Safety and Efficacy of Nifedipine 20 mg Tablets in Hypertension Using Electronic Data Collection in General Practice

Electronic data collection was used in this open study to survey the safety and efficacy of nifedipine when used in the treatment of 3972 patients with mild to moderate essential hypertension. The safety and efficacy results are presented and discussed as well as the advantages, disadvantages and reliability of electronic data collection. The validity of data collected electronically has not previously been tested, such data having been assumed to be reliable. The pattern of adverse events reported in this study is compared with the pattern of reports to the Committee on Safety of Medicine (CSM), to Bayer UK and in a large paper-based study of nifedipine, in order to test these assumptions. Reported adverse medical events pre-treatment, prior to entry to the study and noted at visit 1, were compared with reports during treatment in the study at visits 2 and 3. The expected incidence of flushing and headache was seen which diminished with continued treatment. Reductions were seen in dyspnoea and impotence. Ankle oedema was observed and was not reduced by time alone. After one month of treatment with nifedipine 20 mg tablets twice daily, 66.5% of patients had a sitting phase V diastolic blood pressure of 90 mmHg or below and 79% of 95 mmHg or below.

Carols in the wind

AIM

To compare mood and emotional responses to music played on pipe organs and pipeless (digital) organs.

DESIGN

A two-organ (pipe v. digital) crossover study.

SETTING

St Theodore's Anglican Church, Adelaide.

SUBJECTS

43 non-musician volunteers.

MAIN OUTCOME MEASURES

Changes in mood and emotions measured by the Profile of Mood States.

RESULTS

Both instruments produced significant reductions in the emotions commonly experienced during the Christmas season: tension-anxiety, depression-rejection, anger-hostility and fatigue. There were no significant changes for vigour or confusion-bewilderment, and no significant differences between the mood-altering effects of the two instruments.

CONCLUSIONS

Pipeless organs are as effective as pipe organs in inducing beneficial mood changes.

Privacy considerations in the context of an Australian observational database

Observational databases are increasingly acknowledged for their value in clinical investigation. Australian general practice in particular presents an exciting opportunity to examine treatment in a natural setting. The paper explores issues such as privacy and confidentiality--foremost considerations when conducting this form of pharmacoepidemiological research. Australian legislation is currently addressing these exact issues in order to establish clear directives regarding ethical concerns. The development of a pharmacoepidemiological database arising from the integration of computerized Australian general practice records is described in addition, to the challenges associated with creating a database which considers patient privacy. The database known as 'Medic-GP', presently contains more than 950,000 clinical notes (including consultations, pathology, diagnostic imaging and adverse reactions) over a 5-year time period and relates to 55,000 patients. The paper then details a retrospective study which utilized the database to examine the interaction between antibiotic prescribing and patient outcomes from a community perspective, following a policy intervention. This study illustrates the application of computerized general practice records in research.

A randomised controlled trial of the outcome of health assessment of people aged 75 years and over

OBJECTIVES

To measure the outcomes of a health assessment, conducted by a nurse, of people aged 75 years and older (75+HA) living independently in their own homes.

DESIGN

Randomised controlled trial (RCT).

SETTING

A convenience sample of six general practices within the Adelaide Western Division of General Practice (AWDGP). A random sample of 100 participants was drawn from practice age-sex registers. Data were collected in initial visits between 1 August 1998 and February 1999, then in follow-up visits one year later.

PARTICIPANTS

Participants were aged 75 years and over on 1 August 1998 and living independently in the community. 145 eligible patients were invited to join the study, and 100 of these consented to enrol (69%).

INTERVENTION

A 75+HA conducted in the participant's home by a nurse and reported to their usual general practitioner.

MAIN OUTCOME MEASURES

Primary: number of problems in each group; number of participants with problems; and mortality. Secondary: physical function; psychological (including cognitive) function; falls; and admission to institution.

RESULTS

There were no significant differences between the control and intervention groups at follow-up in the number of problems, the number of participants with problems, or mortality. In the intervention group, there was significant improvement in self-rated health, geriatric depression score (GDS 15), and number of falls.

CONCLUSIONS

This RCT has not demonstrated improvement in health status of the intervention group which received a 75+HA compared with a control group left to usual care.

