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Objective: To quantify the relation between community based antibacterial prescribing and antibacterial resistance in community acquired disease. Design: Cross sectional study of antibacterial prescribing and antibacterial resistance of routine isolates within individual practices and primary care groups. Setting: 405 general practices (38 groups) in south west and north west England. Main outcome measures: Correlation between antibacterial prescribing and resistance for urinary coliforms and Streptococcus pneumoniae. Results: Antibacterial resistance in urinary coliform isolates is common but the correlation with prescribing rates was relatively low for individual practices (ampicillin and amoxicillin rs=0.20, P=0.001; trimethoprim rs=0.24, P=0.0001) and primary care groups (ampicillin and amoxicillin rs=0.44, P=0.05; trimethoprim rs=0.31, P=0.09). Regression coefficients were also low; a practice prescribing 20% less ampicillin and amoxicillin than average would have about 1% fewer resistant isolates (0.94/100; 95% confidence interval 0.02 to 1.85). Resistance of S pneumoniae to both penicillin and erythromycin remains uncommon, and no clear relation with prescribing was found. Conclusions: Routine microbiological isolates should not be used for surveillance of antibacterial resistance in the community or for monitoring the outcome of any change in antibacterial prescribing by general practitioners. Trying to reduce the overall level of antibiotic prescribing in UK general practice may not be the most effective strategy for reducing resistance in the community. What is already known on this topic The probability of an individual hosting a resistant organism is increased by recent use of an antibacterial drug Correlation between antibacterial prescribing and coliform resistance in routine microbiological samples from the community has been reported in one study What this study adds In English general practice, there are significant but low correlations between antibacterial prescribing and resistance in routine isolates of urinary coliforms Substantial differences in prescribing between high and low prescribing practices are associated with only small differences in resistance Improved methods of assessing national antimicrobial resistance are required

Objective: To investigate the relations of maternal diet and smoking during pregnancy to placental and birth weights at term. Design: Prospective cohort study. Setting: District general hospital in the south of England. Participants: 693 pregnant nulliparous white women with singleton pregnancies who were selected from antenatal booking clinics with stratified random sampling. Main outcome measures: Birth and placental weights at term. Results: Placental and birth weights were unrelated to the intake of any macronutrient. Early in pregnancy, vitamin C was the only micronutrient independently associated with birth weight after adjustment for maternal height and smoking. Each ln mg increase in vitamin C was associated with a 50.8 g (95% confidence interval 4.6 g to 97.0 g) increase in birth weight. Vitamin C, vitamin E, and folate were each associated with placental weight after adjustment for maternal characteristics. In simultaneous regression, however, vitamin C was the only nutrient predictive of placental weight: each ln mg increase in vitamin C was associated with a 3.2% (0.4 to 6.1) rise in placental weight. No nutrient late in pregnancy was associated with either placental or birth weight. Conclusions: Concern over the impact of maternal nutrition on the health of the infant has been premature Maternal nutrition, at least in industrialised populations, seems to have only a small effect on placental and birth weights. Other possible determinants of fetal and placental growth should be investigated. Key messages Placental and infant birth weights were not associated with the intake of any macronutrient early or later in pregnancy After adjustment for the effects of maternal height and smoking, only vitamin C independently predicted birth weight. The expected mean difference in birth weight for infants with mothers in the upper and lower thirds of intake was about 70 g Vitamin C was the only nutrient that independently predicted placental weight, but again this relation was of doubtful clinical significance Among relatively well nourished women in industrialised countries, maternal nutrition seems to have only a marginal impact on infant and placental size. Other causes of variation in the size of clinically normal infants should now be investigated

OBJECTIVE: To determine whether tight control of blood pressure prevents macrovascular and microvascular complications in patients with type 2 diabetes. DESIGN: Randomised controlled trial comparing tight control of blood pressure aiming at a blood pressure of

