Self-monitoring of blood glucose changed non-insulin-treated Type 2 diabetes patients' beliefs about diabetes and self-monitoring in a randomized trial.

AIMS: To determine whether differences in beliefs about diabetes and its treatment resulted from different intensities of self-monitoring of blood glucose (SMBG) in non-insulin treated patients with Type 2 diabetes in the Diabetes Glycaemic Education and Monitoring (DiGEM) trial. METHODS: Patients (n = 453) were randomized to usual care, less-intensive SMBG and more intensive SMBG. Beliefs about diabetes were measured with a standard questionnaire (the revised Illness Perceptions Questionnaire; IPQ-R). Changes in beliefs were analysed using analysis of covariance (ancova) with adjustment for baseline values. Mediation analyses assessed whether differences in behavioural outcomes between groups could be attributed to differences in beliefs. RESULTS: Completed questionnaires were returned by 339 patients (74.8%). Respondents were mean (+/- sd) age 65.9 +/- 10 years and with diabetes duration of 4.8 +/- 4.7 years (median 36, range 1-384 months). Concerns about the consequences of diabetes increased in both self-monitoring groups, relative to control subjects [P = 0.004; Cohen's d standardized effect size = 0.19 less intensive and d = 0.36 more intensive monitoring]. No other beliefs about diabetes differed between groups. Beliefs about the importance of self-testing increased in both self-monitoring groups relative to the usual-care group (P < 0.001; d = 0.57 less intensive and d = 0.63 more intensive monitoring). Changes in psychological well-being did not differ between groups, but control patients reported greater increases in general (P = 0.014) and specific (P < 0.001) dietary adherence than did patients in the self-monitoring groups. These outcomes were not mediated by intervention-related changes in beliefs. CONCLUSIONS: Despite changes in some beliefs about diabetes differing between groups there were no corresponding changes in self-reported health behaviours. This suggests that changes in illness beliefs resulting from SMBG do not cause changes in diabetes-related health behaviours.

Why is there a modifying effect of gestational age on risk factors for cerebral palsy?

OBJECTIVE: To investigate risk factors for cerebral palsy in relation to gestational age. DESIGN: Three case-control studies within a geographically defined cohort. SETTING: The former Oxfordshire Health Authority. PARTICIPANTS: A total of 235 singleton children with cerebral palsy not of postnatal origin, born between 1984 and 1993, identified from the Oxford Register of Early Childhood Impairment; 646 controls matched for gestation in three bands: or=37 weeks. RESULTS: Markers of intrapartum hypoxia and infection were associated with an increased risk of cerebral palsy in term and preterm infants. The odds ratio (OR) for hypoxia was 12.2 (95% confidence interval 1.2 to 119) at or=37 weeks. Corresponding ORs for neonatal sepsis were 3.1 (1.8 to 5.4) and 10.6 (2.1 to 51.9). In contrast, pre-eclampsia carried an increased risk of cerebral palsy at >or=37 weeks (OR 5.1 (2.2 to 12.0)) but a decreased risk at

Association between polymorphisms in dopamine metabolic enzymes and tobacco consumption in smokers.

Central dopaminergic reward pathways give rise to dependence and are activated by nicotine. Allelic variants in genes involved in dopamine metabolism may therefore influence the amount of tobacco consumed by smokers. We developed assays for polymorphisms in dopamine beta-hydroxylase (DBH), monoamine oxidase (MAO) and catechol O-methyl transferase (COMT) using the polymerase chain reaction with sequence specific primers (PCR-SSP). We then typed 225 cigarette smokers to assess whether genotype was related to the number of cigarettes smoked a day. Smokers with DBH 1368 GG genotype smoked fewer cigarettes than those with GA/AA [mean difference -2.9 cigarettes, 95% confidence interval (CI) -5.5, -0.4; P = 0.022]. The effect reached statistical significance in women (-3.8, 95% CI -6.4, -1.0, P = 0.007) but not in men (-1.5, 95% CI -6.0, 3.0, P = 0.498). Overall, the effect was greater when analysis was confined to Caucasians (-3.8, 95% CI -6.6, -1.1, P = 0.007). Smokers with MAO-A 1460 TT/TO smoked more cigarettes than those with CC/CT/CO (2.9, 95% CI 0.6, 5.1, P = 0.013). Within each sex group, the trend was similar but not statistically significant (difference for men 2.9, 95% CI -1.0, 6.7; for women 2.0, 95% CI -0.7, 4.8). The effect of the allele was greater in smokers with a high body mass index (> 26) (difference 5.1, 95% CI 1.4, 8.8, P = 0.008). More heavy smokers (> 20 a day) had the DBH 1368A allele when compared to light smokers (< 10 a day). (Relative risk 2.3, 95% CI 1.1, 5.0, P = 0.024.) The trend for increasing prevalence of the DBH A allele in heavy smokers was greater when analysis was restricted to Caucasians (relative risk 3.2, 95% CI 1.3, 8.2, P = 0.004). Conversely, heavy smokers were less likely to have the MAO-A 1460C allele (relative risk 0.3, 95% CI 0.1, 0.7, P = 0.012). Variations in DBH and MAO predict whether a person is a heavy smoker and how many cigarettes they consume. Our results support the view that these enzymes help to determine a smoker's requirement for nicotine and may explain why some people are predisposed to tobacco addiction and why some find it very difficult to stop smoking. This finding has important implications for smoking prevention and offers potential for developing patient-specific therapy for smoking cessation.

