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Objective: To study the feasibility of a cardiovascular prevention programme., Design: Opportunistic screening for cardiovascular risk factors. Advice and treatment to reduce identified cardiovascular risk factors. Individually designed follow-up., Setting: Primary health care in Sollentuna (51,000 inhabitants), Sweden., Subjects: Visitors to health care centres., Main Outcome Measures: Feasibility and effectiveness to reduce identified cardiovascular risk factors., Results: During 4 years 5622 persons, of whom 4655 (83%) were in the age group 20-60 years, participated in the programme. The prevalences of risk factors as smoking, overweight, hypertension, hypercholesterolaemia and hypertriglyceridaemia were high. At follow-up investigations, mean S-cholesterol levels were reduced by 7% among men and 10% among women. S-triglycerides were reduced by 24% and 42%, respectively. Diastolic blood pressures were reduced in men from 95 to 90 mmHg and in women from 94 to 88 mmHg. However, no effects on weight were noted and due to a low follow-up rate meaningful analysis of smoking habits was not possible., Conclusion: A programme for cardiovascular screening and prevention can be integrated in the primary health care system. Prevalent cardiovascular risk factors like hypercholesterolaemia, hypertriglyceridaemia and high blood pressure were significantly reduced after intervention.

This study sought to evaluate how the addition of a general practitioner (GP) surgery influences the utilization of an emergency department (ED). An intervention trial with historical control was conducted in a Swedish university hospital ED. A GP surgery was established in the ED by the addition of GP physicians without the addition of other personnel (nurses, secretaries, aids). The number of persons evaluated and managed by the GP physicians and ED physicians were quantified preintervention (April 1992 to October 1993) and postintervention (April 1994 to October 1995). Further information was obtained by questionnaires distributed to all physicians and patients during three sample study weeks: 1 week before intervention and 6 and 18 months after the intervention. Patient volume, percentages of inappropriate visits, and types of services were recorded. The addition of GP physicians increased the number of visits to the ED by 27% (4,694 per month to 5,952 per month). The percentage of patients managed in the ED who had nonurgent complaints (primary health care needs) increased with the intervention from 22% (95% confidence interval [CI] 19%, 25%) to 33% (95% CI 30%, 37%). The increased demand on the ED of patients with nonurgent complaints increased the average waiting time for patients with urgent or emergent complaints from 35 minutes to 40 minutes (14%). The introduction of GPs to an ED increased the number and proportion of patients presenting to the ED with nonurgent complaints.

The authors examined Type A behavior pattern, which has been investigated primarily as a risk factor for coronary heart disease, as a risk factor for car accidents and near accidents. Type A behavior pattern, which is characterized by excessive impatience, competitiveness, hostility, and time pressure, was assessed by means of the Videotaped Structured Interview. One hundred thirty-five Swedish car drivers (66 men and 69 women) were studied: 78 Type A and 58 Type B (that is, not having, Type A behavior). Time pressure was significantly associated with near accidents when age, sex, annual mileage, and urban driving were controlled in a multivariate model.

Background and Objective: Coronary stents are used nowadays not only for the reduction of restenosis and for treating acute vessel occlusions after PTCA but also after acute myocardial infarction. This study was undertaken to determine whether widening the indications has affected the incidence of acute complications and to compare acute cardiac and vascular complications., Patients and Methods: The data on 197 consecutive patients (155 men, 42 women; mean age 62 +/- 9 [37-85] years) with coronary stents were analysed retrospectively, divided into 5 groups depending on the indications for the stent implantation: 1) acute or threatened vessel occlusion after elective PTCA ("bail-out"); 2) acute myocardial infarction (AMI); 3) unstable angina with threatened vessel occlusion; 4) suboptimal primary results (angiographically assessed) after PTCA; 5) elective stent implantation to prevent restenosis. Acute or subacute stent thrombosis, side-branch occlusion, intra- and transmural infarction, death and emergency aortocoronary bypass operation were classified as acute cardiac complications. Haemorrhage in the inguinal region requiring blood transfusion, false aneurysm and operative vascular reconstruction were classified as vascular complications., Results: An intended stent implantation was impossible in 18 patients (primary success rate 91%). Independent of indication an acute or chronic stent stenosis occurred in three (1.6%) and seven (3.9%) patients, respectively. Side-branch occlusion was observed in 12 patients (6.7%), transmural infarction in nine (5.6%). No emergency bypass operation had to be performed. Comparing the different indication groups there was a significantly increased rate of "non-Q" infarctions in patients with unstable angina pectoris (P < 0.014). Among acute vascular complications (10 [5%] inguinal haemorrhages requiring transfusion and 5 [2.5%] operative vascular reconstructions), false aneurysm was significantly more common in patients with AMI (P < 0.014). Comparing emergency and elective stent implantations, side-branch occlusions were significantly more common in the former (12% vs. 0%; P < 0.08), as were also "non-Q" infarcts (10% vs. 0%; P < 0.002)., Conclusion: Coronary stent implantation for these indications, including AMI, can be taken as firmly established. Stent thrombosis was not significantly increased after "bail out". Implantation in an acute ischaemic episode led to a significantly higher incidence of side-branch occlusion and "non-Q" infarction.

