An international perspective on the cholesterol debate

For the past 5 years there has been an intensive debate and a number of conflicting guidelines suggesting what general practitioners (GPs) should do to screen and manage hyperlipidaemia. At a WONCA seminar in Vancouver in 1992, policies and guidelines from Canada, the UK, The Netherlands, New Zealand, Hong Kong and the USA were reviewed. It was concluded that cholesterol policy and guidelines tend to be influenced more by political and economic factors than by evidence of health benefit. International guidelines for cholesterol screening and management would be of minimal value, as GPs would have to interpret the epidemiological evidence of benefit from lipid screening and lipid lowering strategy in the context of each patient to arrive at optimum management.

The haemodynamic effects of GR 32191, a thromboxane A2 receptor antagonist, in patients with renal artery stenosis and hypertension

This study was designed to determine if GR 32191 a thromboxane A2 receptor antagonist, would lower blood pressure in patients with hypertension and renal artery stenosis. Eight patients with unilateral atheromatous renal artery stenosis and hypertension were studied in a double-blind, single dose, placebo controlled, crossover study. The results show that, GR 32191, given orally, in doses of 20 mg and 40 mg, does not reduce the blood pressure to any clinically important degree.

A comparison of amlodipine with enalapril in the treatment of moderate/severe hypertension

1. The safety and efficacy of amlodipine vs enalapril as monotherapy was evaluated in patients with moderate/severe hypertension (supine DBP 105-125 mm Hg, SBP 140-220 mm Hg). 2. After 2 weeks placebo treatment 31 patients were randomised by the technique of minimisation in an observer-blind study to receive once daily treatment with either amlodipine (15 patients) 5-10 mg, or enalapril (16 patients) 5-20 mg for 8 weeks. The study design concluded with 2 weeks placebo treatment. In addition to clinic measurements, home blood pressure monitoring (Copal UA-251) was performed during the study. 3. Clinic supine systolic blood pressure was reduced from 177 to 152 mm Hg (amlodipine) and 183 to 169 mm Hg (enalapril) (95% CI for the intergroup difference -22.1, 0.3, P = 0.06) after 8 weeks treatment. 4. Clinic supine diastolic blood pressure was reduced from 110 to 93 mm Hg (amlodipine) and 109-102 mm Hg (enalapril) (95% CI for the intergroup difference -17.7, -2.7, P < 0.01) after 8 weeks treatment. 5. Home blood pressure recordings confirmed these reductions in blood pressure. Although the reduction in blood pressure was greater for the amlodipine treated group, the differences between treatments were not statistically significant. 6. Both drugs were reasonably well tolerated. The adverse events occurring most frequently in the amlodipine group were headache (5), peripheral oedema (3), upper respiratory infection (3) and anxiety (2). The adverse events occurring most frequently in the enalapril treated patients were headache (6), dizziness (3) and upper respiratory infection (2).

A comparison of amlodipine with enalapril in the treatment of isolated systolic hypertension

1. The safety and efficacy of amlodipine and enalapril were compared in patients with isolated systolic hypertension (supine DBP < 95 mm Hg and supine SBP 160-200 mm Hg). 2. After 2 weeks treatment with placebo 31 patients were randomised by the technique of minimisation in an observer-blind study to receive once daily treatment with either amlodipine (16 patients) or enalapril (15 patients) for 8 weeks. The study design concluded with 2 weeks placebo treatment. In addition to clinic measurements, home blood pressure monitoring (Copal UA-251) was performed during the study. 3. Mean supine systolic blood pressure was reduced from 185 to 164 mm Hg (amlodipine) and 183 to 159 mm Hg (enalapril) (95% CI for the difference between the drugs -10.5, 15.3) after 8 weeks treatment. 4. Mean supine diastolic blood pressure was reduced from 86 to 80 mm Hg (amlodipine) and 88 to 80 mm Hg (enalapril) (95% CI for the difference between the drugs -4.9, 7.6) after 8 weeks treatment. 5. Home blood pressure recordings confirmed these reductions in blood pressure, although there was no significant difference between treatments for the reductions in blood pressure. 6. Both drugs were reasonably well tolerated. The adverse events occurring most frequently in the amlodipine group were headache (2), peripheral oedema (5) and palpitations (2). The adverse events occurring most frequently in the enalapril group were headache (2), peripheral oedema (2), palpitations (2) and dizziness (3).