The prevalence of hyperlipidemia in renal transplant recipients. Associations with immunosuppressive and antihypertensive therapy.

To determine the extent of persisting hyperlipidemia in renal transplant recipients receiving modern maintenance immunosuppressive and antihypertensive therapy we compared plasma levels of total and high-density lipoprotein and triglyceride in 275 renal transplant recipients with stable graft function with age- and sex-matched groups from the local general population (n = 4055). Total cholesterol and triglyceride were higher in transplanted patients in all age groups, but the difference was much more striking in women. Plasma levels of HDL cholesterol were similar or slightly lower in transplanted patients. Association with parameters of graft function, immunosuppressive therapy, and antihypertensive therapy were studied within the transplanted population using multiple regression. Total cholesterol was significantly and independently associated with age, sex, diuretic therapy, and urinary protein. In 127/134 (95%) of patients the diuretic was a loop diuretic. None of the other classes of antihypertensive drug was independently associated with serum cholesterol. The only variables significantly associated with HDL cholesterol were sex and the plasma creatinine. Plasma triglyceride was significantly and independently associated with both diuretic therapy and beta-blocker therapy and with age, urinary protein excretion, and plasma albumin. Plasma cholesterol, HDL cholesterol, and triglyceride levels were almost identical in patients receiving triple therapy (cyclosporine 3-5 mg/kg; prednisolone 7-10 mg o.d.; azathioprine 1-1.5 mg/kg) to those in patients receiving conventional immunosuppression (prednisolone 7-10 mg o.d.; azathioprine 2-2.5 mg/kg). Thus these results do not support the existence of a persisting long-term effect of cyclosporine on plasma cholesterol and triglyceride at these doses of the drug. The more striking abnormality of plasma cholesterol and triglyceride in females is unexplained but might be connected with greater sensitivity to low doses of corticosteroids.

A controlled assessment of the in vitro fertilization performance of British women of Indian origin compared with white women.

OBJECTIVE: To compare the reproductive performance of Indian versus white women in IVF. DESIGN: Controlled comparative clinical study. SETTING: In vitro fertilization center based in university department in large tertiary level hospital. PATIENTS: Results from first IVF treatment cycles in 44 Indian patients were compared with results from 88 white patients, matched by age and body mass index, over the same treatment year. The patients were selected from a prospectively collected IVF databank. INTERVENTIONS: Standard luteal-phase start long GnRH analogue regime. Ovarian stimulation with FSH and hMG. Transvaginal ultrasound-guided oocyte recovery. In vitro fertilization and ET following established protocols. MAIN OUTCOME MEASURES: Rates of abandoned cycles, egg retrievals, ETs, clinical pregnancies, miscarriages, and live births were compared in the first IVF treatment cycle. Cumulative pregnancy rates (PRs) over three cycles in the two groups of patients were also compared. RESULTS: More cycles were abandoned in the Indian than in the white group: 22.7% versus 9.1%. The Indian live birth rate per cycle was worse: 9.1% versus 22.7%. The performance of the two groups was otherwise similar: ovarian stimulation with hMG and FSH required 26.0 required 26.0 ampules in the Indian group versus 24.6 ampules in the white group, mean number of follicles on the day of egg retrieval 8.7 versus 8.7, mean number of eggs 5.9 versus 5.8, fertilization rate 82.4% versus 82.5%; ET rate 73.5% versus 82.5, mean number of embryos transferred 2.1 versus 1.8, and clinical PR per cycle started 18.2% versus 27.3%. CONCLUSIONS: Under the same IVF regime, Indians performed worse than whites at the stage of ovarian stimulation (higher rate of abandoned cycles for poor response) and in live birth rate. Cumulative conception and live birth rates also tended to be worse in Indians than in whites.

