Letters in the natural course of the disease in an appreciable proportion of those screened.' When Dr Chisholm confirmed that negotiations on the new contract were continuing, he stated 'There is a willingness in the health department to admit that three-yearly checks are not the best way of offering health promotion to all patients, and that scientific evidence offers better ways' (General Practitioner, 8 May 1992). I would like to report the findings of the first 1111 general health checks (out of 1448 eligible patients) performed in a single handed practice between September 1990 and March 1992. The age range of the patients was between 17 and 75 years old. The number of new findings, together with the number of previously known findings is shown in Table 1. Screening identified more than four times as many unknown risk factors as known ones. The outcome of interventions undertaken for patients over the past 10 months includes 18 patients having reached their target weight; 20 patients having stopped smoking and a further 12 patients having reduced their cigarette consumption; 13 patients having reduced their cholesterol level from a mean of 7.65 mmol 1- to 6.25 mmol 1- following dietary interventions by the general practitioner or practice nurse; six patients having reduced their alcohol intake and two patients having stopped drinking alcohol altogether. It is interesting to note the small number of people identified as having a raised cholesterol level (only 11 previousTable 1. Number of previously known, and new findings identified at three yearly checks. No. of patients Previously known New findings findings Stress Family history of CHDa Overweight (body mass index >25) Hypertension (> 1 60/90 mmHg) Smoker Coronary heart disease
Diabetesb
2 5
45 91
3
207
64 7 37 14
85 130 10 3
Raised cholesterol level 11 (>6.5 mmol l-1) Excess alcohol intake (>21 units/week for men >14 units/week for 4 women) 147 Total
21
46 638
CHD = coronary heart disease aln a first degree relative under 60 years old. binitial glycosuria and then raised fasting blood glucose levels.
440
ly known cases and 21 new cases). However, cholesterol levels were checked only in those patients with a family history of premature heart disease, and in hypertensive and diabetic patients, or those with coronary heart disease. In studies where an unselective policy is used for cholesterol screening, the percentage of patients with a raised cholesterol level varies from 8.3 Wo2 to 45 %.3 The impact of health promotion activities aimed at coronary heart disease prevention could be assessed at the threeyearly health check, and expressed in terms of change in risk factor profile. If three yearly health checks are abandoned before then, we will remain unaware of their value as a starting point for modifying risk factors. D J HINDMARSH
The Surgery Bakers Barn Bakers Cross Cranbrook Kent TN17 3NW
physiotherapist was unsatisfied with her progress and referred her back to her general practitioner. The patient presented to the casualty department again before coming to the surgery but another casualty officer refused to order an x-ray. Three months had passed since the initial injury when I saw the patient in the practice. On examining her, I found that she was unable to supinate and pronate the forearm and I became suspicious that bony injury might have been missed by those examining her before me. I ordered an x-ray, following it up with a telephone call to the x-ray department. An x-ray done the same day confirmed my fear, she had a fractured radial head. She was then referred without delay to the fracture clinic and following the successful birth of her child is shortly to undergo osteotomy. S EDOMAN Flat 3 83 Victoria Park Road London E9 7NA
Refeences 1. Morrell DC. Role of research in development of organisation and structure of general practice. BMJ 1991; 302: 1313-1316. 2. Jones A, Davies DH, Dove JR, et al. Identification and treatment of risk factors for coronary heart disease in general practice: a possible screening model. BMJ 1988; 296:
1711-1714. 3. Muir J, Niel A, Roe L, et al. Prevalence of risk factors for heart disease in Oxcheck trial: implications for screening in primary care. BMJ 1991; 302: 1057-1060.
