Diabetes care in general practice

A recent (8 Aug) BMJ Article by Simon Griffin looked at a meta-analysis of trials of diabetes care in general practice.

Five trials identified included 1058 people with diabetes, receiving hospital outpatient follow up for their diabetes. Results were heterogeneous between trials.

In shared care schemes featuring more intensive support through a computerised prompting system for general practitioners and patients, there was no difference in mortality between care in hospital and care in general practice. Glycated haemoglobin tended to be lower in primary care and losses to follow up were significantly lower in primary care (odds ratio 0.37, 0.22 to 0.61).

However, schemes with less well developed support for family doctors were associated with adverse outcomes for patients including poorer follow up, worse glycaemic control, and greater mortality than in hospital care. Computerised central recall, with prompting for patients and their family doctors, can achieve standards of care as good as or better than hospital outpatient care, at least in the short term. The evidence supports provision of regular prompted recall and review of selected people with diabetes by willing general practitioners.

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Violence and mentally ill people

The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. The present government appears to use the threat of violence as a means of persuading society to give more resources to mentally ill people, but it does result in an increase in stigma.

A recent study by Steadman et al. (Arch Gen Psych) enrolled 1136 male and female adult patients with mental disorders in a study that monitored violence to others every 10 weeks during their first year after discharge from the hospital. A comparison group consisted of 519 people living in the neighbourhoods in which the patients resided after hospital discharge.

The study showed that for patients and controls without symptoms of substance abuse there was no significant difference between the prevalence of violence by patients and the prevalence of violence by others living in the same neighbourhoods.

Substance abuse symptoms significantly raised the rate of violence in both the patient and the comparison groups. A higher portion of patients than of others in their neighbourhoods reported symptoms of substance abuse.

Violence in both patient and comparison groups was most frequently targeted at family members and friends, and most often took place at home.

This study was based in the USA where substance abuse is more prevalent than in the UK.

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Cleft Lip and Palate Surgery

The clinical standards advisory group (CSAG) of the Department of Health has investigated 297 children aged 5 and 277 aged 12 who had all undergone cleft repair in Britain. They found that 40 percent had poor dental bite, less than a third had a good lip appearance at the age of 13 and under half could speak with normal intelligibility at that age.

The CSAG stated that of the 57 centres carrying out the operation, only six to eight provided good to excellent care and the overall results were five to 12 times poorer than in the six European centres examined. The key factor causing poor training and poor results was specialists doing one or two operations a year and competition between plastic and maxillo-facial surgeons.

The report found that not only are many surgeons continuing to perform operations they are not competent to do, but they are failing to keep adequate records or perform proper audit.

Only in the area of adveolar bone grafting is there enough information to compare the two specialties and the results are not pretty. Fifty percent of cases carried out by plastic surgeons failed compared to 32 percent done by maxillo-facial surgeons.

For the advice on your nearest specialist centre contact CLAPA, the Cleft Lip and Palate Association, on 0171 824 8110.

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Influenza vaccination in the elderly

Most of the deaths due to influenza occur among people aged over 60 years of age. It is in this group, and others with particular medical disorders (heart or lung disorders, diabetes, chronic renal insufficiency or chronic staphylococcal infections), that influenza vaccination is recommended. The question of how effective the vaccination policy is in elderly persons has been answered by a randomised controlled trial published recently in the Journal of the American Medical association.

People not known to belong to a high-risk group in 15 practices were asked whether they wished to take part in the study and just under 2,000 accepted. People were randomly allocated to active vaccine or control, which were given in double-blind conditions in November. The active vaccine consisted of two Beijing strains, a Singapore and a Panama strain.

Participants were serologically tested for increased antibody levels. The participants and their GPs also completed forms relating to any symptoms of influenza according to defined protocols.

In the vaccinated population the rate of influenza or influenza-like illness was half that in the vaccinated population compared with the population given a placebo vaccination.

Two cases of influenza are expected each winter in every 23 people aged over 60 years. One will be prevented by influenza vaccination. Preventing half the cases in elderly people is a very positive result.

Several studies have shown substantial savings in direct medical costs during successive influenza seasons among elderly people who had been vaccinated.

"Influenza vaccination works, it's inexpensive, and it saves money".

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National Small Clinical Effectiveness Projects

Ten sums of £2,000 are available for small projects which have a national all-Wales relevance

For further information. Tel: 01222 716841,

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Sildenafil (Viagra)

The editor has been asked to remove this section as not representing the views of the Directorates of Public Health and Patient Care