Search

Background: Hospitals experience winter surges in admissions due to respiratory infections. The roles of acute bronchitis and influenza-like illness (ILI) in the timing and severity of these surges are examined over the years 1990-91 to 2004-05., Methods: Respiratory admissions of persons aged > or =65 years in England and Wales were analysed in relation to patients with ILI or acute bronchitis diagnosed by community-based general practitioners from a sentinel surveillance network., Results: Acute bronchitis and ILI accounted for 46 and 7% of the variation in respiratory admissions, respectively: when admissions were lagged by 1 week, these estimates were 20 and 14%, respectively. Admissions peaked in weeks 52, 01 or 02 (late December to early January) in 14 of the 15 winters. Acute bronchitis peaked during weeks 01 or 02; ILI exhibited greater variability and peaks ranged from weeks 46 (mid-November) to 07 (mid-February). During winters where acute bronchitis and ILI peaked concurrently, surges on hospitals were most severe., Conclusions: During each winter acute bronchitis provides a consistent and major contribution to the winter admissions surge in the elderly. The variable incidence of ILI can increase the surge in admissions, especially when ILI and acute bronchitis peak together.

We compared the burden of illness due to a spectrum of respiratory diagnostic categories among persons presenting in a sentinel general practice network in England and Wales during periods of influenza and of respiratory syncytial virus (RSV) activity. During all periods of viral activity, incidence rates of influenza-like illness, bronchitis and common cold were elevated compared to those in baseline periods. Excess rates per 100,000 of acute bronchitis were greater in children aged <1 year (median difference 2702, 95% CI 929-4867) and in children aged 1-4 years (994, 95% CI 338-1747) during RSV active periods rather than influenza; estimates for the two viruses were similar in other age groups. Excess rates of influenza-like illness in all age groups were clearly associated with influenza virus activity. For common cold the estimates of median excess rates were significantly higher in RSV active periods for the age groups <1 year (3728, 95% CI 632-5867) and 5-14 years (339, 95% CI 59-768); estimates were similar in other age groups for the two viruses. The clinical burden of disease associated with RSV is as great if not greater than influenza in patients of all ages presenting to general practitioners.

Background: Impetigo is one of the commonest childhood skin infections. Insect bites are commonly implicated in the development of impetigo. There are, however, very few data available to describe the seasonal incidences and association between the two conditions., Objectives: To describe the seasonal incidence of impetigo in England and Wales and to investigate the reported association with insect bites., Methods: Clinical diagnoses of impetigo and insect bites were recorded from a sentinel GP network over the years 1999-2003., Results: The highest mean weekly rates of impetigo were in children aged 0-4 years (84 per 100 000) and in those aged 5-14 years (54 per 100 000). In contrast, the incidence of insect bite only varied between 3 and 5 per 100 000 for males and between 5 and 9 per 100 000 for females. The relative risk (RR) for females consulting over males with impetigo was similar in children [RR 0.99 (95% CI 0.96-1.02)] and adults [RR 1.20 (1.16-1.25)]; the RR of insect bite was similar in children [RR 1.21 (1.09-1.34)] but almost twice as likely in adults [RR 2.13 (2.02-2.25)]. Insect bite peaked almost coincidentally with temperature whereas there was a lag of one-to-two 4-week periods between impetigo and temperature., Conclusion: There is suggestion of some degree of association between impetigo and insect bites. The improved management of patients consulting with insect bites and better use of antiseptic treatments might provide the basis for reducing the incidence of impetigo in the community.

Background: Practice-based morbidity surveys inform on the prevalence of diseases presenting for health care. The last major survey in England and Wales was conducted in 1991., Aim: To reveal changes in disease prevalence between 1991 and 2001., Design of Study: Population-based analysis of persons presenting to GPs. Annual prevalence of diseases reported in the Weekly Returns Service (WRS) of the Royal College of General Practitioners in 2001 was compared with prevalence reported in Morbidity Statistics from General Practice, Fourth National Study (MSGP4)., Setting: Thirty-eight general practices contributing to the WRS, monitoring a population of 326,000 in 2001., Method: Prevalence was determined from Read codes for morbidity entered in the respective survey years. Diseases and disease groups were defined from Read codes mapping to the chapters, major sub-groups and 3-digit codes of the International Classification of Disease version 9 (ICD9). Age-standardised prevalence rates per 10,000 registered persons and 99% confidence intervals (CIs) were calculated using the national census population for 2001 as the standard. Survey differences in prevalence were identified from non-overlapping CIs., Results: There was a general reduction in the prevalence of disease caused by infection and an increase of degenerative disorders. The prevalence of mental disorders, skin disease and musculoskeletal disorders showed little change. Particular increases were noted for other malignant and benign neoplasms of the skin, hypothyroidism and diabetes. There were marked reductions for disorders of the conjunctiva, ear infections, acute myocardial infarction and heart failure, respiratory infections and injuries., Conclusions: The role of the GP continues to change. These results confirm the importance of the management of chronic diseases as the dominant (though not the sole) role of the GP. The results demonstrate the use of the WRS as a source of data on disease prevalence.