X-rays and pregnant women: a case report Sir, While on holiday in Spain a 30 year old right handed woman, 22 weeks pregnant with her second child, had a fall injuring her right elbow and forearm. She presented to a Spanish doctor who, after examining her, refused to order an x-ray on the grounds of her pregnancy and that there were no clinical signs of fracture. Although she had some swelling of the elbow she was able to flex and extend it. On arrival in England a week later she went to a casualty department where the casualty officer refused to order an x-ray on the same grounds. Two weeks later (that is three weeks after the injury) she saw her general practitioner (one -of five in my practice) because of persistent pain and difficulty carrying out domestic tasks. Her general practitioner felt that although there were restrictions in the elbow joint and forearm movements an x-ray was not justified; she was referred to a physiotherapist. The
Strangulated umbilical hernia in a child Sir, Umbilical hernia is a common condition in infants and children. Wood reported an incidence of one in 5.4 from a sample of 573 infants studied in Bristol.' However, strangulation of the umbilical hernia is rare. The first reported case was in 19322 and only three cases have been reported in the United Kingdom since then.34 A further case and its management are described here. A boy was born at 36 weeks gestation and had a normal neonatal period except for a renal anomaly detected prior to birth. Subsequent investigation showed a bilateral dilated pelvicalyceal system without obstruction. A dimercaptosuccinic acid scan when the child was 21 months showed resolution on both sides. At the same time a large umbilical hernia was brought to medical attention at the hospital; this was easily reducible. When aged two years and four months he was presented to his general practitioner with a slight change in the colour of the umbilical hernia. He was referred by letter for an urgent outpatient appointment. When he was seen in hospital five days later, he had a history of some redness at, and slight blood stained discharge from the umbilicus with no vomiting or constipation. Examination revealed a well hydrated, well perfused child with a peripheral pulse rate of 120 beats per minute. His abdomen was soft
British Journal of General Practice, October 1992
Letters and not distended, and there was a large inflamed, tender irreducible umbilical hernia. A diagnosis of strangulated umbilical hernia was made. At operation a small hernial sac containing gangrenous omentum was found; loops of bowel appeared normal. The omentum and infected skin were resected and the umbilicus reconstructed. The child's recovery was uneventful and he was discharged the following day. A search of the literature revealed only 11 children with strangulated umbilical hernia in total worldwide,2-tl despite umbilical hernia being an extremely common condition. Among the 11 reported cases, delay in presentation was common ranging from 21 hours to nine days. In this case, delay while awaiting an urgent clinic appointment was associated with the need to excise infected skin and gangrenous omentum. Unlike inguinal and femoral hernias, the majority of umbilical hernias in children will disappear completely with increasing age. Thus, the present policy of expectant management should continue. Parents often seek and receive reassurance early on when the large size of the hernia is causing them alarm. One could postulate, however, that the risk of strangulation will occur much later, when the hernial orifice is becoming smaller prior to complete closure. Parents should be instructed that in the unlikely event of the hernia becoming irreducible or painful, they should seek prompt medical attention. Primary care physicians should refer such cases to their surgical colleagues as emergencies, as with incarcerated hernias at any other site. V RUDRAN Bushey Health Centre London Road Bushey Middlesex
R JONES Ealing Hospital Uxbridge Road Southall Middlesex References 1. Wood GE. Some observations on umbilical hernia in infantS. Arch Dis Child 1952; 28: 450-462. 2. Miller RH. Umbilical hernia. N Engl J Med
1932; 20&: 389-391. 3. Haworth JC. Strangulation of umbilical hernia in children. BMJ 1957; 1: 869. 4. Vyas ID. Strangulated tJmbilical hernia in a child. Postgrad Med J 1983; 59: 794-795. 5. Hurlburt HJ, Moseley T. Incarcerated and strangulated umbilical hernia in infants and children. J Fla Med Assoc 1966; 53: 504-506. 6. Chattergee H, Bhat SM. Incarcerated umbilical hernia in cidren. J Indian Med Assoc 1986; 54: 238-239, 7. Jeans PL, Wright JE. Strangulated umbilical hernia in infancy. Aust Pwediatr J 1984; 20:
75.
8. Auldist AW, Lugg P. Strangulation of an umbilical hernia in a child of six months. Aust Paediatr J 1982; 18: 286. 9. Peggs SP. Umbilical hernia: strangulation in a boy aged ten weeks. Med J Aust 1971; 1: 92-93. 10. Mestral AL, Burns H. Incawerated and strangulated umbilical hernias in infants and children. Clin Pediatr (Phila) 1963; 2: 368-370. 11. Crump EP Umbilical hernia. J Pediat, 1952; 40: 214-223.
