临床护理路径管理糖尿病足患者效果评价

目的:观察临床护理路径对糖尿病足患者的效果。方法:将100例糖尿病足患者随机分为两组:实验组(50例)应用临床护理路径模式,对照组采用常规护理模式,比较两组患者的住院时间、医疗费用、患者满意率、血糖、溃疡愈合时间和糖尿病足知识评分。结果:实验组患者的住院日数、医疗费用、血糖和溃疡愈合时间显著低于对照组(P<0.05),患者满意率和糖尿病足知识评分显著高于对照组(P<0.05)。结论:应用临床护理路径可以有效地降低糖尿病患者的血糖、溃疡愈合时间、住院时间和医疗费用,提高患者糖尿病足知识水平和满意率。     

Aglycosuric Diabetes

The usefulness of urine tests for glucose was compared with that of blood sugar determinations in detecting diabetes mellitus in 2000 medical outpatients. Eighty-five patients proved to be diabetic, but 33 of these had no glycosuria on their first visit and would not have been detected by laboratory tests had the blood glucose levels not been measured. Exactly one-half of the new diabetics discovered would have been missed (15 of 30) had only urine tests been performed. The new diabetics who were aglycosuric at their initial examination had a mild form of the disease, were predominantly elderly, and were controlled, in nearly every case, by diet alone. Most of these patients had evidence of an elevated renal threshold for glucose. These results indicate that there is a large group of patients with mild, asymptomatic, diabetes mellitus who remain undetected unless blood tests are employed routinely. Because they have little or no glycosuria these patients do not have polydipsia, polyphagia, polyuria, or loss of weight. Automation in the medical laboratory has made routine blood tests for glucose feasible and rewarding in detecting diabetes mellitus.     

Community care compared with hospital outpatient care for hypertensive patients.

Three hundred and seventy-six patients with treated diastolic blood pressures of less than 105 mm Hg and no history of accelerated hypertension or renal failure were selected from among those attending the Hammersmith Hospital hypertension clinic. Their average lying treated blood pressure was 146 mm Hg systolic and 90 mm Hg diastolic and average age 56 years; 18% were black, 6% Asian, and 76% white. The patients were mostly having multiple treatment, 90% receiving a diuretic, 35% methyldopa, 33% propranolol, 18% atenolol, 9% hydrallazine, and 7% bethanidine. They were randomly allocated to either two years of further hospital outpatient care or referred back to their general practitioners. During the two years 19 (10%) of the 187 patients followed up in hospital defaulted and three had their treatment discontinued. Twelve (6%) of the 189 followed up by their general practitioners defaulted from follow-up and nine had their treatment discontinued. At the end of the trial the average lying blood pressure was 148 mm Hg systolic and 88 mm Hg diastolic in the hospital group and 149 mm Hg systolic and 90 mm Hg diastolic in the general practice group. The change in blood pressure was calculated for each individual and showed an average fall of 1.6 mm Hg in standing diastolic pressure in the hospital group and a rise of 1.4 mm Hg in the general practice group (p less than 0.05). The 90% confidence limits for a difference in standing diastolic pressure between the groups were 1 and 5 mm Hg with the pressure lower in the hospital group. General practice care was not quite as effective in controlling blood pressure as continued specialist supervision over two years in this selected group of treated outpatients with mild or moderate hypertension, but these results show that the discharge back to general practitioners of patients who are well controlled after hospital treatment is a sensible policy.     

Short term effect of captopril on microalbuminuria induced by exercise in normotensive diabetics.

OBJECTIVE--To investigate whether captopril has any effect on microalbuminuria induced by exercise in normotensive diabetic patients with early stage nephropathy. DESIGN--Randomised, double blind, crossover trial. SETTING--Outpatient department. PATIENTS--22 diabetics with stage II nephropathy (urinary albumin excretion rate less than 20 micrograms/min; 15 with type I diabetes and seven with type II), 32 patients with stage III nephropathy (urinary albumin excretion rate 20-200 micrograms/min; 14 with type I diabetes and 18 with type II), and 10 normal subjects. INTERVENTIONS--Four exercise tests on a cycle ergometer: the first two under basal conditions and the third and fourth after subjects had received captopril (two 25 mg doses in 24 hours) or placebo (two tablets in 24 hours). END POINT--Exercised until 90% of maximum heart rate achieved. MEASUREMENTS AND MAIN RESULTS--Mean urinary excretion one hour after the first two exercise tests was 21 micrograms/min in normal subjects, 101 micrograms/min in diabetic patients with stage II nephropathy, and 333 micrograms/min in those with stage III nephropathy. Similar results were obtained after placebo. After captopril the urinary excretion rate one hour after exercise was significantly decreased in diabetics with stage II (36 micrograms/min) and stage III (107 micrograms/min) disease compared with placebo but not in normal subjects. Systolic and diastolic pressures were similar in the three groups after placebo and captopril had been given. CONCLUSIONS--Captopril significantly reduces microalbuminuria induced by exercise in normotensive diabetics without affecting systemic blood pressure. Captopril may reduce renal intracapillary pressure.     

