Serial tests of T-cell function predict long-term survival in an elderly cohort from a Scottish general practice.

INTRODUCTION The care of the elderly presents serious challenges to general practice. In 1979, the first author took over the care of a general practice in Scotland where 21% of registered patients were elderly. This resulted in a high workload and prompted research into how this might be mitigated. AIM To measure serial tests of T-cell function in these individuals in order to identify those whose immune response was impaired and assess the effect of this in a long term follow up. METHODS This research comprised two phases. In the assessment phase (1979-82), patients were invited to have a 3-monthly visit from a research nurse where clinical measurements were made and blood taken for immunological tests of lymphocyte proliferation after culture with phytohaemagglutinin (PHA). For each patient, all records were surveyed and problems identified. In the follow-up phase (post 1982), all deaths were assessed with complete life-long follow up. RESULTS Of 405 people originally invited to participate in this research, 314 (78%) agreed and 246 (153 female, 93 male) entered the follow-up phase and were followed for 36.5 years. Factors significantly associated with lower survival were age, male sex, diastolic blood pressure, current smoking and poor immune function, as demonstrated by the percentage of negative responses in at least six PHA tests. Considered in four groups by percentage of failing tests, the lowest group had a life span 4 years shorter than the highest (P<0.01). The four groups did not differ significantly in general practitioner workload, diagnosed problems or causes of death. DISCUSSION Poor cellular immune function was associated with poor survival over lifetime follow up of >30 years. A sensitive, specific and longitudinally consistent measure of T-cell function is required to predict who may be at risk of poorer survival within our practices.

Thyroid function in adults with Down's syndrome.

The thyroid status of 82 institutionalized adults with Down's syndrome has been assessed. Compared to age and sex matched control subjects, these patients had significantly lower mean total serum thyroxine (T4) and triiodothyronine (T3) concentrations (T4; 69.1+/-22.2 nmol/1; (mean+/-SD) vs. 100.1+/-19.1, P less than 0.001; T13; 1.61+/-0.47 nmol/1 vs. 1.76+/-0.34, P less than 0.025), lower free thyroxine index (FTI), (FTI; 66.1+/-22.4 vs. 95.1+/-20.2, P less than 0.001), and higher basal serum thyrotrophin (TSH) concentrations (TSH; 7.6+/-10.7 mU/1 vs. 3.8+/-1.5, P less than 0.001). These changes were not related to age or sex. Abnormalities in one or more test of thyroid function were demonstrated in at least 38 (46%) of the 82 patients. Two main patterns of abnormality were defined: 1) subnormal T4, FTI and elevated basal TSH levels (primary hypothyroidism) in 13 (16%). All seven of the 13 patients in whom TRH tests were performed showed the expected exaggerated TSH response, and seven out of the 13 patients (54%) had positive thyroid antibodies, 2) Subnormal T4, subnormal or low normal FTI, and basal TSH levels within the normal range in 18 (22%). The mean basal TSH concentration was, however, significantly higher than in patients with normal T4 and FTI levels, suggesting a minor degree of thyroid failure. Only two of the 18 patients (11%) had positive thyroid antibodies. Of the 17 patients in the group tested, 13 showed a normal TSH response to TRH, three an exagerrated response (all females), and one had an impaired response. Other patterns of abnormal thyroid function were observed occasionally: one female patient had biochemical T3 toxicosis; another had the biochemical pattern of subclinical hypothyroidism, four patients with normal basal T4, FTI and TSH levels showed an exaggerated TSH response to TRH and one patient had an impaired response. These data indicate that htyroid dysfunction, in particular hypothyroidism, is common in adults with Down's syndrome, though specific tests are usually required to make the diagnosis. The general reduction in thyroid function in Down's syndrome may be due to impaired development of the thyroid gland. However, frank chemical hypothyroidism may occur only when thyroiditis is superimposed on preexisting diminished thyroid reserve.

Mackenzie's puzzle--the cornerstone of teaching and research in general practice.