Aims: To estimate excess morbidity during periods of influenza and respiratory syncytial virus (RSV) activity., Methods: Retrospective analysis of a sentinel practice network database in active and non-active virus periods., Main Outcome Measures: clinical diagnoses of new episodes of influenza-like illness (ILI), acute bronchitis, asthma, and otitis media., Results: The clinical diagnosis of ILI was consistent with influenza virus activity and acute bronchitis with RSV. During periods of virus activity, estimates of excess morbidity in children aged 1-4 and 5-14 years diagnosed as having acute otitis media exceeded those diagnosed with each of the other three conditions; in children <1 year estimates for acute bronchitis were highest. Using a broad definition of virus activity and summarising the data for all children diagnosed with ILI, 60% was attributable to influenza (40% RSV) as were 37% of episodes diagnosed as acute bronchitis, 9% of those with asthma and 48% of those with otitis media. Using a narrow definition, corresponding proportions were: for ILI diagnoses 77% (23% RSV), acute bronchitis 32%, asthma zero, and otitis media 45%. Acute bronchitis was diagnosed twice as frequently in association with RSV as with influenza in all age groups: excess asthma episodes were only evident in RSV active periods., Conclusions: Except in relation to ILI, RSV caused more illness than the influenza virus in the respiratory diagnoses examined, emphasising the need for RSV prevention and treatment. Influenza was not associated with excess asthma episodes.

Study Objective: To quantify mortality attributable to influenza and respiratory syncytial virus (RSV) infection in children., Design and Methods: Comparison of death rates (all cause and certified respiratory) in England over winters 1989/90 to 1999/00 during and outside influenza and RSV circulation periods. Virus active weeks were defined from clinical and virological surveillance data. Excess deaths associated with weeks of either influenza or RSV activity over virus non-active weeks were estimated in each winter for age groups 1-12 months, 1-4, 5-9, and 10-14 years. The estimate obtained was allotted to influenza and RSV in the proportion derived from independent separate calculations for each virus., Main Results: Average winter respiratory deaths attributed to influenza in children 1 month-14 years were 22 and to RSV 28; and all cause deaths to influenza 78 and to RSV 79. All cause RSV attributed deaths in infants 1-12 months exceeded those for influenza every year except 1989/90; the average RSV and influenza attributed death rates were 8.4 and 6.7 per 100 000 population respectively. Corresponding rates for children 1-4 years were 0.9 and 0.8 and for older children all rates were 0.2 or less, except for an influenza rate of 0.4 in children 10-14 years., Conclusions: Influenza and RSV account for similar numbers of deaths in children. The impact varies by winter and between age groups and is considerably underestimated if analysis is restricted to respiratory certified deaths. Summing the impact over the 11 winters studied, compared with influenza RSV is associated with more deaths in infants less than 12 months, almost equal numbers in children 1-4 years, and fewer in older children. Improved information systems are needed to investigate paediatric deaths.

Accurate estimation of monitored populations is essential for epidemiological study. Many countries do not have systems of patient registration and routine disease surveillance is thereby hindered. We studied the incidence of shingles over time and investigated the hypothesis that the incidence is consistent and could be used as a proxy for estimating the monitored population. Annual incidence rates of shingles reported in the Weekly Returns Service (WRS) since 1970 and in the Dutch Sentinel Network (DSN) over the period 1998--2001 were studied. Gender specific annual rates (1998--2001) were compared after standardising for age. The population in the DSN was estimated by applying the WRS incidence rates to the numbers of DSN incident cases. The incidence of shingles was annually and seasonally consistent. Incidence in males was similar in both networks and in females approximately 18% greater in the WRS: in age groups 15-64 years, incidence was similar in both networks, but in children 0-14 years and in persons 65 years and over, it was higher in the WRS. The total populations in the DSN estimated from average age/gender specific rates in the WRS were within 12% of the observed in each of the 4 years surveyed. The incidence of shingles in the two countries was sufficiently close to estimate the surveyed population aged 15-64 years from knowledge of incident cases in the community. Routine monitoring of shingles in sentinel practice networks is commended as a method of assuring recording quality and as a means of estimating the survey population where the registered population is not known.