An observational study of the medical events associated with clinician-initiated changes in treatment for essential hypertension

We report a retrospective longitudinal observational study of co-morbidities and medical events associated with initiations and changes in antihypertensive therapy in 475 hypertensive patients of a large general practice. The median follow-up time was 7.0 years for males and 7.2 years for females. The data showed a low frequency of appropriate lifestyle recommendations (<30%), a gender-bias in lifestyle recommendations against women and that more than half of all patients' blood pressure (BP) was uncontrolled when last seen. Nearly half of all patients had co-morbidities relevant to essential hypertension (EHT) at first treatment for EHT and more than 11% of patients had more than one such co-morbidity. Whilst there was an increase in usage of ACE inhibitors and calcium channel blockers (CCB) as first treatment for EHT, there was also evidence that the existence of relevant co-morbidities rationally accounted for the majority of that increase. There were 5176 medical events relevant to EHT associated with change of drug or dosage treatment of EHT and the study provided evidence that the occurrence of such relevant medical events can rationally account for the majority of changes to EHT treatment. The study suggests that whilst general practitioners may fail to promote lifestyle changes to their patients with EHT, there is evidence that, when examined in sufficient detail, general practitioners' decisions to initiate changes in antihypertensive therapy are in keeping with the evidence base.

Establishing a practice based primary care research network. The University Family Practice Network in South Australia

BACKGROUND

Practice based research networks enable the study of primary care problems in a primary care setting. To be successful, our experience indicates that a network will need to incorporate a number of key components. In South Australia, a University Family Practice Network has been established to undertake primary health care research and teaching and to contribute to the general practice workforce. The University Family Practice Network is composed of five practices and is managed jointly by the Department of General Practice, Adelaide University and the South Australian Centre for Rural and Remote Health, Adelaide University and the University of South Australia.

OBJECTIVE

This article details the successful establishment of the University Family Practice Network in the hope of providing a model for other universities who may be interested in setting up a practice based research network.

DISCUSSION

The characteristics of this network include fractional academic positions for general practitioners, computerised medical records, location in rural and urban sites, regular meetings and the appointment of a research fellow. A number of benefits have arisen since the network's establishment that will assist its future development and sustainability. These include collocation with allied health services, development of local expertise and workforce support.

Positive impact of rural academic family practices on rural medical recruitment and retention in South Australia

Difficulty recruiting and retaining doctors in rural and remote Australia is well recognised. Here, we describe the positive impact on recruitment and retention of general practitioners of a network of university-linked rural family practices in South Australia. Between August 1995 and October 1999, 17 doctors were recruited; eight (47%) were female and six (35%) worked part time. Four doctors left the practices after an average of 20 months service (annual turnover of 6%). Of the two general practice registrars placed in the single accredited practice, one has since joined the practice and the other will do so in 2000. Five doctors are overseas-trained (24%) and four are expected to stay permanently. Rural academic family practices have successfully recruited and retained medical staff in this setting over the past few years. This model of practice may be a useful recruitment and retention strategy for other parts of Australia.

WISDOM. Will Australian women participate?

AIM

This study investigated the likelihood of 50-69 year old women participating in the Women's International Study of long Duration Oestrogen after Menopause (WISDOM)--a 10 year randomised placebo controlled trial of hormone replacement therapy involving 10 years treatment plus a further 10 years follow up of major health outcomes.

METHODS

The Health Monitor 2 (a representative population telephone survey) was used. Participants were 268 women aged 50-69 years from a total survey population of 2003 adults. Sociodemographic characteristics were collected.

RESULTS

Of the women surveyed 20.9% indicated they were likely to participate and this was independent of sociodemographic characteristics and self reported health status. Women aged 50-54 were more likely to participate than older women.

DISCUSSION

After allowing for exclusion criteria, it is estimated that approximately 10% of 50-69 year old women approached for recruitment in WISDOM may actually participate. There are likely to be sufficient altruistic women in this population to run WISDOM in Australia.

Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study

BACKGROUND

Hospital admissions among patients with congestive heart failure (CHF) are a major contributor to health-care costs. Previous investigations suggest that the therapeutic efficacy of pharmacotherapy in CHF may be improved by strategies incorporating home visits to identify and address factors precipitating deterioration and resultant readmission.

METHODS

Chronic CHF patients discharged home after acute hospital admission were randomly assigned usual care (n=100) or a multidisciplinary, home-based intervention (n=100), consisting of a home visit by a cardiac nurse 7-14 days after discharge. The primary endpoint of the study was frequency of unplanned readmission plus out-of-hospital death within 6 months.

