Nicotine chewing gum in general practice: effect of follow up appointments.

Two hundred smokers who were judged by their general practitioner to be motivated to stop smoking were allocated to one of two groups. All were offered an initial appointment at which they were advised to stop smoking and offered nicotine gum. One group then received no further appointments. The other was offered four further appointments over three months. Both groups were followed up at six and 12 months. At one year follow up 15.5% overall had stopped smoking, 14% in the low and 17% in the high contact group. This is better than most results so far reported for nicotine chewing gum in general practice, suggesting that general practitioners can use it to good effect. We compare this result with others achieved in general practice.     

Dietary habits and mortality in 11,000 vegetarians and health conscious people: results of a 17 year follow up.

OBJECTIVE: To investigate the association of dietary habits with mortality in a cohort of vegetarians and other health conscious people. DESIGN: Observational study. SETTING: United Kingdom. SUBJECTS: 4336 men and 6435 women recruited through health food shops, vegetarian societies, and magazines. MAIN OUTCOME MEASURES: Mortality ratios for vegetarianism and for daily versus less than daily consumption of wholemeal bread, bran cereals, nuts or dried fruit, fresh fruit, and raw salad in relation to all cause mortality and mortality from ischaemic heart disease, cerebrovascular disease, all malignant neoplasms, lung cancer, colorectal cancer, and breast cancer. RESULTS: 2064 (19%) subjects smoked, 4627 (43%) were vegetarian, 6699 (62%) ate wholemeal bread daily, 2948 (27%) ate bran cereals daily, 4091 (38%) ate nuts or dried fruit daily, 8304 (77%) ate fresh fruit daily, and 4105 (38%) ate raw salad daily. After a mean of 16.8 years follow up there were 1343 deaths before age 80. Overall the cohort had a mortality about half that of the general population. Within the cohort, daily consumption of fresh fruit was associated with significantly reduced mortality from ischaemic heart disease (rate ratio adjusted for smoking 0.76 (95% confidence interval 0.60 to 0.97)), cerebrovascular disease (0.68 (0.47 to 0.98)), and for all causes combined (0.79 (0.70 to 0.90)). CONCLUSIONS: In this cohort of health conscious individuals, daily consumption of fresh fruit is associated with a reduced mortality from ischaemic heart disease, cerebrovascular disease, and all causes combined.     

Three year follow up of patients with raised blood pressure identified at health checks in general practice.

OBJECTIVE--To assess the extent of three year follow up of blood pressure, weight, and smoking habit in patients with raised blood pressure identified at health checks. DESIGN--Retrospective audit of medical and nursing records. SETTING--Three general practices in Oxfordshire. PATIENTS--386 of 448 patients with raised blood pressure (diastolic greater than or equal to 90 or systolic greater than or equal to 160 mm Hg) identified from 2935 patients aged 35-64 attending health checks in 1982-4. MEASUREMENTS and MAIN RESULTS--All records of blood pressure, weight, and smoking habit in the medical record were abstracted for three years after the initial health check. All 42 patients with an initial diastolic blood pressure greater than or equal to 105 mm Hg and 316 of 344 patients with an initial pressure of 90-104 mm Hg had at least one further measurement of their blood pressure. Follow up of smoking habit and of weight was less complete with only half of the 100 smokers and 67 of the 87 obese patients (body mass index greater than or equal to 30) having any documented follow up of these risk factors. Annual follow up in the second and third years occurred in 228/297 (76.8%) and 232/320 (72.5%) in patients with blood pressure greater than 95 mm Hg at the beginning of each year. For patients who smoked annual follow up in these years occurred in fewer than a third and for those who were obese in just over half. On the assumption that those not followed up had not changed, at the end of three years the proportion of patients with diastolic blood pressure greater than or equal to 100 mm Hg had fallen from 61 patients (15.8%) to 31 (8.1%); the proportion of smokers had fallen from 103 (26.7%) to 94 (24.4%); and the proportion of obese patients had fallen from 87 (22.5%) to 79 (20.5%). CONCLUSIONS--These changes were modest and in the absence of a control group cannot be attributed necessarily to health checks. Although the standard of follow up was better than in previously reported studies of the management of hypertension, the results emphasise the need to develop formal protocols for dietary and antismoking interventions and to evaluate formally the effectiveness (and cost effectiveness) of health checks.     

Fundholding in general practice and financial risk.

