Evaluation of extended training for general practice in Northern Ireland: qualitative study

Objective To evaluate participants'' perceptions of the impact on them of an additional six months'' training beyond the standard 12 month general practice vocational training scheme.Design Qualitative study using focus groups.Setting General practice vocational training in Northern Ireland.Participants 13 general practitioner registrars, six of whom participated in the additional six months'' training, and four trainers involved in the additional six months'' training.Main outcome measures: Participants'' views about their experiences in 18 month and 12 month courses.Results Participants reported that the 12 month course was generally positive but was too pressurised and focused on examinations, and also that it had a negative impact on self care. The nature of the learning and assessment was reported to have left participants feeling averse to further continuing education and lacking in confidence. In contrast, the extended six month component was reported to have restimulated learning by focusing more on patient care and promoting self directed learning. It developed confidence, promoted teamwork, and gave experience of two practice contexts, and was reported as valuable by both ex-registrars and trainers. However, both the 12 and 18 month courses left participants feeling underprepared for practice management and self care.Conclusions 12 months'' training in general practice does not provide doctors with the necessary competencies and confidence to enter independent practice. The extended period was reported to promote greater professional development, critical evaluation skills, and orientation to lifelong learning but does not fill all the gaps.     

Urinary incontinence in the community--analysis of a MORI poll.

OBJECTIVES--To investigate the prevalence of urinary incontinence among people living at home, their responses to it, and its emotional and social effects. DESIGN--Random sample of 4007 adults interviewed in their own homes. SETTING--Random sample of 178 constituency sampling points throughout Great Britain. SUBJECTS--1883 men, 2124 women aged 30 and over. MAIN OUTCOME MEASURES--Responses to questionnaire. RESULTS--6.6% (125) men and 14.0% (297) women had been incontinent of urine at some time--2.8% (52) men and 7.5% (159) women in the previous two months and 61% (124) of these for more than four years. 52% (108) had consulted their general practitioner at the onset of incontinence and a further 31% (65) later. Doctors commonly took a urine sample (163, 54%), referred the patient to a specialist (127, 42%), and prescribed tablets (109, 36%); only 22% (66) carried out an abdominal, rectal, or vaginal examination. Patients were not embarrassed in seeing their doctor and most thought they were treated sympathetically. 60% (265) of all those affected were concerned or worried about their incontinence, and in almost half incontinence limited their daily social activities. CONCLUSION--More people with incontinence seem to be consulting their doctors about it than has been found in previous studies, but the procedures carried out by general practitioners still seem to be suboptimal. Urinary incontinence has a profound effect on the day to day lives of most of those who suffer from it.     

Urinary incontinence: prevalence,need for treatment,and effectiveness of intervention by nurse.

OBJECTIVE--To measure the unmet need of patients with regular urinary incontinence (incontinence twice or more a month) treatable by a nurse. DESIGN--Self completed postal questionnaire and randomised controlled trial of assessment and intervention by a nurse. SETTING--One urban and one rural general practice in Somerset. SUBJECTS--7300 adults randomly selected from 10,300 aged 35 and over on the combined practice lists. 515 women and 185 men with regular incontinence were offered assessment and treatment, of whom 134 women and 49 men had no intervention for three months (historical controls). They then joined the assessment and treatment programme. INTERVENTION--Four sessions of pelvic floor exercises and bladder retraining supervised by non-specialist nurse who had taken a three week course on assessing and treating uncomplicated incontinence. MAIN OUTCOME MEASURES--Number of patients desiring treatment; self reported cure, improvement, or deterioration in continence after three months. RESULTS--The questionnaire achieved a 79% response. Validated responses showed a prevalence of 4.4% in men and 16.4% in women aged 35-64. 315 (45%) of the 700 patients offered assessment refused it and seven had moved away or died, 64 men and 41 women were referred to their general practitioner. 197 of 292 treated women (68%) reported cure or improvement compared with seven (5%) of controls. 22 of the 86 men desiring treatment were suitable for intervention by the nurse. Seventeen were cured or improved compared with none of the men in the control group. CONCLUSIONS--About half the people with regular urinary incontinence took up the offer of treatment (9.2% of women and 3.4% of men in the study population). This condition can be effectively managed by a nurse with limited training.     

Antenatal ultrasonography to detect fetal renal abnormalities: a prospective screening programme.