Relationship between blood pressure measured in the clinic and by ambulatory monitoring and left ventricular size as measured by electrocardiogram in elderly patients with isolated systolic hypertension

OBJECTIVE

To assess the additional diagnostic precision conferred by ambulatory blood pressure monitoring on clinic blood pressure measurement in evaluating the severity of isolated systolic hypertension.

METHODS

The association between left ventricular size as determined by ECG voltages [R-wave voltages in lead V5 (RV5) and S-wave voltages in lead V1 (SV1)] and blood pressure as assessed by clinic measurements and ambulatory blood pressure monitoring was studied in 97 elderly patients included in the placebo run-in phase of the Syst-Eur trial. The additional diagnostic precision conferred by ambulatory monitoring on clinic blood pressure measurements was assessed by relating the residual ambulatory blood pressure level to the ECG-left ventricular size. The residual ambulatory blood pressure level was calculated by subtracting the predicted ambulatory blood pressure level for each patient (using the linear regression equation relating both techniques for the group) from the observed ambulatory blood pressure.

RESULTS

Clinic systolic blood pressure was on average 20 mmHg higher (P < 0.001) than daytime ambulatory blood pressure while diastolic blood pressure was similar with both techniques. The sum of SV1 + RV5 was significantly related to clinic systolic pressure (r = 0.25), and 24-h (systolic, r = 0.37; diastolic, r = 0.29), daytime (systolic, r = 0.30; diastolic, r = 0.19) and night-time (systolic, r = 0.33; diastolic, r = 0.28) ambulatory blood pressure levels. These findings were not affected by adjustment for gender, age and the body mass index. The sum of SV1 + RV5 was significantly related to the residual 24-h (systolic, r = 0.30; diastolic, r = 0.31), daytime systolic (r = 0.20) and night-time (systolic, r = 0.31; diastolic, r = 0.29) ambulatory blood pressure monitoring levels.

CONCLUSION

Ambulatory blood pressure monitoring adds to the diagnostic precision of clinic blood pressure measurement in assessing the severity of hypertension in this population. The ongoing side project on ambulatory blood pressure monitoring in the Syst-Eur study should establish whether these findings hold true for morbidity and mortality.

James Mackenzie Lecture 1992. The Indians' revenge

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Motivational effect of cholesterol measurement in general practice health checks

A randomized trial was conducted in five general practices in and around Aylesbury, Buckinghamshire to assess the motivational effect of cholesterol measurement on compliance with advice to reduce dietary fat intake and to stop smoking. The advice was given by practice nurses during health checks for cardiovascular risk factors. A total of 578 patients were recruited to the study and randomized into two groups. Both groups were given the same advice and were followed up after a median of three months, but the intervention group was also given immediate feedback on their cholesterol concentration. Follow up was completed for 88.2% of subjects, and those who were not followed up were assumed not to have changed their behaviour. The mean fall in total cholesterol at follow up was 0.11 mmol l-1 (95% confidence interval 0.03 to 0.18) in the intervention group who were told their cholesterol result and 0.02 mmol l-1 (95% CI -0.06 to 0.10) in the control group who were not. The proportion of smokers who were not smoking at follow up was 10.7% and 10.1% in the two groups, respectively. Patients in the intervention group with an initial total cholesterol level of 6.50 mmol l-1 or greater showed a mean fall of 6.2% in cholesterol level whereas those with an initial cholesterol level of less than 5.20 mmol l-1 experienced a mean increase of 3.6%, but as differences of this magnitude were also seen in the control group they probably reflect regression to the mean rather than an effect of knowledge of cholesterol level.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory blood pressure monitoring in elderly patients with isolated systolic hypertension

OBJECTIVES

This study compared clinic and ambulatory blood pressure measurement and the reproducibility of these measurements in older patients with isolated systolic hypertension (ISH).