Objectives: To estimate the economic efficiency of tight blood pressure control, with angiotensin converting enzyme inhibitors or beta blockers, compared with less tight control in hypertensive patients with type 2 diabetes. Design: Cost effectiveness analysis incorporating within trial analysis and estimation of impact on life expectancy through use of the within trial hazards of reaching a defined clinical end point. Use of resources driven by trial protocol and use of resources in standard clinical practice were both considered. Setting: 20 hospital based clinics in England, Scotland, and Northern Ireland. Subjects: 1148 hypertensive patients with type 2 diabetes from UK prospective diabetes study randomised to tight control of blood pressure (n=758) or less tight control (n=390). Main outcome measure: Cost effectiveness ratios based on (a) use of healthcare resources associated with tight control and less tight control and treatment of complications and (b) within trial time free from diabetes related end points, and life years gained. Results: Based on use of resources driven by trial protocol, the incremental cost effectiveness of tight control compared with less tight control was cost saving. Based on use of resources in standard clinical practice, incremental cost per extra year free from end points amounted to £1049 (costs and effects discounted at 6% per year) and £434 (costs discounted at 6% per year and effects not discounted). The incremental cost per life year gained was £720 (costs and effects discounted at 6% per year) and £291 (costs discounted at 6% per year and effects not discounted). Conclusions: Tight control of blood pressure in hypertensive patients with type 2 diabetes substantially reduced the cost of complications, increased the interval without complications and survival, and had a cost effectiveness ratio that compares favourably with many accepted healthcare programmes.

OBJECTIVE: To investigate the relation between decreased maternal food intake and risk factors for coronary heart disease in adult life. DESIGN: Cross sectional study. SUBJECTS: 169 subjects exposed to malnutrition in utero (intrauterine group) during the siege of Leningrad (now St Petersburg) in 1941-4; 192 subjects born in Leningrad just before rationing began, before the siege (infant group); and 188 subjects born concurrently with the first two groups but outside the area of the siege (unexposed group). SETTING: Ott Institute of Obstetrics and Gynaecology, St Petersburg. MAIN OUTCOME MEASURES: Development of risk factors for coronary heart disease and diabetes mellitus-obesity, blood pressure, glucose tolerance, insulin concentrations, lipids, albumin excretion rate, and clotting factors. RESULTS: There was no difference between the subjects exposed to starvation in utero and those starved during infant life in: (a) glucose tolerance (mean fasting glucose: intrauterine group 5.2 (95% confidence interval 5.1 to 5.3), infant group 5.3 (5.1 to 5.5), P = 0.94; mean 2 hour glucose: intrauterine group 6.1 (5.8 to 6.4), infant group 6.0 (5.7 to 6.3), P = 0.99); (b) insulin concentration; (c) blood pressure; (d) lipid concentration; or (e) coagulation factors. Concentrations of von Willebrand factor were raised in the intrauterine group (156.5 (79.1 to 309.5)) compared with the infant group (127.6 (63.9 to 254.8); P < 0.001), and female subjects in the intrauterine group had a stronger interaction between obesity and both systolic (P = 0.01) and diastolic (P = 0.04) blood pressure than in the infant group. Short adult stature was associated with raised concentrations of glucose and insulin 2 hours after a glucose load-independently of siege exposure. Subjects in the unexposed group had non-systematic differences in subscapular to triceps skinfold ratio, diastolic blood pressure, and clotting factors compared with the exposed groups. CONCLUSIONS: Intrauterine malnutrition was not associated with glucose intolerance, dyslipidaemia, hypertension, or cardiovascular disease in adulthood. Subjects exposed to malnutrition showed evidence of endothelial dysfunction and a stronger influence of obesity on blood pressure.

Fully informed decisions cannot be made unless guidelines consider the effect of treatment on healthy life expectancy, say John S Yudkin and colleagues

Objective : To assess the effectiveness of health checks by nurses in reducing risk factors for cardiovascular disease in patients from general practice. Design : Randomised controlled trial. Setting : Five urban general practices in Bedfordshire. Subjects : 2136 patients receiving an initial health check in 1989-91 and scheduled to be re-examined one year later in 1990-2 (intervention group); 3988 patients receiving an initial health check in 1990-2 (control group). All patients were aged 35-64 years at recruitment in 1989. Main outcome measures : Serum total cholesterol concentration, blood pressure, body mass index, confirmed smoking cessation. Results : Mean serum total cholesterol was 2.3% lower in the intervention group than in the controls (difference 0.14 mmol/l (95% confidence interval 0.08 to 0.20)); the difference was greater in women (3.2%, P =100 mm Hg was 2.6% (55/2131) in the intervention group and 3.4% (137/3987) in the controls (difference 0.9% (0.0 to 1.7); the proportion with total cholesterol concentration >=8 mmol/l 4.8% (100/2068) and 7.6% (295/3905) (difference 2.7% (1.5 to 4.0)); and that with body mass index >=30 12.4% (264/2125) and 14.0% (559/3984) (difference 1.6% (-0.2 to 3.4)). Conclusion : General health checks by nurses are ineffective in helping smokers to stop smoking, but they help patients to modify their diet and total cholesterol concentration. The public health importance of this dietary change depends on whether it is sustained. © 1994, BMJ Publishing Group Ltd. All rights reserved.