Hepatitis B virus infection in medical and health care personnel.

Analysis of 51 cases of hepatitis B virus infection in health care workers admitted as patients to the liver unit over seven years showed three healthy carriers of hepatitis B virus, seven cases of fulminant hepatic persistent hepatitis, 17 cases of chronic active hepatitis (of whom 11 had cirrhosis), and five cases of hepatocellular carcinoma. To date 11 of these patients have died. Only 15 of the 51 patients had a history of direct occupational exposure and only three patients could recall specific inoculation injuries. In contrast, the source of infection was apparent in 32 of 50 consecutive cases of fulminant hepatic failure or acute hepatitis B in nonmedical staff. Since specific inoculation injuries are not the usual mode of infection ion medical staff and since only a few of the patients who are hepatitis B virus carriers will be detected by selective screening of "high-risk" patients, the overall risk of infection can be reduced only by stricter precautions in the handling of any patient''s blood and by the use of hepatitis B virus vaccines for medical staff at high risk.     

Novel role for specialist nurses in managing diabetes in the community.

To develop care of diabetes further a specialist nurse established contact with general practices in Sheffield Health District and identified difficulties in providing a service for diabetics. One hundred and thirty practices were visited, and full data were collected from 104. Each practice agreed to establish a register of diabetics, and information and support were subsequently provided to help in developing services. In collecting information from each practice the nurse covered specific points on staff, facilities, and organisation. Over two years the service offered in 60 practices considerably improved, allowing a minimum standard of diabetic care to be achieved. This allowed coordinated and effective referral of certain patients from hospital diabetic clinics and improved services to those not attending any clinics.     

Primary Care Detection of Chronic Kidney Disease in Adults with Type-2 Diabetes: The ADD-CKD Study (Awareness,Detection and Drug Therapy in Type 2 Diabetes and Chronic Kidney Disease)

This US, multicenter, observational study assessed the CKD prevalence in adult patients with type-2 diabetes mellitus (T2DM) and characterized the proportion of detected and undiagnosed CKD in the primary care setting using the following: a clinician survey; a patient physical exam and medical history; a single blood draw for estimated glomerular filtration rate (eGFR) and glycosolated hemoglobin (HbA1c); urine dipstick for protein; urine albumin-creatinine ratio (ACR); two patient quality of life questionnaires; and a 15-month medical record review. The study consisted of 9339 adults with T2DM and 466 investigator sites. Of the 9339 enrolled, 9307 had complete data collection for analysis. The 15-month retrospective review showed urine protein, urine ACR, and eGFR testing were not performed in 51.4%, 52.9% and 15.2% of individuals, respectively. Of the 9307 patients, 5036 (54.1%) had Stage 1–5 CKD based on eGFR and albuminuria; however, only 607 (12.1%) of those patients were identified as having CKD by their clinicians. Clinicians were more successful in diagnosing patients with Stage 3–5 CKD than Stages 1 and 2. There were no differences in clinicians’ likelihood of identification of CKD based on practice setting, number of years in practice, or self-reported patients seen per week. Awareness or patient self-reported CKD was 81.1% with practitioner detection versus 2.6% in the absence of diagnosis. Primary care of T2DM demonstrates recommended urine CKD testing is underutilized, and CKD is significantly under-diagnosed. This is the first study to show CKD detection is associated with awareness.     

Twenty five years of case finding and audit in a socially deprived community.