PATIENTS

Eighty-seven patients aged greater than or equal to 60 years with ISH on clinic measurement were followed in the placebo run-in phase of the Syst-Eur trial.

METHODS

Clinic blood pressure was defined as the mean of two blood pressure readings on each of three clinic visits (six readings in total). Ambulatory blood pressure was measured over 24 h using non-invasive ambulatory blood pressure monitors.

RESULTS

Daytime ambulatory systolic pressure was, on average, 21 mmHg lower than the clinic blood pressure, whereas diastolic pressure was, on average, similar with both techniques of measurement. In the 42 patients who had repeat measurements, clinic blood pressure levels nad the amplitude of the diurnal blood pressure profile (fitted by Fourier analysis) were equally reproducible. However, both were less reproducible than ambulatory blood pressure levels. The repeatability coefficients, expressed as per cent of near maximum variation (four times the standard deviation of a given measurement), were 52% and 45% for the clinic systolic and diastolic pressures, 56% and 42% for the amplitude of the diurnal profile, and 29% and 26% for mean 24-h pressures.

CONCLUSIONS

In older patients with ISH, clinic and ambulatory systolic blood pressure measurements may differ largely: the prognostic significance of this difference remains to be elucidated. Furthermore, in these patients the level of pressure is more reproducible by daytime ambulatory blood pressure measurement than by clinic measurement.

Caffeine restriction: effect on mild hypertension

OBJECTIVE

To determine the effects on blood pressure of modifying dietary caffeine intake in patients with mild and borderline hypertension by monitoring ambulatory and clinic blood pressure.

DESIGN

Four way, randomised, crossover trial of four consecutive two week dietary regimens: normal diet, caffeine free diet alone, caffeine free diet with decaffeinated instant coffee, caffeine free diet with caffeinated instant coffee (instant coffee phases conducted double blind).

SETTING

Hospital hypertension clinic, Scotland.

PATIENTS

52 patients (23 men; aged 26-67 years) with untreated borderline or mild hypertension (diastolic blood pressure 90-105 mm Hg) who normally drank a minimum of three cups of coffee daily.

MAIN OUTCOME MEASURES

Mean ambulatory blood pressure over 24 hours; mean morning, daytime, and night time ambulatory blood pressure; sitting clinic blood pressure at 1700; plasma caffeine concentration at 1700 on the last day of each regimen.

RESULTS

Mean 24 hour ambulatory blood pressure was not different between regimens. There was no difference in blood pressure variability between regimens. During the caffeine free diet alone morning ambulatory diastolic blood pressure was higher (2.8 mm Hg) than during the caffeine free diet with caffeinated coffee. Mean sitting clinic systolic blood pressure was higher at 1700 (4.7 mm Hg) with a caffeine free diet than with the caffeine free diet with caffeinated coffee (p less than 0.05). Dietary compliance as assessed by plasma caffeine concentration was excellent. There was no significant correlation between plasma caffeine concentration and blood pressure.

CONCLUSIONS

Drinking caffeinated instant coffee over a two week period does not adversely influence blood pressure in patients with borderline or mild hypertension; abstinence is of no benefit.

A comparison of the chronic effects of oral xamoterol and enalapril on blood pressure and renal function in mild to moderate heart failure

