General practitioners' views on genetic screening for common diseases.

In a questionnaire survey of 359 general practitioners (response rate 94%), 60% accepted the need to provide genetic services, but far fewer felt competent to do so. Nevertheless, as many as 76% had referred patients to a genetics unit in the past year, and 50% had counselled about genetics.

Coronary event and case fatality rates in an English population: results of the Oxford myocardial infarction incidence study. The Oxford Myocardial Infarction Incidence Study Group.

OBJECTIVES: To determine coronary event and case fatality rates in an English population aged less than 80 years in Oxfordshire, and to compare these rates with those reported by the UK monitoring trends and determinants of cardiovascular disease (MONICA) centres in Scotland and Northern Ireland and those ascertained in Oxfordshire in 1966-67. DESIGN: A population wide surveillance study conducted in 1994-95 using prospective and retrospective case ascertainment. SETTING: A resident population in Oxfordshire of 568,800. SUBJECTS: Patients with suspected myocardial infarction or coronary death. OUTCOME MEASURES: A diagnosis of definite or possible myocardial infarction or coronary death using WHO MONICA diagnostic criteria based on symptoms, electrocardiograms, cardiac enzymes, necropsy findings, and past medical history. RESULTS: The annual rate for a first or recurrent coronary event per 100,000 population aged less than 65 years in 1994-95 was 273 for men and 66 for women after age adjustment to a standard world population. Rates in the age group 65-79 years were 1350 for men and 677 for women. Between 1966-67 and 1994-95, the age standardised event rate in the age group 30-69 years decreased significantly by 33% (95% confidence interval (CI) 44 to 21) in men, and there was a non-significant reduction of 8% (95% CI -33 to 17) in women. The age standardised 28 day case fatality rates also decreased significantly by 28% (95% CI 41 to 15) in men and by 32% (95% CI 55 to 9) in women. CONCLUSIONS: The coronary event rate in Oxfordshire was much lower than rates reported by MONICA centres in Glasgow and Belfast, and similar to rates reported by MONICA centres in France and northern Italy. The substantially lower event rate accounts for lower coronary heart disease mortality in Oxfordshire than in Scotland and Northern Ireland. The reduced coronary mortality in this region is attributable to declines in coronary event and case fatality rates.

Systematic review of dietary intervention trials to lower blood total cholesterol in free-living subjects.

OBJECTIVES: To estimate the efficacy of dietary advice to lower blood total cholesterol concentration in free-living subjects and to investigate the efficacy of different dietary recommendations. DESIGN: Systematic overview of 19 randomised controlled trials including 28 comparisons. SUBJECTS: Free-living subjects. INTERVENTIONS: Individualised dietary advice to modify fat intake. MAIN OUTCOME MEASURE: Percentage difference in blood total cholesterol concentration between the intervention and control groups. RESULTS: The percentage reduction in blood total cholesterol attributable to dietary advice after at least six months of intervention was 5.3% (95% confidence interval 4.7% to 5.9%). Including both short and long duration studies, the effect was 8.5% at 3 months and 5.5% at 12 months. Diets equivalent to the step 2 diet of the American Heart Association were of similar efficacy to diets that aimed to lower total fat intake or to raise the polyunsaturated to saturated fatty acid ratio. These diets were moderately more effective than the step 1 diet of the American Heart Association (6.1% v 3.0% reduction in blood total cholesterol concentration; P<0.0001). On the basis of reported food intake, the targets for dietary change were seldom achieved. The observed reductions in blood total cholesterol concentrations in the individual trials were consistent with those predicted from dietary intake on the basis of the Keys equation. CONCLUSIONS: Individualised dietary advice for reducing cholesterol concentration is modestly effective in free-living subjects. More intensive diets achieve a greater reduction in serum cholesterol concentration. Failure to comply fully with dietary recommendations is the likely explanation for this limited efficacy.

Smoking cessation interventions for dental patients--attitudes and reported practices of dentists in the Oxford region.

