Treatment of urinary incontinence in women in general practice: observational study.

OBJECTIVE--To examine what is attainable when treating urinary incontinence in women in general practice. DESIGN--Observational study with 12 months'' follow up. Interview and clinical examination before, during, and after treatment of women seeking help for urinary incontinence in general practice. SETTING--General practice in the rural district of Rissa, Norway. SUBJECTS--105 women aged 20 or more with urinary incontinence. INTERVENTIONS--Treatment with pelvic floor exercises, electrostimulation, oestrogen, anticholinergic drugs, bladder training, and protective pads. MAIN OUTCOME MEASURES--Subjective and objective measures of urinary incontinence; number of patients referred to a specialist. RESULTS--After 12 months'' follow up 70% (69/99) of the women were cured or much better; the mean score on a 100 mm visual analogue scale decreased from 37 to 20 mm; and the proportion of women who were greatly bothered by their incontinence decreased by 62%. 20% (20/98) of women became continent, and the percentage of women with severe incontinence decreased from 64% (63/99) to 28% (27/98). Mean leakage per 24 hours measured by a pad test decreased from 28 g at the start of treatment to 13 g after 12 months. The number of light weight pads or sanitary towels decreased from 1.6 to 0.6 a day. In all, 17/105 (16%) patients were referred to a specialist. CONCLUSIONS--Urinary incontinence in women can be effectively managed in general practice with fairly simple treatment. Most women will be satisfied with the results.     

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%).     

Self referral to an accident and emergency department for another opinion.

OBJECTIVE--To determine whether patients referring themselves to an accident and emergency department for another opinion after consulting their general practitioner present with serious illness, show any risk factors for being admitted, or are more likely to be patients of particular practitioners. DESIGN--Six month prospective survey. SETTING--District general hospital''s accident and emergency department, receiving 42,000 new patients a year. PATIENTS--180 Patients identified as attending for another opinion having already consulted a general practitioner. INTERVENTIONS--Classified as admission, referral to specialist clinic, follow up in accident and emergency department, or referral back to general practitioner. END POINT--Admission, with an analysis of admitted patients. MEASUREMENTS AND MAIN RESULTS--General outcome, diagnostic category, age, time of attendance, time since seen by general practitioner, and name of general practitioner were recorded. Forty seven patients were admitted, 99 were discharged back to the general practitioner (62 without a letter), and two died. Patients were most likely to be admitted if they attended within 24 hours after seeing a general practitioner, were aged under 5, or presented with respiratory or gastrointestinal complaints. Some general practitioners were overrepresented. CONCLUSIONS--Important disorders present in this way, and therefore these patients should be seen by a doctor. Information about these attendances could be useful to general practitioners in reviewing their performance.     

Comparison of physiotherapy,manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised,single blind study.

OBJECTIVE: To compare the efficacy of physiotherapy, manipulation, and corticosteroid injection for treating patients with shoulder complaints in general practice. DESIGN: Randomised, single blind study. SETTING: Seven general practices in the Netherlands. SUBJECTS: 198 patients with shoulder complaints, of whom 172 were divided, on the basis of physical examination, into two diagnostic groups: a shoulder girdle group (n = 58) and a synovial group (n = 114). INTERVENTIONS: Patients in the shoulder girdle group were randomised to manipulation or physiotherapy, and patients in the synovial group were randomised to corticosteroid injection, manipulation, or physiotherapy. MAIN OUTCOME MEASURES: Duration of shoulder complaints analysed by survival analysis. RESULTS: In the shoulder girdle group duration of complaints was significantly shorter after manipulation compared with physiotherapy (P < 0.001). Also the number of patients reporting treatment failure was less with manipulation. In the synovial group duration of complaints was shortest after corticosteroid injection compared with manipulation and physiotherapy (P < 0.001). Drop out due to treatment failure was low in the injection group (17%) and high in the manipulation group (59%) and physiotherapy group (51%). CONCLUSIONS: For treating shoulder girdle disorders, manipulation seems to be the preferred treatment. For the synovial disorders, corticosteroid injection seems the best treatment.     

