Resource needs of an occupational health service to accommodate a hepatitis B vaccination programme.

The administrative, organizational and clinical commitment of an occupational health department to implement the DHSS recommendation for a hepatitis B vaccination programme for the health care workers in a District General Hospital was reviewed to evaluate the resource implications needed to accommodate the additional workload. The deficiencies observed in the existing DHSS guidance in implementing the plan are described. It is suggested that the Department of Health, while making future recommendations for vaccination, should be more precise in identifying those at risk, in describing the desired titre to be achieved after vaccination, and in describing the follow-up plan for those who accept the vaccination, those who refuse and those who do not seroconvert. The recommendation should describe the commitment of the Health Authorities and must include recommendations for appropriate and adequate resources to support such a programme. Vaccination for 1000 employees at risk required 4000 additional consultations necessitating 16 additional hours of occupational health commitment per week. Eighteen months after initiating the vaccination programme, 677 employees had accepted the vaccine. After receiving 3 vaccines 508 (75 per cent) recipients had protective seroconversion (anti-Hbs greater than 100 I.U.) and a further 61 (9 per cent) converted after the 4th injection, thereby offering protective immunity to 84 per cent of the recipients. During the period 84 (12.4 per cent) were lost to follow-up. Recommendations have been made to accommodate the additional commitment through the vaccination programme to standardize our care and prevent disruption of the existing service.

Occupational hazard in hospital staff exposed to 2 per cent glutaraldehyde in an endoscopy unit.

The occupational hazards associated with exposure to 2 per cent glutaraldehyde have been assessed in medical and nursing staff working in an endoscopy unit. Eight of the nine staff were affected and the clinical manifestations included watering of eyes, rhinitis, dermatitis, respiratory difficulties, nausea and headache. The atmospheric concentrations of glutaraldehyde were assessed and the effect on clinical manifestations is discussed. Glutaraldehyde is an irritant and sensitiser. Guidelines for those exposed to the compound are discussed to prevent, monitor and manage any health hazard.

Prevalence of depression in general practice patients over 75 years of age.

The prevalence of depression among 74 male and 211 female patients aged 75 years or over registered with a group general practice was assessed, using the geriatric depression scale. Test scores of 0- 10, suggesting no depressive illness, were observed in 63 (85%) men and 172 (82%) women. Mild depression (scores 11-20) was observed in 10 (14%) men and 36(17%) women and severe depression (scores 21-30) in one (1%) man and three (1%) women. No significant statistical association was found with age or sex, suggesting that elderly men and women are equally prone to depression.A general practitioner found clinical manifestations of depression in 29 of the patients (10%). The geriatric depression scale scores were compared with clinical diagnoses of depression. Those with high scores were more likely to be depressed and vice versa. Thirty two elderly patients (11%) with no clinical manifestation of depression recorded high scores on the geriatric depression scale. These patients may be described as ;psychiatric cases'. Uncertainty about the importance of early identification of these cases necessitates further screening and regular follow-up of elderly patients.

Minimum data set necessary to promote the care of the elderly in general practice.

A preliminary data set was designed to allow uniform information collection, to initiate structured intervention and thereby to promote anticipatory care of the elderly. A questionnaire inviting comment on the data set was sent to 116 general practitioners in training practices and 40 consultants in geriatric medicine in the northern region and also to the 18 professors in general practice in the United Kingdom. The response rates from the three groups were 76%, 55% and 67% respectively.There was good agreement between the three groups regarding the content of the data set suggesting that it may be possible to introduce uniform information collection which in turn would standardize records of the elderly and aid computerization.The need for periodic screening of the elderly was considered necessary by 37% of general practitioners, 59% of consultants and 33% of professors. The cause of such low interest in screening and its effect on computerized care and surveillance of the elderly are discussed.

Evaluation of the mental function of the elderly in a general practice.

A mental function test was carried out on 378 individuals over 70 years of age registered with a group practice in the city of Newcastle upon Tyne. A high score (11 or over) was observed in 64.9% of women and 78.3% of men; a medium score (between three and 10) was observed in 34.0% of women and 20.8% of men; and only 0.8% of individuals of both sexes were found to have a low score (less than three). It was found that older age groups of both sexes had lower scores than younger groups (P < 0.001) and this was more pronounced in women than men (P < 0.05).These observations are significantly different (P < 0.001) from those obtained in hospital studies. The need for surveillance which influences mortality, morbidity and resource allocation is discussed.

The future of general practice in Newcastle upon Tyne.

A plan is presented for the future of general practice in Newcastle upon Tyne, in which general practices rather than individual practitioners would be responsible for providing a package of guaranteed minimum services. The services would include, at least, 24 h care of acute illness, continuity of care, management of specified chronic conditions according to agreed protocols, and certain preventive programmes. A computerised reporting system linked to computerised patient registration would enable targets to be set for the preventive programmes. Such an approach to primary health care follows the philosophy of Health for All, and could form the basis of a new general practitioner contract. Appropriate government funding in the future might be assured if general practice could demonstrate its ability to deliver a cost-effective service.

Role of the occupational health service in screening and increasing the uptake of rubella immunisation.

An occupational health department in a district general hospital in Newcastle upon Tyne screened 487 women of childbearing age for rubella immunity who were prospective employees and whose immunity state was unknown. Ninety per cent of these women were immune. Of the 51 who were found to be susceptible, 29 accepted vaccination.

Evaluation of quality of contents of general practice records.