OBJECTIVE--To evaluate audit and case finding (whole population care) in a community over 25 years. DESIGN--Contemporary screening for and audits of care of chronic disease and risk factors; retrospective review of computerised practice records; and comparisons of mortality and social indices with neighbouring communities. SETTING--One general practice in Glyncorrwg, West Glamorgan. SUBJECTS--1800 people registered with the practice in 1987 and 558 people who died from 1964 to 1987, whose records had been retained. MAIN OUTCOME MEASURES--Detection of high blood pressure, smoking, airways obstruction, obesity, diabetes, and alcohol problems in adults aged 20-79; prevalence of smoking in this population and in hypertensive and diabetic groups; age standardised mortality ratios in relation to indices of social deprivation. RESULTS--In the population aged 20-79 (1207 patients) 249 (21%) had peak expiratory flow rate less than 50% of expected value or which improved by 15% or more with an inhaled beta agonist, 207 (17%) had body mass index at or over 30 kg/m2, 118 (10%) had untreated mean arterial pressures greater than 159/104 mm Hg (three readings), 80 (7%) (65 (16%) men, 15 (4%) women) had recognised alcohol problems, and 35 (3%) had diabetes. The proportion of men aged 20-64 who said they smoked fell from 61% (290/476) in 1968-70 to 36% (162/456) in 1985 whereas that of women who smoked was unchanged (43%, 187/436 v 42%, 190/448 respectively). In 116 screened hypertensive patients group mean blood pressure fell from 186/110 mm Hg before treatment to 146/84 mm Hg at 1987 audit, as did the proportion of smokers (56% v 20%), but body mass index and total cholesterol concentration showed no significant change. In 34 diabetic patients mean blood pressure and the proportion of smokers fell (171/93 mm Hg v 155/81 mm Hg; 44% v 12%). The age standardised mortality ratio in 1981-6 was lower than in a neighbouring village without a developed case finding programme (actual to expected deaths less than 65 = 21 to 22 in Glyncorrwg, 48 to 30 in control village). CONCLUSIONS--Whole population care through organised case finding and audit is feasible but only with a labour intensive approach combining accessibility, flexibility, and continuity, as well as a planned and structured approach, which requires substantial expansion of staff numbers and assiduous recording. It may reduce risks for at least some high risk groups. Despite their shortcomings the available data are consistent with the hypothesis that whole population care helps reduce mortality. Incentives in the new contract, which encourage the uncritical development of structured process, may diminish health outputs.     

Doctor-patient communications revisited

To test a new approach to detecting and managing hypertension, 34 family practices in southwestern Ontario that comprised 32 124 patients aged 20 to 65 years were randomly assigned in a 5-year study to either undertake a system of care in which a medical assistant oversaw screening and attended to education, compliance and follow-up (experimental group) or continue their usual practices (control group). The 17 physicians in the experimental practices (15 659 patients) were matched with the 17 in the control practices (16 465 patients) according to size of the community, sex, level of practice activity and length of time in practice. Hypertension was defined as at least two diastolic blood pressure readings over 90 mm Hg. More patients in the experimental group than in the control group were screened at least once (91% v. 80%); the former were more likely to have lower systolic blood pressure (p less than 0.02), to be compliant (p less than 0.05) and to be very satisfied with care (p less than 0.01). There were no significant differences between the two groups in the rates of illness and death due to cardiovascular disease for all patients or for hypertensive patients. The unassisted family physician can provide effective care for hypertensive patients. However, minor modifications in the physician''s practices can improve care.     

Utilisation of dental services in a university hospital palliative and long-term care unit in Geneva

Objectives: Dental care plays an important role in the multidisciplinary approach, which is used in palliative and long‐term care to address the complex needs of terminally ill patients. The aim of this study was to assess the utilisation of dental services in a University Hospital Palliative and Long‐term Care Unit. Material and method: Over an observation period of 13 months, structured questionnaires were filled in after each dental appointment. The survey covered three main topics: the initiation and incentive from the dental consultation, particular difficulties because of the patient’s health or the hospital’s organisation as well as the accomplished treatment. Results: Two hundred and seventy‐five questionnaires from a total of 102 patients were available for analysis. The patients’ median age was 83 years (SD 10.3, range 49–101 years), 63 were female, 39 male. A majority of first appointments were initiated by a physician (n = 49 of 102), mainly because of pain (n = 62 of 275). 10.5% of the appointments were cancelled on the same day. Only one‐fifth of the patients were able to reach the practice on foot. Six used a walking stick and 54 relied on a wheelchair. Eighteen patients needed to be seen in their bed. The most frequently performed procedures were extractions and removal of denture sore spots (n = 67 of 275) followed by the manufacturing of new dentures (n = 38 of 275). In more than 17% of the appointments, no particular treatment was performed. Conclusion: The utilisation of dental services in terminally ill and severely compromised elderly patients shown justifies a dental service in a palliative care or geriatric hospital setting. The particular dental work profile requires a practitioner with empathy and professional experience.     