OBJECTIVE--To evaluate screening for abnormalities of the fetal renal tract by ultrasonography and to determine the incidence of such abnormalities in a population. DESIGN--A 12 month prospective population study. Follow up of infants to between 9 and 18 months. SETTING--A district general hospital. PARTICIPANTS--6292 Pregnant women reaching 28 weeks'' gestation within the study period. INTERVENTIONS--Antenatal ultrasound scanning was offered to all of the women. Babies in whom an abnormality of the renal tract had been detected antenatally underwent ultrasound scanning at the end of the first week. If the abnormality was confirmed contrast radiography was performed. END POINT--Confirmation of suspected renal abnormality by postnatal investigations. Detection of abnormality in children thought to be normal antenatally. MEASUREMENTS AND MAIN RESULTS--Of the 92 babies who had abnormal antenatal scans, 42 had abnormalities confirmed postnatally. Four of them died and 21 had had or were awaiting an operation at 18 months'' follow up. Seven children had renal abnormalities that were missed antenatally. The incidence of abnormalities detected by screening antenatally was 0.65%, and the overall incidence at 18 months'' follow up was 0.76%. CONCLUSIONS--The incidence of structural renal abnormalities in babies is higher than reported previously. Antenatal ultrasonography is an effective way of detecting such abnormalities.     

Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up.

OBJECTIVE--To compare the effectiveness of manipulative therapy, physiotherapy, treatment by the general practitioner, and placebo therapy in patients with persistent non-specific back and neck complaints. DESIGN--Randomised clinical trial. SETTING--Primary health care in the Netherlands. PATIENTS--256 patients with non-specific back and neck complaints of at least six weeks'' duration who had not received physiotherapy or manipulative therapy in the past two years. INTERVENTIONS--At the discretion of the manipulative therapists, physiotherapists, and general practitioners. Physiotherapy consisted of exercises, massage, and physical therapy (heat, electrotherapy, ultrasound, shortwave diathermy). Manipulative therapy consisted of manipulation and mobilisation of the spine. Treatment by general practitioners consisted of drugs (for example, analgesics), advice about posture, home exercises, and (bed)rest. Placebo treatment consisted of detuned shortwave diathermy (10 minutes) and detuned ultrasound (10 minutes). MAIN OUTCOME MEASURES--Changes in severity of the main complaint and limitation of physical functioning measured on 10 point scales by a blinded research assistant and global perceived effect measured on a 6 point scale by the patients. RESULTS--Many patients in the general practitioner and placebo groups received other treatment during follow up. Improvement in the main complaint was larger with manipulative therapy (4.5) than with physiotherapy (3.8) after 12 months'' follow up (difference 0.9; 95% confidence interval 0.1 to 1.7). Manipulative therapy also gave larger improvements in physical functioning (difference 0.6; -0.1 to 1.3). The global perceived effect after six and 12 months'' follow up was similar for both treatments. CONCLUSIONS--Manipulative therapy and physiotherapy are better than general practitioner and placebo treatment. Furthermore, manipulative therapy is slightly better than physiotherapy after 12 months.     

Reported prevalence of urinary incontinence in women in a general practice

To determine the prevalence of urinary incontinence and other urinary symptoms a questionnaire was sent to all women aged 25 and over and to women under 21 taking oral contraceptives registered with a rural practice (n=937); the questionnaire was completed by 833 women (89%). The overall prevalence of urinary incontinence was 41% (343/833); rates were lower in nulliparous and postmenopausal women (30/181 (17%) and 120/344 (35%) respectively) than parous and premenopausal women (313/652 (48%) and 225/479 (47%) respectively). Incontinence was significantly associated with perineal suturing after childbirth, being present in 201 of 376 (53%) women with sutures compared with 113 of 270 (42%) without. Of the 166 women with a history of minor gynaecological surgery, 100 had symptoms of incontinence, compared with 263 of the 657 (37%) without such a history. Incontinence was not related to type of delivery, and postnatal exercises for the pelvic floor were not beneficial.Inappropriate leakage of urine is perceived by many women as common and therefore not serious; thus it is often not reported to the doctor. Nevertheless, the 6% of women who always require protection against leakage could be helped by treatment.     

Outcome of planned home births in an inner city practice.

