiological abnormalities of the genito-urinary tract, of which two were obstructive lesions requiring surgery.

Symptoms usually ascribed to the urinary tract in older children and adults did not discriminate for infection in this age group and were not a reliable indicator of the presence, or of the absence, of significant bacteriuria.

The incidence of significant bacteriuria was considerably above that recorded by surveys on asymptomatic children. Proteus infections were four times more common among boys than girls, and under the age of three the proportion of boys with bacteriuria exceeded that of girls.

Dip-slide culture is a valuable tool in the diagnosis, management, and follow-up of urinary tract infection.

     

Monitoring the dose of digoxin

All patients being prescribed digoxin in a general practice were examined and the serum urea, creatinine, electrolytes, and digoxin concentrations were determined.

Sixty-six patients were identified (0·73 per cent of the practice population). After excluding six, whose tablet-taking was unreliable, it was found that two patients had serum digoxin levels above the usually accepted upper limit and a total of 23 patients (38 per cent of the digoxin takers) had some alteration made to their dose, including eight whose digoxin was stopped. We believe that serum digoxin estimations are useful in determining the optimum dose of digoxin in general practice.

     

Control of hypertension in family practice by the doctor-nurse team

In Israel, most hypertensives are treated by the family doctor alone. In 45 family practices, nurses were given a more active part to play in the follow-up of these patients, including measuring weight and blood pressure, giving dietary guidance, checking patient compliance and actively following up drop-outs. After two years' follow-up, of a total of 4,255 patients studied, 82·4 per cent were under control (diastolic blood pressure less than 95 mmHg) compared to 42·1 per cent at the onset of the study. The drop-out rate was 0·65 per cent.     

Multipractice studies: significance of the information given to participating doctors

A total of 1,176 general practitioners were asked to take part in a multipractice study. One group of 568 practitioners was given very detailed information about the study and 19·7 per cent agreed to take part. The remaining 605 practitioners were given only a brief introduction to the study. Of this group 33·4 per cent agreed to take part. Two thirds of the doctors participating in the trial were sent weekly reminders about the study while the remaining third were not. We found that the reminders did not affect the number of patients registered by the practitioners.     

Frequency of deletion of short arm satellites in acrocentric chromosomes

The frequency of deletion of short arm satellites has been examined in various populations. Four out of 2509 males in psychiatric institutions and prisons had Dps- or Gps- (1·6 per 1000), and five out of 6187 persons in the general population had Dps- or Gps- (0·8 per 1000). The difference is not significant.

The segregation rate of the chromosome with lack of short arm satellite material did not deviate from unity in the few families where such calculations were possible. There was no increase in abortions or non-disjunction in the families with an acrocentric chromosome lacking short arm satellite material.

The study indicates that the frequency of Dps- and Gps- in the population is between 0·5 and 1·0 per 1000 and that the lack of short arm satellite material is without any deleterious effect on phenotype.

     

Serum associated leucocyte locomotion inhibition and leucocyte motility in malignant melanoma: effect of BCG treatment

Serum-associated leucocyte locomotion inhibition (SALLI) and leucocyte motility were investigated in patients with malignant melanoma. Ten days after tumour excision twelve out of eighteen patients' sera exhibited a SALLI exceeding the normal range of 15%. The mean SALLI thus reached was 59·2±5·2%. No correlation was observed between SALLI and the level of invasion or the stage of the disease.

Six patients selected at random who had a mean SALLI of 71·5±5·8% after tumour excision were further treated by BCG immunotherapy and presented after 8·2±2·9 months of therapy with a significantly (P<0·01) lower SALLI of 32·6±8·1%. In eight patients treated exclusively by surgical excision, SALLI remained basically unchanged in the course of 10±2·8 months (29·0±8·0% vs 30·4±12·9%).

The mean index of leucocyte locomotion (LL) of eight melanoma patients who had received BCG for 11·2±2·3 months was 5·9±0·9 cells/field and thus significantly (P<0·01) higher in comparison with the mean index of LL (2·8±0·5) found in eight patients treated by surgical excision only 12·4±2·1 months before testing.

In addition, patients receiving BCG had a significantly higher (P<0·05) mean value of LL than fifteen healthy controls who presented with a mean index of LL of 3·4±0·3 cells/field. Our results permit the suggestion that BCG decreases SALLI and increases LL in melanoma patients.

     

Antigen-binding thymus-derived lymphocytes: I. Rapid method for isolation of theta-positive antigen-stimulated cells

A rapid method for separating SRBC-stimulated populations of theta (θ)-positive thymus-derived lymphocytes from bone marrow-derived lymphocytes and plaque-forming cells has been developed using cotton wool columns. The column effluent was monitored for plaque-forming and `rosette'-forming cells. Stimulated θ-negative cells were found to adhere preferentially to cotton wool. The total recovery of small lymphocytes was 12±3 per cent and the yield of rosette-forming cells was 5.5±4 per cent of which 85±5 per cent were θ-positive.     

An analysis of 3,199 patients booked for delivery in general-practitioner obstetric units

The outcome of 3,199 women booked for delivery in six general-practitioner obstetric units in one year was analyzed.

Five per cent cancelled their bookings, 26 per cent were transferred to a consultant unit after referral for routine problems of pregnancy (mainly postmaturity), and 14 per cent were transferred for problems arising in labour (principally uterine inertia). One per cent were transferred after confinement.

Fifty-four per cent were delivered successfully in the general-practitioner units.

There were 3,037 live births, 27 stillbirths and 22 neonatal deaths. Nine stillbirths and nine neonatal deaths resulted from congenital abnormalities, while two stillbirths and 11 neonatal deaths were due to immaturity. There were 25 sets of twins and one set of triplets. Seventy-five babies were abnormal, 105 weighed less than 2,500g, and 198 over 4,000g.

In this series almost 60 per cent of eventual perinatal deaths were transferred during pregnancy, and over 85 per cent before delivery.

The perinatal mortality of all women initially booked for a general-practitioner unit who delivered was 15·. The perinatal mortality of the 1,795 births in the six general-practitioner obstetric units was 3·9.