FINDINGS

During 6 months' follow-up there were 129 primary endpoint events in the usual-care group and 77 in the intervention group (p=0.02). More intervention-group than usual-care patients remained event-free (38 vs 51; p=0.04). Overall, there were fewer unplanned readmissions (68 vs 118; p=0.03) and associated days in hospital (460 vs 1173; p=0.02) among intervention-group patients. Hospital-based costs were Australian $490,300 for the intervention group and A$922,600 for the usual-care group (p=0.16); the mean cost of the intervention was A$350 per patient, and other community-based costs were similar for both groups.

INTERPRETATION

A home-based intervention has the potential to decrease the rate of unplanned readmissions and associated health-care costs, prolong event-free and total survival, and improve quality of life among patients with chronic CHF.

Long-term follow up of patients with toenail onychomycosis after treatment with terbinafine

The long-term outcome of 111 patients treated with oral terbinafine for toenail onychomycosis with a novel treatment protocol was assessed a median of 138 weeks after entry into the trial. All but three patients had either one or two 12 week courses of terbinafine 250 mg daily. Of the 77 evaluable patients, 72.7% were still classified as responders (i.e. negative mycological culture and at least 3 mm of new unaffected nail growth) on reassessment. The present study shows that a favourable long-term outcome can be achieved in patients who have been treated with at least one 12 week course of terbinafine.

Training, skills and approach to high-risk obstetrics in rural GP obstetricians

One hundred and sixty seven (82%) of the 204 practising South Australian rural GP obstetricians responded to a questionnaire on training, skills and approach to high-risk obstetrics. The mean length of training was 8.5 months; 78% of GP obstetricians held a diploma. There was a mean of 13 years experience and 22 deliveries per year. However, 26.3% of practitioners had stopped obstetrics in the previous 12 months and cited indemnity insurance and lifestyle factors as the main reason for stopping. The GPs practised a wide range of skills; forceps (96%), Caesarean section (42%) and had good access to epidural services (83.6%), blood transfusions (91%) and specialist advice. High-risk obstetrics such as twin pregnancy, fetal growth retardation, insulin-dependent diabetes and preterm labour, are avoided by most rural GP obstetricians. The mean visual analogue comfort score for providing obstetric care was 7.46 (2.16) and correlated with length of training (p = 0.008) and number of deliveries per year (p = 0.02). Health authorities must continue to support and encourage country GP obstetricians to provide this essential service to rural women.

Second Australian National Blood Pressure Study (ANBP2). Australian Comparative Outcome Trial of ACE inhibitor- and diuretic-based treatment of hypertension in the elderly. Management Committee on behalf of the High Blood Pressure Research Council of Australia

The Second Australian National Blood Pressure Study (ANBP2) is a comparative outcome trial being conducted in general practices throughout Australia of ACE inhibitor- and diuretic-based treatment in 6000 hypertensive patients aged 65-84 years. The study is using a prospective randomised open-label design with blinding of endpoint assessments. The primary objective is to determine whether there is any difference in total cardiovascular events (fatal and non-fatal) over a five year treatment period between the two treatment regimens. Eligible hypertensive patients (average sitting blood pressure at the 2nd and 3rd screening visits > 160 mm Hg systolic and/or > 90 mm Hg diastolic) may be either untreated or previously treated and should have no history of recent cardiovascular morbidity or serious intercurrent illness. Patients are randomised to one of the treatment arms with randomisation stratified for practice and for age. Following randomisation each patient's blood pressure is managed by his/her general practitioner according to guidelines relevant to each treatment arm. Over 700 patients have now been randomised with recruitment intended to be complete by the end of 1997.

Non-dermatophytes in onychomycosis of the toenails

A multicentre trial for the treatment of dermatophyte onychomycosis of the toenails with terbinafine was carried out in Australia and New Zealand. Between eight and 12 nail samples were obtained from each of the 118 patients in the 48-week trial, and each sample was investigated by direct microscopy and culture for dermatophyte and non-dermatophyte fungi. Patients were randomized to treatment with terbinafine at 250 mg/day or placebo for the first 12 weeks of the study, then non-responders were offered a 12-week course of terbinafine from week 28. All patients had a dermatophyte infection. In 42 patients (36%) microscopy and mycological culture identified dermatophytes alone. In the remaining 76 patients (64%), a non-dermatophyte mould or yeast was also isolated at some stage during the trial, but in only three patients did the same non-dermatophyte persist in two or more successive nail specimens. The presence of a fungal contaminant in addition to a dermatophyte had no apparent effect on the efficacy of treatment with terbinafine. We conclude that non-dermatophyte moulds and yeasts are generally found as contaminating organisms in dermatophyte onychomycosis, secondary to the dermatophytes, and that they do not influence the outcome of treatment.