OBJECTIVE--To assess the outcome of pregnancy for women booking for home births in an inner London practice between 1977 and 1989. DESIGN--Retrospective review of practice obstetric records. SETTING--A general practice in London. SUBJECTS--285 women registered with the practice or referred by neighbouring general practitioners or local community midwives. MAIN OUTCOME MEASURES--Place of birth and number of cases transferred to specialist care before, during, and after labour. RESULTS--Of 285 women who booked for home births, eight left the practice area before the onset of labour, giving a study population of 277 women. Six had spontaneous abortions, 26 were transferred to specialist care during pregnancy, another 26 were transferred during labour, and four were transferred in the postpartum period. 215 women (77.6%, 95% confidence interval 72.7 to 82.5) had normal births at home without needing specialist help. Transfer to specialist care during pregnancy was not significantly related to parity, but nulliparous women were significantly more likely to require transfer during labour (p = 0.00002). Postnatal complications requiring specialist attention were uncommon among mothers delivered at home (four cases) and rare among their babies (three cases). CONCLUSIONS--Birth at home is practical and safe for a self selected population of multiparous women, but nulliparous women are more likely to require transfer to hospital during labour because of delay in labour. Close cooperation between the general practitioner and both community midwives and hospital obstetricians is important in minimising the risks of trial of labour at home.     

Need for open access non-screening mammography in a hospital with a specialist breast clinic service.

OBJECTIVE--Assessment of open access non-screening mammography in a hospital with a breast clinic. DESIGN--Retrospective analysis of patients sent for first mammogram to our open access service by general practitioners and breast clinic in the year April 1989 to March 1990. SETTING--District general hospital serving 200,000 people before the introduction of breast screening. SUBJECTS--361 symptomatic women referred directly by general practitioners and 226 women referred by the breast clinic for first, non-screening mammograms. MAIN OUTCOME MEASURES--Radiographic reports on all patients. Final diagnosis in patients reported as having possible or probable neoplasm. RESULTS--Of the women referred directly by general practitioners one (0.2%) was reported as showing probable malignancy (later histologically confirmed) and 15 (4%) as showing possible malignancy (on follow up none had proved malignancy). Of the women referred by the breast clinic 38 (17%) were reported as showing probable malignancy (all had confirmed carcinomas) and 35 (15%) as showing possible malignancy (19 (54%) had proved malignancy). 18 of the proved malignancies were in women under 50 years old, 26 were in women over 64 years, and 14 were in women of screening age. 54 (93%) of the 58 patients with proved breast cancer and an abnormal mammogram had a discrete breast lump. CONCLUSIONS--General practitioners accurately divided women into low and high risk groups, resulting in few abnormalities being detected in patients referred directly for mammography. This suggests that an open access non-screening mammography service for general practitioners is unnecessary in an area with a specialist breast clinic. The large proportion of cancers in women outside of screening age emphasises the need for such clinics.     

Prevalence of urinary incontinence.

The prevalence of urinary incontinence was investigated by determining the number of incontinent patients under the care of various health and social service agencies in two London boroughs and by a postal survey of the 22 430 people aged 5 years and over on the practice lists of 12 general practitioners in different parts of the country. The prevalence of incontinence known to the health and social service agencies was 0.2% in women and 0.1% in men aged 15-64 and 2.5% in women and 1.3% in men aged 65 and over. The postal survey, to which 89% of the people whose correct address was known replied, showed a prevalence of urinary incontinence of 8.5% in women and 1.6% in men aged 15-64 and 11.6% in women and 6.9% in men aged 65 and over. Nulliparous women had a lower prevalence than those who had had one, two, or three babies, but within the parity range of one to three there were no differences in prevalence. The prevalence was appreciably increased in women who had had four or more babies. Incontinence was moderate or severe in a fifth of those who reported it in the postal survey, of whom less than a third were receiving health or social services for the condition. Incontinence is a common symptom, and many unrecognised cases appear to exist. There may be considerable scope for improving its management.     

Abortion Act in Somerset

A survey conducted with a sample of 20% of general practitioners over six months in 1972 disclosed a request rate for termination approaching 10% of all pregnancies. The attitude and performance of the practitioner were considered to be important in the patient''s requests for this, and patients were thought to know about these. This implies that in three-quarters of the practices there was a sizeable demand for abortion which remained latent.Altogether, 20% of specialist consultations were made privately and in none of these cases was abortion refused. Under the Health Service the refusal rate was 19%, but 7 of the 12 women refused N.H.S. abortions subsequently obtained it privately.     

Long term follow up of women with borderline cervical smear test results: effects of age and viral infection on progression to high grade dyskaryosis.