This study evaluates the effects of an intervention on hostility and time pressure in primary health care patients. A total of 47 men and women were studied, of whom 22 participated in an intervention program and 25 were controls. The intervention group changed global Type A behavior, hostility and time pressure significantly more than the control group and this change was stable up to 2 years following the study. Men altered their behavior significantly more than women.

Background and Objective: The time elapsed until effective infarct vessel perfusion has been identified as an essential determinant of survival after acute myocardial infarction (MI). Significant mortality rate reduction has not been demonstrated for patients who received thrombolytic treatment more than 12 to 24 hours after MI. For this reason such patients have so far largely been denied reperfusion treatment and have thus been excluded from any potential benefit of an reopened infarct vessel. It was the aim of this study to assess the applicability and safety of achieving reperfusion by percutaneous transluminal coronary angioplasty (PTCA) without prior thrombolysis (primary PTCA) within 12 (> 12) to 24 (< or = 24) hours after onset of pain, taking into account early and late results in selected consecutive patients., Patients and Methods: The data were analysed retrospectively of 35 patients (29 men, 6 women; mean age 60 [49-78] years) who had been admitted and treated by primary PTCA for MI more than 12-24 hours after onset of pain, with persisting ECG changes and (or) continuing chest pain. Reperfusion rates, acute haemodynamic parameters, acute cardiac and noncardiac complications, 30-day mortality rate, 3-month angiographic results and late mortality rate were obtained after an average of 23 (4-36) months., Results: Complete infarct vessel reperfusion was achieved in 30 patients (85.7%), the infarct vessel remaining occluded in five. The early measurement of mean left ventricular ejection fraction was 53% (8-76%). A small, conservatively managed pericardial effusion occurred in one patient due to coronary artery penetration. Three patients who were in cardiogenic shock on admission died (8.6% 30-day mortality rate). Nine cases of restenosis and two of re-occlusion of the infarct vessel were documented in 24 patients who were investigated invasively 3 months after the primary PTCA. One patient had sustained a nonfatal MI. During the follow-up period one patient died of a noncardiac cause., Interpretation: In this selected group of patients who received treatment more than 12 to 24 hours after MI primary PTCA achieved a high rate of reperfusion, while early and late complications were rare. Using individualized criteria of patient selection, primary PTCA can accomplish recanalization. The question of prognostic advantage can only be answered by results in a larger and randomized cohort of patients.

Objective: To develop a short and easily used self-report measure of Type A behaviour (Simplified Type A Questionnaire = STAQ) and to examine its capacity to predict Type A behaviour as assessed by more time-consuming measures., Design: A Videotaped Structured Interview (VSI) and a self-report measure, previously validated in Sweden, were used as comparison instruments to the STAQ., Setting: Primary health care., Patients: 206 (81 men and 125 women) aged 17-75 years attending a health centre during one year., Main Outcome Measures: The reliability, measured by Cronbach's alpha and split-half correlation. The specificity and sensitivity of the STAQ. The correlaiton between the STAQ and the two other diagnostic measures., Results: The reliability of the STAQ was 0.70 and 0.75, respectively. The specificity was 83% and the sensitivity 75%. The correlation between the STAQ and the VSI was 0.45. The correlation between the STAQ and the previously validated self-report was 0.61., Conclusions: The STAQ has good psychometric properties and, in comparison with other diagnostic measurement instruments in medical service, it has an acceptable discrimination capacity.

