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A paper chromatographic analysis in 60 patients with muscular dystrophy from 49 families and in 351 of their relatives showed a high incidence of generalized hyperaminoaciduria in both patients and relatives. There was a higher incidence of threoninuria in patients and their relatives than in controls. One family was found to have excess histidinuria and another excess lysinuria.

Objectives: To determine whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital. Design: A non-randomised, population based study before (1996) and after (1999) introduction of the medical emergency team. Setting: 300 bed tertiary referral teaching hospital. Participants: All patients admitted to the hospital in 1996 (n=19 317) and 1999 (n=22 847). Interventions: Medical emergency team (two doctors and one senior intensive care nurse) attended clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response activated by the bedside nurse or doctor according to predefined criteria. Main outcome measures: Incidence and outcome of unexpected cardiac arrest. Results: The incidence of unexpected cardiac arrest was 3.77 per 1000 hospital admissions (73 cases) in 1996 (before intervention) and 2.05 per 1000 admissions (47 cases) in 1999 (after intervention), with mortality being 77% (56 patients) and 55% (26 patients), respectively. After adjustment for case mix the intervention was associated with a 50% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.50, 95% confidence interval 0.35 to 0.73). Conclusions: In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital. What is already known on this topic In most studies mortality from unexpected cardiac arrest in hospital exceeds 50% Such events are usually preceded by signs of clinical deterioration in the hours before cardiac arrest What this paper adds Early intervention by a medical emergency team significantly reduced the incidence of and mortality from unexpected cardiac arrest in hospital

Objectives To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998. Design Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates. Setting Southern England. Subjects 5312 people admitted to hospital with acute pancreatitis. Main outcome measures Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission. Results The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100 000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women. Conclusions Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.

Objective To determine whether there was a change in hospital admissions for acute myocardial infarction while a local law banning smoking in public and in workplaces was in effect. Design Analysis of admissions from December 1997 through November 2003 using Poisson analysis. Setting Helena, Montana, a geographically isolated community with one hospital serving a population of 68 140. Participants All patients admitted for acute myocardial infarction. Main outcome measures Number of monthly admissions for acute myocardial infarction for people living in and outside Helena. Results During the six months the law was enforced the number of admissions fell significantly (− 16 admissions, 95% confidence interval - 31.7 to - 0.3), from an average of 40 admissions during the same months in the years before and after the law to a total of 24 admissions during the six months the law was effect. There was a non-significant increase of 5.6 (− 5.2 to 16.4) in the number of admissions from outside Helena during the same period, from 12.4 in the years before and after the law to 18 while the law was in effect. Conclusions Laws to enforce smoke-free workplaces and public places may be associated with an effect on morbidity from heart disease.

Objective To determine whether any increase in the incidence of breast cancer in women detected by mammography is compensated for by a drop in the incidence after age 69, years when women are no longer invited for screening. Design Population based cohort study of incidence of breast cancer during the introduction of nationwide screening programmes. Setting Norway and Sweden. Participants All women aged above 30 years (1.4 and 2.9 million, respectively, in 2000). Main outcome measures Changes in age specific incidence rates of invasive breast cancer associated with the introduction of the screening programmes. Results As a result of screenin creening is defined as the detection of low malignancy lesions that otherwise would not be detected in a patient9s lifetime. It is often argued that overdiagnosis is not a problem for screening in breast cancer.1 – 3 For example, Boer et al predicted a 31% increase in incidence of breast cancer in the Dutch mass screening programme that would be nearly fully compensated for by a strong drop in the incidence after age 69 years conclusion Without screening one third of all invasive breast cancers in the age group 50-69 years would not have been detected in the patients9 lifetime. This level of overdiagnosis is larger than previously reported