OBJECTIVE--To follow up and assess the significance of borderline change in cervical smears. DESIGN--Retrospective study of women undergoing routine cervical cytological screening in 1981. SETTING--Avon Cervical Screening Programme, covering 250,000 women in Bristol and Weston super Mare. SUBJECTS--437 women showing borderline cervical changes in 1981 and 437 age matched controls with normal results in 1981. MAIN OUTCOME MEASURES--Cytological progression to high grade dyskaryosis (cervical intraepithelial neoplasia grade III or invasive carcinoma). RESULTS--During follow up ranging from 13 to 106 months 98 of the 437 women (22.4%) with borderline cytological changes on routine cervical cytology screening had a subsequent smear test showing high grade dyskaryosis compared with three of the 437 women (0.9%) in the control group. The risk of progression was greater in women aged 20 to 39 than in those aged 40 and over. Human papillomavirus infection had initially been diagnosed cytologically in 101 of the 437 (23%) women with borderline results. Significantly fewer of these women developed high grade dyskaryosis (13/98 (13%) v 88/339 (26%), p less than 0.05). CONCLUSIONS--Women with borderline smear test results are at increased risk of developing high grade dyskaryosis, particularly if the borderline changes occur without cytological features of human papillomavirus infection. Progression occurs within three years in 50% of cases, although a linearly increasing risk was sustained over the nine years of follow up and was greatest in women aged 20 to 39. Careful follow up of these women is indicated.     

Fair shares in health care? Ethnic and socioeconomic influences on recording of preventive care in selected inner London general practices. Healthy Eastenders Project.

OBJECTIVE--To describe the association of ethnic and socioeconomic status with recording of preventive care information by selected general practitioners. DESIGN--Random selection of people aged 20-64 registered with 43 general practitioners. Ethnic and social characteristics of stratified samples were determined at interview in the subject''s home. Recording of preventive information was ascertained from general practitioners'' medical records. SETTING--Inner London borough of Tower Hamlets. SUBJECTS--505 ut of 739 people confirmed as residents at their home address (190 white, 86 black, 112 Bangladeshi, 105 Chinese or Vietnamese, 12 other). MAIN OUTCOME MEASURES--Socioeconomic characteristics, consultation with general practitioner, and recorded preventive activities for ethnic groups. RESULTS--Minority ethnic groups were considerably more disadvantaged than white people and five times more likely to be overcrowded (31% v 6%), three times less likely to own their own home(11% v 37%), twice as likely to be in social classes IV and V (54% v 28%) and less likely to be employed (34% v 63%). There were no significant differences between white, black, Bangladeshi, and Chinese or Vietnamese subjects in recording smoking, blood pressure, alcohol consumption, weight, and height in the general practitioners'' medical records. White women were more likely to have a record of mammography (46% v 20%; P=0.03) and of cervical smears than women in minority ethnic groups. CONCLUSION--Despite major socioeconomic inequity, equitable recording of preventive activity for the major causes of death for white, black and Bangladeshi populations is possible. Chinese and Vietnamese people had lower levels of recording and consultation. Mammography and, to a lesser extent, cervical cytology are inequitably recorded and require additional support at practice level.     

Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians.

OBJECTIVE--To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care. DESIGN--Multicentre randomised controlled trial. SETTING--51 general practices linked to nine Scottish maternity hospitals. SUBJECTS--1765 women at low risk of antenatal complications. INTERVENTION--Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications. MAIN OUTCOME MEASURES--Comparisons of health service use, indicators of quality of care, and women''s satisfaction. RESULTS--Continuity of care was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6). CONCLUSION--Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit.     

A general practitioner in an ophthalmology accident and emergency department.

After a short period of intensive training, a general practitioner successfully replaced a senior house officer (SHO) in the accident and emergency department of an eye hospital on one morning a week for a year. An unbiased observer compared the performance of the general practitioner after one year with that of a full-time SHO who had had 17 months'' experience; their performances were about equal. Although a sessional general practitioner costs about 28% more than an SHO, the real cost is much less because undue length of service as an SHO or change to another specialty (because of the SHO surplus) delays achievement of a permanent grade. Continuity is a great advantage of the general practitioner. Replacement of some SHOs by general practitioners would reduce the surplus of SHOs with poor promotion prospects. The commonest diagnoses were Meibomian cysts (18%), corneal foreign bodies (20%), corneal abrasions (12%), and conjunctivitis (8%).     

Development of renal scars in children: missed opportunities in management. South Bedfordshire Practitioners' Group.