OBJECTIVE: To investigate various aspects of dentists' beliefs and practices with respect to helping their patients stop smoking. DESIGN: Postal questionnaire survey conducted in 1996. SETTING: The general dental practitioners on the health authority lists of Berkshire, Buckinghamshire, Northamptonshire and Oxfordshire. SUBJECTS: The 869 dentists registered on 1 April 1996. RESULTS: A high response rate (78%; 674/869) was obtained. The majority of respondents (82%; 95% CI: 79, 85) thought dentists should encourage their patients to stop smoking although only 37% (95% CI: 34, 41) believed dentists to be effective in smoking cessation and even fewer (18%; 95% CI: 15, 21) routinely recorded their patients' smoking status. Of respondents, 51% (95% CI: 46, 55) said they always discussed smoking with patients who had periodontal problems but only 9% (95% CI: 7, 12) always did so with patients who had no major oral health problem. Newer graduates were more likely to routinely record their patients' smoking status (P = 0.02), and to think that doctors' advice (P = 0.001) and nicotine replacement therapy (P < 0.001) were effective in promoting smoking cessation. Dentists in mainly private practices were more active than those in NHS or mixed practices in recording patients' smoking status (P < 0.001) and in discussing smoking (P = 0.002). CONCLUSIONS: Most respondents thought that dentists should encourage their patients to stop smoking but few are active in this area.

Garlic powder in the treatment of moderate hyperlipidaemia: a controlled trial and meta-analysis.

OBJECTIVE: To determine the effect of 900 mg/day of dried garlic powder (standardised to 1.3% allicin) in reducing total cholesterol. DESIGN: Double-blind, randomised six-month parallel trial. SUBJECTS: 115 individuals with a repeat total cholesterol concentration of 6.0-8.5 mmol/l and low-density lipoprotein (LDL) cholesterol of 3.5 mmol/l or above after six weeks of dietary advice. INTERVENTION: The active treatment group received dried garlic tablets (standardised to 1.3% allicin) at a dosage of 300 mg three times daily. The control group received a matching placebo. OUTCOME MEASURES: Primary end-point: total cholesterol concentration; secondary end-points: concentrations of LDL and high-density lipoprotein cholesterol, apolipoproteins (apo) A1 and B, and triglycerides. RESULTS: There were no significant differences between the groups receiving garlic and placebo in the mean concentrations of serum lipids, lipoproteins or apo A1 or B, by analysis either on intention-to-treat or treatment received. In a meta-analysis which included the results from this trial, garlic was associated with a mean reduction in total cholesterol of -0.65 mmol/l (95% confidence intervals: -0.53 to -0.76). CONCLUSIONS: In this trial, garlic was less effective in reducing total cholesterol than suggested by previous meta-analyses. Possible explanations are publication bias, overestimation of treatment effects in trials with inadequate concealment of treatment allocation, or a type 2 error. We conclude that meta-analyses should be interpreted critically and with particular caution if the constituent trials are small.

