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Objective : To measure the change in cardiovascular risk factors achievable in families over one year by a cardiovascular screening and lifestyle intervention in general practice. Design : Randomised controlled trial in 26 general practices in 13 towns in Britain. Subjects : 12472 men aged 40-59 and their partners (7460 men and 5012 women) identified by household. Intervention : Nurse led programme using a family centred approach with follow up according to degree of risk. Main outcome measures : After one year the pairs of practices were compared for differences in (a) total coronary (Dundee) risk score and (b) cigarette smoking, weight, blood pressure, and random blood cholesterol and glucose concentrations. Results : In men the overall reduction in coronary risk score was 16% (95% confidence interval 11% to 21%) in the intervention practices at one year. This was partitioned between systolic pressure (7%), smoking (5%), and cholesterol concentration (4%). The reduction for women was similar. For both sexes reported cigarette smoking at one year was lower by about 4%, systolic pressure by 7 mm Hg, diastolic pressure by 3 mm Hg, weight by 1 kg, and cholesterol concentration by 0.1 mmol/l, but there was no shift in glucose concentration. Weight, blood pressure, and cholesterol concentration showed the greatest difference at the top of the distribution. If maintained long term the differences in risk factors achieved would mean only a 12% reduction in risk of coronary events. Conclusions : As most general practices are not using such an intensive programme the changes in coronary risk factors achieved by the voluntary health promotion package for primary care are likely to be even smaller. The government's screening policy cannot be justified by these results.

Objective: To use population impact measures to help prioritise the National Service Framework (NSF) strategies recommended by the UK government for reducing the population burden of coronary heart disease (CHD). Design: Modelling study. Setting: Primary care. Data sources: Published data on incidence, baseline risk and prevalence of risk factors for CHD and the proportion treated, eligible for treatment, and adhering to the different interventions. Data from metaanalyses and systematic reviews for relative risk and relative risk reduction associated with different risk factors and interventions. Main outcome measures: Population impact measures for the decline in the prevalence of a risk factor and the increased uptake of interventions expressed as number of CHD events prevented in the population. Results: If lifestyle targets for primary prevention are met, 73 522 (95% CI 54 117 to 95 826) CHD events would be prevented per year, with the greatest gain coming from reduced cholesterol and blood pressure levels. In those at high risk of developing CHD, achieving target levels for lifestyle interventions would prevent 4410 (95% CI 1 993 to 8014) CHD events and for pharmacological treatments 2008 (95% CI 790 to 3627) CHD events. For patients with established CHD, achieving NSF targets will result in the prevention of 3067 (95% CI 1572 to 5878) CHD events through improved drug treatment and 1103 (95% CI 179 to 2097) events through lifestyle interventions. Conclusion: Current strategies focus largely on secondary prevention, but many more cardiovascular events would be prevented by meeting the government's public health and primary prevention targets than targeting people at high risk or those with established heart disease.

potential routes for a multisynaptic itch reflex from the substantia to the nucleus of the trigeminal nerve in the medulla.The transmission of nerve impulses that give rise to a spinal reflex may be blocked by local anaesthesia. Our patients have not complained of itch since we added a small amount of bupivacaine to our intrathecal heroin preparation (1-0 mg freeze-dried heroin and 0-25 mg bupivacaine plain in 1-0 ml saline; pH 6-183, specific gravity 1-004 at 37°C).On this evidence an enkephalinergic reflex may well provide a credible alternative to histamine release as an explanation for facial itching associated with intraspinal administration of opiates. The reflex might be relayed at a central level by a medullary itch centre having a close functional link with the spinal nucleus of the trigeminal nerve.