1. We compared the effects, after 3 weeks oral therapy, of xamoterol 200 mg twice daily and enalapril 2.5, 5 or 10 mg twice daily on home and clinic blood pressure, glomerular filtration rate (GFR) and renal plasma flow, stroke and minute distances, linear resistance and on plasma renin activity in 19 patients with mild to moderate heart failure in a single-blind randomised crossover study. 2. Enalapril reduced mean home blood pressure by 17/7 mm Hg compared with xamoterol (P less than 0.0001) and by 19/7 mm Hg compared with placebo. Compared with placebo xamoterol had no effect. Enalapril reduced predose blood pressure, compared with xamoterol, on average by 15/5 mm Hg (P = 0.02 systolic, 0.09 diastolic) and by 20/7 mm Hg compared with placebo. At 4 h post-dose the mean differences were: xamoterol-enalapril 13/10 mm Hg (P = 0.01 systolic, 0.0007 diastolic) and placebo-enalapril 23/9 mm Hg. 3. Stroke and minute distances were marginally less 4 h following xamoterol than following enalapril: mean (s.e. mean) values were 9.4 (0.7) vs 10.4 (0.8) cm (P = 0.23) and 699 (51.7) vs 767 (62.1) cm (P = 0.04) respectively. Linear resistance was reduced by enalapril, from the placebo value of 13.2 (1.2) to 11.0 (0.9) mm Hg m-1 and marginally increased by xamoterol, to 14.2 (1.2) mm Hg m-1, the difference between active treatments being statistically significant (P = 0.03). 4. Renal plasma flow, GFR and filtration fraction were not influenced by enalapril or xamoterol therapy. There were no significant correlations between glomerular filtration rate and either blood pressure or stroke distance.(ABSTRACT TRUNCATED AT 250 WORDS)

Bench and ambulatory field evaluation of the A & D TM-2420 automated sphygmomanometer

Adequate evaluation of automated sphygmomanometers, in terms of safety, accuracy, mechanical reliability, patient acceptability and ability to record ambulatory blood pressure is essential before these devices are used in clinical practice and in clinical trials. We have evaluated the accuracy and performance of the A & D TM-2420 automated sphygmomanometer, an auscultatory device designed for ambulatory blood pressure recording. Four devices were tested for accuracy by simultaneous comparison against two experienced observers using standard mercury column sphygmomanometers. Two of these devices developed faults that precluded complete evaluation. One of the remaining devices met and one failed to meet the somewhat liberal criteria for accuracy recommended by the American Association for the Advancement of Medical Instrumentation, the current standard for evaluation (mean difference of less than or equal to 5 mmHg and standard deviation of differences less than or equal to 8 mmHg). The mean differences (standard deviation of differences) between observers for simultaneous triplicate observations of systolic/diastolic pressure in 50 subjects, including 35 hypertensives, were 0.8 (3.0)/-0.6 (2.4) mmHg. In comparison, the differences between each device and each observer were: device 11, observer 1, -6.4 (5.4)/-6.3 (9.9); device 11, observer 2, -5.6 (4.7)/-7.0 (10.4); device 12, observer 1, -4.9 (5.2)/-4.0 (7.5); device 12, observer 2, -4.1 (4.9)/- -4.5 (7.7) mmHg. Ambulatory trials were carried out with a further 10 devices. Of these, seven developed faults requiring their return to the supplier. Numerous additional problems were encountered with microphones, cuffs, leads and connections, the processing unit, error algorithms and data-handling software. The device was not capable of making truly ambulatory recordings. We do not confirm the previously favourable, but limited, evaluation of this device. We stress the vital importance of subjecting a number of devices to benchtesting for accuracy, and the need to undertake extensive 'field' testing before any devices can be considered suitable for ambulatory recording. Exercise testing under laboratory conditions is not an adequate substitue for true ambulatory evaluation.

Randomized controlled trial of anti-smoking advice by nurses in general practice

Practice nurses are playing an increasingly prominent role in preventive care, including the provision of anti-smoking advice during routine health checks. A randomized controlled trial was designed to assess the effectiveness of anti-smoking advice provided by nurses in helping smokers to stop smoking. A total of 14,830 patients aged 16-65 years from 11 general practices completed a brief questionnaire on general health, including smoking status, at surgery attendance. The doctor identified 4330 smokers and randomly allocated 4210 to control or intervention groups. The doctor asked those in the intervention group to make an appointment with the practice nurse for a health check. The attendance rate at the health check was 26%. Smokers were sent follow-up questionnaires at one month and one year, and those who did not respond to two reminders were assumed to have continued to smoke. There was no significant difference in reported cessation between the intervention and control groups at one month or one year. However, there was a significant difference in the proportion of patients who reported giving up within one month and who had not lapsed by one year--0.9% in controls and 3.6% in the intervention group (P less than 0.01). Nevertheless, the effect of the nurse intervention itself may be small as the sustained cessation rate in attenders was only 42.4% higher than in non-attenders. The deception rate in reporting cessation, as measured by urinary cotinine, was of the order of 25%.