Background: There is good evidence of reduced prescribing of antibiotics in recent years, but the reason for this has not been established., Aim: To study the incidence of respiratory tract infections presenting to general practitioners (GPs) in England and Wales in relation to the incidence of other infections and to the prescription of antibiotics., Setting: Sentinel practices in England and Wales who contribute to the Weekly Returns Service (WRS) of the Royal College of General Practitioners., Design: Time-series analysis of disease incidence data reported by the practices and of antibiotic prescription data from the Prescription Pricing Authority (PPA) during the years 1994-2000., Method: Incidence data reported weekly from 73 practices in England and Wales, serving a population of 600,000, for acute respiratory tract infections, otitis media, infectious mononucleosis, shingles, urinary tract infections, and skin infections, were consolidated into quarterly datasets and examined graphically for evidence of secular and seasonal trends. Trends in antibiotic prescription items (data for England only were supplied by the PPA) were examined for association after adjustment for seasonal variation., Results: The incidence of respiratory tract infections and antibiotic prescribing showed virtually identical seasonal variation, with both declining from 1995: respiratory tract infections by 48% in winter and 38% in summer, and antibiotic prescriptions by 34% and 21%, respectively. Trends in both were very highly correlated. The incidence of shingles and skin infections was constant. The incidence of urinary tract infections declined by 10%. The incidence of otitis media in children and acute bronchitis in the elderly followed the all-age trend in the reduction of respiratory tract infections., Conclusion: The considerable reduction in the incidence of respiratory tract infections between 1995 and 2000 is the main reason for the decline in antibiotic prescribing rather than changing prescribing thresholds for antibiotics.

A vaccine is now available to prevent varicella-zoster infection, but its place in routine preventive care is not yet determined. The age specific incidence of shingles was examined separately by gender and age groups (15-24, 25-44, 45-64, 65-74 and 75 years and more) over the years 1994-2001. These incidence data were applied to national available data for the UK on current life expectancy to calculate the risk of shingles infections at varying ages. The potential benefit of an effective vaccine was estimated using three models of vaccine efficacy applied separately to males and females at ages 50, 60 and 65 years and assuming vaccination at a single age. Similar calculations were made using a two dose strategy at age 45 and 65 years and at age 50 and 70 years. The cost per case saved was estimated from a vaccination cost of pound 40 per dose. The probability of having had an attack of shingles before age 45 years is 8.6% for males and 10.5% for females, The risk of acquiring shingles over an expected lifetime (assuming no preventive vaccination) for males aged 45 years is 22% and for females 32%. Whichever vaccine efficacy model was chosen, a single vaccination policy at age 65 years was the most favourable option in both males and females. A two age vaccination policy was estimated to increase the cost per case saved by 30% over a single age policy but administration at age 50 and 70 years substantially increased the number of cases saved as compared with a single age policy and was potentially better than vaccination at 45 and 65 years.

Background: A study was undertaken to determine trends in the incidence of new episodes of asthma presented to general practitioners participating in the Weekly Returns Service of the Royal College of General Practitioners, comprising 92 practices with a registered population of approximately 680 000 persons well distributed throughout England and Wales. These practices monitor the morbidity presented at every consultation, distinguishing between new episodes of illness and ongoing consultations., Methods: Age specific weekly rates of new episodes of asthma (and of acute bronchitis) presenting to the general practitioners over the years 1989-98 were examined in four week blocks and analysed by multiple regression, separating secular from seasonal trends., Results: Quadratic trends in episodes of asthma were evident in each of the age groups with peaks in 1993/4. Corresponding analyses for acute bronchitis disclosed similar trends generally peaking in the winter of 1993/4. Mean weekly incidence data (all ages combined) decreased in all quarters since 1993. Regional analysis (North/Central/South) showed similar decreases., Conclusions: There has been a gradual decrease in the incidence of asthma episodes and of acute bronchitis presenting to general practitioners since 1993. The trend of an increase before 1993 followed by a decrease cannot be explained by changes in the patterns of health care usage or diagnostic preference of doctors.

