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Some small for gestational age fetuses have higher risk of late fetal death than others
In small for gestational age fetuses, without congenital
malformations, constitutionally small fetuses
for example twins or the
fetuses of short mothershave been assumed to at lower risk of late
fetal death than fetuses affected by conditions such as pre-eclampsia
or cigarette consumption. Cnattingius et al (p 1483) tested that
assumption in over 1 million births in the Swedish birth register.
Overall, late fetal mortality was increased in women who were over 35, nulliparous, smoked, or were 
155 cm tall and greatly increased in
those with pre-eclampsia, essential hypertension, and twin pregnancies.
But in very small for gestational age fetuses death rates were lower in
women aged under 35, 155 cm tall, with twins, or with severe
eclampsia or hypertension.
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Compression treatment is recommended to promote healing of venous leg
ulcers, and early work in Charing Cross showed that a four layer
compression bandage achieved a high rate of healing (74%) in 2 weeks.
The cost of effective bandages, however, has meant that this has not
been a viable option in the home. On p 1487 Morrell et al evaluate the
cost effectiveness of four layer compression bandaging in community
based clinics in a randomised controlled trial in Trent. The healing
rates in the clinics were greater than in the control group, who
received standard treatment at home, and no significant difference was
found in mean total NHS costs. The authors suggest that for patients
who are willing to travel, an effective leg ulcer service could be
provided in community clinics at a reduced cost.
The sex of patients has been shown to influence the management of
cardiovascular disorders. Schüppel et al evaluated the effect of sex
on doctors' choice of pacemaker in a large German database (p 1492).
Women were more likely to receive single chamber pacemakers and less
likely to receive dual chamber or rate responsive systems than men.
This remained true even after demographic and clinical variables were
controlled for. The reason for the apparent discrimination could not be
determined from the study.
With an increase in the number of suicides among men, Shajahan
and Cavanagh hypothesised that there would be a fall in the ratio of
the number of women to men admitted to Scottish hospitals for
depression from 1980 to 1995a period of socioeconomic change. On
p 1496 they show that the rate of admission for depression fell among
women from 6.1/10 000 in 1980 to 5.3 in 1995 and rose among men from
3.1 to 3.5. This finding confirms other studies, and the authors
conclude that the rise in prevalence is genuine and not just a result
of changes in diagnostic practice.
The out of hours service in Denmark (population 5.2m) was
reformed at the beginning of 1992. All 15 counties now have a
coordination centre where all patients' calls are triaged by general
practitioners, who decide whether the patient needs a home visit, a
consultation in an out of hours consultation room, or telephone advice.
One of the main reasons for the reform was the huge out of hours
workload for general practitioners, and this has decreased considerably since 1992. On p 1502 Christensen and Olesen outline the main points of the reform and describe its effects on number of out of hours
services, workload of general practitioners, cost of the service, and
patient satisfaction.
Various measures have encouraged the provision of diabetes care
in general practice in Britain. On p 1505 Goyder et al examined data
on patients with diabetes in five general practices in Leicester in
1990-5 to see if the proportion reviewed in general practice had risen.
Overall the proportion having their annual review in general practice
rose from 17% (of 282) in 1990 to 35% (of 514) in 1995 while the
proportion seen in outpatient clinics fell only from 35% to 30%; the
proportion reviewed in neither setting fell from 54% to 37%. The
authors conclude that previously unmet needs are being met rather than
care shifted from primary care.
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