The "Help Your Patient Stop" initiative. Evaluation of smoking prevalence and dissemination of WHO/UICC guidelines in UK general practice

The World Health Organisation and the International Agency against Cancer in 1988 published joint guidelines on smoking cessation for primary health care teams. A booklet entitled Help Your Patient Stop was produced in the United Kingdom as a model for the international dissemination of these guidelines. This booklet was sent to UK general practitioners by post; about 4 weeks later, a random sample of 5000 were asked to complete a postal questionnaire about the booklet and their smoking habits. The response rate was 75%. About half (50.5%) remembered receiving the booklet, 27.7% had read it, and only 8.8% could write down any of the three essential activities in smoking cessation which the booklet was intended to promote and which were printed in bold letters on the inside back cover. Although the booklet itself might be an adequate model for other countries, unless dissemination and marketing of the information it contains can be improved, its achievement will be limited. However, the survey did have one optimistic feature: only 13.5% of general practitioners reported that they smoke; and only a third of those who gave full details of their smoking habit smoke cigarettes.

Germ-line gene therapy and the clinical ethos of medical genetics

Although the ability to perform gene therapy in human germ-line cells is still hypothetical, the rate of progress in molecular and cell biology suggests that it will only be a matter of time before reliable clinical techniques will be within reach. Three sets of arguments are commonly advanced against developing those techniques, respectively pointing to the clinical risks, social dangers and better alternatives. In this paper we analyze those arguments from the perspective of the client-centered ethos that traditionally governs practice in medical genetics. This perspective clarifies the merits of these arguments for geneticists, and suggests useful new directions for the professional discussion of germ-line gene therapy. It suggests, for example, that the much discussed prospect of germ-line therapy in human pre-embryos may always be more problematic for medical genetics than adult germ-line interventions, even though the latter faces greater technical difficulties.

Coronary heart disease: prevention and risk factors

Primary care is the ideal place to screen for coronary heart disease and to provide effective follow-up for those at risk. Nurse facilitators are available to help GPs wanting to introduce a screening service.

A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 1. Methodology, demography and incident cases of first-ever stroke

A prospective study of acute cerebrovascular disease in a community of about 105,000 people is reported. The study protocol combined rapid clinical assessment of patients with accurate diagnosis of the pathological type of stroke by CT or necropsy, whether or not they were admitted to hospital. The study population was defined as those people who were registered with one of 50 collaborating general practitioners (GPs). Referrals to the study were primarily from the GPs though, to ensure complete case ascertainment, hospital casualty and admission registers, death certificates and special data from the Oxford Record Linkage Study were also scrutinized. Six hundred and seventy five cases of clinically definite first-ever in a lifetime stroke were registered in four years yielding a crude annual incidence of 1.60/1,000 or 2.00/1,000 when adjusted to the 1981 population of England and Wales. The age and sex specific incidence rates for first stroke showed a steep rise with age for both sexes. The odds of a male sustaining a first stroke were 26% greater than those of a female. Ninety one per cent of patients were examined in a median time of four days after the event by a study neurologist and 88% had cerebral CT or necropsy.

Sexual behaviour, contraceptive practice and knowledge of AIDS of Oxford University students

In summer 1987, 584 students at Oxford University were sent a questionnaire enquiring about their sexual behaviour and contraceptive practice, and about the effect that AIDS has had on these. Of the 374 students who replied, 65% of the women and 62% of the men had experienced sexual intercourse. Twenty-seven per cent of female undergraduates did not use adequate contraception on the first occasion of intercourse. During the 4-week period preceding the questionnaire, 15% of sexually active female undergraduates did not use adequate contraception. The use of contraception has changed over the last 5 years, with fewer students using oral contraceptives as their most frequent means of contraception and more using barrier methods. In general, knowledge about AIDS was high. Most students did not consider that they were at risk of becoming infected by the AIDS virus and, by their reported sexual behaviour, very few students appeared to be at any risk. However, 35% of women and 44% of men who were sexually active said that because of risk of AIDS they had been more likely to use the sheath, and 49% of women and 30% of men said that they had, or would have, fewer partners. These findings suggest that attitudes, and possibly behaviour, are changing towards a reduction in risks of sexually transmitted infection.