Nutrient intakes during pregnancy: the influence of smoking status and age.

STUDY OBJECTIVE: To examine the relation of antioxidant and other nutrient intakes in pregnancy to smoking and sociodemographic variables. DESIGN: Cohort study. SETTING: St Mary's Maternity Hospital, Portsmouth. PARTICIPANTS: Pregnant nulliparous women, with no existing complications of pregnancy, were recruited from antenatal booking clinics. A total of 774 women completed seven day food diaries, and supplied detailed data on their use of nutrient supplements. MAIN RESULTS: Smokers had lower intakes of most micronutrients. After adjustment for the confounding effects of maternal age, height, and education, only vitamin C and carotenoid intakes remained significantly depressed. Age was strongly and significantly associated with the intake of most nutrients, including antioxidants, and this association was independent of other maternal factors. Antioxidant intake was therefore lowest in young women who smoked: for example smokers under 24 years had a mean vitamin C intake of 57 mg (SD 35) compared with 106 mg (SD 52) for non-smokers aged 28 and over (difference 49 mg, 95% CI 39, 59). The corresponding intakes of carotenoid equivalents were 1335 micrograms (SD 982) and 2093 micrograms (SD 1283) (difference 758 micrograms, 95% CI 496, 1020). CONCLUSIONS: The study has identified, for the first time, young pregnant women as a group at particular risk of low micronutrient intake. The health implications of poor nutrition now need to be evaluated, particularly for those women who smoke.

Factors affecting response to an invitation to attend for a health check.

OBJECTIVE: To describe the characteristics of general practice patients who fail to respond to an invitation to attend for a health check, in relation to demographic variables, risk factor status, health status, and attitudes to behaviour modification. DESIGN: Postal questionnaire before invitation to attend a health check and subsequent record of attendance. SETTING: Five urban general practices in Bedfordshire, UK. SUBJECTS: A total of 2678 patients aged 35-64 years were invited for a health check in 1989-90. RESULTS: The number of patients who did not attend was low overall but was higher among men than women (21 v 15%, p < 0.001), and in unmarried than married patients (24 v 16%, p < 0.001). Failure to attend was also higher among people in manual than in non-manual occupations (21 v 15%, p < 0.001), in people living in rented accommodation than in homeowners (29 v 16%, p < 0.001), and in those without access to a car than in car users (27 v 16%, p < 0.001). There was no difference in non-attendance rate according to age at completion of full time education. After adjustment for age, sex, marital state, and social class, the odds ratio for non-attendance was 1.74 (95% confidence interval (CI) 1.41, 2.14) for smokers; 1.07 (95% CI 0.76, 1.51) for heavy drinkers; 1.91 (95% CI 1.41, 2.58) for those with a less healthy diet; and 1.50 (95% CI 1.09, 2.07) for those who were obese. Patients who had visited their general practice more frequently and those who indicated a willingness to change their behaviour were significantly more likely to attend the health check. CONCLUSIONS: Health check attendance was lowest among patients who rarely attended the surgery and those who reported higher risk behaviour. Attendance was not, however, confined to the 'worried well'. Equal numbers of those with and without chest pain attended, as did at least three quarters of those in each risk group. This high rate of attendance reflects the time and effort invested in systematic recruitment. The development of a robust recruiting strategy is essential if substantial numbers, and particularly those at highest risk, are to be reached.

Hormone replacement therapy: characteristics of users and non-users in a British general practice cohort identified through computerised prescribing records.