Basic Problem and Objective: Percutaneous transluminal coronary angioplasty (PTCA) is being increasingly considered as an alternative to thrombolytic treatment of acute myocardial infarction. Studies performed so far, some on selected groups of patients, have produced high initial results of success. This prospective study was undertaken to determined primary success, complications and recurrence after primary PTCA in acute myocardial infarction (AMI)., Patients and Methods: Primary treatment in the form of immediate PTCA of the infarct vessel was undertaken in 111 patients (84 men, 27 women; mean age 58.6 +/- 10.3 years) with AMI. PTCA was judged successful if the infarct vessel had been reopened to perfusion grade 3 and restenosis was < 50%. No thrombolytic treatment was given, but heparin infusions were given during and for 24-48 hours after the procedure. 13 patients (11.7%) were in cardiogenic shock or required cardiopulmonary resuscitation for infarct-related arrhythmias., Results: The primary success rate of PTCA for the whole group was 91% (101 of 111 patients), but only 77% (ten of 13) among patients in cardiogenic shock and (or) after resuscitation. Acute re-occlusion (0-6 days after PTCA) occurred in seven patients. Eight patients (7.2%) died during the hospital phase (0-4 weeks), seven of whom had been in shock or required resuscitation (death rate 54%). The overall complication rate of the intervention was 6.3%. No emergency aortocoronary bypass was necessary. Repeat coronary angiography was performed in 71 of the 101 successfully treated patients 6 or 12 weeks after the PTCA. Re-occlusion was demonstrated in four (5.6%), a restenosis of more than 50% in 25% of patients. Mean left ventricular ejection fraction, obtained by planimetry from the levocardiogram was 58.6 +/- 9.3%., Conclusion: PTCA, performed immediately after acute myocardial infarction is an effective therapeutic measure with a high primary success rate.

Objectives: To study two different procedures for inviting subjects to screening for malignant melanoma, and to study the role of specially trained nurses as primary examiners., Methods: The study was carried out in Stockholm county and comprised 5000 randomly selected men and women aged 40 to 60, of whom 2,500 were invited with a personal invitation letter and with a set time of appointment and 2,500 were sent a questionnaire and instructions for self examination of the skin. To test the nurses' competence, a survey was made, comparing the judgments of skin examination between nurses and doctors., Results: 1654 (66%) of those invited for a skin examination took part. 1507 (60%) replied in the questionnaire group, of whom 1024 (41%) requested and attended a subsequent skin examination. Of the subjects attending from both groups, the nurses judged 9% v 11% as having skin lesions suggesting malignant melanoma, whereas the two doctors referred 4% v 3% of the subjects for surgical biopsy. Two malignant melanomas were detected, both of them in the questionnaire group. In the study of nurses' screening competence, both nurses and doctors equally judged one case out of 19 as having a lesion suspicious for malignant melanoma., Conclusions: When the questionnaire method was used the results were achieved with one third fewer skin examinations, but it is difficult to conclude whether one of the procedures is better than the other. The results also indicate that nurses can be trained to be the primary examiners in a melanoma screening programme.

The impact of psychosocial and behavioral factors on serum lipids was examined in 46 male and 47 female students with a mean age of 23 years. Subjects were recruited from the University of Stockholm and the study was performed with the Student Health Care Organization in order to have a basis for intervention programs. Significant associations between serum lipids and parental education, regularity of breakfast habits, nourishing eating, social support, depressive feelings and quality of life are found. However, there is no consistent pattern for these associations in men and women. Thus, some associations are significant for men and some for women. Women with parents having higher levels of education had lower values of cholesterol, triglycerides and apo B, and higher values of apo A-1 (representing the 'good' cholesterol) than women whose parents were not highly educated. When controlling the associations for confounding factors such as age, body mass index, physical activity, coffee, alcohol, smoking habits, nourishing eating and quality of life, the associations were strongly confirmed. No similar associations were found in men. Men who reported low social support or social integration and a low perceived quality of life showed a tendency to higher levels of lipids compared to those who reported high integration and quality of life. Regularity of dietary habits was found to be associated to serum lipids in men, the greater the regularity, the lower the lipid levels. The strongest association was found for regularity of breakfast habits. This association was also strongly significant in the regression analysis after controlling for the described confounding factors.(ABSTRACT TRUNCATED AT 250 WORDS)