Herpes simplex virus type 1-specific cytotoxic T lymphocytes recognize virus nonstructural proteins

The specificity of herpes simplex virus type 1-specific cytotoxic T cells was examined with target cells expressing either input viral structural antigens or antigens resulting from permissive infection or cells from an interrupted infection in which they expressed predominantly nonstructural immediate-early proteins. These studies indicated that only an insignificant minority of cytotoxic T cells recognized the input viral antigens, whereas a significant proportion (20 to 35%) recognized target cells that expressed the immediate-early proteins despite the absence of serologically detectable viral antigens upon the infected cell surface. The finding that a significant proportion of cytotoxic T-cell populations obtained from the draining lymph nodes of mice acutely infected with herpes simplex virus type 1 also recognized immediately-early gene-expressing target cells indicates the importance of nonstructural herpes simplex virus proteins to antiviral immunity in vivo.

Promoting prevention in primary care: controlled trial of low technology, low cost approach

A study is described in which three general practices were provided with low cost, low technology support from a "facilitator" and were compared with control practices in the ascertainment of major risk factors for cardiovascular disease in middle aged patients. Patients who were attending for a consultation with their general practitioners were recruited to make an appointment with a practice nurse for a health check, and this was compared with ordinary consultations in the control practices. Practices were helped by the facilitator to develop the nurse's role. During the study the increase between intervention and control practices in blood pressure recording was doubled and in the recording of smoking habit it was quadrupled, and there was a fivefold increase in the recording of weight. This model can be applied to other aspects of prevention and general practice care.

Practice nurses and antismoking education

A questionnaire on antismoking activities and education was sent to 369 nurses in general practice. The response rate was 80%. Although most of the nurses sometimes advised patients about smoking, routine antismoking education occurred less frequently. Only a few regularly referred smokers to other agencies for help, recommended aids to stop smoking, or used antismoking literature. Although the nurses thought that they had an important role in helping smokers to give up, they expressed little confidence in their effectiveness, believing that advice from the general practitioner and the smoker's personal determination to give up have more impact. The nurses expressed a need for training in antismoking education. Seventy seven per cent were interested in attending seminars and listed information about smoking, techniques for stopping, and counselling skills as priorities. If practice nurses are to use opportunities in primary care to help smokers there is clearly a need to provide further training and to establish the effectiveness of nurses in their role as smoking educators.

Facilitating prevention in primary care

We believe that many general practitioners would practice preventive medicine if they had the opportunity to organise their practice to do this. We therefore provided a "facilitator," who understands the work of a general practice, to help practices that were interested in prevention to set up programmes. She, for example, helped the primary care team to set up objectives, trained practice nurses to measure blood pressure, and set up a system to measure the progress of the programme.

Placebo controlled trial of nicotine chewing gum in general practice

Of 2110 adult cigarette smokers originally recruited to a study of the effect of antismoking advice in general practice, 429 who reported at follow up after one year that they had tried unsuccessfully to stop smoking were offered "a special antismoking chewing gum," either nicotine gum or a placebo gum, in a double blind study. Of 200 who were willing to try the gum, 101 were randomly allocated to the nicotine gum and 99 to the placebo gum. They were followed up at six months by an unannounced home visit, at which they were interviewed and asked to provide a breath sample for analysis of carbon monoxide. Twenty five claimed that they had stopped smoking, but, of them, seven exhaled levels of carbon monoxide indicative of continued smoking. Of the 18 in whom giving up smoking was validated, 10 had received active gum and eight placebo gum, a difference which was not significant (odds in favour of nicotine gum = 1.25, 95% confidence limits 0.47-3.31). The value of nicotine chewing gum, if any, can be quite small when it is used in general practice.