The new-found popularity of generalism as a political force has emphasized the need to clarify the essential philosophy that underpins its practice, teaching, and research. Drawing on the example of Sir James Mackenzie, the author seeks to clarify certain essential issues that need to be emphasized if we are to promote and develop general practice as a distinct academic discipline. Dissatisfaction, uncertainty about our role, and continuing contact with real people seems to be essential to continuing creativity.

The effect of epilepsy on road traffic accidents and casualties.

A prospective study was carried out between October 1992 and June 1994 to investigate the effect of epilepsy as a risk factor in road traffic accidents (RTA) and casualties in the United Arab Emirates (UAE). The aim of this paper was to investigate the risk and effect of epilepsy on road traffic accidents and casualties and identify possible risk factors for traffic accidents and casualties and identify possible risk factors for traffic accidents and violations among these drivers. Most (70%) were young drivers and under age 40 years; 43% were UAE nationals; 41% had a primary school education; 48.8% had a full license to drive private or commercial taxis; 41% had less than two years driving experience and 17.1% used seat bolts regularly. Most (65.9%) admitted to crossing red traffic lights; 46.3% to parking in forbidden areas; 66% to speeding; 36% to smoking while driving; 34.1% to using the telephone whilst driving; 43.9% to putting their child in the front seat; 20.8% had been previously involved in an RTA; and 53.7% had sustained serious injury. A figure of 34.1% had at least one seizure per year and 26.8% had at least one seizure per month. The most common violations were careless driving (34.1%) and traffic regulation violations (24.4%). Significantly higher risk was observed for property damage (RR = 1.85; 95% CI = 0.64-5.14) and traffic violations (RR-1.91; 95% CI = 0.54-2.29). In the UAE there are no restrictions on the issue of driving licenses to people prone to epileptic seizures. In conclusion, it is emphasized that patients with conditions such as epilepsy should feel obliged to inform the traffic authorities or the health authorities about their condition. It seems likely that the problem could be greatly reduced if appropriate action was taken concerning epileptic drivers. It is hoped that the results and recommendations of this study will be useful to traffic and health authorities.

Disability in late adolescence. III: Utilization of health services.

Adolescent health service usage is a neglected research area. Data are important for planning of services and for prioritizing needs. A sample of 871 18-year-olds was surveyed about its use of health services in the preceding year. A significant proportion had made a consultation and were mostly satisfied with the service received. For a subsample of that cohort, who had a difficulty in their daily living, only a third had consulted a health professional for that difficulty over the past year. Help-seeking was related to the severity of that difficulty, particularly for the limitations that it imposed on everyday life. Some dissatisfactions with consultations were expressed in relation to expectations of the efficacy of treatment and to the communication of the health professionals.

Disability in late adolescence. I: Introduction, methods, and overview.

The research sought to describe the nature and severity of disability and its impact in a large sample of 18-year-olds. It was conducted as part of a larger longitudinal study of the health and development of a cohort of approximately 1000 children. This paper presents an overview of the methods used together with the results on the prevalence of specific disabilities. The three leading disabilities were: coping with dust, pollens, or chemicals (rate: 272 per 1000), equipment dependence (186), and disability in endurance (160).

Cell-mediated immunity in patients with myalgic encephalomyelitis syndrome.

Cell-mediated immunity was measured in 33 patients with myalgic encephalomyelitis syndrome and 33 age and sex matched healthy controls, using the multitest CMI device. The multitest scores in myalgic encephalomyelitis syndrome were significantly less than the controls suggesting a T-cell abnormality in these patients.

A comparative trial of lisinopril and nifedipine in mild to moderate hypertension in general practice.

AIMS: to compare lisinopril and nifedipine in the management of essential hypertension in 52 patients in general practice with respect to the obtaining of target diastolic blood pressure and freedom from side effects. METHOD: an open label, parallel randomised trial over an eight week period. RESULTS: lisinopril and nifedipine were found to effectively lower diastolic blood pressure with the latter having a significantly higher level of withdrawals and clinical side effects. CONCLUSION: lisinopril is equivalent to nifedipine in its hypertensive effect and has a better side effect profile.