In a 52-year-old patient with beginning dilatative cardiomyopathy dizziness and syncopes could be observed due to a ventricular bigeminy at rest and under exercise conditions. The patient also showed a marked reduction of exercise capacity and was handicapped in his profession as electrician and unable to work for more than 10 months. Antiarrhythmic drug therapy including the subsequent use of all available antiarrhythmic agents failed in suppressing this arrhythmia. In an electrophysiological study the arrhythmogenic focus could be localized in the right ventricular outflow tract. Application of radiofrequency current resulted in instantaneous termination of the extrasystoly; this result could be documented in repeat Holter monitorings over 12 weeks to present. This case report shows that radiofrequency catheter ablation can in special cases be applied for therapy of extrasystolic phenomena when clinical symptoms necessitate treatment and antiarrhythmic drug therapy fails.

This study reports on 261 consecutive patients admitted to the Wuppertal Heart Center with acute myocardial infarction (186 men, 75 women; average age: 58.2 +/- 11.6 years) and then treated by primary coronary artery angioplasty. Sixteen patients with cardiogenic shock were included, as well as 42 patients aged > or = 70 years, 51 patients with contraindications for thrombolysis, and 13 patients with prior coronary bypass surgery. All patients were treated between 12/89 to 6/94 and had not received prior thrombolytic therapy. The period of time between onset of pain and revascularization of the infarct-related vessel averaged 224 +/- 205 min. Half of the patients had multi-vessel disease, and about 31% had had a prior myocardial infarction. 100 patients suffered from an anterior wall infarction, 109 patients from an inferior wall infarction, 50 patients from a posterolateral infarction, and in two cases the infarct localization could not be determined from the ECG. Mean biplane left ventricular ejection fraction averaged 56 +/- 13%, left ventricular end-diastolic pressure 20 +/- 7 mm Hg. In about 50% of the patients collaterals to the infarct-related coronary artery could be documented. With the first contrast injection into the infarct-related vessel TIMI flow 0/I was demonstrated in 94.9%, TIMI flow II in 5.7% and TIMI flow III in 0.4%. Reopening of the infarct-related coronary artery with establishment of TIMI-flow III was primarily successful in 91.9%. Average time for coronary angiography and angioplasty in the cathlab was 69 +/- 28 min. In 29 patients an autoperfusion balloon catheter was used to treat manifest or threatening reocclusion. Thirty-day-mortality in the total study group was 3.4%. In patients aged > or = 70 years mortality raised to 14.3%; in patients in cardiogenic shock mortality increased to 18.7%, in patients with inferior wall infarction up to 5.5%, and in cases with multi-vessel disease up to 5.0%. The in-hospital and 30-day course were complicated by major peripheral bleeding in seven patients (2.7%) requiring blood transfusions and surgical femoral vascular repair, and in another two patients with a false aneurysm which was treated by surgical means. No hemorrhagic stroke occurred, but three ischemic strokes with complete restitutio ad integrum within the 30-day-observation period were registered. As major cardiac complication early re-occlusion of the initially reopened infarct-related coronary artery was diagnosed in 10 patients; 11 patients developed a re-infarction within the first 30-days, in three cases leading to a fatal outcome.(ABSTRACT TRUNCATED AT 400 WORDS)

In this case report the electrophysiological findings in a 24 year old female patient are demonstrated. For about 12 years she suffered from recurrent atrioventricular reentrant tachycardia with a rate of 230 beats per minute. Electrophysiological study resulted in diagnosis of a posteroseptal accessory pathway. Ablation was attempted primarily from a left ventricular access, but the pathway could not be reached from this position. After contrasting the coronary sinus a large coronary sinus aneurysm could be diagnosed. The accessory pathway was located in the "neck"-region of the aneurysm. By application of radiofrequency current in this location the bypass tract could be ablated. This case report shows that accessory pathways in coronary sinus aneurysms can be ablated without complications in this location.