城市生态学自然模拟实验研究进展

自然模拟实验,通过适当控制影响因素研究自然状态下生态系统变化,已经越来越受到生态学家的欢迎。新兴的快速发展的城市生态学越来越多的采用自然模拟实验方法。研究从城市生态学的实验设计方法(如人工梯度、自然梯度和城市建设实验)、环境因子(如空气污染、热岛、灯光和地表硬化)生态效应和生态系统(如社区、绿地、绿化屋顶和集水区)响应等方面,分析了国内外大量城市生态学自然模拟实验的研究案例,并总结了城市生态学自然模拟实验的特点,指出了城市生态学模拟实验应该考虑的主要问题,并提出未来主要发展方向：(1)多种环境因子复合影响模拟实验研究,(2)生态系统结构和功能响应模拟实验研究,(3)近自然的长期模拟实验研究,(4)大范围的联网模拟实验研究和(5)面向城市生态恢复和建设的模拟实验研究。希望研究能够为推进我国城市生态学的实验研究起到抛砖引玉作用。     

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.     

Efficacy of tacrine and lecithin in mild to moderate Alzheimer's disease: double blind trial.

OBJECTIVE--To assess the efficacy of tacrine and lecithin in treating Alzheimer''s disease over nine months. DESIGN--Double blind randomised controlled trial. SETTING--Outpatients clinic of university department of geriatric medicine. SUBJECTS--53 subjects (26 women, 27 men) with probable Alzheimer''s disease. 41 completed the dose finding phase and were randomised to treatment. 32 (14 tacrine, 18 placebo) completed nine months'' treatment. INTERVENTIONS--Lecithin and tacrine or lecithin and placebo for 36 weeks. MAIN OUTCOME MEASURES--Scores on neuropsychological tests sensitive to deficits in the cholinergic system; mini-mental state score; behaviour change; mood; functional state; and stress in carers. RESULTS--The tacrine and placebo groups were similar except that the tacrine group had a longer duration of disease (mean 5.4 v 2.5 years in placebo group; P = 0.003). Only 17 of the 32 patients could tolerate the maximum dose of tacrine (100 mg). No significant difference was found between the groups for any of the tests after nine months'' treatment except for the digit backwards test, which is insensitive to cholinergic deficit. Analysis of subjects taking the maximum dose of tacrine and of subjects with mild dementia also found no differences. CONCLUSIONS--Tacrine produces no clinically relevant improvement over 36 weeks at the doses tolerated by these patients.     

Biosomatic effects of the electromagnetic fields on view of the physiotherapy personnel health

The effects of electromagnetic fields (EMFs) in physiotherapy have been discussed mainly with regard to the patient's safety, while the operator's safety is neglected. This paper presents the medical assessment and specific tendencies in the health status of personnel in physical therapy wards – where the EMFs are everyday background factor. This paper summarizes the somatic part of results from the study among physiotherapy personnel from facilities with different equipment and work load by using survey card designed by us for health status screening in somatic and neurobehavioral aspects. The main specific somatic findings and complaints in investigated group include parodontosis – 42%; cardiovascular disorders – 41.6%; allergic conditions with skin or systemic manifestation – 40.8%; photosensibilization – 34.1%; skin diseases – 31.5%; musculoskeletal disorders – 30.0% and neoplasm disorders – 7.5%. Keeping in mind that better part of the personnel in the physical therapy units is female, a special attention was paid to the pathology of the reproductive system; menstrual disturbances are observed in 20.0%. These findings are collected in complex for the first time in physiotherapy personnel, and when data were available from other professional groups, we found a good correlation.     

Sulphasalazine in ankylosing spondylitis: a double blind controlled study in 60 patients.

Sulphasalazine has been reported to be effective in ankylosing spondylitis with peripheral arthritis, but its efficacy in spondylitis is unknown. Thus 60 patients with active ankylosing spondylitis without peripheral arthritis or gastrointestinal symptoms were randomly allocated to one of two therapeutic groups. One group received 2 g sulphasalazine daily for six months and the other a placebo. Thirteen patients (six given placebo and seven given sulphasalazine) dropped out of the trial and were considered to be treatment failures. After six months'' follow up efficacy was rated as good or very good by 15 of the 30 patients given sulphasalazine and by only six of the 30 given placebo (p less than 0.02). Furthermore, in the patients given sulphasalazine the daily consumption of non-steroidal anti-inflammatory drugs, functional index, and plasma IgG concentrations had fallen significantly. These data suggest that sulphasalazine may be a safe and effective treatment for spondylitis in ankylosing spondylitis.     

Relaxation therapy and continuous ambulatory blood pressure in mild hypertension: a controlled study.