The quality of contents of general practice records was assessed by retrieving clinical information pertaining to hypertension in 171 consecutive records, and the quality of communication storage was assessed by seeking evidence of tuberculin skin tests or BCG vaccination, or both, in 298 consecutive records. There was no mention of urine analysis and blood test results in 43.3% and no record of fundal examination in 61.4% of the records of patients with hypertension. Electrocardiography was performed in 67.8% and chest x ray examination was done in 65.5% of these patients. These observations have importance for patient care, education, and research. The information regarding tuberculin skin test or BCG immunization, or both, was not available in 78% of the records. Reassessment of the individuals, however, showed that 89% of the studied population had had the test or vaccination, or both. There was thus a deficiency in communication and storage.

Death certification in general practice: review of records.

The records of death that had been certified by general practitioners in one practice over 18 years were assessed in the light of the recent joint publications of the Royal College of Physicians and the Royal College of Pathologists. Over this period roughly 30% of the deaths in the practice population occurred outside hospital and a total of 262 certificates were issued. A review of 262 counterfoils of records of death certification showed that 12 counterfoils (4.6%) had no age and sex mentioned, and three counterfoils did not describe the place of death. The average age at death outside hospital was 71.6 years--the age of women being 75.1 years compared with that of men of 68.2 years. Only 2% of patients had had a necropsy. The common causes of death stated in the certificates were: cardiovascular 41%, carcinoma 35%, respiratory 15%, and stroke 8%. All contributory causes are also mentioned. Ninety seven per cent of the patients were seen after death by the doctors in the practice and 68% had been seen in the two days preceding death. We emphasise the importance of keeping accurate records of deaths in general practice for audit and research as well as for planning services for terminally ill and recently bereaved patients.

The importance of tuberculin retesting in the adult community at risk.

Tuberculosis immunization status was assessed in 2,501 individuals seeking employment in a district general hospital between January 1979 and December 1981. For 587 (23 per cent) of the employment seekers there was no evidence of BCG vaccination and nor were any of them aware of having had a tuberculin skin test at school. Tuberculin skin tests (Heaf's test) on these 587 individuals showed no reaction in 163 (28 per cent) and a strong (grade 4) reaction in 50 individuals. Only five of the individuals with grade 4 reaction to Heaf's test needed chemotherapy. During the same period, 43 patients with tuberculosis were in contact with 1,568 members of the hospitals's staff.The management of occupational contact is described and the need to rescreen the population at risk is discussed.

The effect of hypotensive drugs on the quality of life.

Quality of life after antihypertensive therapy was assessed in 75 patients with controlled hypertension using questionnaires given to patients, close companions and doctors. The overall assessments of the three groups differed significantly.The questionnaire completed by relatives rated 19 patients (25 per cent) to have suffered mild adverse changes, 33 patients (45 per cent) to have had moderate adverse changes and 22 patients (30 per cent) severe adverse changes. The deteriorations were attributed to undue pre-occupation with sickness, decline in energy, general activity and sexual activity, and irritability. The implications of the therapeutic regimes are discussed. The value of such an assessment in social readjustment and occupational rehabilitation is suggested.

The medical management of renal artery stenosis in transplant recipients.

The investigation, management and clinical course of 12 patients developing stenosis of the renal artery following transplantation are described. The possible aetiology of the three arteriographic patterns of stenosis is discussed. Surgical correction of graft arterial stenosis is difficult and may lead to graft loss, whereas the outcome with antihypertensive drug treatment with or without anticoagulants is good. Surgery should only be contemplated if medical treatment is failing or if renal function is deteriorating.

Plasma renin activity following renal transplantation.

Plasma renin activity (PRA) was studied serially for up to 21 days following transplantation in thirteen patients receiving renal allografts. PRA was measured during fasting and recumvency and its relationship to renal function, diuretic administration, plasma sodium, allograft rejection and blood pressure was examined. PRA fell steadily as renal function improved and plasma sodium rose following transplantation and when rejection episodes were excluded an inverse relationship between PRA and renal function could be seen. It is not possible to say whether the changes in PRA and function are causally related or whether changes in plasma sodium alone account for the observed changes in PRA. Some rejection episodes were accompanied by an increase in PRA, but this was not sufficiently consistent to be of value in the diagnosis of rejection. PRA also increased in relation to frusemide-induced fluid loss. There was no relationship in these patients between PRA and blood pressure.

Practolol-induced autoantibodies and their relation to oculo-cutaneous complications.

Tissue auto-antibodies were investigated in fifty-one patients (twenty-five female, twenty-six male) receiving practolol for ischaemic heart disease or dysrhythmias and compared with those found in 204 patients (fifty-eight female, 146 male) with ischaemic heart disease who did not receive practolol. Antinuclear factor (ANF) was found in 24% female and 16% male patients receiving practolol, but only in 5% of female and 4% of male patients who were not taking practolol. Thyroid cytoplasmic antibody (TCA) was detected in 16% female and 20% of male patients receiving practolol, compared to 10% of females and 6% of males in the control group. The incidence of ANF and TCA was significantly higher (P less than 0-05) in patients receiving practolol compared to the control group. The occurrence of gastric parietal cell antibody (PCA) and smooth muscle antibody (SMA) was not associated with practolol therapy (odds ratio of 2-4 and 1-9 respectively). The incidence of skin and eye complications was found to be 10% and the female to male ratio of this complication was 4 : 1. The correlation between autoantibody production and oculo-cutaneous complications could not be established in such a small group but three of the patients with the complications were found to have PCA, although PCA was found not to be associated with practolol therapy. Four of the five patients with the complications did not have circulating ANF.