OBJECTIVE--To estimate the financial effect of random yearly variations in need for services on fundholding practices with various list sizes. DESIGN--A simulation model was derived using historical data on general practitioner referrals for the 113 surgical procedures covered by the general practitioner fund, combined with data on the hospital prices for those procedures. PATIENTS--Resident population of Central Birmingham Health Authority. MAIN OUTCOME MEASURES--Expected expenditure on the relevant surgical procedures for the whole district and for practices with list sizes of 9000, 12,000, 15,000, 18,000, 21,000, or 24,000 for each of 100 simulated years. RESULTS--By using average hospital prices for the West Midlands region the mean (SD) annual expenditure for the 179,400 residents was 4,832,471 pounds (87,149 pounds); the random variation between the 5th and 95th most expensive years was 5.7% of the mean cost. For a practice with a list size of 9000 the values were 244,891 pounds (18,349 pounds), with a variation of 27.5%. With a list size of 24,000 the values were 652,762 pounds (32,512 pounds), with a variation of 15.3%. CONCLUSIONS--Random variations in need for inpatient services will have a significant financial impact on the practice fund. The problem will be particularly great for smaller practices. Additional measures are required to ensure that the scheme is not undermined and that the potential benefits are secured.     

Operations for portal hypertension due to extrahepatic obstruction: results and 10 year follow up.

Between 1976 and 1984, 136 patients with portal hypertension due to extrahepatic obstruction were operated on. Twenty two patients had emergency and 114 elective operations. The operative mortality was 9% and 1%, respectively. Altogether 117 patients (86%) were followed up for from two to 10 years: 17 rebled, none developed encephalopathy or sepsis after splenectomy, and 90% and 75% were alive at five and 10 years respectively. Unlike endoscopic sclerotherapy and treatment with propranolol, operative treatment of variceal bleeding can usually be completed during one admission and carries a low mortality and a fairly low morbidity. Operation seems to be the best form of treatment for poor patients living far from medical facilities in developing countries and may be the treatment of choice in developed countries as well.     

Fetal growth and subsequent risk of breast cancer: results from long term follow up of Swedish cohort

ObjectiveTo investigate whether size at birth and rate of fetal growth influence the risk of breast cancer in adulthood.DesignCohort identified from detailed birth records, with 97% follow up.SettingUppsala Academic Hospital, Sweden.Participants5358 singleton females born during 1915-29, alive and traced to the 1960 census.ResultsSize at birth was positively associated with rates of breast cancer in premenopausal women. In women who weighed ⩾4000 g at birth rates of breast cancer were 3.5 times (95% confidence interval 1.3 to 9.3) those in women of similar gestational age who weighed <3000 g at birth. Rates in women in the top fifths of the distributions of birth length and head circumference were 3.4 (1.5 to 7.9) and 4.0 (1.6 to 10.0) times those in the lowest fifths (adjusted for gestational age). The effect of birth weight disappeared after adjustment for birth length or head circumference, whereas the effects of birth length and head circumference remained significant after adjustment for birth weight. For a given size at birth, gestational age was inversely associated with risk (P=0.03 for linear trend). Adjustment for markers of adult risk factors did not affect these findings. Birth size was not associated with rates of breast cancer in postmenopausal women.ConclusionsSize at birth, particularly length and head circumference, is associated with risk of breast cancer in women aged <50 years. Fetal growth rate, as measured by birth size adjusted for gestational age, rather than size at birth may be the aetiologically relevant factor in premenopausal breast cancer.

What is already known on this topic

There is some evidence that birth weight is related to risk of breast cancerThe exact nature of any association and whether it differs at premenopausal and postmenopausal ages is unclearFew studies have examined the effect of other measures of birth size and of gestational age

What this study adds

There are strong positive associations between measures of birth size and rates of breast cancer at premenopausal ages that persisted after adjustment for adult risk factorsFor a given birth size, gestational age was inversely associated with risk, suggesting that the rate of fetal growth may be aetiologically relevant to premenopausal breast cancerThere was no association between birth characteristics and rates of breast cancer at postmenopausal ages     

Effectiveness of programme for reducing cardiovascular risk for men in one general practice.

OBJECTIVES--To assess the effectiveness of a programme for reducing cardiovascular risk in men in terms of clinical measurements and perceptions of patients. DESIGN--Collection of paired data on men attending well person clinics over three to five years. Questionnaire to determine changes in risk related habits. SETTING--Well person clinics in rural general practice with five partners in mid-Wales. SUBJECTS--The first 687 men seen in the clinic: analysable data obtained on 520. Initial age range 28-60 years. MAIN OUTCOME MEASURES--Analysis of serum cholesterol concentration (mmol/l) and blood pressure (mm Hg). Changes in diet, exercise, smoking, and drinking. RESULTS--Mean (SD) cholesterol concentration for all subjects increased from 5.8 (1.0) to 6.0 (1.0), p < 0.001. Overall percentage of ideal weight and mean systolic blood pressure also increased. Mean diastolic blood pressure was unchanged at 84 mm Hg. Professed dietary change, age, and number of visits all had significant effects on final cholesterol concentration. Those seen more often showed a significant decrease in cholesterol concentrations (in those seen more than twice mean (SD) initial value 6.7 (0.9) mmol/l v final value 6.5 (1.0) mmol/l, p < 0.001). Those over 45 years at start of study showed a significant decrease in diastolic blood pressure (mean (SD) initial value 89 (9) mm Hg v final value 86 (7) mm Hg, p < 0.001). CONCLUSIONS--These clinics are not effective in achieving a reduction in mean cholesterol concentration or blood pressure, despite evidence that the message of reduction in risk had been successfully transmitted. Success was achieved in older patients and those in whom a definite problem was identified. Identification of high risk groups and clinical case finding with appropriate long term follow up may be more cost effective in reducing cardiovascular risk than non-specific screening of the whole population.     

