Coping with pressures in acute medicine--the second RCP consultant questionnaire survey.

The second questionnaire survey of consultant physicians involved in acute unselected takes in 1999 achieved a 76% response rate, and the results have been compared with those from the first survey of 1997. The proportion of consultants whose trainees worked partial shifts had increased from 42% to 61%, although these patterns of duty were adjudged to have detrimental effects on the quality and continuity of care, and on junior staff education and training. The benefits of ward-based systems were counterbalanced by their disadvantages, but introductions of admission wards and assessment units were considered a resounding success. The number of hospitals with 'physician of the week' schemes had increased from 12 to 23, but opinion of their value was sharply divided. The provision and competence of all grades of locums was identified as an increasing problem. Seventy per cent of respondents stated that they would never participate in 'hands-on' emergency care, although 86% thought that future consultants might have to do so. Seventy-nine per cent reported increases in the pressures of their posts and in their working hours, and the tensions between general and specialist duties were highlighted. Most consultants considered that the only long-term solution to the staffing crisis was a marked expansion in the numbers of all grades of medical staff.

Consultant post prospects in medical specialties.

Consultant post prospects for Specialist Registrars (SpRs) in all the medical specialties have been analysed using the databases of the Royal College of Physicians and the Joint Committee on Higher Medical Training (JCHMT). A 'bulge' in the numbers of SpRs obtaining Certificates of Completion of Specialist Training (CCSTs) is anticipated over the next 2-3 years, but this effect will be alleviated by the increasing trend to spend extra years in research or flexible training. There are profound differences between the specialties in the ratios of SpRs holding National Training Numbers (NTNs) to consultants, and in the proportions of female SpRs, and these factors will markedly influence consultant post prospects. The outlook within most specialties is favourable, but this is critically dependent on the rate of consultant expansion over the next few years.

Implications of new diagnostic criteria for abnormal glucose homeostasis in women with previous gestational diabetes.

OBJECTIVE: To determine the consequences of applying revised American Diabetes Association (ADA) (1997) and World Health Organization (WHO) (1998) recommendations for the classification of glucose intolerance in women with previous gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: There were 192 women with previous GDM who took an oral glucose tolerance test (OGTT) 1-86 months after delivery and were classified by WHO (1985), ADA (1997, fasting glucose), and revised WHO (1998) guidelines. RESULTS: Among the 165 women without a preexisting diagnosis of diabetes, WHO-1985 and ADA-1997 provided similar estimates of diabetes prevalence (13.3% vs. 11.5%) but widely differing estimates of impaired glucose homeostasis (31.5% impaired glucose tolerance [IGT] by WHO-1985 vs. 10.9% impaired fasting glucose by ADA-1997 criteria). Overall, 56 women (34%) showed a classification discrepancy between WHO-1985 and ADA-1997 criteria, including 44 with normal fasting glucose by ADA-1997 criteria, but abnormal 2-h glucose by WHO-1985 criteria (40 IGT, 4 diabetes). The cardiovascular risk profile of these women was more favorable than that of 18 women with impaired fasting glucose. WHO-1998 recommendations reproduced ADA-1997 findings when used as a fasting screen, but behaved similarly to WHO-1985 criteria when 2-h glucose values were also analyzed. CONCLUSIONS: All criteria produced similar estimates of diabetes prevalence. However, analyses based on a single fasting glucose screen (and a threshold of 6.1 mmol/l) failed to identify 60% of women with abnormal 2-h glucose levels. Screening women with previous GDM (and by analogy, other groups at high risk of diabetes) with a single fasting glucose has low sensitivity for the detection of abnormal glucose tolerance. Recent guidelines recommending this approach require reevaluation.

The scope for cardiovascular disease risk factor intervention among people with diabetes mellitus in England: a population-based analysis from the Health Surveys for England 1991-94.