Background: Seasonal variations in asthma are widely recognised. This study was undertaken to investigate the relative differences in seasonal patterns by age as they impact on episodes of care in general practice, hospital admissions, and deaths., Methods: General practice episode data from the Weekly Returns Service of the Royal College of General Practitioners, hospital admissions for asthma in England, and deaths registered as due to asthma in England and Wales over the years 1990-7 were examined. Age specific weekly rates of new episodes of asthma presenting to general practitioners, numbers of hospital admissions and deaths were analysed by the multiplicative decomposition method to separate secular from seasonal trends. The seasonal indices thereby obtained were plotted as three week moving averages., Results: In children aged 0-4 and 5-14 years general practice episodes and admissions to hospital were strikingly congruent in timing and in magnitude, except in September when particularly high rates of admission (absolute and relative to general practice episodes) occurred. In the 15-44 age group there were marked mid summer peaks of general practice episodes and deaths but admissions to hospital were at about the annual average; in September/October there were peaks of episodes and admissions whereas deaths peaked in November. In the 45-64 age group a peak in general practice episodes of asthma was evident in mid summer when admissions were about average and deaths were at a minimum; all three measures tended to increase gradually with the approach of winter. Finally, in those age over 65 years, general practice episodes of asthma, admissions to hospital, and deaths followed similar 'U' shaped patterns with substantial peaks in mid winter., Conclusions: The seasonal pattern of asthma evolves with age. There are important differences in the seasonal pattern of general practice episodes, admissions to hospital, and deaths. Individual seasonal histories are important for the management of asthma. The combined analysis of these three data sets provides a new perspective on the epidemiology of asthma.

Background: A prospective cohort analysis of mortality, among entrants to a population-based psychiatric case register, was undertaken to identify specific causes of death responsible for the increased risk of mortality previously reported in this large group of unselected patients., Methods: The analysis was based on a study population of 16,871 cases, aged 15-89 years, from Worcester and Kidderminster Health Districts, entering the case register between 1974 and 1984 and generating a total of 85,073 patient-years (PYR) of observation. The underlying cause of death was coded to the relevant revision of the International Classification of Diseases (ICD). Numbers of deaths observed in the study population were compared with the number of deaths expected on the basis of mortality rates for England and Wales. Comparisons were made for eight main causes of death, aggregated at Chapter level of the ICD, and 11 categories of psychiatric diagnoses. Two indices of mortality were used for evaluation: relative risk (RR) = observed deaths/expected deaths; and excess mortality rate (EMR) = (observed-expected deaths)/PYR., Results: RRs were significantly raised for accidents, including suicides, as anticipated, and for various main causes of death. The increased risk of accidental death was found across the majority of the 11 psychiatric diagnostic groups although the EMRs were low at less than 5/1000 PYR. Deaths from respiratory disorders gave rise to the highest RRs after accidental deaths, and were responsible for substantial excess mortality among in-patients and patients with psychotic illnesses (especially dementia). The largest numbers of deaths of both sexes were due to diseases of the circulatory system, with a 40 per cent excess of observed over expected values in the whole series. The excess was due mainly to deaths of in-patients and of patients with psychotic diagnoses. No excess of deaths owing to neoplasms was found for either in-patients or out-patient groups., Conclusions: The findings that psychiatric illness is associated with an increased risk of death from "natural' causes and that the level of risk was related to the severity and to the diagnostic category of the illness have implications for patterns of care and use of resources.

Study Objective: The study aimed to examine the concurrence in the variation of monthly numbers of deaths in summer and winter from the four main underlying causes - respiratory, circulatory, neoplastic, and all others - in four countries. In particular, the hypothesis that most non-respiratory concurrent deaths are miscoded respiratory deaths and that a large proportion of the winter mortality currently attributed to circulatory disorders should be attributed to respiratory causes was considered., Design: Mortality data were analysed graphically in relation to cause. Each of the four series of monthly data underwent time series analysis to remove auto-correlation, seasonality, and secular trends. Associations between paired causes of death and between multiple series (using Kendall's coefficient of concordance) were then examined after modelling., Setting: Monthly deaths (65 years and over) related to underlying cause were examined for England and Wales (nine years), The Netherlands (nine years), Denmark (10 years), and Portugal (10 years - all ages). Weekly data for England and Wales (51 weeks) were also analysed., Main Results: All combinations of monthly deaths related to underlying cause were strongly associated in all four countries. This concurrence was evident down to the lowest monthly values so that all seasonally related deaths above the minimum monthly value can be used as an estimate of the "concurrent" proportion. Associations involving deaths from neoplasm were weakest. Concurrence was evident even on a weekly analysis (England and Wales). Concurrent deaths in England and Wales accounted for 31.1% of respiratory, 16.0% of circulatory, 3.5% of neoplastic, 14.1% of deaths from other causes and 14.2% for all deaths combined. The equivalent percentages for concurrent deaths from all causes were 8.4% in the Netherlands, 9.3% in Denmark, and 16.8% in Portugal., Conclusions: Concurrence, which was present in each of the underlying causal groups in each of the four national data sets examined, suggests a common cause separate from the underlying cause that has been used in the presentation of mortality statistics. If the person concerned had not died at that time, as a result of this cause, he would not have died from the recorded underlying cause. Most of these non-respiratory concurrent deaths are miscoded. As a consequence, a large proportion of winter mortality currently attributed to circulatory disorders should be attributed to other causes, probably respiratory. More intensive research into the contribution made by acute respiratory diseases is proposed. The proportion of concurrent deaths varied in the four countries thereby limiting the validity of simple comparisons of national mortality statistics.