Effect of protein restriction in insulin dependent diabetics at risk of nephropathy.

Persistent proteinuria is strongly associated with increased mortality in insulin dependent diabetes, and risk of this condition can be predicted many years in advance by subclinical increases in albumin excretion rate (microalbuminuria). Eight normotensive insulin dependent diabetics with microalbuminuria who had overnight albumin excretion rates of between 15 and 200 micrograms/min underwent a three week randomised crossover study of their normal protein diet (median 92 (range 55-117) g/day) and a low protein diet (47 (38-57) g/day). Both diets were isoenergetic, and the low protein diet was supplemented with calcium and phosphate. Median overnight albumin excretion rate fell from 23.0 (15.0-170.1) micrograms/min during the normal diet to 15.4 (4.1-97.8) micrograms/min during the low protein diet. No consistent change was found in urinary excretion of beta 2 microglobulin during the two diets. The reduction in albumin excretion rate was accompanied by a significant fall in median glomerular filtration rate and fractional renal clearance of albumin. Kidney volume remained unchanged. There were no significant changes in glycaemic control or arterial blood pressure. In these few patients restriction of dietary protein had a beneficial effect on microalbuminuria, independent of changes in glucose concentrations and arterial blood pressure.     

Chronobiological pattern of growth hormone secretion in normal subjects and in retinopathic diabetics. Lack of suppression by a plurichronocorticoid drug.

Nyctohemeral variations in plasma concentrations of HGH, glucose, and FFA were studied in 22 normal subjects and 48 diabetic patients affected with retinopathy. In the normal subjects, (fourteen males and eight females, mean age 40+/-3 years; body weight less than 110% of I.B.W.) the determinations were made on blood samples drawn every hour. Seven of these normal subjects were examined before and after 10 days of administration of a new plurichronocorticoid drug (administered at 08(00) and 15(00), with a total amount of 14 mg of prednisolone and 15 mg of cortisone). In patients with diabetic retinopathy (32 male and sixteen female patients, mean age 46+/-2 years, body weight less than 110% of I.B.W.) the determinations were made on blood samples drawn every 3 hrs. All the diabetic patients were insulin treated and were under good or discrete metabolic control, and presented advanced retinopathy. Both in the normal subjects and in retinopathic diabetics, the mean HGH curve showed a characteristic elevation during the early nighttime hours (between 21(00) and 02(00). Despite higher values in plasma glucose and FFA, in diabetics the nocturnal elevation of HGH was only slightly lower than in the normals. The comparison between daytime and nighttime determinations, both in the normal subjects and in the diabetics, reveals statistically significant differences. These results suggest that in subjects with diabetic retinopathy, in the phase of good or discrete metabolic control, spontaneous HGH secretion is not increased, and that nocturnal elevation of HGH is not substantially influenced by higher plasma levels of glucose and FFA. Ten days of plurichronocorticoid treatment with a new drug which exhausts its activity before the evening, did not modify the circadian rhythm of HGH.     

Why blind diabetics with renal failure should be offered treatment.

During May 1978 to April 1983 this renal dialysis unit treated 65 patients by continuous ambulatory peritoneal dialysis. Of these, 24 had type I (insulin dependent) diabetes, of whom 20 were blind; eight had type II (non-insulin dependent) diabetes, of whom three were blind; and 33 did not have diabetes and were not blind. The cumulative actuarial survival rates of these patients at five years were 60% for blind diabetics, 40% for sighted diabetics, and 46% for the non-diabetics. Of the 23 blind patients, 22 successfully achieved self care, including the self administration of insulin into the peritoneal dialysis solution. Blind patients had the least peritonitis and fewest complications of continuous ambulatory peritoneal dialysis, and none objected to the treatment or requested to be taken off it or be allowed to die. It was concluded that blind diabetic patients with renal failure showed both the will and the ability to stay alive and that their treatment was worth while.     

Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial

ObjectivesTo investigate the effect of a computer based clinical decision support system and a risk chart on absolute cardiovascular risk, blood pressure, and prescribing of cardiovascular drugs in hypertensive patients.DesignCluster randomised controlled trial.Setting27 general practices in Avon.Participants614 patients aged between 60 and 79 years with high blood pressure.InterventionsPatients were randomised to computer based clinical decision support system plus cardiovascular risk chart; cardiovascular risk chart alone; or usual care.ResultsPatients in the computer based clinical decision support system and chart only groups were no more likely to have cardiovascular risk reduced to below 10% than patients receiving usual care. Patients in the computer based clinical decision support group were more likely to have a cardiovascular risk ⩾10% than chart only patients, odds ratio 2.3 (95% confidence interval 1.1 to 4.8). The chart only group had significantly lower systolic blood pressure compared with the usual care group (difference in means −4.6 mm Hg (95% confidence interval −8.4 to −0.8)). Reduction of diastolic blood pressure did not differ between the three groups. The chart only group were twice as likely to be prescribed two classes of cardiovascular drugs and over three times as likely to be prescribed three or more classes of drugs compared with the other groups.ConclusionsThe computer based clinical decision support system did not confer any benefit in absolute risk reduction or blood pressure control and requires further development and evaluation before use in clinical care can be recommended. Use of chart guidelines are associated with a potentially important reduction in systolic blood pressure.     

Oxygen transport and peripheral microcirculation in long-term diabetes

The purpose of this investigation was to evaluate the impact of long-term diabetes on muscle blood flow (MBF) and oxygen transport (vO2) during exercise. Twelve male patients (58 +/- 8 years, mean +/- SD), with at least a 10-year history of diabetes controlled by insulin, and seven age-matched controls (56 +/- 5 years, mean +/- SD) participated in this study. No patient had been clinically diagnosed as having peripheral vascular disease, and on the average resting ankle/arm systolic blood pressure ratios were normal. Following a baseline period, 5 min of cycle ergometer exercises at 75 W were performed in the upright position and, after 1-hr recovery, in the supine position. Continuous vO2 was determined via breath-by-breath analysis. MBF was measured in the vastus lateralis (VL) and tibialis anterior (TA) by 133Xe clearance. In the erect position, the diabetic group (compared with the control group, respectively) exhibited significantly (P less than 0.05) lower exercise MBF [ml. (100 g.min)-1] in both VL (19 +/- 2.5 vs 30.9 +/- 2) and TA (13.7 +/- 2 vs 22.0 +/- 4), a lower steady-state VO2 (1.3 +/- 0.3 vs 1.7 +/- 0.2 liters.min-1) during exercise including the values in the last 15 sec of exercise, and greater accumulation of blood lactate (35 +/- 2 vs 22.0 +/- 2 mg/100 ml). The same trends in the data were observed during supine exercise; however, the blood pressure of the diabetics was significantly elevated during exercise when compared with that of controls. The reduced exercise MBF in the TA and VL demonstrated that impaired microvascular flow, without clinically overt peripheral vascular disease, in long-term diabetics leads to reduced oxygen delivery and exercise tolerance.     

Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up.

OBJECTIVE--Determination of the long term incidence of uraemia, hypertension, and toxaemia in pregnancy associated with non-obstructive focal renal scarring after pyelonephritis in childhood 25-35 years earlier. DESIGN--27 Year follow up of patients with non-obstructive focal scarring identified from a retrospective review of intravenous urograms performed in childhood between 1951 and 1967. SETTING--Paediatric primary referral centre and urological clinic in tertiary referral centre. PATIENTS--30 Patients (mean age 33 (range 22-41] with non-obstructive focal renal scarring first detected between 1951 and 1967 and a history of febrile urinary tract infection. MAIN OUTCOME MEASURE--Hypertension and complications of renal damage. RESULTS--Three patients had developed end stage renal disease, seven had developed hypertension, two of 16 women had a history of toxaemia during pregnancy, and seven patients had undergone renal surgery during follow up. Of the 20 patients who had neither had renal surgery nor had end stage renal disease, all had a significantly lower glomerular filtration rate and renal plasma flow and higher diastolic blood pressure, mean arterial blood pressure, plasma renin activity, and serum beta 2 microglobulin concentration than 13 healthy age matched controls. Diastolic blood pressure and plasma renin activity were positively correlated (r = 0.50, p less than 0.05) and so were fractional sodium excretion and both systolic and diastolic blood pressures (r = 0.54, p less than 0.01, r = 0.51, p less than 0.01 respectively). The progress of renal damage was unrelated to the incidence of recurrent infections. CONCLUSIONS--Children with focal renal scarring due to pyelonephritis are at high risk of serious long term consequences. It is essential that they are given adequate attention and care during adolescence and pregnancy.     