General practice and drug misuse Sir, The letter by George and Martin is to be welcomed (July Journal, p.302). General practitioners have always been in the front line with regard to the management of drug users and have regularly contributed to the debate on the care of drug abusers in the community. The progress of the human immunodeficiency virus and the acquired immune deficiency syndrome has seen 'harm minimizations emerge as the primary role of the treatment of intravenous drug abusers.' The issue of prescribing for intravenous drug abusers is central to such an approach and has been strongly advocated in the recent Department of Health guidelines for doctors.2 We do, however, have some reservations regarding the methodology of George and Martins' survey and of the conclusions they draw from their data. A sample of geinral practitioners attending a seminar on drug abuse is likely to comprise those who would be more likely to have an interest in drug abusers and would therefore be favourably disposed to them. As a result, the sample may not be representative of all West Sussex general practitioners. We were surprised that injectable methadone seems to have been the focus of the authors' enquiries with regard to prescribing and that general practitioners were not asked about oral methadone. The Department of Health guidelines2 recommend that 'straightforward elements' of care (an example of which is the prescribing of oral methadone) are to be taken on by 'any doctor'. while 'more complicated interventions' such as the prescribiag of injectable drugs, should be dealt with by doctors with 'relevant specialized training, expertise and back-up. If such guidelines were to be followed, most general practitioners would not be eixcted to prescribe injectable drugs to intravenous drug abusers. The authors feel their data present a 'more hopeful view' of shared care as some 601s of their sample were willing to engage in the management of intravenous drug abusers. However, even among this
Bdtish Journal of Geieral Prctice, October 1q2
interested group of general practitioners, 400/ implied no willingness to be involved, 21% would not accept a new patient with a history of drug abuse and 56% were unaware of any drug abusers on thein lists. There is ample evidence that general practitioners find drug abusers a difficult patient group,3'4 and that general practitioners:ar wary of prescribing for them.5 We feel that it is likely that the results would have been less hopeful in a truly representative sample Recent work has shown how intravenous drug abusers can be cared for successfully in a general practice setting5'6 and has highlighted the need for improved liaison between specialist drug, treatment agencies and the general practitioner.57 If 'harm minimization' is to become a reality, the general practitioner will have an increasingly important role to play. It is essential that general practitioners have a say in what functions they are prepared to fulfil and what support they will require from specialist agencies. This can only be achieved by canvassing the views of representative samples of general practitioners in different geographical areas. BRIAN A KIDD GEORGE E RALSTON Southern General Hospital Drug Project 1345 Govan Road Glasgow G51 4TF
References 1. Cooper JR. Methadone treatment and AIDS.
JAMA 1989; N26 1664-1668. 2. Department of Health Medical Working Group on Drug Misuse and Dependence. Guidelines on clinical management. London: HMSO, 1991. 3. McKeganey N. Shadowland: general practitioners and the treatment of opiate abusing patients. Br J Addict 1988; 83: 373-386. 4. Greenwood J. Unpopular patients. GPs' attitudes to drug users. Druglink 1992; July/August: 8-10. 5. Greenwood J. Persuading general practitioners to prescribe. Br J Addict 1992; 87: 567-575. 6. Cohen J, Schatnroth A, Nazareth I, et al. Problem drug use in a central London general -practice. BMJ 192; 304: 1158-1160. 7. Rozewicz L, Caan W, Johns A. Managing drug misuse in general practice. BMJ 1992; 304:1442.
Sir, I read with great interest the article by Ronald and colleaguesi on their practice's response to the local problem of drug misuse (June Journal, p.232). This is a topical issue, another practice with a large population of drug misusers having also reported its findings recently.' There are interesting differences in the approaches reported by the two practices and my own which, presumably reflect the attitudes of the doctors involved and the 441
Diabetesb
2 5
45 91
3
207
64 7 37 14
85 130 10 3
Raised cholesterol level 11 (>6.5 mmol l-1) Excess alcohol intake (>21 units/week for men >14 units/week for 4 women) 147 Total
21
46 638
CHD = coronary heart disease aln a first degree relative under 60 years old. binitial glycosuria and then raised fasting blood glucose levels.
440
ly known cases and 21 new cases). However, cholesterol levels were checked only in those patients with a family history of premature heart disease, and in hypertensive and diabetic patients, or those with coronary heart disease. In studies where an unselective policy is used for cholesterol screening, the percentage of patients with a raised cholesterol level varies from 8.3 Wo2 to 45 %.3 The impact of health promotion activities aimed at coronary heart disease prevention could be assessed at the threeyearly health check, and expressed in terms of change in risk factor profile. If three yearly health checks are abandoned before then, we will remain unaware of their value as a starting point for modifying risk factors. D J HINDMARSH
The Surgery Bakers Barn Bakers Cross Cranbrook Kent TN17 3NW
physiotherapist was unsatisfied with her progress and referred her back to her general practitioner. The patient presented to the casualty department again before coming to the surgery but another casualty officer refused to order an x-ray. Three months had passed since the initial injury when I saw the patient in the practice. On examining her, I found that she was unable to supinate and pronate the forearm and I became suspicious that bony injury might have been missed by those examining her before me. I ordered an x-ray, following it up with a telephone call to the x-ray department. An x-ray done the same day confirmed my fear, she had a fractured radial head. She was then referred without delay to the fracture clinic and following the successful birth of her child is shortly to undergo osteotomy. S EDOMAN Flat 3 83 Victoria Park Road London E9 7NA
Refeences 1. Morrell DC. Role of research in development of organisation and structure of general practice. BMJ 1991; 302: 1313-1316. 2. Jones A, Davies DH, Dove JR, et al. Identification and treatment of risk factors for coronary heart disease in general practice: a possible screening model. BMJ 1988; 296:
1711-1714. 3. Muir J, Niel A, Roe L, et al. Prevalence of risk factors for heart disease in Oxcheck trial: implications for screening in primary care. BMJ 1991; 302: 1057-1060.
