Maximizing the contribution doctors make to NHS management.

Management is an increasingly important issue for many doctors. If doctors wish to influence resource allocation, they must involve themselves in health service management. This article describes the results of an enquiry action learning project involving six doctors.

Antihypertensive therapy in the prevention of stroke: what, when and for whom?

It is clear that antihypertensive regimens based on a low dose thiazide diuretic are effective for the primary prevention of stroke, particularly in older patients. In patients with diabetes mellitus who are at a higher risk of stroke, low dose thiazide diuretics and ACE inhibitors are of benefit. In those with isolated systolic hypertension, long-acting dihydropyridine calcium antagonists, in addition tolow dose thiazide diuretics, have also been shown to significantly reduce stroke risk.

Conceptual issues in scoring radiographic progression in rheumatoid arthritis.

Radiographic scoring systems for rheumatoid arthritis (RA) should be based on current understanding of disease pathology. Evidence suggests that there may be at least two intraarticular pathologies that may result in change in different radiographic features. There is therefore a strong argument for devising a radiographic score based on the observation of features rather than broad categorizations of the total radiographic change.

Intra-articular therapy in osteoarthritis.

Although intra-articular therapy is widely used in the treatment of osteoarthritis (OA), those controlled clinical trials which include placebo groups suggest that there is little to be gained over joint aspiration alone, or even over a simple needle prick. Glucocorticoids may however offer a small additional symptom benefit over one or two weeks. Viscosupplementation may offer a slightly longer benefit.

Cardiopulmonary and arterial baroreflex-mediated control of forearm vasomotor tone is impaired after acute stroke.

Background And Purpose: Elevated blood pressure (BP) levels are well recognized after acute stroke and are associated with increased BP variability. The underlying mechanisms producing such changes are unclear but may include abnormalities of baroreceptor-mediated control of heart rate and vasomotor tone. Lower body negative pressure (LBNP) can be used to assess the integrity of "low-pressure" cardiopulmonary and "high-pressure" arterial baroreceptor-derived responses by inducing nonhypotensive and hypotensive stimuli.

Cardiac baroreceptor sensitivity is impaired after acute stroke.

Background And Purpose: The blood pressure (BP) fall and increased BP variability after acute stroke have been previously described. The underlying pathophysiological mechanisms producing these findings are unclear but may include abnormalities of cardiac baroreceptor reflex arc and/or changes in sympathetic nervous system activity. To date, evidence of impaired cardiac baroreceptor sensitivity (BRS) after stroke is limited to patients with chronic disease as determined by invasive methodology.

Prognostic criteria in rheumatoid arthritis: can we predict which patients will require specific anti-rheumatoid treatment?

Unlabelled: Longitudinal studies of rheumatoid arthritis (RA) have shown that joint damage often occurs early in the disease. Therefore, the early treatment of RA with "disease modifying" drugs is gaining acceptance. However, many patients presenting with inflammatory polyarthropathy will follow a benign course.

Rheumatology out-patient workload increases inexorably.

Rheumatology out-patient consultations in the south-west of England from 1 to 30 November 1994 were recorded by standard methods and compared to 1988, 1990, 1991 and 1992. Historical records at one centre provided additional detailed information. There has been an overall increase of 31% in the number of patients seen (30% for follow-up cases, 36% for new referrals), but the mean waiting time for new patient consultations increased from 65 to 108 days.

Validation of the SpaceLabs 90207 automatic non-invasive blood pressure monitor in elderly subjects.

OBJECTIVE: To validate the SpaceLabs 90207 ambulatory blood pressure monitor in the elderly. METHODS: Eighty-five subjects aged 60-90 years were recruited from hospital inpatients. Using the same-arm sequential measurement technique two observers recorded blood pressure with a mercury sphygmomanometer first and then by using the SpaceLabs 90207 ambulatory monitor.

The management of urinary incontinence in residential and nursing homes for older people.

We assessed the management of urinary incontinence amongst older people in residential and nursing homes and examined strategies for continence care in the homes. A random sample of local authority and private residential and nursing homes was drawn from an earlier census of long-term care. Strategies for continence care, the standard of care provided and the need for more help were determined by means of a structured questionnaire and the observations of a continence adviser.

What method should be used to define 'night' when assessing diurnal systolic blood pressure variation in the elderly?

Diurnal blood pressure (BP) variation can be assessed by cusums-derived measures and by the day-night BP difference from time-, activity- and diary-defined 'night' periods. Reproducibility of diurnal systolic BP (SBP) variation by these different methods was studied in 19 active elderly normotensives, mean age 68.5 years.

A prospective study of primary and secondary risk factor management in stroke patients.

Stroke is a common event which often results in death or major loss of independence with immense human and financial costs, so identification of patients at risk, and prevention of stroke at the individual and population levels, is a high clinical and health priority. From August 1993 to July 1994, 468 stroke patients admitted to our hospital were assessed for the presence of stroke risk factors. All patients were followed up in hospital, and on discharge or death all hospital records were reviewed.

Postprandial and orthostatic cardiovascular changes after acute stroke.

Background And Purpose: Large falls in blood pressure after meals have been demonstrated in fit and frail elderly subjects; these changes may be associated with an increased incidence of stroke. Postprandial falls in BP may be particularly deleterious after acute stroke, when normal baroreflex mechanisms and cerebral autoregulation are already impaired, resulting in stroke progression. Therefore, the postprandial hemodynamic responses to orthostasis were examined in nine acute stroke subjects and eight age-, sex-, and blood pressure-matched control subjects after an oral energy load.

Changes in the sweatspot test with ageing and relation to cardiovascular autonomic function.

The sweatspot test assesses the local sweat response to an intradermal injection of acetylcholine. It has been reported as a more sensitive indicator of autonomic dysfunction in important diabetic men than either pupillary or cardiovascular tests, and has been used to establish the presence of autonomic dysfunction in patients with idiopathic chronic constipation. However, the usefulness of this test as a simple and quick method of diagnosing autonomic dysfunction in an elderly population has not been established.

The acute effects of a single dopamine infusion in elderly patients with congestive cardiac failure.

1. Dopamine (DA) at low doses (2.5 micrograms kg-1 min-1) produces a measurable increase in glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) in young healthy subjects and has a therapeutic effect in younger patients with congestive cardiac failure (CCF).