Protection of kidney function and decrease in albuminuria by captopril in insulin dependent diabetics with nephropathy.

STUDY OBJECTIVE--To assess whether long term inhibition of angiotensin converting enzyme with captopril and frusemide or bendrofluazide protects kidney function in diabetic nephropathy. DESIGN--Non-randomised controlled before-after trial of matched hypertensive insulin dependent diabetics with nephropathy treated with captopril and frusemide or bendrofluazide. SETTING--Outpatient diabetic clinic in tertiary referral centre. PATIENTS--Treatment group of 18 hypertensive insulin dependent diabetics with nephropathy (mean age 33), who had not been treated previously. Control group of 13 patients (mean age 32) fulfilling the same entry criteria from a prospective study. INTERVENTIONS--Treatment group was given daily captopril 37.5-100.0 mg and frusemide (mean) 98 mg (10 patients) or bendrofluazide (mean) 4 mg (seven). Treatment was continued for about two and a half years. Controls were not treated. END POINT--Measurement of arterial blood pressure, albuminuria, and glomerular filtration. MEASUREMENTS AND MAIN RESULTS--Baseline values were identical in treated and untreated groups respectively: mean blood pressure 146/93 (SE 3/1) mm Hg v 137/95 (2/1) mm Hg; geometric mean albuminuria 982 (antilog SE 1.2) micrograms/min v 936 (1.2) micrograms/min; and mean glomerular filtration rate 98 (SE 5) ml/min/1.73 m2 v 96 (6) ml/min/1.73 m2. Mean arterial blood pressure fell by 8.7 (1.3) mm Hg with captopril and rose by 6.6 (1.5) mm Hg in controls, (p less than 0.001); Albumin excretion decreased to 390 (1.1) micrograms/min with captopril and rose to 1367 (1.3) micrograms/min in controls (p less than 0.001). The rate of decrease in glomerular filtration rate was lower with captopril (5.8 (0.7) ml/year v 10.0 (1.3) ml/year) (p less than 0.01). Rate of fall in glomerular filtration rate and mean arterial blood pressure were significantly correlated (n = 31, r = 0.37, p less than 0.05). CONCLUSIONS--Captopril is a valuable new drug for treating hypertension in insulin dependent diabetics with nephropathy.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Factors related to first dose hypotensive effect of captopril: prediction and treatment.

The blood pressure response to the first dose of captopril (6.25 mg, 12.5 mg, or 25 mg) was measured in 65 treated, severely hypertensive patients. Mean supine blood pressure was 187/108 mm Hg immediately before captopril was given. Twenty one patients experienced a fall in supine systolic pressure greater than 50 mm Hg, including five whose pressure fell more than 100 mm Hg and two whose pressure fell more than 150 mm Hg. Six patients developed symptoms of acute hypotension, including dizziness, stupor, dysphasia, and hemiparesis. Percentage reductions in blood pressure were greatest in those with secondary hypertension (p less than 0.05), high pretreatment blood pressure (p less than 0.05), and high concentrations of plasma renin and angiotensin II (p less than 0.01). No significant correlation was found between fall in blood pressure and serum sodium concentration, age, renal function, and the dose of captopril given. A severe first dose effect cannot be consistently predicted in individual patients who have received other antihypertensive drugs for severe hypertension. Such patients should have close medical supervision for at least three hours after the first dose of captopril.     

Health checks on patients 75 years and over in Nottinghamshire after the new GP contract.

OBJECTIVE--To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN--Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING--20 general practices in one family health services authority. SUBJECTS--Patients of 75 years and over in 20 general practices. RESULTS--Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients'' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS--The way health checks were performed varied greatly, both in their organisation and the practices'' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.