The possible relationship between the incidence of respiratory diseases as reported to general practitioners and numbers of registered deaths in England and Wales has been examined. Morbidity data from sentinel practices for the period 1986-1990 (population covered increased from 220,000 to 470,000) were used to calculate weekly rates of aggregated respiratory disease for persons of all ages and for elderly persons (aged 65 years and over). The elderly respiratory disease rates and numbers of deaths were aggregated into 4-week periods; secular and seasonal trends were removed from each series and the two sets of residuals were examined graphically and cross correlation coefficients calculated. There was a very strong positive association between the respiratory disease rate and number of deaths in the same 4-week period and there was also a significant but less pronounced association between respiratory disease in one 4-week period and deaths in the next. After prior separation of weeks according to temperature into four bands, weekly rates for respiratory disease were also strongly associated with the number of weekly deaths for each temperature band. The synchronisation of peaks and troughs in the two series throughout the year supports the hypothesis that a cause and effect relationship exists between respiratory disease in the elderly and number of deaths. Other climatic and meteorological variables besides temperature may play a part in determining the spread of a respiratory disease. There is a for further research to identify the micro-organisms responsible for acute respiratory infections in the elderly.

Examination of thyroxine usage in a study in the United States of America revealed that many patients were prescribed thyroxine for non-thyroid indications, such as obesity and fatigue. Many of those receiving thyroxine had high or low serum thyroid stimulating hormone levels, indicating prescription of incorrect doses or lack of patient compliance with therapy. Long term thyroxine therapy may have effects upon the risk of osteoporosis. The aims of this study were to investigate indications for thyroxine prescription in the United Kingdom and to examine the frequency of abnormal serum thyroid stimulating hormone concentrations in those prescribed thyroxine for hypothyroidism. This was in order to determine the relevance of measurement of thyroid stimulating hormone level in monitoring thyroxine therapy. Subjects receiving thyroxine were identified from the computerized prescribing records of four general practices in the West Midlands. Of 18,944 patients registered, 146 (0.8%) were being prescribed thyroxine; 134 of these had primary hypothyroidism and the remainder had other thyroid or pituitary diseases prior to treatment. Of the 97 patients with primary hypothyroidism who agreed to have their thyroid stimulating hormone level measured, abnormal serum levels were found in 48%, high levels in 27% and low levels in 21%. There was a significant relationship between prescribed thyroxine dose and median serum thyroid stimulating hormone level: high hormone levels were found in 47% of those prescribed less than 100 micrograms thyroxine per day, while low levels were found in 24% of those prescribed 100 micrograms or more. Thus, thyroxine prescription was common in the four practices sampled, although indications for its use were appropriate.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: We determined the effect of subclinical hyperthyroidism (defined as low circulating TSH with normal serum free T4) and subclinical hypothyroidism (raised serum TSH with normal free T4) on fasting levels of blood lipids., Design: Prospective study of lipid concentrations in patients identified as having abnormal TSH., Patients: Patients were identified in a population screening study of those over 60 years, with persistently low TSH with normal free T4 (n = 27) or high TSH but normal free T4 (n = 57). Patients were matched to controls with normal serum TSH by age, sex and body mass index., Measurements: Serum TSH, free T4, free T3, total cholesterol, low density lipoprotein (LDL) cholesterol and high density lipoprotein (HDL) cholesterol., Results: Serum free T4 measurements were significantly higher in those with subclinical hyperthyroidism than in their controls (P < 0.001) and lower in those with subclinical hypothyroidism than in matched controls (P < 0.001). Measurement of fasting lipids in patients and controls revealed a marked (12.2%) reduction in serum total cholesterol in subclinical hyperthyroidism (P < 0.01); no significant difference in fasting lipids between patients with subclinical hypothyroidism and controls was observed., Conclusions: Differences in free T4 between those with low or high TSH and controls with normal TSH suggest that abnormalities of TSH directly reflect thyroid hormone excess and deficiency. A reduction in cholesterol in those with subclinical hyperthyroidism suggests a direct influence of thyroid hormone excess on lipid metabolism in these patients.