Which smokers are helped to give up smoking using transdermal nicotine patches? Results from a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Nicotine replacement therapy is effective in helping people to give up smoking. The three forms now available--transdermal patches, chewing gum and nasal spray--deliver nicotine at different rates and to different levels. Therefore, it might be expected that smokers with different characteristics, and at different levels of nicotine dependence, will be helped more by one or other method. AIM: The aim of the study was to examine whether the effectiveness of transdermal patches is related to nicotine dependence or to other smoker characteristics and to investigate factors predicting smoking cessation using patches. METHOD: Data from a randomized, double-blind, placebo-controlled trial of nicotine transdermal patches were analysed retrospectively. The trial, conducted in 1990-1992, involved 1686 patients recruited from 19 general practices in Oxfordshire. The main outcome measure was continuous smoking cessation from 8 to 52 weeks after the start of patch use, biochemically validated at 12, 24 and 52 weeks. The effectiveness of the patches was measured by the relative odds of sustained cessation using nicotine patches compared with placebo patches. RESULTS: Nicotine transdermal patches were more effective in smokers with moderate nicotine dependence [odds ratio (OR) 1.94; 95% confidence interval (CI) 1.24-3.04] than in mildly or highly dependent smokers (OR 0.98; 95% CI 0.58-1.65) (difference in ORs P < 0.05) and more effective in those aged 24-49 years (OR 1.89; 95% CI 1.24-2.87) than in older smokers aged 50-65 years (OR 0.88; 95% CI 0.49-1.59) (difference in ORs P < 0.05). Abstinence from smoking in the first week of the trial was the strongest predictor of sustained cessation and was more common among smokers using nicotine patches than those using placebo patches (33% of 842 compared with 22% of 844; P < 0.001). Of first-week abstainers, 25 and 28% of 277 and 182 in the nicotine and placebo groups, respectively, achieved sustained cessation compared with 4% of 565 and 2% of 662 first-week smokers. CONCLUSION: Nicotine transdermal patches were most effective for smokers with moderate nicotine dependence and for younger smokers. Early abstinence from smoking was the strongest predictor of sustained cessation. A week's trial of the patch proceeding to longer term use if abstinence is achieved may be an effective policy.

Economic implications of smoking cessation therapies: a review of economic appraisals.

There is a paucity of studies on the economics of smoking cessation. Those undertaken have investigated only a narrow range of available interventions, using variable methodologies which make interstudy comparisons problematical. There is a need for more economic appraisal in this area and for greater consistency in the methodologies employed. Growing evidence on the effectiveness of pharmacotherapies has not been matched by evidence of their cost effectiveness, and studies in this area, particularly on transdermal nicotine, are urgently required. Cost-benefit analyses (CBAs) have focused on programmes targeted at pregnant women and indicate that resource savings, mainly from reductions in the number of low birthweight neonates, can exceed the costs of the measures. Efforts to persuade pregnant women to quit thus appear to be highly cost beneficial, but further evidence on the efficiency of measures targeted at other groups or to the general population of smokers is required. Cost-effectiveness analyses (CEAs) suggest that measures targeted at specific groups are more cost effective than those targeted at the general population of smokers, and that the cost effectiveness of such programmes is further improved by providing educational materials that are specific to the targeted groups. Advice on how to maintain abstinence appears to improve the cost effectiveness of help with quitting, and routine advice from physicians to their smoking patients is a cost-effective way of reducing smoking prevalence.

Diabetes in the elderly: the Oxford Community Diabetes Study.

Most diabetic patients are elderly but their clinical characteristics remain poorly defined. A population survey identified 259 known diabetic patients aged 60 years or more giving a prevalence of 3% in this age group. A total of 193 patients (75%) were interviewed and examined, 155 (80%) of whom had been diagnosed at under 70 years of age. Forty-two patients (22%) were insulin-treated but clinical characteristics suggested that at least 95% of all elderly patients had Type 2 diabetes. Blood glucose control was poor with median HbA1 9.7% (range 4.9-17.1%, normal reference range 5.0-7.5%), and 55% were either overweight or obese. There was a high morbidity from diabetes and other conditions: the prevalence of hypertension (untreated blood pressure of 160/95 mmHg or more or antihypertensive medication) was 52%, of stroke 5%, of nephropathy (urinary albumin concentration greater than or equal to 300 mg l-1) 3%, of lower limb amputations 4%, and of foot ulcers 7%. The prevalence of symmetrically impaired distal vibration perception was 23%, and 54% of patients either needed or were receiving chiropody. The prevalence of a corrected distant visual acuity of 6/12 or worse was 32% and of retinopathy of any degree was 26%. There was extensive co-morbidity which was not confined to a single subgroup of patients.

Comparison between the weekly returns service and the Oxford regional sentinel practice scheme for monitoring communicable diseases.