Objective As a result of recent failures in clinical governance the government has made a commitment to bring individual surgeons9 mortality data into the public domain. We have analysed a database to compare crude mortality after coronary artery bypass surgery with outcomes that were stratified by risk. Design Retrospective analysis of prospectively collected data. Setting All NHS centres in the geographical north west of England that undertake cardiac surgery in adults. Participants All patients undergoing isolated bypass graft surgery for the first time between April 1999 and March 2002. Main outcome measures Surgeon specific postoperative mortality and predicted mortality by EuroSCORE. Results 8572 patients were operated on by 23 surgeons. Overall mortality was 1.7%. Observed mortality between surgeons ranged from 0% to 3.7%; predicted mortality ranged from 2% to 3.7%. Eighty five per cent (7286) of the patients had a EuroSCORE of 5 or less; 49% of the deaths were in this lower risk group. A large proportion of the variability in predicted mortality between surgeons was due to a small but differing number of high risk patients. Conclusions It is possible to collect risk stratified data on all patients undergoing coronary bypass surgery. For most the predicted mortality is low. The small proportion of high risk patients is responsible for most of the differences in predicted mortality between surgeons. Crude comparisons of death rates can be misleading and may encourage surgeons to practise risk averse behaviour. We recommend a comparison of death rates that is stratified by risk and based on low risk cases as the national benchmark for assessing consultant specific performance.

Objective: To examine premature mortality in adults in relation to socioeconomic conditions in childhood and adulthood. Design: Nationally representative birth cohort study with prospective information on socioeconomic conditions. Setting: England, Scotland, and Wales. Study members: 2132 women and 2322 men born in March 1946 and followed until age 55 years. Main outcome measures: Deaths between 26 and 54 years of age notified by the NHS central register. Results: Study members whose father9s occupation was manual at age 4, or who lived in the worst housing, or who received the poorest care in childhood had double the death rate during adulthood of those living in the best socioeconomic conditions. All indicators of socioeconomic disadvantage at age 26 years, particularly lack of home ownership, were associated with a higher death rate. Manual origins and poor care in childhood remained associated with mortality even after adjusting for social class in adulthood or home ownership. The hazard ratio was 2.6 (95% confidence interval 1.5 to 4.4) for those living in manual households as children and as adults compared with those living in non-manual households at both life stages. The hazard ratio for those from manual origins who did not own their own home at age 26 years was 4.9 (2.3 to 10.5) compared with those from non-manual origins who were home owners. Conclusions: Socioeconomic conditions in childhood as well as early adulthood have strongly influenced the survival of British people born in the immediate post war era. What is already known on this topic Associations between socioeconomic conditions in childhood and mortality in adulthood suggest that risks to survival begin in early life Studies have been generally retrospective, been unrepresentative, used only one marker of childhood conditions, controlled inadequately for adult conditions, or not included women What this study adds The death rate for women and men between 26 and 54 years living in poor socioeconomic conditions in childhood was double that of those living in the best conditions Those for whom socioeconomic disadvantage continued into early adulthood were between three and five times more likely to die than those in the most advantageous conditions

Objective: To determine the effectiveness of a brief cognitive behavioural intervention in reducing the incidence of sexually transmitted infections among gay men. Design: Randomised controlled trial with 12 months9 follow up. Setting: Sexual health clinic in London. Participants: 343 gay men with an acute sexually transmitted infection or who reported having had unprotected anal intercourse in the past year. Main outcome measures: Number of new sexually transmitted infections diagnosed during follow up and self reported incidence of unprotected anal intercourse. Results: 72% (361/499) of men invited to enter the study did so. 90% (308/343) of participants returned at least one follow up questionnaire or re-attended the clinic and requested a check up for sexually transmitted infections during follow up. At baseline, 37% (63/172) of the intervention group and 30% (50/166) of the control group reported having had unprotected anal intercourse in the past month. At 12 months, the proportions were 27% (31/114) and 32% (39/124) respectively (P=0.56). However, 31% (38/123) of the intervention group and 21% (35/168) of controls had had at least one new infection diagnosed at the clinic (adjusted odds ratio 1.66, 95% confidence interval 1.00 to 2.74). Considering only men who requested a check up for sexually transmitted infections, the proportion diagnosed with a new infection was 58% (53/91) for men in the intervention group and 43% (35/81) for men in the control group (adjusted odds ratio 1.84, 0.99 to 3.40). Using a regional database that includes information from 23 sexual health clinics in London, we determined that few participants had attended other sexual health clinics. Conclusions: This behavioural intervention was acceptable and feasible to deliver, but it did not reduce the risk of acquiring a new sexually transmitted infection among these gay men at high risk. Even carefully designed interventions should not be assumed to bring benefit. It is important to evaluate their effects in randomised trials with objective clinical end points. What is already known on this topic The need for effective HIV prevention strategies based on reducing sexual risk behaviour remains important Few interventions to reduce sexual risk behaviour have been rigorously evaluated using randomised controlled trials What this study adds This is the first randomised controlled trial of an intervention addressing sexual behaviour in homosexual men that uses sexually transmitted infections and self reported behaviour as end points The intervention was brief and feasible to use in a busy clinic, but it did not reduce the risk of participants acquiring new infections The potential for behavioural interventions to do more harm than good needs to be taken seriously