OBJECTIVE--To determine the long term effects of relaxation therapy on 24 hour ambulatory intra-arterial blood pressure in patients with mild untreated and uncomplicated hypertension. DESIGN--Four week screening period followed by randomisation to receive either relaxation therapy or non-specific counselling for one year. Ambulatory intra-arterial blood pressure was measured before and after treatment. SETTING--Outpatient clinic in Amsterdam''s university hospital. SUBJECTS--35 Subjects aged 20-60 who were being treated by general practitioners for hypertension but were referred to take part in the study. At three consecutive screening visits all subjects had a diastolic blood pressure without treatment of 95-110 mm Hg. Subjects were excluded if they had damaged target organs, secondary hypertension, diabetes mellitus, a cholesterol concentration greater than 8 mmol/l, or a history of malignant hypertension. INTERVENTIONS--The group allocated to relaxation therapy was trained for eight weeks (one hour a week) in muscle relaxation, yoga exercises, and stress management and continued exercising twice daily for one year with monthly visits to the clinic. The control group had the same attendance schedule but had no training and were requested just to sit and relax twice a day. All subjects were asked not to change their diet or physical activity. MAIN OUTCOME MEASURE--Changes in ambulatory intra-arterial blood pressure after one year of relaxation therapy or non-specific counselling. RESULTS--Mean urinary sodium excretion, serum concentration of cholesterol, and body weight did not change in either group. Diastolic pressures measured by sphygmomanometry were 2 and 3 mm Hg lower in subjects in the relaxation group and control group respectively at the one year follow up compared with initial readings. The mean diastolic ambulatory intra-arterial pressure during the daytime had not changed after one year in either group, but small treatment effects could not be excluded: the mean change for the relaxation group was -1 mm Hg (95% confidence interval -6 to 3.9 mm Hg) and for the control group -0.4 mm Hg (-5.3 to 4.6 mm Hg). Mean ambulatory pressure in the evening also had not changed over the year, and in both groups nighttime pressure was 5 mm Hg higher. The variability in blood pressure was the same at both measurements. CONCLUSIONS--Relaxation therapy was an ineffective method of lowering 24 hour blood pressure, being no more beneficial than non-specific advice, support, and reassurance--themselves ineffective as a treatment for hypertension.     

Cost-effectiveness of postural exercise therapy versus physiotherapy in computer screen-workers with early non-specific work-related upper limb disorders (WRULD); a randomized controlled trial

Background

Exercise therapies generate substantial costs in computer workers with non-specific work-related upper limb disorders (WRULD).

Aims

To study if postural exercise therapy is cost-effective compared to regular physiotherapy in screen-workers with early complaints, both from health care and societal perspective.

Methods

Prospective randomized trial including cost-effectiveness analysis; one year follow-up. Participants: Eighty-eight screen-workers with early non-specific WRULD; six drop-outs. Interventions: A ten week postural exercise program versus regular physiotherapy. Outcome measures: Effectiveness measures: Pain: visual analogous scale (VAS), self-perceived WRULD (yes/no). Functional outcome: Disabilities of Arm, Shoulder and Hand- Dutch Language Version (DASH-DLV). Quality of life outcome: EQ-5D. Economic measures: health care costs including patient and family costs and productivity costs resulting in societal costs. Cost-effectiveness measures: health care costs and societal costs related to the effectiveness measures. Outcome measures were assessed at baseline; three, six and twelve months after baseline.

Results

At baseline both groups were comparable for baseline characteristics except scores on the Pain Catastrophizing Scale and comparable for costs. No significant differences between the groups concerning effectiveness at one year follow-up were found. Effectiveness scores slightly improved over time. After one year 55% of participants were free of complaints. After one year the postural exercise group had higher mean total health care costs, but lower productivity costs compared to the physiotherapy group. Mean societal costs after one year (therefore) were in favor of postural exercise therapy [- €622; 95% CI -2087; +590)]. After one year, only self- perceived WRULD seemed to result in acceptable cost-effectiveness of the postural exercise strategy over physiotherapy; however the probability of acceptable cost-effectiveness did not exceed 60%. Considering societal costs related to QALYs, postural exercise therapy had a probability of over 80% to be cost-effective over a wide range of cost-effectiveness ceiling ratios; however based on a marginal QALY-difference of 0.1 over a 12 month time frame.

