Health promotion in general practice

Liver cell models in in vitro toxicology

In vitro liver preparations are increasingly used for the study of hepatotoxicity of chemicals. In recent years their actual advantages and limitations have been better defined. The cell models, slices, and mainly primary hepatocyte cultures, appear to be the most powerful in vitro systems, as liver-specific functions and responsiveness to inducers are retained either for a few days or several weeks depending on culture conditions. Maintenance of phase I and phase II xenobiotic metabolizing enzyme activities allows various chemical investigations to be performed, including determination of kinetic parameters, metabolic profile, interspecies comparison, inhibition and induction effects, and drug-drug interactions. In vitro liver cell models also have various applications in toxicology: screening of cytotoxic and genotoxic compounds, evaluation of chemoprotective agents, and determination of characteristic liver lesions and associated biochemical mechanisms induced by toxic compounds. Extrapolation of the results to the in vivo situation remains a matter of debate. Presently, the most convincing applications of liver cell models are the studies on different aspects of metabolism and mechanisms of toxicity. For the future, there is a need for better culture conditions and differentiated hepatocyte cell lines to overcome the limited availability of human liver tissues. In addition, strategies for in vitro analysis of potentially toxic chemicals must be better defined.

Psychoneuroimmunology

This paper develops hypotheses regarding the interactions among stress, immunity, and chemical sensitivities and gives an overview of the questions and hypotheses generated by a working group exploring the application of psychoneuroimmunology to chemical sensitivities. Consideration is given to prospective longitudinal studies designed to find cases among at-risk exposed populations. Relevant immune parameters to be measured longitudinally and in challenge studies for patients with MCS are discussed. Immune system changes in response to the chronic stress of having MCS and as primary responses to chemical exposure also are considered.

Who should give lifestyle advice in general practice and what factors influence attendance at health promotion clinics? Survey of patients' views

BACKGROUND

Health promotion activity in general practice has increased greatly since 1990. A large proportion of this work is undertaken by practice nurses. Little is known about patients' views about the providers of health promotion or their views about general practice health promotion clinics.

AIM

A study was carried out in 1992 to determine patients' views about the provision of health promotion advice by general practitioners and practice nurses and their views about attending health promotion clinics.

METHOD

A postal questionnaire was sent to a random sample of 1750 patients aged 16 years and over from five general practices in south Tyneside. The questionnaire explored patients' preferences regarding health promotion advice from the general practitioner or practice nurse in relation to four areas of lifestyle advice and factors that might encourage patients to attend a health promotion clinic.

RESULTS

A response rate of 75% was obtained from 1639 eligible patients. Receiving health promotion advice from either the general practitioner or the practice nurse was the most commonly preferred option expressed by patients overall. The ability of health promotion clinic staff to deal with patients' concerns about their illness and short waiting times were more likely to influence patients' attendance at health promotion clinics than the presence of a general practitioner or practice nurse.

CONCLUSION

In the present study, many patients found health advice received from practice nurses and general practitioners equally acceptable. However, it was the ability of health professionals to respond to patients' health concerns in the health promotion clinic rather than the type of health professional running the clinic that was important for patients.

Provision of health promotion clinics in relation to population need: another example of the inverse care law?

The new contract encourages health promotion in general practice. The aim of this study was to explore the pattern of provision of health promotion clinics across one family health services authority and to relate this to possible indicators of health need in the practice population. Single-handed practices were less likely to be running health promotion clinics. The proportion of practices running clinics increased with increasing numbers of partners. Practices located in wards where the standardized mortality ratio was greater than 100, and practices receiving deprivation payments were less likely to be offering health promotion clinics. This was explained by the presence of most single-handed practitioners in deprived, historically unhealthy wards. If effective, health promotion clinics will have tended to benefit populations in Bedfordshire at lower risk of ill-health. Other shortcomings of the clinic-based health promotion model are discussed.

Twenty five years of case finding and audit in a socially deprived community

OBJECTIVE

To evaluate audit and case finding (whole population care) in a community over 25 years.

DESIGN

Contemporary screening for and audits of care of chronic disease and risk factors; retrospective review of computerised practice records; and comparisons of mortality and social indices with neighbouring communities.

SETTING

One general practice in Glyncorrwg, West Glamorgan.

SUBJECTS

1800 people registered with the practice in 1987 and 558 people who died from 1964 to 1987, whose records had been retained.

MAIN OUTCOME MEASURES

Detection of high blood pressure, smoking, airways obstruction, obesity, diabetes, and alcohol problems in adults aged 20-79; prevalence of smoking in this population and in hypertensive and diabetic groups; age standardised mortality ratios in relation to indices of social deprivation.

RESULTS

In the population aged 20-79 (1207 patients) 249 (21%) had peak expiratory flow rate less than 50% of expected value or which improved by 15% or more with an inhaled beta agonist, 207 (17%) had body mass index at or over 30 kg/m2, 118 (10%) had untreated mean arterial pressures greater than 159/104 mm Hg (three readings), 80 (7%) (65 (16%) men, 15 (4%) women) had recognised alcohol problems, and 35 (3%) had diabetes. The proportion of men aged 20-64 who said they smoked fell from 61% (290/476) in 1968-70 to 36% (162/456) in 1985 whereas that of women who smoked was unchanged (43%, 187/436 v 42%, 190/448 respectively). In 116 screened hypertensive patients group mean blood pressure fell from 186/110 mm Hg before treatment to 146/84 mm Hg at 1987 audit, as did the proportion of smokers (56% v 20%), but body mass index and total cholesterol concentration showed no significant change. In 34 diabetic patients mean blood pressure and the proportion of smokers fell (171/93 mm Hg v 155/81 mm Hg; 44% v 12%). The age standardised mortality ratio in 1981-6 was lower than in a neighbouring village without a developed case finding programme (actual to expected deaths less than 65 = 21 to 22 in Glyncorrwg, 48 to 30 in control village).

CONCLUSIONS

Whole population care through organised case finding and audit is feasible but only with a labour intensive approach combining accessibility, flexibility, and continuity, as well as a planned and structured approach, which requires substantial expansion of staff numbers and assiduous recording. It may reduce risks for at least some high risk groups. Despite their shortcomings the available data are consistent with the hypothesis that whole population care helps reduce mortality. Incentives in the new contract, which encourage the uncritical development of structured process, may diminish health outputs.