This study reports on 16 patients suffering from cardiogenic shock in the setting of acute myocardial infarction (11 men, five women; average age: 52.5 +/- 14 years) treated by means of primary coronary angioplasty: These 16 patients were part of a total population of 261 patients suffering from acute myocardial infarction at the time of admittance to the Wuppertal Heart Center, who were consecutively treated during the period from 1/90 to 6/94 by primary coronary angioplasty without having received any prior thrombolytic therapy. For all patients, primary re-opening of the vessel infarcted was successful. The period of time between onset of pain until re-opening of the vessel averaged 176 +/- 49 min. Eleven patients suffered from multi-vessel coronary artery disease. Prior to re-opening, systolic blood pressures averaged 66 +/- 10 mm Hg; average biplan left ventricular ejection fraction, 40 +/- 12%; left ventricular end-diastolic pressures (LVEDP), 26 +/- 7 mm Hg. In 63% of the cases evaluated, it proved possible to document collaterals to the infarcted vessel. Thirteen patients survived acute coronary occlusion. Two patients died due to protracted myocardial pumping failure, despite re-opened arteries that effectively re-established coronary flows. Showing symptoms of re-occlusion, one patient developed electromechanical decoupling. Thirteen patients were discharged from the hospital for normal life or subsequent treatment. Overall, this corresponds to an in-hospital survival rate of 81%. During follow-up examinations performed over 14 +/- 8 months (range 3 to 30 months), all of the patients are alive. Mean left ventricular ejection fraction increased to 56% +/- 17%; mean left ventricular end-diastolic pressure dropped to 14 mm Hg +/- 5 mm Hg. In the infarct-related artery there was no recurrence of stenoses exceeding 50%. By now, one of the patients has received elective aorto-coronary bypass grafting; for another one, multi-vessel PTCA of non-infarcted arteries is being employed; 77% of the patients state that they are satisfied with the quality of their lives. These results demonstrate that rapid revascularization using coronary angioplasty in cardiogenic shock following acute myocardial infarction substantially improves the prognosis for survival and favorably influences long-term outcome. Thus, primary PTCA is the method of choice for treating cardiogenic shock; any patient-and particularly those resistant to lyse therapy-should immediately receive this treatment.

Since the first implantation in 1980 about 55,000 automatic Cardioverter/Defibrillators (ICD) were implanted worldwide. This paper overviews the development of indications for ICD implantation as well as clinical results especially with respect to prophylaxis of sudden cardiac death.

From January 1990 to February 1993, 88 patients (group 1) received an emergency stent implantation with threatening vascular occlusion within the framework of an elective PTCA or a second emergency PTCA after up to 5 days following a primary successful PTCA. In addition, 36 patients (group 2) received an intracoronary stent during emergency PTCA of instable angina pectoris or acute myocardial infarction. The attempted stent implantation was not successful in 6 other patients. All patients were anticoagulated with heparin, aspirin (100 to 500 mg), and phenprocoumon. Since October 1991, 3 x 75 mg dipyridamole was given and heparinization was stopped after measuring the anticoagulation factor II (prothrombin time < 40%). Main complications within the first 2 to 3 weeks were acute and subacute stent thrombosis (21.8%) and complications of the puncture site (bleeding 19.3%, a. spurium/av-fistula 1.6%). The risk of acute stent thrombosis was significantly higher in patients of group 2 (instable angina pectoris despite of drug therapy or acute myocardial infarction) compared with group 1 (42.4 versus 14.8%). Implantation of multiple stents to stabilize extended dissections had a lower occlusion rate (6.3%). Acute myocardial infarctions were registered in group 1 in 25% (11.4% following implantation, 13.6% following stent occlusion, CK 153 to 3380 U/I, average 826 U/I) and in 58.3% of the high risk patients in group 2 (50% just before or following implantation, 36.1% infarctions or re-infarctions caused by stent occlusion, CK 152 to 1950 U/I, average 657 U/I). The risk of infarction could be limited to approximately 58% of the patients of group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