Communication of the diagnosis of Down's syndrome in New Zealand, 1972-88.

A postal questionnaire was sent to 117 mothers of Down's syndrome children born between 1972 and 1988 in New Zealand, and the response is compared to a similar study of 123 mothers in Scotland whose children were born between 1972 and 1981. Highly significant differences were found in the number of New Zealand children delivered by general practitioners and in the rate of breast feeding amongst New Zealand Down's syndrome children. Significant differences were also found in the later New Zealand cohort with respect to the mothers having seen a social worker, having been given literature and been given an appointment to see a paediatrician. In common with the Scottish study, only half of the mothers felt that their general practitioner or Plunket nurse had been helpful to them after the birth of their child. The implications of the results for the care of Down's syndrome children in New Zealand are discussed.

The use of general practice services by 18 year olds in New Zealand.

AIMS: To ascertain the opinions of 861 eighteen year olds about their use and opinion of health services. METHODS: A computer generated questionnaire delivered to 440 males and 421 females at or around their eighteenth birthday. RESULTS: General practice was the overwhelmingly predominant provider of health services to this group with 69% of males and 86% of females having consulted. Satisfaction with the service given by general practitioners was high, as it was with other less common providers. Female users were significantly more likely than males to have problems of embarrassment with the doctor or a worry that their parents might be told of the consultation. While only 4% of females preferred to discuss their health problems with a male doctor, 88% had a male doctor. For 50% of the females, choice of doctor depends on the nature of the problem for which they consult. CONCLUSIONS: General practice is seen by these adolescents as providing a highly satisfactory service and the general practitioner is by far the most commonly consulted health professional. There is, however, no doubt that more choice in the gender of the doctor would improve satisfaction with the service. The study also demonstrates that having the same doctor for all problems is not necessarily acceptable to adolescent female patients.

General practitioners acceptance of the validity of chronic fatigue syndrome as a diagnosis.

AIM: To identify whether general practitioners accept the validity of a diagnosis of chronic fatigue syndrome (CFS). METHOD: An anonymous questionnaire was sent out to 98 general practitioners in Otago. RESULTS: The clinical validity of chronic fatigue syndrome was accepted by 74 (90%); 57 believed they had sufficient knowledge about the condition to make a differential diagnosis; 72 indicated they had had patients with chronic fatigue syndrome in the past; 62 currently had patients; there is a minimum prevalence rate of 167/100,000 in the general practice population; 83 replies were received. CONCLUSION: The 90% acceptance rate of chronic fatigue syndrome as a clinically valid diagnosis suggests that amongst the Otago general practitioners the controversy had receded. The low numbers suggest that they are on the conservative end of the diagnostic spectrum.

Red cell shape changes following trigger finger fatigue in subjects with chronic tiredness and healthy controls.

AIMS: To investigate the possibility of a correlation between the percentage of nondiscocytic erythrocytes and muscle fatiguability in subjects with the symptom of chronic tiredness. METHODS: Sixty nine volunteers suffering from persisting or intermittent tiredness and 72 healthy controls provided 3-drop samples of venous blood for red cell shape analysis before and after inducing fatigue in the trigger finger muscles by repeatedly pulling the trigger of an antique revolver. Elapsed time and the number of pulls were recorded. A work index was calculated from the number of trigger pulls divided by the time in seconds then multiplied by the number of trigger pulls. RESULTS: Subjects with tiredness had fewer discoid cells (males 62.5% vs 69.2%, p = 0.029; females 65.8% vs 71.8%, p = 0.002) than controls. They also had fewer trigger pulls (males 62.3 vs 84.0, p = 0.003; females 29.5 vs 36.8, p = 0.042) and lower "work indices" (males 75.6 vs 104.7, p = 0.001; females 26.1 vs 39.6, p = 0.001) than controls at the first trigger pulling. After 5 minutes rest the number of trigger pulls for males was fewer than the controls (56.0 vs 64.2) but the difference was not significant, but the female values (24.3 vs 33.2) were significantly different (p = 0.008). Work indices for both sexes were significantly different from controls (males p = 0.020, females p = 0.001). CONCLUSIONS: The association of increased nondiscocytes and impaired muscle function could indicate a cause and effect relationship. This would be in agreement with the physiological concept of fatigue as a consequence of inadequate oxygen delivery.