X-rays and pregnant women: a case report Sir, While on holiday in Spain a 30 year old right handed woman, 22 weeks pregnant with her second child, had a fall injuring her right elbow and forearm. She presented to a Spanish doctor who, after examining her, refused to order an x-ray on the grounds of her pregnancy and that there were no clinical signs of fracture. Although she had some swelling of the elbow she was able to flex and extend it. On arrival in England a week later she went to a casualty department where the casualty officer refused to order an x-ray on the same grounds. Two weeks later (that is three weeks after the injury) she saw her general practitioner (one -of five in my practice) because of persistent pain and difficulty carrying out domestic tasks. Her general practitioner felt that although there were restrictions in the elbow joint and forearm movements an x-ray was not justified; she was referred to a physiotherapist. The
Strangulated umbilical hernia in a child Sir, Umbilical hernia is a common condition in infants and children. Wood reported an incidence of one in 5.4 from a sample of 573 infants studied in Bristol.' However, strangulation of the umbilical hernia is rare. The first reported case was in 19322 and only three cases have been reported in the United Kingdom since then.34 A further case and its management are described here. A boy was born at 36 weeks gestation and had a normal neonatal period except for a renal anomaly detected prior to birth. Subsequent investigation showed a bilateral dilated pelvicalyceal system without obstruction. A dimercaptosuccinic acid scan when the child was 21 months showed resolution on both sides. At the same time a large umbilical hernia was brought to medical attention at the hospital; this was easily reducible. When aged two years and four months he was presented to his general practitioner with a slight change in the colour of the umbilical hernia. He was referred by letter for an urgent outpatient appointment. When he was seen in hospital five days later, he had a history of some redness at, and slight blood stained discharge from the umbilicus with no vomiting or constipation. Examination revealed a well hydrated, well perfused child with a peripheral pulse rate of 120 beats per minute. His abdomen was soft
British Journal of General Practice, October 1992
Letters and not distended, and there was a large inflamed, tender irreducible umbilical hernia. A diagnosis of strangulated umbilical hernia was made. At operation a small hernial sac containing gangrenous omentum was found; loops of bowel appeared normal. The omentum and infected skin were resected and the umbilicus reconstructed. The child's recovery was uneventful and he was discharged the following day. A search of the literature revealed only 11 children with strangulated umbilical hernia in total worldwide,2-tl despite umbilical hernia being an extremely common condition. Among the 11 reported cases, delay in presentation was common ranging from 21 hours to nine days. In this case, delay while awaiting an urgent clinic appointment was associated with the need to excise infected skin and gangrenous omentum. Unlike inguinal and femoral hernias, the majority of umbilical hernias in children will disappear completely with increasing age. Thus, the present policy of expectant management should continue. Parents often seek and receive reassurance early on when the large size of the hernia is causing them alarm. One could postulate, however, that the risk of strangulation will occur much later, when the hernial orifice is becoming smaller prior to complete closure. Parents should be instructed that in the unlikely event of the hernia becoming irreducible or painful, they should seek prompt medical attention. Primary care physicians should refer such cases to their surgical colleagues as emergencies, as with incarcerated hernias at any other site. V RUDRAN Bushey Health Centre London Road Bushey Middlesex
R JONES Ealing Hospital Uxbridge Road Southall Middlesex References 1. Wood GE. Some observations on umbilical hernia in infantS. Arch Dis Child 1952; 28: 450-462. 2. Miller RH. Umbilical hernia. N Engl J Med
1932; 20&: 389-391. 3. Haworth JC. Strangulation of umbilical hernia in children. BMJ 1957; 1: 869. 4. Vyas ID. Strangulated tJmbilical hernia in a child. Postgrad Med J 1983; 59: 794-795. 5. Hurlburt HJ, Moseley T. Incarcerated and strangulated umbilical hernia in infants and children. J Fla Med Assoc 1966; 53: 504-506. 6. Chattergee H, Bhat SM. Incarcerated umbilical hernia in cidren. J Indian Med Assoc 1986; 54: 238-239, 7. Jeans PL, Wright JE. Strangulated umbilical hernia in infancy. Aust Pwediatr J 1984; 20:
75.