Study Objective: The aim was to examine the scale, source, and relevance of variation between general practices in respect of the rates with which patients consulted with illnesses falling in each of several diagnostic groups., Design: This study involved a general practice morbidity survey conducted over two years, 1970-72. All patients who consulted their general practitioners were identified and the number of these who consulted with diagnoses attributable to each of the 18 main chapters of the International classification of diseases were counted. Patients who consulted for more than one diagnosis within a chapter were counted once only; those who consulted for one or more diagnoses in each of several chapters were counted once for each chapter., Setting: This was a national survey involving general practitioners in England and Wales., Subjects: The study involved 214,524 patients from 53 selected general practices (115 doctors) who were registered with their general practitioners for the whole of the year 1970-71 and for whom their morbidity data had been linked with their social data from the 1971 census., Measurements and Main Results: Using the numbers of patients on the practice lists as denominators, practice patient consulting rates (PPCR) were calculated for each practice and for each ICD chapter. Variability in chapter PPCR was examined by calculating coefficients of variation and, after allowance for random variation, coefficients of residual variation. There were large interpractice (doctor) variations in all chapter rates. These variations were only marginally attributable to: chance; different age, sex and social class mixes of practice populations; geographical locations; and practice organisation. The rates were, however, consistent from one year to the next for any one practice. Approximately half of the interpractice (doctor) diagnostic variability was associated with overall patient consulting behaviour. When the effects of this behaviour were discounted, any major residual diagnostic variability was confined largely to ICD chapters I-V, XVI, and XVII, ie, those chapters where aetiology forms the basis of classification., Conclusion: Variations in recorded diagnostic rates are mainly due to the consistent but idiosyncratic and selective exclusion by practitioners of some components from the total set which often coexist in a new diagnosis. Because of the scale of interpractice diagnostic variability, the use of algorithms and information technology is largely precluded from outcome studies, auditing procedures, and studies of practice work loads in general. However, (1) the consistency of any individual doctor's pattern of diagnostic recording from one year to another permits studies of trends; and (2) given a reasonable number of recording practices, the population mean practice consulting rates can be estimated with sufficient accuracy for many epidemiological research and administrative uses.

General practitioners are increasingly expected to screen elderly patients for common disorders, such as hypothyroidism, and the identification of at-risk patients by simple means would reduce the financial and other costs of such screening. A general practice based study of 1193 patients aged 60 years and over has been carried out to investigate the usefulness of the following factors in identifying those in whom biochemical testing for hypothyroidism would be indicated: personal history or family history of thyroid disease, symptoms of thyroid disease and body mass index. Of the 190 patients with either a personal or family history of thyroid disease, 28 (14.7%) had an elevated concentration of thyroid-stimulating hormone. Thus, 66 of the 94 patients (70.2%) with elevated concentrations of thyroid-stimulating hormone had no such thyroid history. Similarly, only nine (4.7%) of the patients with a personal or family history of thyroid disease required thyroxine replacement therapy. Thus, 22 of the 31 patients (71.0%) requiring such treatment had no such history. Discriminant analysis of the responses of women patients to questions concerning personal or family history of thyroid disease, the presence of symptoms of hypothyroidism, their age and body mass index identified only 51.3% of those with an elevated thyroid-stimulating hormone concentration and 77.2% of those with normal thyroid-stimulating hormone. Analysis of the responses of the men patients was even less discriminating.(ABSTRACT TRUNCATED AT 250 WORDS)

The primary aim of the study was to evaluate practice differences in reported morbidity in the second and third national morbidity surveys (1970/71, 1981/82) and to discuss their cause. A secondary aim concerned the validation of trends identified from analysis of the data from the total populations in the practices. Altogether 19 practices participated in both surveys. Annual prevalences (that is, the number of patients attending the general practitioner with a condition per 1000 persons at risk) were examined for: all conditions; each of three categories of seriousness of disease; diseases aggregated by chapter of the International classification of diseases; and each of 130 rubrics of the disease classification. Annual prevalence for 'all conditions' was approximately the same for males in both surveys, whereas for females there was an increase. In both sexes, annual prevalence for 'serious conditions' increased slightly and for 'trivial conditions' increased substantially. For 'intermediate conditions', there was a modest decrease in males. In the analysis at ICD chapter level, substantial increases in prevalence occurred in infectious diseases, nervous system diseases, circulatory diseases, genitourinary diseases, musculoskeletal diseases, symptoms, signs and ill-defined conditions, injuries and poisonings. Decreases were found in blood diseases, mental disorders and digestive diseases. Among 130 individual conditions examined, increased annual prevalence was found for mumps, fungal infections, hypothyroidism, diabetes, gout, senile dementia, angina, left heart failure, catarrh, hay fever and asthma, orchitis, acne, osteoarthritis and for some symptoms. Decreases were found for iron deficiency anaemia, anxiety state, refractive errors, haemorrhoids, chronic bronchitis, functional disorders of the stomach, carbuncle and skin infections.(ABSTRACT TRUNCATED AT 250 WORDS)