AIMS: To examine the scope for cardiovascular disease risk factor intervention among diabetic patients in England was examined using data from the Health Surveys for England 1991-94. This evaluation included calculating the proportion who require lipid lowering therapy according to the Standing Medical Advisory Committee (SMAC) guidelines. METHODS: The Health Survey for England is an annual, nationwide household-based in which anthropomorphic data, blood pressure, lipids and details of cardiovascular risk factors are collected from households after random stratification for geographical and socio-economic factors within a population sample of 39639 adults, 970 (2.3%) diabetic subjects were identified. RESULTS: Overall, 51% of those with diabetes had hypertension (systolic blood pressure > or = 160 mmHg or a diastolic BP > or = 95 mmHg or being on antihypertensive therapy), 27% were obese (body mass index > or = 30 kg/m2) and 19% were current smokers. One-third of those with hypertension were untreated and less than one-half of those on treatment had their hypertension controlled to below 160/ 95 mmHg. More than one-quarter had poor glycaemic control (glycated Hb>11% or an HbA1c>7.5%). Of those aged <70 years, 29% required lipid lowering therapy according to the SMAC guidelines and almost all (94%) of these were not on treatment. An analysis showed that, because the SMAC guidelines do not require high density lipoprotein (HDL) cholesterol to be measured, their use is likely to result in substantial underestimation of the need for lipid lowering, particularly in diabetic women. CONCLUSION: In England, among those with diabetes there is considerable unmet need for cardiovascular risk factor intervention, particularly for hypertension and raised cholesterol. With this baseline established, future improvements can be monitored.

Subcutaneous glucagon-like peptide-1 improves postprandial glycaemic control over a 3-week period in patients with early type 2 diabetes.

1.Glucagon-like peptide-1 (7-36) amide (GLP-1) is released into the circulation after meals and is the most potent physiological insulinotropic hormone in man. GLP-1 has the advantages over other therapeutic agents for Type 2 diabetes of also suppressing glucagon secretion and delaying gastric emptying. One of the initial abnormalities of Type 2 diabetes is the loss of the first-phase insulin response, leading to postprandial hyperglycaemia.2. To investigate the therapeutic potential of GLP-1 in Type 2 diabetes, six patients were entered into a 6-week, double-blind crossover trial during which each received 3 weeks treatment with subcutaneous GLP-1 or saline, self-administered three times a day immediately before meals. A standard test meal was given at the beginning and end of each treatment period.3.GLP-1 reduced plasma glucose area under the curve (AUC) after the standard test meal by 58% (AUC, 0-240 min: GLP-1 start of treatment, 196+/-141 mmol.min-1.l-1; saline start of treatment, 469+/-124 mmol.min-1.l-1; F=16.4, P<0.05). The plasma insulin excursions were significantly higher with GLP-1 compared with saline over the initial postprandial 30 min, the time period during which the GLP-1 concentration was considerably elevated. The plasma glucagon levels were significantly lower over the 240-min postprandial period with GLP-1 treatment. The beneficial effects of GLP-1 on plasma glucose, insulin and glucagon concentrations were fully maintained for the 3-week treatment period. 4. We have demonstrated a significant improvement in postprandial glycaemic control with subcutaneous GLP-1 treatment. GLP-1 improves glycaemic control partially by restoring the first-phase insulin response and suppressing glucagon and is a potential treatment for Type 2 diabetes.

Comparison of prevalence and risk factors for microalbuminuria in South Asians and Europeans with type 2 diabetes mellitus.

Although Type 2 (non-insulin-dependent) diabetes mellitus (Type 2 DM) is more common in South Asians than in Europeans in the UK, very little is known about complications and their risk factors in South Asians. We sought microalbuminuria in a cross-sectional study of 583 European and 889 South Asian Type 2 DM clinic attenders to Ealing Hospital, London, over 1 year. Albumin/creatinine ratios were measured in early morning urines. Prevalence of microalbuminuria was greater in South Asians compared to Europeans (40% versus 33% in men, p = 0.003, and 33% versus 19% in women, p < 0.0001). Glycaemic control was worse and prevalence of hypertension, retinopathy and heart disease was higher in South Asians. Key risk factors for microalbuminuria in both ethnic groups were glycaemic control, diabetes duration, blood pressure, triglyceride and retinopathy, but none accounted for the higher microalbuminuria prevalence in South Asians. Age and sex adjusted odds ratio for microalbuminuria was 1.78 (95% CI 1.02, 2.82, p = 0.02) in South Asians versus Europeans. After adjustment for confounders, this became 2.07, 95% CI 1.13, 3.79, p = 0.02. We conclude that microalbuminuria is more common in South Asians with Type 2 DM than in Europeans and, although risk factor relationships appeared similar in both groups, and some risk factors were more prominent in South Asians, this cannot account for the high prevalence of microalbuminuria observed in South Asians.