Is outcome for low risk obstetric patients influenced by parity and intervention?

Maternal and perinatal morbidity were examined to assess the influence of parity and intervention procedures among 1032 women considered low risk at commencement of labour. A diagnosis of fetal distress, failure to progress during labour, maternal problems after delivery and consultation with or transfer of the neonate to a paediatrician occurred more frequently amongst nulliparous women (p less than 0.001). Failure to progress in labour was found to be influenced by parity (primigravida), maternal age (less than 20 years) and also by the use of epidural anaesthetic for pain relief (p less than 0.001). Prevalence of abnormal delivery was found to be influenced by parity (primigravida), failure to progress in labour and diagnosis of fetal distress. The use of epidural anaesthesia for pain relief was also found to increase the rate of abnormal delivery (p less than 0.001). Statistically significant differences occurred between the groups of patients, with patients of private specialists having the highest rates for induction (34%), use of epidural for pain relief (40%) and abnormal delivery (46%).

'What makes it really good, makes it really bad.' An exploration of early student experience in the first cohort of the Rural Clinical School in the University of Western Australia.

INTRODUCTION: The Australian Commonwealth Department of Health and Ageing has implemented the Government's Regional Health Strategy. This strategy provides funding to universities for the establishment of Rural Clinical Schools (RCS) on a national basis. The strategy aims to secure a rural education and training network to increase the availability and viability of rural health services in the long term. The University of Western Australia set up the RCS in 2002 with the objective of setting up a full 5th year medical course in remote communities (RRAMA [Rural Remote and Metropolitan Area Classification] 4-7) for the 2003 academic year. There were 21 students in five areas: Kalgoorlie/Esperance (9 students), Broome (4 students), Port Hedland (3 students) and Geraldton (5 students). These students covered the 5th year curriculum with internal assessment and final examinations, in the same manner as city students. Only the delivery was different, according to geographical location. METHODS: Structured questionnaires using open-ended questions were distributed to students on two occasions. At the sixth month, semi-structured interviews were held with each student. The interviews were transcribed and a thematic analysis of the data was undertaken. Constant comparison of data was undertaken, themes identified and relationships among the themes clarified. RESULTS: In general, students were very happy with the teaching and learning opportunities they had during the first half of the year. However the initial themes of curriculum content, curriculum delivery, and assessment, were eclipsed by an overarching theme of anxiety and its management. The issue of student anxiety was addressed during the analysis. A number of factors were identified which ameliorated student anxiety or contributed to increased anxiety. From this evaluation a number of contributory factors to such student anxiety were identified. The investigators became more cognisant of the impact of group dynamics and of the need to structure the 'unstructured' environment of rural and remote medicine. In this way, students focus on only a few learning tasks at a time. They complete each topic with at least one other student so they can share the experience. The key role of each site coordinator also became apparent. The site coordinator should know the curriculum thoroughly and transmit this information to other teachers and preceptors at their site. It was also found desirable that the RCS was clear as to which assessment processes were flexible and which were 'fixed'. The medical school must clarify which curriculum content is essential, which is desirable and which is additional. Issues of workload must be monitored, and good work practices must be encouraged and supported. It was found that the high level of commitment to learning lead to the potential for burnout, generating the student comment: 'What makes the RCS really, really good makes it really bad...' CONCLUSION: Setting up an innovative program is always a major task, but setting up five different offices with four centers of learning separated by thousands of kilometers has not been undertaken, apparently, anywhere else in the world. It has been a 'fast uphill journey' that has been subject to evolving change as the RCS has adapted to conditions not expected from an academic point of view. Key contributory factors to student anxiety were identified and organizational strategies were implemented immediately, where possible, to reduce such anxiety. These insights were also used in the preparation for, and implementation of, the 2004 curriculum.