STUDY OBJECTIVE: To assess the feasibility of recruiting a cohort of women, including long term users of postmenopausal hormone replacement therapy (HRT), through computerised general practice prescribing records, and to compare clinical and demographic characteristics of users and non-user controls. DESIGN: Cross sectional analysis of questionnaire data. SETTING: Subjects were recruited through 17 general practices in the Oxfordshire, south west Thames, and north west Thames regions that contributed to the VAMP Research Database. PARTICIPANTS: A total of 2964 women aged 45-64 years were identified. Altogether 1482 were long term (> 1 year) users of HRT and 1482 were non-user controls: 1037 (70%) of the users and 819 (55.3%) of the controls agreed to participate and provided questionnaire data. MAIN RESULTS: Users of HRT were more likely to have undergone hysterectomy than controls. Most women with a history of hysterectomy used unopposed oestrogen, while those with intact uteri generally used a combination of oestrogen and a progestagen. Among women who had undergone hysterectomy, HRT users did not differ significantly from controls over a range of demographic and clinical characteristics but they were more likely to be past users of oral contraceptives. Among women with intact uteri, users were similar to controls in terms of reported clinical characteristics, but were of higher social class and were more likely to be past users of oral contraceptives and to have had a mammogram after the age of 50. Compared with the general population, all categories of women recruited to the study were of higher social class and exhibited more health conscious behaviours. CONCLUSIONS: Electronic general practice prescribing records provide a feasible and efficient method for recruiting women to a cohort of HRT. Women who agreed to participate in this study were not representative of the general population, emphasising the importance of internal controls in such a study. Among participants, HRT users who had not undergone hysterectomy showed evidence of better health than non-users on some dimensions. In the whole sample, however, there were no appreciable differences in social class and self reported health indicators between users and controls.

Cancer in pregnancy.

OBJECTIVE: To estimate the incidence of cancer arising in pregnancy and to report its recurrence in those women with a past history of the disease. DESIGN: Retrospective study over 11 years. SETTING: John Radcliffe Maternity Hospital. PATIENTS: 25,568 Oxford District Health Authority residents who delivered at the John Radcliffe Maternity Hospital, and 6775 residents who had a termination of pregnancy, between 1 January 1981 and 31 December 1985. INTERVENTIONS: Retrospective analysis of case records to identify pregnancies complicated by cancer and follow-up through patients' general practitioners. MAIN OUTCOME MEASURES: Maternal mortality and disease recurrence. RESULTS: The study identified 32 pregnancies complicated by cancer in 28 women and four terminations of pregnancy performed for cancer as the main or secondary indication. By the end of 1991, three women had died, one woman had been treated for disease recurrence, 17 women were in good health and seven women had been lost to follow-up. There were six cases of cancer arising de novo in pregnancy, i.e. an incidence of 2.35 per 10,000 deliveries (95% confidence interval 0.47 to 4.22). Only one pregnancy was complicated by disease recurrence. CONCLUSION: The incidence of cancer arising de novo in pregnancy is lower than the most quoted figure of 9.92 per 10,000 pregnancies.

Lack of willpower or lack of wherewithal? "Internal" and "external" barriers to changing diet and exercise in a three year follow-up of participants in a health check.

The aims of this paper were to assess whether anticipated barriers to change in diet and exercise which were cited before a health check intervention were related to subsequent behaviour changes. In 1989 a health and lifestyle questionnaire was posted to 17,965 people aged 35-64 who were registered with five general practices in Bedfordshire. Taking account of non-contacts, a response rate of 80.3% was achieved and 11,090 people described their exercise and dietary habits. Those expressing an interest in changing each behaviour were asked to identify reasons why change might be difficult. Two types of barriers--"internal" and "external"--were identified. A total of 2205 respondents were invited to attend a health check in Year One and a recheck three years later and 1660 attended. In this subgroup improvement in exercise and diet was examined in relation to the participants' baseline characteristics, including the type of barriers selected. Internal barriers to change (e.g. lack of willpower, too lazy, too busy) were chosen most frequently. In a logistic regression including a range of baseline variables those who selected only internal barriers were less likely to take more exercise (OR 0.59, 95% CI 0.41, 0.86) than those who cited only external (e.g. no transport, can't afford sports facilities) or mixed barriers to changing. There was a similar but not statistically significant trend for changing diet (OR 0.78, 95% CI 0.48, 1.28). Those who are aware of external limitations may be better placed to circumvent them. Further research is needed to explore this relationship between type of barrier and behaviour change.

Health and school performance of teenagers born before 29 weeks gestation.

OBJECTIVE: To ascertain the health and school performance of teenagers born before 29 weeks gestation (extremely low gestational age (ELGA)) and to compare those in mainstream school with classroom controls. METHODS: Three geographically defined cohorts of babies born in 1983 and 1984 were traced at the age of 15-16 years. Their health, abilities, and educational performance were ascertained using postal questionnaires to the teenagers themselves, their parents, their general practitioners, and the teachers of those in mainstream school. Identical questionnaires were sent to classroom controls. RESULTS: Of the 218 teenagers surviving to the age of 16 years, information was obtained on 179. Of these, 29 were in special schools and 150 in mainstream school, 10 of whom had severe motor or sensory impairment. Using the Child Health Questionnaire, parents of teenagers in mainstream school reported a higher incidence of problems than controls in physical functioning (difference in mean scores 9.0 (95% confidence interval (CI) 4.9 to 13.1)) and family life (difference in mean scores for family cohesion 7.0 (95% CI 1.6 to 12.4)). In all areas of learning, teachers rated the ability of the ELGA teenagers in mainstream school lower than the control group. Parents of teenagers in special schools reported a higher rate of problems in most areas. CONCLUSIONS: One in six ELGA survivors at age 16 years have severe disabilities and are in special schools. Most ELGA survivors are in mainstream school and are coping well as they enter adult life, although some will continue to need additional health, educational, and social services.