OBJECTIVE--To assess the antecedent medical care of children with renal scars. DESIGN--Retrospective study of both general practice and hospital records. SETTING--12 Group practices in south Bedfordshire and the radiology and paediatric outpatient departments of a district general hospital. SUBJECTS--23 Children with renal scars (six boys, 17 girls) from the 12 group practices, identified from outpatient, radiology, and general practice records. MAIN OUTCOME MEASURES--Number of children in whom a diagnosis of urinary tract infection had been made without prior examination of a mid-stream specimen of urine; number of children who had had a confirmed urinary tract infection that had not been investigated further; number who had experienced delays in investigation or referral; and number who had received inadequate follow up. RESULTS--In all, 11 of the children had received suboptimal medical care, but the management of the other 12 could not have been better. The most common error was failure to investigate possible urinary tract infections, but follow up of confirmed infections was also inadequate. These problems occurred in hospital as well as in general practice. CONCLUSION--Opportunities for intervention had been missed in nearly half of this sample of children with renal scars.     

Comparison of chloroquine,pyrimethamine and sulfadoxine,and chlorproguanil and dapsone as treatment for falciparum malaria in pregnant and non-pregnant women,Kakamega District,Kenya.

OBJECTIVE--To compare treatment and protection against falciparum malaria in pregnant and non-pregnant women with three drug regimens. DESIGN--Prospective intervention study with six weeks'' follow up. Patients received one of three drug regimens in order of entry. SETTING--Primary care hospital and secondary girls'' school in rural western Kenya. PATIENTS--158 of 988 pregnant women (89 primigravid and 69 multigravid) in the third trimester and 105 of 1488 non-pregnant schoolgirls of reproductive age were parasitaemic (more than 500 asexual forms/microliter. These women were divided into three treatment groups by gravid state. INTERVENTIONS--Women were treated with chloroquine base 25 mg/kg over three days or pyrimethamine 75 mg and sulfadoxine 1500 mg as a single dose or chlorproguanil 1.2 mg/kg and dapsone 2.4 mg/kg as a single dose. MAIN OUTCOME MEASURES--Parasitaemia and haemoglobin concentrations measured at seven day intervals for six weeks. RESULTS--Primigravid women were more likely to be parasitaemic on follow up than multigravidas or nulligravidas, whose response was about the same. Parasites did not clear by day 7 in primigravidas in six (20%) of 30 who received chloroquine, three (8%) of 35 treated with pyrimethamine and sulfadoxine, and none of 23 treated with chlorproguanil and dapsone. At day 28, 83%, 19%, and 67% of primigravidas in these treatment groups were parasitaemic. Haemoglobin concentrations rose in all women, but improvement was sustained only in women who remained free of parasites. CONCLUSIONS--Clearance of parasites was better with either pyrimethamine and sulfadoxine or chlorproguanil and dapsone than with chloroquine. Longest protection was obtained with pyrimethamine and sulfadoxine.     

Effectiveness of a nicotine patch in helping people stop smoking: results of a randomised trial in general practice. Imperial Cancer Research Fund General Practice Research Group.

OBJECTIVE--To assess the effectiveness of 12 weeks'' treatment with a 24 hour transdermal nicotine patch in helping heavy smokers to stop smoking; also to assess the value of a specially written support booklet about smoking cessation and patch use compared with a simple advice pamphlet. DESIGN--Double blind placebo controlled randomised trial with a 2 x 2 factorial design. SETTING--19 general practices in Oxfordshire. SUBJECTS--1686 heavy smokers aged 25-64 (mean cigarette consumption 24/day; mean duration of smoking 25 years). MAIN OUTCOME MEASURE--Sustained cessation for the last four weeks of the 12 week treatment period, confirmed by saliva cotinine estimation (226/262 cases; 86.3%) or expired carbon monoxide concentration (36/262; 13.7%). Patients lost to follow up (155/1686; 9%) were assumed to have continued to smoke. RESULTS--Cessation was confirmed in 163 patients (19.4%) using the nicotine patch and 99 patients (11.7%) using the placebo patch (difference 7.6% (95% confidence interval 4.2% to 11.1%); p < 0.0001). There was no significant advantage in using the more detailed written support material. The most important adverse effect of the patch was local skin irritation, which occurred in 15.8% (133/842) and 5.1% (43/844) of patients using the nicotine and placebo patches respectively, was graded as severe in 4.8% (40) and 1.1% (nine), and was stated as a reason for withdrawal from the trial in 9.5% (80) and 2.8% (24). CONCLUSION--Nicotine patches are effective in a general practice setting with nursing support, but the extent to which this effect is sustained cannot be assessed until the results of longer term follow up are known.     