To study the impact of diet and exercise and the combination thereof on cardiovascular risk factors, 157 healthy men aged 35-60 years (mean +/- S.D.; 46.2 +/- 5.0) with slightly to moderately raised cardiovascular risk factors, were randomized to 4 groups, diet (D, n = 40), exercise (E, n = 39), diet plus exercise (DE, n = 39), and no active intervention (controls (C, n = 39)), and investigated at baseline and after 6 months. BMI was significantly reduced in Groups E and DE (mean difference and 95% confidence intervals (CI), -0.3 (-0.5, -0.01) and -0.6 (-0.9, -0.3) kg/m2, respectively). Waist circumference was reduced in all 3 intervention groups (D, E, and DE), -1.3 (-2.5, -0.1), -2.2 (-3.2, -1.3) and -3.0 (-3.9, -2.0) cm, but not in the control group. Blood pressure (BP) was reduced in all 3 intervention groups, systolic BP 4-7 mmHg and diastolic BP 2-6 mmHg. Serum cholesterol was reduced in Group DE, -0.45 (-0.77, -0.13) mmol/l. VLDL-cholesterol was reduced in Groups E and DE, -0.14 (-0.26, -0.03) and -0.09 (-0.18, -0.01) mmol/l, whereas LDL-cholesterol was reduced in Groups D and DE -0.30 (-0.54, -0.06) and -0.35 (-0.64, -0.05) mmol/l. In contrast, neither HDL-cholesterol nor serum triglycerides were influenced by the interventions. According to the coronary risk profile derived from the Framingham study, all 3 intervention groups (D, E, and DE) significantly reduced their estimated 10-year risk (-13, -12, and -14%, respectively). We conclude that even with rather moderate changes in diet and exercise, several important cardiovascular risk factors can be affected and that diet and exercise were about equally effective in reducing cardiovascular risk.

Objective: To integrate prevention of cardiovascular disease within the primary health care., Design: A prevention programme which combines population and individual high-risk strategy., Setting: The Primary Health Care in Sollentuna, Stockholm, Sweden., Main Outcome Measure: Characteristics of, and risk factor prevalence among, persons registered in the prevention programme., Results: During the first year more than 2000 persons, representing every tenth visitor and 6% of the population aged 15-60 years, were registered in the prevention programme. 90% were < or = 60 years and 62% were women. A large proportion (70%) had risk factors that required advice, treatment, and follow up. 24% of the men and 27% of the women were smokers, 68% and 62% respectively, had serum cholesterol > or = 5.2 mmol/l, and 33% and 22% had a diastolic blood pressure > or = 90 mmHg., Conclusion: The present study implies that it is possible to integrate a large scale prevention programme in the existing primary health care organization. The prevalence of risk factors in those who enter the prevention programme is high, which places great demands for treatment and follow up.

To design an effective course in behaviour influence all GPs and general nurses at two health care centres were interviewed concerning procedure and perceived barriers to prevention. The results demonstrated that most doctors and nurses regarded health counselling as important in medical health service. They also maintained that they have time and space for this activity. However, most doctors and nurses were hesitant and/or disappointed concerning their perceived efficacy in affecting people's life habits. The explanation may be that the personnel lack an effective methodology to handle these issues. Few had a more developed educational theory where the starting-point was the patient. Another explanation may be that many doctors and nurses had a non-patient-centred style, which previous studies demonstrate to be less successful in affecting people's behaviour. This was expressed in the notion that the doctor/nurse has to be a model from which the patient can learn the 'right' life habits. It was also expressed in the notion that the reasons why patients do not change behaviour were mostly psychological, but no importance was attached to the role of different values. The results point out the need for education in patient-centred pedagogics.

In a study that covered ten years a questionnaire about use of health care facilities was mailed each autumn to 1/60 representative samples of the population in Sollentuna, a Swedish primary care district with three health centres. Primary care was the health care form with the greatest contact area with the population studied. However, the strengthening of district physician resources at one of the three health centres did not, in the long term, lead to more people coming into contact with this form of medical care. It was more common for those who visited a private doctor or school/company doctor also to consult a district physician than vice versa. Similarly, hospital patients visited the health centre to a greater degree than patients of health centres visited hospitals. The only long-term change in the flow of patients that could be registered was a reduction in the number of patients who visited hospital emergency departments. It is concluded that the implementation of an annual survey may be considerably more helpful than more sparse investigations in distinguishing between temporary fluctuations and real changes.