Role of primary care in the prevention of malignant melanoma.

One of the targets for health in the United Kingdom is the reduction in the year-on-year increase in the incidence of skin cancer. Most of the mortality associated with skin cancer is attributable to malignant melanoma. One possible way to reduce the incidence of malignant melanoma is to develop a strategy for prevention based in primary care. This paper considers the arguments for and against three possible strategies: giving general advice; identifying patients at high risk; and undertaking early diagnosis. It is concluded that elements of all three strategies are likely to prove useful, but that major studies need to be undertaken before any strategy is adopted on a national basis.

An assessment of morbidity registers for coronary heart disease in primary care. ASSIST (ASSessment of Implementation STrategy) trial collaborative group.

BACKGROUND: Organised care delivered systematically to all patients with established coronary heart disease (CHD) can reduce their risk factors and improve their quality of life. Therefore, identifying all patients with established CHD in a general practice population is an important first step for delivering this effective healthcare. However, there is little information on how registers are compiled, the factors that predict inclusion on the register or the relationship between registration and level of care provided. AIM: To assess the completeness of morbidity registers for CHD in primary care, the factors that predict inclusion on the register, and the relationship between registration and level of care provided. METHOD: Observational study at baseline of 1979 patients aged 55 to 75 years with established CHD in 18 general practices recruited for a cluster randomised controlled trial. RESULTS: The proportion of CHD patients correctly identified on practice morbidity registers varied from 29.3% to 100%. Four factors were significantly and independently associated with being on a register: a relevant surgery contact since diagnosis (OR = 2.1, 95% CI = 1.6%-2.9%); a relevant repeat prescription since diagnosis (OR = 1.6, 95% CI = 1.1%-2.3%); a diagnosis of myocardial infarction (OR = 1.5, 95% CI = 1.2%-1.9%); and a revascularisation procedure (OR = 1.5, 95% CI = 1.1%-2.0%). Inclusion on a register was strongly associated with being adequately assessed (i.e. assessed for smoking status, blood pressure, and cholesterol) (OR = 1.8, 95% CI = 1.3%-2.3%) and with treatment with aspirin or a lipid-lowering agent (OR = 1.4 for each agent). CONCLUSION: A wide variation in registration levels between practices exists. There is evidence that practices using multiple methods of case detection achieve higher levels of registration. The association between registration and better care does not prove causality but an effective call-recall system is impossible without complete registration.

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.

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.

General practice careers: changing experience of men and women vocational trainees between 1974 and 1989.

The aim of this study was to consider the careers pursued by men and women general practitioner trainees following the completion of their training, and to assess changes since 1974. It was based on a postal questionnaire survey involving 995 doctors who had completed general practice vocational training in the Oxford region between 1974 and 1989. A total of 796 doctors replied to the questionnaire (498 men and 298 women, overall response rate 80%). The vast majority of ex-trainees were working in general practice at the time of the survey (men 87%, women 71%). Women were less likely to have become principals than men (75% versus 97%). Most women (71% of those completing training before 1988) reported at least one period of non-employment. While the duration of maternity leave dropped only slightly during the 15 years studied, the length of voluntary and involuntary unemployment experienced by women fell markedly. Men experienced little unemployment with no change in length of unemployment over time. Considerably fewer women than men (6% versus 13%) had become involved in teaching or training. The degree of difficulty in choosing and following a general practice career remained constant over time for women. In contrast there was a significant increase in the difficulties experienced by men. The proportion of men and women completing training in 1984-89 who found following a general practice career 'difficult or very difficult' was similar (10% of men, 13% of women). The possibility of improving these experiences, particularly by encouraging flexibility in the early years after completion of training, is discussed.

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)

Evaluation of the impact of two educational interventions on GP management of familial breast/ovarian cancer cases: a cluster randomised controlled trial.