OBJECTIVES--To assess the rate of impairment and disability among babies born very preterm and to investigate the association between such impairment and gestational age at birth. DESIGN--Cohort study of a geographically defined population of babies. SETTING--Oxford Regional Health Authority. SUBJECTS--All babies born alive before 29 weeks of gestation to mothers resident in the region during 1984-6. MAIN OUTCOME MEASURES--Survival rates and rates of impairment and disability among survivors at the age of 4 years. RESULTS--Of the 342 babies, half (170) survived to be discharged home. Of the 164 survivors to age 4 years, 153 (93%) were assessed. A total of 35 (23%; 95% confidence interval 16% to 30%) were severely disabled and only 54 (35%; 28% to 43%) were unimpaired. The risk of impairment and disability increased with decreasing gestational age at birth (p < 0.003). CONCLUSIONS--With the increasing survival rate among babies born before 29 weeks of gestation, we need urgently to establish reliable ways of monitoring the proportion of survivors who have a disability.

OBJECTIVE--To compare the theoretical benefits of different approaches to reduce risk factors for coronary heart disease in subjects at risk. DESIGN--The results of findings from meta-analyses of intervention studies on cause specific mortality and of observational studies on smokers and ex-smokers were applied to observational data on 10 year cause specific mortality derived from the multiple risk factor intervention trial. Lifetable analyses were used to estimate gains in life expectancy. SUBJECTS--Diabetic and non-diabetic men initially 35-57 years of age. MAIN OUTCOME MEASURES--10 year mortality from coronary heart disease, 10 year total mortality, man years of intervention to prevent one death and one death from coronary heart disease, gain in life expectancy, and drug costs per year of additional life in diabetic and non-diabetic men of 45. RESULTS--In non-diabetic men a 10 year mortality from coronary heart disease of 14.4 per 1000 would be reduced by a mean of 0.58, 0.82, 2.64, and 2.74 per 1000 by antihypertensive treatment, lowering cholesterol concentration, taking aspirin, and stopping smoking respectively; a 10 year total mortality of 44.1 per 1000 would fall by a mean of 1.06, 5.16, and 8.65 per 1000 with antihypertensive and aspirin treatment and stopping smoking respectively and increased by a mean of 0.07 per 1000 with the lowering of cholesterol concentration. In diabetic men the reductions in mortality from coronary heart disease would be between three and five times greater, and total mortality would show mean reductions of 5.81, 0.56, 16.17, and 20.84 per 1000 respectively, with all interventions of significant benefit except the lowering of cholesterol concentration. Between 2400 and 3800 man years of pharmacological intervention were calculated as being necessary to prevent one death from coronary heart disease in a non-diabetic man, and between 800 and 1200 man years in a diabetic man. The loss of life expectancy associated with smoking and hypertension is greater than that accruing from hypercholesterolaemia, but stopping smoking would prolong life by a mean of around four years in a 45 year old non-diabetic man and three years in a diabetic man, whereas aspirin and antihypertensive treatment would provide approximately one year of additional life expectancy in both categories. CONCLUSIONS--Studies to date have shown little impact of drugs that lower cholesterol concentration and blood pressure on either coronary heart disease or total mortality. Although new treatments for hypercholesterolaemia and hypertension might help prevent coronary heart disease, other approaches to reduce the burden of premature death are required.

OBJECTIVE--To evaluate the effectiveness and acceptability of centrally organised prompting for coordinating community care of non-insulin dependent diabetic patients. DESIGN--Randomised single centre trial. Patients allocated to prompted care in the community or to continued attendance at hospital diabetic clinic (controls). Median follow up two years. SETTING--Two hospital outpatient clinics, 38 general practices, and 11 optometrists in the catchment area of a district general hospital in Islington. PATIENTS--181 patients attending hospital outpatient clinics. NULL HYPOTHESIS--There is no difference in process of medical care measures and medical outcome between prompted community care and hospital clinic care. RESULTS--14 hospital patients failed to receive a single review in the clinic as compared with three patients in the prompted group (chi 2 = 6.1, df = 1; p = 0.013). Follow up for retinal screening was better in prompted patients than in controls; two prompted patients defaulted as against 12 controls (chi 2 = 6.9, df = 1; p = 0.008). Three measures per patient yearly were more frequent in prompted patients: tests for albuminuria (median 3.0 v 2.3; p = 0.03), plasma glucose estimations (3.1 v 2.5; p = 0.003), and glycated haemoglobin estimations (2.4 v 0.9; p < 0.001). Continuity of care was better in the prompted group (3.2 v 2.2 reviews by each doctor seen; p < 0.001). The study ended with no significant differences between the groups in last recorded random plasma glucose concentration, glycated haemoglobin value, numbers admitted to hospital for a diabetes related reason, and number of deaths. Questionnaires revealed a high level of patient, general practitioner, and optometrist satisfaction. CONCLUSIONS--Six monthly prompting of non-insulin treated diabetic patients for care by inner city general practitioners and by optometrists is effective and acceptable.