Insulin Resistance Is Associated with Prevalence of Physician-Diagnosed Urinary Incontinence in Postmenopausal Non-Diabetic Adult Women: Data from the Fourth Korea National Health and Nutrition Examination Survey

Objective

To investigate the association between insulin resistance (IR) and urinary incontinence in Korean adult women by analyzing the data from the Korea National Health and Nutrition Examination Survey IV (KNHANES) 2007–2009

Methods

A nationally representative sample of 5318 non-diabetic Korean women ≥19-years-of-age (3043 premenopausal and 2275 postmenopausal women) was included from KNHANES 2008–2010. IR was measured using the homeostasis model assessment of IR (HOMA-IR). Participants in the highest and lowest quartile of HOMA-IR were defined as insulin-resistant and insulin-sensitive respectively. Women who have current physician-diagnosed urinary incontinence were classified as having urinary incontinence.

Results

Incontinence was found in 9.18% of the total population, 8.51% of the premenopausal population, and 10.86% of the postmenopausal population. The prevalence of incontinence increased with age, reaching a peak at 60-69-years-of-age. The prevalence of urinary incontinence increased significantly with higher HOMA-IR quartiles in pre- and post-menopausal women (p for linear association = 0.0458 and 0.0009 respectively). Among post-menopausal women, those in the highest quartile of HOMA-IR were significantly more likely to have urinary incontinence compared to those in the lowest quartile [adjusted odds ratio, 1.72; 95% confidence interval, 1.07–2.77]. However premenopausal population exhibited no association between incontinence and HOMA-IR quartiles

Conclusion

Our results suggest that the prevalence of incontinence increased across HOMA-IR in non-diabetic adult women, and especially, IR might be a risk factor for incontinence in postmenopausal non-diabetic women.     

Influence of past reproductive performance on risk of spontaneous abortion.

OBJECTIVE--To investigate the incidence of spontaneous abortion in a population of women in order to establish their risk of spontaneous abortion and the obstetric factors predisposing to it. DESIGN--Prospective study of women recruited by radio and poster appeal and from hospital outpatient clinics. SETTING--English provincial community. PATIENTS--630 Women from the general population intending to become pregnant. INTERVENTIONS--The viability of the pregnancy was assessed by abdominal ultrasonography before completion of the eighth week, and the assessment was repeated if vaginal bleeding occurred. MAIN OUTCOME MEASURE--Spontaneous abortion or live births in women with or without a previous history of spontaneous abortion. RESULTS--The overall incidence of clinically recognisable spontaneous abortion before 20 weeks of gestation was 12% (50/407 pregnancies). The risk of spontaneous abortion in each category of patient was classified with respect to the patient''s past reproductive performance and found to be influenced greatly by her previous obstetric history. In primigravidas and women with a history of consistently successful pregnancies the incidences of abortion were low (5% (4/87) and 4% (3/73) respectively), whereas women with only unsuccessful histories had a much greater risk of aborting the study pregnancy (24% (24/98)), even when their sole pregnancy had ended in abortion (20% (12/59)). The outcome of the last pregnancy also influenced the outcome of the study pregnancy; only 5% of women (5/95) whose previous pregnancy had been successful aborted, whereas the incidence of loss of pregnancy among women whose last pregnancy had aborted was 19% (40/214). CONCLUSIONS--A knowledge of the patient''s reproductive history is essential for the clinical assessment of her risk of spontaneous abortion. As the most important predictive factor for spontaneous abortion is a previous abortion, the outcome of a woman''s first pregnancy has profound consequences for all subsequent pregnancies.     

An evaluation of home visiting of patients by physicians in geriatric medicine

The practice of preadmission home visiting of patients referred to geriatric medicine units has in recent years been criticised as being unnecessary on the grounds that if there is no waiting list there is no need for allocation of priority for admission; as being wasteful of doctors'' time; as being resented by general practitioners; and as failing to provide adequate clinical information. The geriatric medicine department at the City Hospital with no waiting list for patients referred by general practitioners has retained home visits for most referrals because of the advantages in terms of acceptability to general practitioners (98-100%); the quantity and quality of information obtained; the usefulness of this information in deciding appropriate management and in planning discharge from hospital; and the provision of a unique teaching opportunity, which is highly valued by students and teachers alike.