Restructuring. 1. Setting the framework--restructuring the organisation

The NHS has undergone several major overhauls since it was set up in 1948. This series of five articles examines some of the current fashions in organisational restructuring--from process re-engineering and patient-focused care to GP fundholding--and analyses some of their longer-term consequences from the perspective of professional training and development. Finally, we consider what the shape of the NHS might look like in the late 1990s.     

Combining qualitative with quantitative approaches to study contraceptive pill use

According to large-scale studies, oral contraceptive users become pregnant at rates that exceed ideal use failure rates. It is thought that a major cause is missed pills, but current research on consistent contraceptive pill taking is characterized by inadequate measures and a failure to investigate women's thinking about their own patterns of use. The purpose of this study was to gain some understanding about women's interpretations of consistency in their own pill taking through combining qualitative with quantitative data. The study was conducted in China, where contraception is free and widely available. Five urban and five rural oral contraceptive users were followed for up to three pill-taking cycles during 1996 for a total of 759 person-days. Consistency of pill taking was measured with electronic data obtained from a new blister package made by Anderson Clinical Technologies (Elmhurst, IL). Data from these devices were reviewed and interpreted by the study participants during in-depth private interviews. The users' reasons for missing pills included disruptions in their daily routines, their husband's absence, spotting, and trouble implementing the family planning program's instructions to take one pill per day for 22 days and start the next cycle on the fifth day of menses. One user gave these reasons for two cycles but denied missing numerous pills in her third cycle. Data from a series of four questionnaires showed that most demographic, psychosocial, and service system characteristics were not related to missed pills. However, results suggested that the daily routines of rural living may make consistent use more likely and that instructions for taking the pill may be associated with prolonged pill-free intervals and skipping pills during episodes of spotting. Three of the 10 women were at increased risk of pregnancy during the study period because of their pill-taking pattern. We concluded that the combination of qualitative with quantitative data enhances understanding of contraceptive use. Women themselves offer plausible reasons for their use behaviors. Listening to women could be useful in improving programs.     

Cardiovascular and hormonal responses to a meal in hypertrophic cardiomyopathy: A comparison of patients with and without postprandial exacerbation of symptoms

Some patients with hypertrophic cardiomyopathy experience postprandial exacerbation of symptoms. The aim of this study was to determine whether the hemodynamic and/or hormonal responses to a meal differ between patients with and without postprandial symptoms. Ten hypertrophic cardiomyopathy patients with postprandial symptoms, 10 patients without postprandial symptoms, and 10 normal subjects ate a 740 Kcal meal, following which heart rate, blood pressure, and echocardiographic and gastrointestinal hormone changes were compared among the three groups. Heart rate increased (p<0.001) and diastolic blood pressure fell (p < 0.001) to a similar degree in the three groups. Left ventricular outflow tract velocity increased (p< 0.01) and some patients had substantial increases in outflow tract pressure gradient; however, this was independent of the presence or absence of postprandial symptoms. The atrial contribution to filling increased in normal subjects and in both groups of hypertrophic cardiomyopathy patients. There was no significant difference in the gastrointestinal hormone changes in the three groups. In summary, there is no evidence for a distinctive hemodynamic or hormonal response to food in hypertrophic cardiomyopathy patients with postprandial symptoms. These symptoms more likely reflect differences in underlying cardiac disease characteristics and severity.     

Identification of a mutation in the beta cardiac myosin heavy chain gene in a family with hypertrophic cardiomyopathy.

OBJECTIVE--To investigate the molecular genetic basis of the cause of disease in a family with hypertrophic cardiomyopathy. BACKGROUND--Mutation within the beta cardiac myosin heavy chain gene has been shown to be the pathogenetic mechanism underlying the disease in several families, though clear evidence of heterogeneity has been reported. PATIENTS--A family with a history of hypertrophic cardiomyopathy. RESULTS AND CONCLUSION--This paper reports a mutation at aminoacid position 908 within exon 23 of the beta cardiac myosin heavy chain gene, resulting in a conversion of a leucine to valine. This base substitution was identified in an individual with a confirmed family history but with equivocal symptoms of the disease. Inheritance of the mutation by his symptom free juvenile offspring demonstrates the application of the technique to presymptomatic diagnosis.     

Myocardial beta adrenoceptor density in primary and secondary left ventricular hypertrophy

OBJECTIVES: Myocardial ß-adrenoceptor density has been found tobe reduced in hypertrophic cardiomyopathy, even when systolicfunction is preserved. Our purpose in the current study wasto investigate whether ß-adrenoceptor down-regulationwas unique to hypertrophic cardiomyopathy, or is also presentin secondary myocardial hypertrophy. METHODS: Myocardial ß-adrenoceptor density was measured in11 patients with hypertrophic cardiomyopathy, eight patientswith left ventricular hypertrophy secondary to arterial hypertensionor aortic valve disease and 18 normal control subjects, usingpositron emission tomography with ¹¹C-CGP-12177 as the myocardialß-adrenoceptor ligand. RESULTS: Reflecting the natural incidence of the conditions, the ageof the hypertrophic cardiomyopathy patients was 37 (10) [mean(SD), range 20–51] years and that of the secondary hypertrophypatients 64 (18), [range 26–80] years; P<0.01. Thecontrols' ages were 50 (13), [range 21–65] years; however,since ß-adrenoceptor density is known to be influencedby age, the controls' data was split into groups matched tothe hypertrophic cardiomyopathy and secondary hypertrophy patientsets. For the hypertrophic cardiomyopathy patients, mean leftventricular ß-adrenoceptor was 7.70 (186) pmol . g^–1compared to 10.17 (244) pmol . g^–1 for a matched set of15 controls; P<0.01. In secondary left ventricular hypertrophy,ß-adrenoceptor was 6.35 (1.70) pmol . g^–1 comparedto 9.16 (2.00)pmol . g^–1 for a matched set of 10 controls;P<0.01. Plasma noradrenaline was 5.5 (2.2)nmol . 1^–1in hypertrophic cardiomyopathy and 2.5 (1.0)nmol. 1^–1for the matched controls; P<0.01. The results for adrenalinewere 2.2 (1.1) vs 0.4 (0.3) nmol . 1^–1 respectively; P<0.001.For the secondary hypertrophy patients, the corresponding figureswere 2.5 (1.2) vs 2.5 (1.0) nmol . 1^–1 for noradrenalinefor patients and controls respectively (P=ns); and for adrenaline0.2 (0.1) and 0.3 (0.2) nmol . 1^–1 respectively, P=ns.On multiple regression analysis, no relationships could be demonstratedamongst plasma catecholamines, ß-adrenoceptor, myocardialblood flow and echocardiographic E/A ratio and fractional shortening. CONCLUSION: Myocardial ß-adrenoceptor density appears to be comparablydecreased in both primary and secondary left ventricular hypertrophyin the presence of preserved left ventricular systolic function.