Coping with pressures in acute medicine. The Royal College of Physicians Consultant Questionnaire Survey.

OBJECTIVES: To assess the impact of reduced junior doctors' hours and increasing emergency admissions on patterns of acute medical care, and to evaluate recent innovations. METHODS: Questionnaire survey of all 2,980 consultant physicians in England, Wales and Northern Ireland potentially involved in acute medicine. The response rate was 63% with 1,3632 respondents undertaking unselected takes. RESULTS: WORKLOAD: The median average number of admissions per 24 h was 20-24, but 25% of consultants admitted > or = 30. The median frequency of take duties was 1 day in 5. COMPOSITION OF RESIDENT MEDICAL TEAMS: The most common permutation was one specialist registrar (SpR), senior house officer (SHO) and house physician (HP), coping with 20 admissions on average. However, the teams of 25% of respondents did not include a SpR, and 9% consisted solely of one SHO and one HP, with an average 17 admissions. PARTIAL SHIFT ROTAS: Forty-two per cent of consultants had introduced these. Most were critical of them because of their adverse impact on continuity of care and junior staff training, and their unpopularity with trainees. PATTERNS OF CARE: Only 10% of consultants indicated that myocardial infarction patients were managed exclusively by a cardiological team. Forty per cent operated an age-limit (varying between 65 and 85) for admission under care of the elderly physicians. Seventy per cent had introduced an admissions ward. NEW INITIATIVES TO COPE WITH ADMISSIONS: These included twice-daily consultant take rounds, use of nurse practitioners and staff-grade doctors, 12-hour takes and ward-based admission schemes. Measures to expedite discharges included 'discharge lounges', nurse facilitators, low-dependency wards and 'hospital at home' schemes.

Assessment of simple colorimetric procedures to determine smoking status of diabetic subjects.

The performance of a simple colorimetric assay for urinary nicotine metabolites to assess smoking status in diabetic subjects (n = 251) was investigated. Several variations of the colorimetric assay and a qualitative extraction procedure were evaluated in comparison with a cotinine immunoassay as the "gold standard." Among these, the best overall performance was achieved with the qualitative test (sensitivity 95%; specificity 100%). The quantitative measurement of total nicotine metabolites performed less well (sensitivity 92%; specificity 97%) but could be improved by incorporating a blank extraction (sensitivity 98%; specificity 98%). Allowance for diuresis appeared to offer no advantage over the other methods. These results support previous findings regarding the use of these colorimetric procedures in nondiabetic subjects and, contrary to other recent observations, their performance was not impaired in diabetic patients.

Mortality and morbidity from diabetes in South Asians and Europeans: 11-year follow-up of the Southall Diabetes Survey, London, UK.

Over 20% of middle aged and elderly South Asian people throughout the world have diabetes. The associated mortality and morbidity risks are unclear. We compared mortality and morbidity in a cohort of South Asian and European people with diabetes in London, UK, in an 11-year follow-up of a population-based sample of 730 South Asians (mean age 55 in 1984) and 304 Europeans (mean age 67 in 1984) with diabetes aged 30 years and above in 1984. By 1995, 242 (33%) of South Asians, and 172 (57%) of Europeans had died. The all-cause mortality rate ratio (South Asian versus European) was 1.50 (95% CI 0.72-3.12) for those aged 30-54 years at baseline. Ethnic differences in mortality rates were abolished or reversed in people aged 65 years and above at baseline. The mortality rate ratio for circulatory deaths was 1.80 (95% CI 1.03-3.16, p < 0.05) and for heart disease was 2.02 (95% CI 1.04-3.92, p < 0.05) in those aged 30-64 years at baseline. Seventy-seven per cent of South Asian deaths were caused by circulatory disease, compared with 46% of European deaths. South Asian survivors were 3.8 times (95% CI 1.8-8.0, p = 0.001) more likely to report a history of myocardial infarction than Europeans. South Asian adults with diabetes show a markedly increased predisposition to cardiovascular disease compared with Europeans, especially in younger people. This emphasizes the urgent need to reduce cardiovascular risk in this vulnerable group.