Conclusion

Although our trial failed to find significant differences in VAS, QALYs and ICERs based on VAS and QALYs at one-year follow-up, CEACs suggest that postural exercise therapy according to Mensendieck/Cesar has a higher probability of being cost-effective compared to regular physiotherapy; however further research is required.

Trial registration

ISRCTN 15872455     

Breast feeding and risk of breast cancer in young women. United Kingdom National Case-Control Study Group.

OBJECTIVE--To investigate whether breast feeding is related to subsequent risk of breast cancer. DESIGN--Population based case-control study designed primarily to investigate the relation between oral contraceptives and risk of breast cancer; data obtained from questionnaires administered by interviewers, general practitioner notes, and family planning clinic records. SETTING--11 health regions in Britain. SUBJECTS--Women diagnosed with breast cancer before age 36 living in the defined study areas. One control per case, matched for age, was selected from the list of the case''s general practitioner. 755 case-control pairs were interviewed. MAIN OUTCOME MEASURES--Duration of breast feeding each liveborn infant; timing of return of menses; hormone use; other risk factors for breast cancer. RESULTS--Risk of breast cancer fell with increasing duration of breast feeding (relative risk = 0.94 per three months'' breast feeding; test for trend p = 0.026) and with number of babies breast fed (relative risk = 0.86; test for trend, p = 0.017). Breast feeding each baby for longer than three months conferred no additional benefit. Breast feeding was more strongly negatively associated with risk of breast cancer than duration of postpartum amenorrhoea (chi 2 test for trend, p = 0.69). Hormonal suppression of lactation was unrelated to risk of breast cancer (relative risk = 0.96 per episode of suppressed lactation; test for trend, p = 0.72). CONCLUSIONS--These results suggest that breast feeding protects against the development of breast cancer in young women.     

Targeting heavy smokers in general practice: randomised controlled trial of transdermal nicotine patches.

OBJECTIVES--(a) To evaluate the efficacy of transdermal nicotine patches as an aid to stopping smoking when used as an adjunct to brief advice and support in a general practice setting; (b) to see whether an increase in nicotine patch dosage enhances the rate of initial cessation. DESIGN--Randomised double blind placebo controlled parallel group study with one year of follow up. SETTING--30 general practices in 15 English counties. SUBJECTS--600 dependent heavy smokers (> or = 15 cigarettes daily) who were well motivated to give up. INTERVENTIONS--Brief general practitioner advice, booklet, and 16 hours per day patch treatment for 18 weeks with brief support and follow up at one, three, six, 12, 26, and 52 weeks. MAIN OUTCOME MEASURES--Self reported complete abstinence for up to one year with biochemical validation at all follow up points. RESULTS--Nicotine patches reduced the severity of craving and adverse mood changes in the first weeks of withdrawal and doubled the rate of initial cessation at week 3 (nicotine group 36% of patients (144/400), placebo group 16.5% of patients (33/200)) and of continuous abstinence throughout one year (nicotine group 9.3% (37), placebo group 5.0% (10)). A dose increase at week 1 among patients experiencing difficulty in quitting increased the proportion who achieved abstinence at week 3. There were no adverse systemic effects attributable to nicotine, but the incidence of moderate or severe local irritation or itching at the patch site was 16.4% (63 patients), compared with 3.8% (seven) with placebo. CONCLUSION--Transdermal nicotine patches used as an adjunct to brief advice and support in a general practice setting are an effective aid to long term cessation of smoking in highly dependent smokers.     

Adherence to recommendations for early repeat cervical smear tests.

OBJECTIVE--To assess adherence to recommendations for an early repeat cervical smear test in women with reports of cytological abnormalities, and to evaluate the impact of reminder letters to medical practitioners when such smear tests are overdue. DESIGN--Observational study. SETTING--Cytology (gynaecological) service for Victoria, Australia. SUBJECTS--Two groups of women who had abnormal cervical smears during 1985. Women in group A had some evidence of an important dysplasia and were advised to have a repeat smear in three months'' time whereas women in group B had a less serious abnormality and were advised to have a repeat smear test in six months'' time. In all, 971 of the 1036 women in group A and 1401 of the 1464 women in group B were eligible to have a repeat smear analysed by the service. INTERVENTION--If a repeat smear had not been received within three months of the recommended date a reminder letter generated by the service''s computer was sent to the medical practitioner who had taken the smear. END POINT--Thirty six months after the report on the abnormal smear was issued. MEASUREMENTS AND MAIN RESULTS--In all, 870 (90%) of the women in group A and 1154 (82%) of the women in group B had a repeat smear test. The mean time to a repeat test was 3.0 months (95% confidence interval 0.5 to 16.4) in group A and 6.0 months (1.2 to 30.3) in group B. The reminder letter to the practitioner potentially increased the rate of return for a repeat smear test by 18% in group A and 24% in group B. Adherence to the recommendation for a repeat test increased with increasing age. CONCLUSIONS--Achieving high rates of follow up smear tests and appropriate management in women with cytological abnormalities is critical to the impact of a screening programme for cervical cancer. The reminder system used in this study was not labour intensive or expensive and provided a fail safe mechanism for ensuring that reports of abnormal smears were not overlooked.     