OBJECTIVE--To document how often patients with varying cardiovascular risk levels reported receiving lifestyle advice from general practice. DESIGN--Cross sectional descriptive survey by postal questionnaire. SETTING--5 general practices in Bedfordshire. SUBJECTS--4941 people aged 35-64 years who had consulted a general practitioner at least once during the 12 months before completing the questionnaire and who subsequently attended for a health check as part of the OXCHECK trial. MAIN OUTCOME MEASURES--Report of having received advice from a general practitioner or practice nurse about smoking, alcohol consumption, exercise, or diet during the 12 months before completing the questionnaire. Cardiovascular risk assessed by a nurse during structured health check. RESULTS--The overall reported rate of advice was 27% for smoking, 4.5% for exercise, 12% for diet, and 3% for alcohol consumption. Those with unhealthy behaviour profile or at increased cardiovascular risk received more advice--for example, 47% of smokers with a history of cardiovascular disease received advice on smoking. Among those at increased risk, men were more likely than women to receive advice about exercise (11% v 4%, p = 0.04) and alcohol consumption (10% v 4%, p = 0.007), while women received more advice about weight (17% v 23%, p < 0.001). The rate of receiving advice was unaffected by age, marital status, or social class. CONCLUSION--The low rate of lifestyle advice reported by patients implies that more preventive advice could be provided in primary care.

The process for approving new drugs for type 2 diabetes illustrates the significant shortcomings of the regulatory standards for licensing, reimbursing, and adopting new drugs. Regulatory reform is needed to improve the real-world therapeutic value of anti-diabetic drugs.

Simon Stevens’s address to the NHS Confederation stated the need for rigorous testing of new approaches to service delivery.1 In the same speech he also held up London’s reform of stroke services to justify the centralisation of services. His evidence was based on a before and after study showing a “12% reduction in death rates.” The study compared outcomes for patients treated for …

OBJECTIVE--To examine the use of routinely collected computerised data in clinical audit. DESIGN--Retrospective review of all analyses of obstetric practice based on a computerised data system from January 1983 to June 1988. SETTING--Maternity department of the regional referral hospital in Oxford. MAIN OUTCOME MEASURES--Congruence with the principles of clinical audit; that is, comparing clinical practice with previously agreed standards and changing practice to meet these standards if necessary. RESULTS--Over the five and a half years of the study the data formed the basis of 130 special inquiries into different aspects of obstetric practice. Most inquiries seemed to be aimed only at describing current activities and identifying trends. Genuine clinical audit was rare. Simple audits--for example, concerning induction for pregnancy after term--could be supported by the computerised data, but for detailed and wide ranging audits--for example, reducing antenatal clinic visits for low risk multiparas--the data had to be supplemented from other sources. CONCLUSIONS--Routinely collected computerised data enable ongoing clinical audit, but it becomes a reality only when clinicians agree on standards of practice and have a flexible attitude towards change. Even then, genuine clinical audits of obstetric practice demand more detailed and comprehensive data than are generally available on such systems.

An open letter to the BMA and the Academy of Medical Royal Colleges calls on them to make a joint public statement of opposition to the amended section 75 regulations

The overall effectiveness of nicotine replacement therapy could be greater if the therapy were targeted at those most likely to respond. Variants of the dopamine D2 receptor ( DRD2 32806 C/T) have been implicated in the initiation and maintenance of smoking,1 2 and these variants may also be related to response to nicotine replacement therapy.3 Additionally, mechanisms of nicotine addiction may differ in men and women.4 With this evidence in mind, we examined whether the response to nicotine replacement therapy is modified by sex and genotype. A randomised controlled trial of nicotine patches in 1991-2 recruited 1686 heavy smokers (≥15 cigarettes a day).5 The participants wore patches for 12 weeks. Abstinence from smoking was confirmed at one week by expired carbon monoxide concentration ≤ 10 ppm, and at 12, 24, and 52 weeks by salivary cotinine concentration ≤ 20 ng/ml (89% of cases) or by expired carbon monoxide concentration ≤10 ppm. In 1999-2000, we contacted 1532 of the 1625 participants still alive; the mean …