Preliminary results of a district call scheme for cervical screening organised in general practice.

A recognised problem with the cervical screening programme in the United Kingdom is the failure to include women who have never had a cervical smear test, who are a high risk group. The implementation of a district based call scheme in East Berkshire in 1986 is described whereby women aged 20-64 with no record of a cervical smear test who were judged to be eligible for testing by their general practitioner were sent a personal invitation from their general practitioner to attend for a test. A list of high risk unscreened women was kept by each practice, and a duplicate sent to the cytology laboratory to update the central records. Six months after each batch of invitations had been sent the resulting number of women having a smear test was assessed. Forty three of 51 practices approached agreed to participate in the five year scheme. During the first year lists were sent to the 43 participating practices. The first list was returned to the cytology laboratory by 37 practices and the second by 33; practices varied in their responses, however, some needing considerable persuasion to return the lists. Of 972 identified unscreened women from the total 3757 women listed in the lists of the family practitioner committee, 247 (25%) had a cervical smear test in response to the invitation, representing an overall increase of 7% in the screened population. The preliminary findings of the five year study have shown that screening can be improved by a systematic call scheme. Coordinated support from the area health authority in health education, monitoring of screening, and feedback of data from the scheme to practices is required to reduce the proportion of unscreened women.     

Growth in utero and cognitive function in adult life: follow up study of people born between 1920 and 1943.

OBJECTIVES--To examine the relation between fetal growth and cognitive function in adult life. DESIGN--A follow up study of men and women whose birth weights and other measurements of body size had been recorded at birth. SETTING--Hertfordshire, Preston, and Sheffield. SUBJECTS--1576 men and women born in Hertfordshire, Sheffield, or Preston between 1920 and 1943. MAIN OUTCOME MEASURES--Intelligence quotient as measured by the AH4 test and amount of decline in cognitive function with age as estimated by the difference between score on the Mill Hill vocabulary test and score on the AH4 test. RESULTS--Score on the intelligence test was higher in people who had a large biparietal head diameter at birth, but it was not related to any other measure of body size or proportions. No association was found between decline in cognitive function and any measure of size or proportions at birth. CONCLUSION--Impaired fetal growth was not associated with poorer cognitive performance in adult life. Adaptations made by the fetus in response to conditions that retard its growth seem to be largely successful in maintaining brain development.     

10 year follow up study of mortality among users of hostels for homeless people in Copenhagen

Objectives To investigate mortality among users of hostels for homeless people in Copenhagen, and to identify predictors of death such as conditions during upbringing, mental illness, and misuse of alcohol and drugs.Design Register based follow up study.Setting Two hostels for homeless people in Copenhagen, DenmarkParticipants 579 people who stayed in one hostel in Copenhagen in 1991, and a representative sample of 185 people who stayed in the original hostel and one other in Copenhagen.Main outcome measure Cause specific mortality.Results The age and sex standardised mortality ratio for both sexes was 3.8 (95% confidence interval 3.5 to 4.1); 2.8 (2.6 to 3.1) for men and 5.6 (4.3 to 6.9) for women. The age and sex standardised mortality ratio for suicide for both sexes was 6.0 (3.9 to 8.1), for death from natural causes 2.6 (2.3 to 2.9), for unintentional injuries 14.6 (11.4 to 17.8), and for unknown cause of death 62.9 (52.7 to 73.2). Mortality was comparatively higher in the younger age groups. It was also significantly higher among homeless people who had stayed in a hostel more than once and stayed fewer than 11 days, compared with the rest of the study group. Risk factors for early death were premature death of the father and misuse of alcohol and sedatives.Conclusion Homeless people staying in hostels, particularly young women, are more likely to die early than the general population. Other predictors of early death include adverse experiences in childhood, such as death of the father, and misuse of alcohol and sedatives.     

Follow up study of angina in patients aged 30 to 59 in general practice.

In 1979, 51 general practitioners in the Northern region identified 336 patients aged 30 to 59 who had angina pectoris. Information was obtained on their treatment and how angina affected their daily lives. This study reviews the same patients after an interval of four years. Of the 307 who were not lost to follow up, 38 (12%) had died and 44 (14%) were free from angina in the last year. Drugs seemed to be used to their best advantage, with a fourfold increase in the use of the newer calcium antagonists and long acting trinitrate preparations. Many patients still suffered from angina, which was severely affecting their daily lives, but only 41 patients had had exercise electrocardiograms recorded or more detailed investigations; this includes 16 (6%) patients who had had coronary artery bypass surgery.     

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.