Helicobacter pylori infection and upper gastrointestinal patholgy in a British immigrant Indian community.

OBJECTIVES: To assess the pattern of upper gastrointestinal pathology and the prevalence of Helicobacter pylori infection in the Southall Indian community. DESIGN: A prospective study of endoscopic findings in 124 Indian and 107 whites from the Southall area. In a separate study blood samples were taken from 100 Indian subjects presenting to a single general practitioner in Southall. METHODS: The presence of gastritis and H. pylori infection was assessed histologically in Indian and white patients undergoing endoscopy. Serum samples were analysed using a specific enzyme-linked immunosorbent assay (ELISA) for anti-H. pylori immunoglobulin G. RESULTS: In the endoscopic study, Indian and white patients had the same rate of H. pylori infection (52% vs. 43%, respectively) (P= NS). The pattern of upper gastrointestinal pathology was similar in whites and Indians. In the general practice based study 41 subjects were H. pylori seropositive. Seropositivity increased with age (P<0.05). CONCLUSION: There is no excess of H. pylori-related pathology in Southall immigrant Indians. The similarity of upper gastrointestinal pathology in UK Indian and white patients presenting for endoscopy suggests that the high rates of duodenal ulceration, gastritis and H. pylori infection in India are environmentally rather than racially determined.

Attitudes of consultant physicians to the Calman proposals: a questionnaire survey. North West Thames Diabetes and Endocrinology Specialist Group.

OBJECTIVE: To determine the views of a large and representative group of consultant physicians on the Calman proposals, in which acute general medical services will change from being primarily consultant led to consultant provided. DESIGN: Postal questionnaires. SUBJECTS: All 236 consultant physicians in acute hospitals in North West and South West Thames regions. RESULTS: Replies were received from 179 (76%). One hundred and thirty seven (77%) indicated that they would not resume emergency residential duties, and 126 (71%) indicated that they would probably withdraw from general medical duties under these circumstances. One hundred and twenty six (70%) and 137 (77%) had not inserted a central venous line or temporary pacemaker, respectively, within the previous five years. Of 157 answering a question on the impact of the Calman proposals on the quality of patient services, 125 considered that it would be detrimental, and only 18 (11%) thought that it would be beneficial. CONCLUSION: Most consultant physicians are not prepared to resume emergency duties and could not do so without retraining in practical procedures. There is widespread antagonism to the Calman proposals, and most physicians consider that their impact on the quality of patient services will be detrimental.

Hyperkalaemia in diabetes: prevalence and associations.

Hyperkalaemia is associated with diabetes, but there are no recent reports of its prevalence and associations. Serum potassium concentrations were measured in all 1764 patients attending a diabetic clinic over a 12-month period and found to be > 5.0 mmol/l in 270 (15%), and > 5.4 mmol/l in 67 (4%). There was no other evident cause of hyperkalaemia in 41 of these 67 patients. These data serve to highlight the risk of dangerous hyperkalaemia in diabetic patients, particularly with concurrent administration of angiotensin-converting-enzyme inhibitors and potassium-sparing diuretics.

Help for house officers: EFCOS--the Ealing Hospital Firm Computer System.

The Ealing Hospital Firm Computer System is a novel database system which has been designed to meet the needs of house physicians in a busy general medical unit. It is maintained exclusively by them and produces instant lists of all patients on their firm, with all relevant information needed to organise their clinical work. It has proved extremely popular, and its value to both junior and senior staff has been documented in an anonymous questionnaire survey. The system is available for distribution on a non-profit basis, and other colleagues are invited to use it.