Controlled trial of three different antismoking interventions in general practice

Of 6052 adult patients who consulted their doctors in six Oxfordshire general practices between October 1980 and February 1981, 2110 (35%) were smokers. The smokers were allocated to one of four study groups--a control (non-intervention) group; a group that received verbal and written antismoking advice from the general practitioner; a group that received this advice and also a demonstration of exhaled carbon monoxide; and a group that received the advice plus the offer of further help from a health visitor. After one year 72% of smokers replied to a postal follow up questionnaire: 11% of the control group claimed to have stopped smoking compared with 15% in the group that received advice alone, 17% in the exhaled carbon monoxide group, and 13% in the health visitor group. Validation of these findings by assays of urinary concentrations of cotinine showed that between 24% and 40% of subjects may have misreported their smoking habits, but there was no indication that the rate of misreporting was higher in the intervention groups than in the control group. Giving advice routinely against smoking has a useful effect, and showing an immediate, personal, and potentially harmful consequence of smoking using a CO-oximeter may improve this, particularly in lower socioeconomic groups.

A community study of diabetes in Oxfordshire

A mailed questionnaire was used to identify people with diagnosed diabetes in a population of approximately 14,000. A response rate of 90 per cent was obtained and the prevalence of diabetes was found to be 0.8 per cent. The questionnaire method compared favourably with other methods of identifying diabetics in the area.Eighty-two diabetics were interviewed and examined for diabetic complications and 55 of these completed a questionnaire on their attitudes to diabetes and its care.The medical records of all 108 diabetics identified were examined. A greater proportion of patients who attended either a general practice mini-clinic or a hospital diabetic clinic had examination for complications recorded than patients attending their general practitioner in ordinary surgery time. Patients attending on demand were seen less often and had fewer observations recorded when they came.Comparison of measures of control between hospital and general practice patients showed that hospital patients tended to be more tightly controlled even though most were on insulin and likely to have more severe diabetes.Half of non-insulin diabetics and a quarter of those on insulin considered that their diabetes should be managed solely by their general practitioner.This was a pilot study and caution should be exercised in interpreting results from comparatively small numbers. The study has since been extended to a larger population. f10sl60

Anti-smoking education in Oxfordshire general practices

A postal questionnaire survey of 360 Oxfordshire general practitioners and health visitors on the subject of anti-smoking education was conducted in May-June 1980. Two mailings produced a response rate of 87 per cent. Involvement in anti-smoking education was felt to be more relevant for the doctors than for the health visitors. Health visitors thought that health education officers had a major role to play; they were also more likely than doctors to use literature as an aid in counselling smokers. In general, the mass media were not thought to be effective in helping individual smokers to give up the habit. Both doctors and health visitors were in favour of their professional organizations exerting pressure on Parliament, but only one respondent had ever written to an MP about smoking.

The use of sequential silver and quinacrine staining to determine the parental origin and breakpoints of a ring-22 human chromosome

We delineated a G-ring syndrome in 1968 and suggested it was due to a ring-22 (Weleber et al. 1969). We confirmed in 1972 that the ring was derived from chromosome 22 (Magenis et al. 1973). The present report constitutes a new case of the ring-22 syndrome with clinical findings virtually identical to those we described earlier. By sequential staining techniques with silver and quinacrine, it was possible to determine the parental origin of the ring (maternal) and to estimate the breakpoints in the chromosome 22 (22p12 and 22q13) leading to the ring configuration. The clinical abnormalities are due to terminal deletion of 22q distal to the breakpoint in band 22q13. The silver technique, especially in sequence with other stains, provides new and useful data concerning the origin and precise cytology of this, one of the tiniest rings known in humans.

A needs-assessment method for planning alternatives to hospitalization

A one-day caseload survey was conducted in Los Angeles County's public inpatient facilities in order to estimate needs for alternatives to hospitalization. According to the primary therapists of each client in the caseload, 43 per cent of the inpatients could, on the day of the survey, be served in alternative programs. Responses to questions about the kinds of living arrangements and medical-diagnostic services needed in community programs for those clients showed a high need for residential care with close supervision or locked wards or both. The author concludes that while a significant number of inpatient days could be eliminated through the use of minimal-supervision alternatives, a large decrease in hospitalization could be expected only if more intensive community programs were implemented.