8. Auldist AW, Lugg P. Strangulation of an umbilical hernia in a child of six months. Aust Paediatr J 1982; 18: 286. 9. Peggs SP. Umbilical hernia: strangulation in a boy aged ten weeks. Med J Aust 1971; 1: 92-93. 10. Mestral AL, Burns H. Incawerated and strangulated umbilical hernias in infants and children. Clin Pediatr (Phila) 1963; 2: 368-370. 11. Crump EP Umbilical hernia. J Pediat, 1952; 40: 214-223.
General practice and drug misuse Sir, The letter by George and Martin is to be welcomed (July Journal, p.302). General practitioners have always been in the front line with regard to the management of drug users and have regularly contributed to the debate on the care of drug abusers in the community. The progress of the human immunodeficiency virus and the acquired immune deficiency syndrome has seen 'harm minimizations emerge as the primary role of the treatment of intravenous drug abusers.' The issue of prescribing for intravenous drug abusers is central to such an approach and has been strongly advocated in the recent Department of Health guidelines for doctors.2 We do, however, have some reservations regarding the methodology of George and Martins' survey and of the conclusions they draw from their data. A sample of geinral practitioners attending a seminar on drug abuse is likely to comprise those who would be more likely to have an interest in drug abusers and would therefore be favourably disposed to them. As a result, the sample may not be representative of all West Sussex general practitioners. We were surprised that injectable methadone seems to have been the focus of the authors' enquiries with regard to prescribing and that general practitioners were not asked about oral methadone. The Department of Health guidelines2 recommend that 'straightforward elements' of care (an example of which is the prescribing of oral methadone) are to be taken on by 'any doctor'. while 'more complicated interventions' such as the prescribiag of injectable drugs, should be dealt with by doctors with 'relevant specialized training, expertise and back-up. If such guidelines were to be followed, most general practitioners would not be eixcted to prescribe injectable drugs to intravenous drug abusers. The authors feel their data present a 'more hopeful view' of shared care as some 601s of their sample were willing to engage in the management of intravenous drug abusers. However, even among this
Bdtish Journal of Geieral Prctice, October 1q2
interested group of general practitioners, 400/ implied no willingness to be involved, 21% would not accept a new patient with a history of drug abuse and 56% were unaware of any drug abusers on thein lists. There is ample evidence that general practitioners find drug abusers a difficult patient group,3'4 and that general practitioners:ar wary of prescribing for them.5 We feel that it is likely that the results would have been less hopeful in a truly representative sample Recent work has shown how intravenous drug abusers can be cared for successfully in a general practice setting5'6 and has highlighted the need for improved liaison between specialist drug, treatment agencies and the general practitioner.57 If 'harm minimization' is to become a reality, the general practitioner will have an increasingly important role to play. It is essential that general practitioners have a say in what functions they are prepared to fulfil and what support they will require from specialist agencies. This can only be achieved by canvassing the views of representative samples of general practitioners in different geographical areas. BRIAN A KIDD GEORGE E RALSTON Southern General Hospital Drug Project 1345 Govan Road Glasgow G51 4TF
References 1. Cooper JR. Methadone treatment and AIDS.
JAMA 1989; N26 1664-1668. 2. Department of Health Medical Working Group on Drug Misuse and Dependence. Guidelines on clinical management. London: HMSO, 1991. 3. McKeganey N. Shadowland: general practitioners and the treatment of opiate abusing patients. Br J Addict 1988; 83: 373-386. 4. Greenwood J. Unpopular patients. GPs' attitudes to drug users. Druglink 1992; July/August: 8-10. 5. Greenwood J. Persuading general practitioners to prescribe. Br J Addict 1992; 87: 567-575. 6. Cohen J, Schatnroth A, Nazareth I, et al. Problem drug use in a central London general -practice. BMJ 192; 304: 1158-1160. 7. Rozewicz L, Caan W, Johns A. Managing drug misuse in general practice. BMJ 1992; 304:1442.
Sir, I read with great interest the article by Ronald and colleaguesi on their practice's response to the local problem of drug misuse (June Journal, p.232). This is a topical issue, another practice with a large population of drug misusers having also reported its findings recently.' There are interesting differences in the approaches reported by the two practices and my own which, presumably reflect the attitudes of the doctors involved and the 441