Study Objective: The aim was to examine disease concurrence, using diabetes mellitus as an ullustrative example., Design: The study involved a general practice morbidity survey, conducted over 12 months in 1981-82. All patients who consulted their general practitioners with a diagnosis of diabetes mellitus (type 1 or type 2) were identified and the number of these who consulted with additional morbidities were counted for each rubric of the Royal College of General Practitioners' modification of the International Classification of Disease. These observed numbers were then compared with expected numbers calculated from the total non-diabetic population after standardisation by age. Standardised person consulting ratios (SPCR) were derived and the 99% confidence intervals (CI) surrounding these values calculated., Setting: This was a national survey involving the whole of England and Wales., Patients: The study involved 280,000 patients from selected general practices, of whom 953 males and 1035 females consulted their general practitioners with diabetes., Measurements and Main Results: In an examination of 80 disease rubrics in the diabetic population in which there were at least 20 observed or expected cases, there were 34 among males and 28 among females in which there were increased values of the SPCR, and none in which the SPCR was decreased. SPCRs were high for infections generally (bacterial, fungal, and viral) and particularly so for cardiovascular disorders and for hypothyroidism in males. Though SPCRs for upper respiratory infections were increased, those for asthma and hay fever were not. SPCRs for neoplasms as a group were not raised., Conclusion: By confirming other work and widely held clinical opinion, this study has shown the potential of this data base for the examination of disease concurrence.

Increasing use of assays for TSH with improved sensitivity as a first-line test of thyroid function has raised questions regarding prevalence and clinical significance of abnormal results, especially values below normal. We have assessed the thyroid status of 1210 patients aged over 60 registered with a single general practice by measurement of serum TSH using a sensitive assay. High TSH values were more common in females (11.6%) than males (2.9%). TSH values below normal were present in 6.3% of females and 5.5% of males, with values below the limit of detection of the assay present in 1.5% of females and 1.4% of males. Anti-thyroid antibodies were found in 60% of those with high TSH but only 5.6% of those with subnormal TSH. Eighteen patients were hypothyroid (high TSH, low free thyroxine) and one thyrotoxic (low TSH, raised free thyroxine) at initial testing. Seventy-three patients with elevated TSH but normal free T4 were followed for 12 months; 13 (17.8%) developed low free T4 levels and commenced thyroxine, TSH returned to normal in four (5.5%) and 56 (76.7%) continued to have high TSH values. Sixty-six patients with TSH results below normal were followed. Of the 50 subjects with low but detectable TSH at initial testing, 38 (76%) returned to normal at 12 months; of those 16 with undetectable TSH followed, 14 (87.5%) remained low at 12 months. Only one subject (who had an undetectable TSH) developed thyrotoxicosis. In view of the marked prevalence of thyroid dysfunction in the elderly, we suggest that screening of all patients over 60 should be considered.(ABSTRACT TRUNCATED AT 250 WORDS)

This paper reports on the surveillance of influenza by the weekly returns service of the Royal College of General Practitioners during the epidemic of November/December 1989. An epidemic of influenza became evident in mid-November and incidence peaked in the week beginning 6 December. The increase in incidence of influenza-like illness and of aggregated data for all respiratory disease to above the levels for non-epidemic years occurred one week before that attributed to influenza. The pattern of incidence was similar in the three geographic regions of England and Wales. The peak was first achieved in the age group 5-14 years and last in age 65+ years. The pattern of deaths from all causes closely followed the pattern of respiratory disease with an interval of between one and two weeks. During the period 15 November to the end of the year there were approximately twice as many people reporting respiratory disease than was usual for this time of year. The peak weekly incidence was the highest recorded for 12 years but it was substantially less than the peaks for the winters of 1969/70, 1972/73 and 1975/76. Further research is in progress to establish the most effective means of monitoring influenza epidemics.

Thirty-two adult females who consulted a general practitioner with psychiatric training were assessed by questionnaires on first attendance and at follow-up 6 months later. Major life events and the degree of social support were of importance. Failure to improve was associated with major negative life events; in the absence of such events, improvement seemed likely to occur given a high degree of social support; major positive events appeared to be associated with improvement, regardless of the degree of social interaction. These factors, and the initial and final GHQ scores, are inter-related in a complex manner and it is suggested that these findings merit further investigation on a larger sample of patients.