BACKGROUND: It has been suggested that primary care should become more involved in providing genetic services, such as basic risk assessment, to enable patients with a moderate/high risk to be referred and those with a low risk to receive reassurance and advice from their general practitioner (GP). However, GPs currently lack knowledge and confidence in this area. AIM: To investigate the effect of an in-practice educational session and information pack on GP management of familial breast/ovarian cancer cases. DESIGN OF STUDY: Cluster randomised controlled trial. SETTING: GP principals in 170 practices in Oxfordshire and Northamptonshire. Of the 688 GPs, 426 (62%) participated. METHOD: Practices were randomised either to Group A (receiving an inpractice educational session plus information pack), Group B (receiving an information pack alone), or Group C (receiving neither an educational session nor a pack). The main study outcome was the proportion of GPs making the correct referral decision on at least five out of six family history vignettes. A secondary outcome was GPs' reported confidence in managing patients with a family history of breast/ovarian cancer, measured by a score that was generated by combining responses to four questions. RESULTS: There was a 40% (95% CI = 30-50%, P < 0.001) improvement in the proportion of GPs who made the correct referral decision on at least five out of the six vignettes in Group A (111/140 [79%]) compared with Group C (controls) (63/162 [39%]), and a 42% (95% CI = 31-52%, P < 0.001) improvement in Group B (100/124 [81%]) compared with the control group. There was a trend in reported confidence in the management of individuals with a family history of breast/ovarian cancer from a mean confidence score of 2.3 in Group A to 2.0 in Group B and 1.5 in Group C (P < 0.001). CONCLUSION: Providing GPs with an information pack significantly improved referral decisions regarding patients with a family history of breast/ovarian cancer. Although extremely well received, an in-house educational session produced no additional improvements. There were, however, greater levels of reported confidence in the group who received the educational session in addition to the information pack.

Patients with cancer holding their own records: a randomised controlled trial.

BACKGROUND: The burden of cancer care in general practice is increasing. Patient-held records may facilitate effective, coordinated care, but no randomised controlled trials of their use in cancer care have been conducted, and concerns about possible negative effects remain. AIM: To evaluate the use of a supplementary patient-held record in cancer care. METHOD: Six hundred and fifty radiotherapy outpatients with any form of cancer were randomised either to hold a supplementary record or to receive normal care. It was explained to record holders that the supplementary record was intended to improve communication with health professionals and act as an aide memoire. After three months, patients' satisfaction with communication and with participation in their own care were assessed. Global health status, emotional functioning, and cognitive functioning were measured using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire. RESULTS: There were no significant differences between groups in any of the outcome measures. Patients in both groups expressed a high level of satisfaction with communication and participation in their care. Mean (SD) scores in the intervention and control groups were: global health status, 66.8 (24.2) and 65.3 (23.7); emotional functioning, 75.0 (24.6) and 77.4 (22.8); cognitive functioning, 84.5 (21.0) and 84.0 (21.3). CONCLUSION: A supplementary patient-held record for radiotherapy outpatients appears to have no effect on satisfaction with communication, participation in care, or quality of life.

Randomized trial of nurse-assisted strategies for smoking cessation in primary care.

BACKGROUND: Brief advice to stop smoking from general practitioners (GPs) has been repeatedly shown to increase smoking cessation by a small, but measurable amount. Some studies have suggested that adding more intensive interventions to brief advice may increase its effectiveness, but it is unclear whether this is true in general practice. AIMS: To determine whether brief advice from a doctor together with counselling and follow-up from a trained practice nurse is more effective than brief advice alone in helping people to stop smoking. METHODS: The design was a randomized controlled trial. Four hundred and ninety-seven general practice patients aged older than 18 years and smoking at least one cigarette per day in six general practices in Oxfordshire, Berkshire, and Buckinghamshire were randomized to one of two interventions: brief verbal or written advice from a GP plus extended counselling and follow-up from a trained practice nurse; brief advice from a GP alone. The primary outcome was sustained abstinence from smoking at three and 12 months. A secondary outcome was forward movement in the stages of change cycle. RESULTS: The proportion showing sustained abstinence was 3.6% in the extended counselling group, and 4.4% in the brief advice group (difference = -0.8%; 95% confidence interval = -4.3% to 2.6%). Seventy-four (30%) of those randomized to extended counselling actually took up this offer. No significant progression in stages of change was detected between the two groups. CONCLUSIONS: In unselected general practice patients who smoke, brief advice from a GP combined with intensive intervention and follow-up by a practice nurse is no more effective than brief advice alone.