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.     

Effects of "natural oestrogen" replacement therapy on menopausal symptoms and blood clotting.

In a double-blind study on the value of equine ("natural") oestrogens 30 patients presenting with menopausal symptoms in a group practice were monitored for possible adverse effects on blood clotting, weight, and blood pressure. The women were randomly allocated to two groups and given either three months'' hormone treatment followed by three months'' placebo or vice versa. An appreciable amelioration of all symptoms on placebo made it difficult to asses the genuine value of oestrogen treatment during the period of study. Both groups made a dramatic clinical improvement during the first three months. Nevertheless, the symptoms of the 15 women who received oestrogen first returned after the cross-over to placebo without any suggestion of a placebo response. In contrast, the other group who took placebo first did not deteriorate after changing to oestrogen. The menopausal index and the karyopyknotic index were not reliable guides to the need for oestrogen treatment. Hot flushes, however, were proportionately reduced on oestrogen and they seemed to be more readily eliminated in individual cases by oestrogen. The results of blood clotting studies indicated that natural oestrogen administration raised the levels of the extrinsic clotting factors VII and X and accelerated the prothrombin time. The findings were similar to those observed after three months synthetic oestrogen administration with oral contraception. Long-term studies and epidemiological surveys of the clinical incidence of thrombotic and other sequelae are needed before large-scale oestrogen replacement treatment can be recommended.     

Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome)

OBJECTIVE--To compare the effectiveness of arthroscopic surgery, a supervised exercise regimen, and placebo soft laser treatment in patients with rotator cuff disease (stage II impingement syndrome). DESIGN--Randomised clinical trial. SETTING--Hospital departments of orthopaedics and of physical medicine and rehabilitation. PATIENTS--125 patients aged 18-66 who had had rotator cuff disease for at least three months and whose condition was resistant to treatment. INTERVENTIONS--Arthroscopic subacromial decompression performed by two experienced surgeons; exercise regimen over three to six months supervised by one experienced physiotherapist; or 12 sessions of detuned soft laser treatment over six weeks. MAIN OUTCOME MEASURES--Change in the overall Neer shoulder score (pain during previous week and blinded evaluation of function and range of movement by one clinician) after six months. RESULTS--No differences were found between the three groups in duration of sick leave and daily intake of analgesics. After six months the difference in improvement in overall Neer score between surgery and supervised exercises was 4.0 (95% confidence interval -2 to 11) and 2.0 (-1.4 to 5.4) after adjustment for sex. The condition improved significantly compared with placebo in both groups given the active treatments. Treatment costs were higher for those given surgery (720 pounds v 390 pounds). CONCLUSIONS--Surgery or a supervised exercise regimen significantly, and equally, improved rotator cuff disease compared with placebo.     

General practice orthopaedic outpatient referrals in North Staffordshire.

A study was made of 813 orthopaedic referrals by 134 general practitioners in North Staffordshire. The referral rates showed no relation to practice list size or the doctors'' previous orthopaedic experience. The published waiting times did not accurately reflect clinic vacancies, and no effective priority rating of letters by consultants was shown. Less than 1% of patients had an appointment within four weeks. One quarter of the patients failed to attend and, of those who did, 27% received physiotherapy or a "simple" appliance, or both, while 16% received treatment already available from their general practitioner. Patients from high referring doctors showed the same pattern of distribution in body area affected and treatment outcome as those from low referring doctors, but had a significantly longer time to wait for their appointment. A survey of non-attenders showed that 56% of the patients failed to attend because the condition had resolved.     

Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.