In a study that covers three years, the extent of medical activities was analyzed in relation to the sex, age and treatment diagnoses of patients visiting district physicians at three health centres in a Swedish primary care district. All visits were registered with the aid of a specially designed encounter form. The most frequent medical activities were: drug prescriptions, follow-up measures and clinical chemical investigations. Diabetes, other metabolic diseases, malignant tumours and cardiovascular disease were the diagnosis groups associated with the most activities, while traumas, middle ear infections and check-up visits were associated with the least. In the case of both men and women, the number of activities per visit increased in proportion to age. The present study indicates that quantitative measures of medical activities, combined with diagnoses or other patient characteristics as sex and age, can be employed in clearly quantifying the content of consultations in primary health care.

In a study that covered ten years a questionnaire about perceived health and use of health care services was mailed each autumn to 1/60 representative samples of the population in Sollentuna, a Swedish primary care district. The majority of respondents thought that their health was good, and only a small minority reported themselves as quite, or very sick. Those assessments were stable during the ten year period. The tendency to visit the health services increased with the degree of severity of the illness. This increase was most marked in the case of visits to emergency departments and visits by appointment at hospitals, and least in the case of visits to private doctors and company/school physicians, while visits to doctors at health centres and to district nurses occupied an intermediate position. Thus, by including a simple question about perceived health in a questionnaire designed to measure use of health care services, important information about the relations between use of health services and health conditions could be obtained.

All general practitioners at three Swedish health centres continuously assessed their patients' degree of functional deficiency on a 1-5 scale over a period of 5 1/2 years. They also registered diagnoses and certain other medical measures. Around 85% were judged to be ill to some degree, but few were seriously ill. There were small differences in functional capacity between men and women of different ages: both benign, self-limiting complaints and severe illnesses could be associated with considerable problems, while many patients with severe diseases had little discomfort. There was also a considerable discrepancy between functional impairment and work capacity. Using a combination of functional assessment with routine registration of diagnoses seems to be a useful method of obtaining a modulated, distinct picture of the types of patient encountering the general practitioner. However, further development work within the field is needed.

In a study that covers ten years, a questionnaire about use of health care facilities and satisfaction with care was mailed out each autumn to 1/60 representative samples of the population in Sollentuna, a Swedish primary care district with three health centres. An open-ended question concerning "what is good and what is bad in the health service today" was used to measure the respondents' attitudes. The health centres attracted most comment and were considered on the whole to function better in terms of service and care than the hospitals. The latter were heavily criticized for long queues and poor availability. The continuity, however, was considered fairly poor in both the primary care and the hospitals. The few comments on private practitioners were almost without exception positive. The attributes of (all types of) care to which the respondents attached the greatest importance were closely connected with the orientation and objectives which have been stated internationally for primary care, viz. availability, continuity, quality/safety, primary responsibility, and co-ordination. Improvement of resources and reorganization in small health care teams at one of the three health centres prompted a significant increase of positive attitudes to primary care.

In a study that covers ten years, the panorama of diagnosis was studied at three health centres in a Swedish primary care district with the aid of an encounter form. Frequencies for the different diagnosis groups varied considerably. In the case of malignant tumours, diseases of the thyroid, other endocrine diseases, symptoms and check-up visits there were more than 3-fold differences in diagnosis frequencies between various years. The results for individual years, therefore, were not representative of diagnosis distribution in the long-term perspective. Both systematic changes and temporary fluctuations occurred during the period. There was no evident lowest common denominator for the six diagnosis groups that increased (benign tumours, diseases of the thyroid and symptoms) or decreased (urinary tract infections, other urogenital diseases and back complaints). Although frequencies for individual diagnosis groups varied sharply from year to year, the diagnosis panorama in its entirety did, however, not change decisively. Permanent district physicians took charge mainly of the chronically ill, while other doctors were more involved with acute illness. It can be concluded that with such a varied diagnosis panorama in primary care it is difficult, based on temporary statistics from individual health centres, to draw general conclusions about the composition of patients. Thus, reliable figures on diagnosis should probably be founded on continuous registration at each clinic rather than on data collected periodically from especially selected reference centres.

Forty-seven patients in psychogeriatric day centre were analysed regarding use of resources, costs and well-being. The level of well-being was based on interviews with staff and relatives and related to the economic outcome--a cost utility analysis. A 6 month period prior to day care was compared with the first 6 months in such care. The use of resources at home increased by 20% while the use of institutional care was reduced by 22%. Fifty-three percent of the patients improved in their well-being after participation in day care. When the cost of utility analysis was applied, the cost for a well-year was 4293 pounds.