Twenty eight practices carried out a review of patient records for information about preventive procedures on two occasions in 1980 and 1982. We have now undertaken a survey of certain characteristics of the practices in an attempt to demonstrate features associated with effective preventive care. Significant favourable factors are a small list size, the setting up of a formal screening programme for cervical cytology and measuring blood pressure, and few registered patients in social classes IV and V. More successful practices also tend to be training practices, have principals with higher qualifications, and have developed good records organization. Opportunistic screening for cervical cytology and measuring blood pressure was not shown to be more effective than no policy of screening at all.

This study was based on the recording of psychotropic drug prescribing over two weeks by 269 doctors using practice activity analysis (PAA) data sheets. The overall mean rates for patients receiving one or more psychotropic drugs were 17.5 per 1,000 list size and 130 per 1,000 consultations; and for prescriptions issued the rates were 20.6 per 1,000 list size and 153 per 1,000 consultations. Recorders were classified into five categories ;low' to ;high', by the volume of prescribing and this paper is concerned with the comparison between them. Between the high and low categories there was a twofold difference in the prescribing of new prescriptions, a fourfold difference for continuing prescriptions and a tenfold difference for repeat prescriptions; 51 per cent of all prescriptions were issued as ;repeats'.Other features of prescribing have been studied in each of the categories. Prescribing rates vary little with workload. Increasing trends are evident from the low to high categories for the use of polytherapy and for the proportion of elderly persons who received prescriptions; the proportion of male patients (28 per cent) was consistent in all categories. The relative proportion of prescriptions by drug group (tranquillizers, antidepressants and hypnotics) was reasonably uniform in all categories.

Systematic screening of death certificates referable to residents of two health districts covered by a psychiatric case register allows the study of excess mortality in unselected psychiatric patients from a defined area of known population. Deaths among the case register patients exceeded those expected by 80%; the relative risk was maximal during the first year after registration and was significantly raised in both sexes and in patients of all age-groups. Patients may be selected by service use and by diagnostic group: the excess mortality of "inpatients" both in relative and absolute terms exceeded that of "outpatients". For dementia patients both the relative risk and more notably the absolute risk was high, and the excess mortality was significantly raised in both sexes and all age-groups. It was again greatest during the first year after registration. Deaths of patients with schizophrenia and paranoid psychosis exceeded those expected by 40 per cent and the excess was limited to the first year after registration and occurred predominantly among men.

The efficacy of a Gamgee-lined hat in reducing the rate of fall in rectal temperature of infants during the first 30 minutes of life was studied. The trial, which included 211 infants, was randomised, prospective, and controlled. One hundred and seven infants were exposed to overhead radiantheaters. Of these, only 30 had normal deliveries, so the analysis was confined to the infants who were not subjected to radiant heat, and in this group no conclusions were drawn about the efficacy of a hat or a radiant heater. In the 104 infants not subjected to radiant heat, body weight, initial rectal temperature, the application of hat, the environmental temperature, and the duration of exposure while naked were all found to influence measureably the rate of fall in rectal temperature during the first 30 minutes. Gamgee-lined hats should be routinely used to minimise heat loss, especially in small infants exposed at birth, during surgical operations, and during investigations necessitating prolonged exposure.

As an introduction to a prospective study on the complex non-invasive estimation of pulmonary arterial pressure, the mortality experience of 834 patients with chronic respiratory disease was analysed historically. In patients with chronic obstructive lung disease, chronic fibrosing alveolitis and pulmonary tuberculosis, the relationships between mortality and values of ten physiological variables were examined. The most important variable as regards mortality in chronic obstructive lung disease was FEV1.0; after controlling for FEV1.0, pulmonary arterial pressure, arterial oxygen and carbon dioxide pressures were all strongly related to mortality. By contrast, in fibrosing alveolitis, values of FEV1.0 had little relation to mortality, and pulmonary arterial pressure was the most important variable, followed by FVC and FEV/VC. In patients with tuberculosis, arterial oxygen and pulmonary arterial pressure had the strongest relationship with mortality. Pulmonary arterial pressure was therefore strongly related to mortality in all three conditions; FEV1.0 had its highest predictive power in chronic obstructive lung disease and arterial oxygen saturation in tuberculosis. In chronic obstructive lung disease, pulmonary arterial pressure had a stronger influence in relation to mortality of younger than of older patients.