Significance of non-dermatophyte moulds and yeasts in onychomycosis

In a multicentre, randomised, double-blind, 48-week clinical trial, 118 patients with toe-nail onychomycosis were given terbinafine (250 mg daily) or placebo for 12 weeks, followed by 12 weeks of observation. Non-responders were offered 12 further weeks of terbinafine (250 mg daily) from week 28. Each patient had 8-12 consecutive nail specimens collected from the same nail, allowing for an assessment of the fungal nail flora from 1,321 nail specimens. By week 48, the overall mycological cure rate for terbinafine patients was 94%. 64% of patients had an underlying dermatophyte infection with at least 1 non-dermatophyte mould or yeast isolated from at least 1 specimen. These contaminants often overgrow or mask the presence of a dermatophyte. In only 2.5% of all patients was the same non-dermatophyte isolated from 2 or more consecutive specimens, probably representing secondary colonisation which exploits nutrients released by the underlying dermatophyte. The presence of incidental non-dermatophyte contaminants or secondary colonisers did not affect treatment outcome, and in this study treatment of the primary dermatophyte pathogen with terbinafine cleared the nails from infection in all cases. 80% of patients remained mycologically negative after 2 years.

Principles behind practice. 6. Disease causation. The role of epidemiological evidence

How can epidemiology contribute to understanding the cause of clinical disease? We discuss the nature of causality and the intrinsic limitations of all empirical science, including epidemiology, in establishing "proof" of causality. Our examples relate to eye disease: How the cause of blindness from retrolental fibroplasia was unravelled. How the congenital rubella syndrome was discovered as a cause of congenital cataract. How allopurinol was cleared from suspicion as a cause of cataract.

Nitrendipine therapy in asthmatic subjects

Nitrendipine was given to eight patients with chronic stable asthma prior to a histamine challenge study and compared in a double-blind cross-over fashion with placebo. There were no significant differences in either the bronchoconstrictor effects of histamine, or in oxygen saturation during the histamine challenges, suggesting that nitrendipine should be safely tolerated if used to treat hypertension in patients with airflow obstruction.

Improving family care. Interaction between general practice and primary school

Members of families in difficulties may present to general practitioners with somatic complaints and their children may refuse to go to school. Greater communication between school and practice would provide earlier identification of troubled families. This study, conducted in a country town in Victoria in 1988, showed that teachers would welcome more contact with general practitioners.

General practice data derived tolerability assessment of antihypertensive drugs

A large hypertensive population of patients in general practice was used to assess the tolerability of nifedipine in previously untreated patients and was compared with other antihypertensive drugs in previously treated patients. A total of 3972 patients with a sitting diastolic blood pressure between 95 and 115 mmHg were treated with 20 mg nifedipine twice daily for 1 month. In non-responders the dose was increased to 40 mg twice daily for a second month; responders continued to take 20 mg twice daily. A total of 2772 patients had been previously untreated for hypertension, whereas 857 had previously been treated with beta-blockers alone or in combination and 346 had received diuretics alone or in combination. Adverse events were recorded for 28 days prior to treatment being initiated with or changed to nifedipine and for two 28-day nifedipine treatment periods. Flushing and headache, which diminished with time, occurred during nifedipine treatment. Ankle oedema did not diminish with time. Reductions were seen in occurrences of dyspnoea, impotence, lethargy and cold extremities.

Post marketing surveillance of new drugs. Patient safety in the hands of GPs

Is the post market surveillance--the monitoring for safety and tolerability of new drugs--reliable? Will it become compulsory? How does it compare with current detection methods? How reliable are promotional claims drawn from it? This review is a guide to the present, and the implications for the future for general practice.

Does communication between investigators improve the conduct of the multicentre study?

Meetings between investigators participating in multicentre clinical trials are rarely held. Evidence is presented from a computerised system of multicentre trial management that there are advantages to both physicians and companies in improving communication and holding regular meetings.

Chlormethiazole as sleep cover for the elderly. Intravenous infusion during local analgesia

A method of avoiding postoperative confusion when local analgesic techniques are indicated for the elderly is described. Basal sedation using 0.8% chlormethiazole infusion intravenously, was employed. Mental function was not altered when the technique was used and it is suggested that the length of stay in hospital can be reduced.