Weekly data for seven conditions reported to the weekly returns service of the Royal College of General Practitioners' Birmingham research unit over a 52-week period have been compared with those reported to the Oxford regional sentinel practice scheme. The mean weekly recorded rates for otitis media, asthma and intestinal infectious disease were similar in both systems; in the weekly returns service, mean weekly rates for common cold, acute bronchitis and influenza/influenza-like illness were approximately twice and for sore throat/tonsillitis slightly higher than rates in the Oxford scheme.In the weekly returns service no recommendations are made about criteria for diagnosis but in the Oxford scheme diagnostic criteria agreed by the participants are used. Where rates in both monitoring systems are the same, agreed criteria are likely to be conventional clinical practice and therefore superfluous. Where rates are different, the use of criteria enhances specificity of the information content but results in an underestimation of the total incidence of - respiratory disease presented to general practitioners.For common cold, acute bronchitis, otitis media and influenza/ influenza-like illness the associations between the rates in the two systems were high (R>/=O. 79), as might be expected, but these high values cross validate both recording systems in their monitoring of trends. For the remaining (non-epidemic) conditions the associations were low. There were no significant associations between the rates for asthma and the upper respiratory infectious diseases in either recording system, which suggests there was effective discrimination of asthma.

Diabetes mellitus: attitudes, knowledge and glycaemic control in a cross-sectional population.

A questionnaire to households in Oxfordshire identified 431 diabetic patients living in the area and 272 of them completed a questionnaire about their attitudes to and knowledge of diabetes, and were subsequently interviewed. Most did not regard diabetes as a serious disease and had little knowledge of possible complications. Patients found dietary compliance the most difficult part of their treatment. Among non-insulin treated patients there was a significant association between difficulty with diet and body mass index and glycosylated haemoglobin values. The results suggest that there is a need for more effective advice on diet and for better education of patients about the nature of diabetes and its complications.

The Oxford Community Diabetes Study: evidence for an increase in the prevalence of known diabetes in Great Britain.

A prevalence survey for known diabetes was conducted in a geographically defined population of nearly 40,100 in Oxford in April 1982. The age-adjusted prevalence rate was 10.4/1000 which did not differ significantly from age-adjusted rates of 9.5/1000 in Poole and 10.5/1000 in Southall. The prevalence increased with age and was higher in men than women over the age of 30 years. Our results confirm that there has been a change in the male to female sex ratio and suggest that there are about 500,000 diagnosed diabetics in England and Wales including about 190,000 insulin-treated patients. These findings are consistent with a secular increase in the prevalence of diagnosed diabetes over the last two decades which has important implications for the planning and provision of resources for care.

Medical student attitudes and general practice.

A study of the influence of general practice attachment on the attitudes and preconceptions of new clinical students is reported. An attitude questionnaire was administered to a cohort of Oxford clinical students immediately before and after a two-week period of general practice attachment, introduced as part of the clinical introductory course. Changes in responses to the questionnaire suggest a shift of attitudes favourable to general practice, and the acquisition of a broader view of medical care.

Primary care in Norway.

The organization of primary care in Norway is described and the shortage of general practitioners, particularly in remote areas, discussed. Improvement in working conditions is one approach to solving this problem. However, enhanced status for the general practitioner, achieved by improvements in his vocational training, is acknowledged as an important prerequisite for better recruitment to general practice.

Hospital discharge reports: content and design.

The information required by family doctors on initial and final discharge reports from hospitals was specified and 546 such reports from hospitals in Aylesbury, Amersham, Banbury, Oxford, and High Wycombe were reviewed for the availability and accessibility of important information. Several items could have been recorded better, including the name of the hospital, the specialty (or department) concerned, and the name of the consultant in charge of the case. Drug reactions seemed to be under-reported in the initial discharge reports and information about treatment on discharge was inadequate. The recording of the prognosis and information given to the patient was deficient and communication on follow-up needs to be improved. The use of obscure abbreviations was widespread. There is room for improvement in the ease of access to important information, especially the diagnostic assessment, and the time taken for final reports to reach the general practitioner.