Objectives: To establish the age and sex specific mortality for people with diabetes in comparison with local and national background populations; to investigate the relationship between mortality and material deprivation in an unselected population with diabetes. Design: Longitudinal study, using a population based district diabetes register. Setting: South Tees, United Kingdom. Participants: All people known to have diabetes living in Middlesbrough and Redcar and Cleveland local authorities on 1 January 1994. Main outcome measure: Death, from any cause, between 1 January 1994 and 31 December 1999. Results: Over the six years of the study 1205 (24.9%) of 4842 participants died. All cause standardised mortality ratios for type 1 diabetes were 641 (95% confidence interval 406 to 962) in women and 294 (200 to 418) in men, and those for type 2 diabetes were 160 (147 to 174) in women and 141 (130 to 152) in men. Cause specific standardised mortality ratios were increased for ischaemic heart disease, cerebrovascular disease, and renal disease; no reductions in mortality from other causes were seen. The risk of premature death increased significantly with increasing material deprivation (P Conclusions: Diabetes is associated with excess mortality, even in an area with high background death rates from cardiovascular disease. This excess mortality is evident in all age groups, most pronounced in young people with type 1 diabetes, and exacerbated by material deprivation. Aggressive approaches to the management of cardiovascular risk factors could reduce the excess mortality in people with diabetes. What is already known on this topic Mortality, mainly from cardiovascular disease, is increased in people with diabetes, but this excess varies considerably by country and ethnic group Previous British studies have reported no excess mortality in old age, a reduction in deaths from non-cardiovascular causes, and that mortality may be adversely affected by deprivation What this study adds Mortality is increased, across all ages, in an unselected population with diabetes compared with the local population without diabetes, which itself has high mortality Most of the excess is from cardiovascular causes, but there are no reductions in other causes of death Mortality among people with diabetes is increased even in the most affluent group, and this excess increases with worsening material deprivation

Objective: To evaluate whether electrodermal testing for environmental allergies can distinguish between volunteers who had previously reacted positively on skin prick tests for allergy to house dust mite or cat dander and volunteers who had reacted negatively to both allergens. Design: Double blind, randomised block design. Setting: A general practice in southern England. Participants: 15 volunteers who had a positive result and 15 volunteers who had a negative result on a previous skin prick test for allergy to house dust mite or cat dander. Intervention: Each participant was tested with 6 items by each of 3 operators of the Vegatest electrodermal testing device in 3 separate sessions (a total of 54 tests per participant). For each participant the 54 items comprised 18 samples each of house dust mite, cat dander, and distilled water, though these were randomly allocated among the operators in each session. A research nurse sat with the participant and operator in all sessions to ensure blinding and adherence to the protocol and to record the outcome of each test. Outcome: The presence or absence of an allergy according to the standard protocol for electrodermal testing. Results: All the non-atopic participants completed all 3 testing sessions (810 individual tests); 774 (95.5%) of the individual tests conducted on the atopic participants complied with the testing protocol. The results of the electrodermal tests did not correlate with those of the skin prick tests. Electrodermal testing could not distinguish between atopic and non-atopic participants. No operator of the Vegatest device was better than any other, and no single participant's atopic status was consistently correctly diagnosed. Conclusion: Electrodermal testing cannot be used to diagnose environmental allergies.

Objective: To investigate the association between cholesterol lowering interventions and risk of death from suicide, accident, or trauma (non-illness mortality). Design: Meta-analysis of the non-illness mortality outcomes of large, randomised clinical trials of cholesterol lowering treatments. Studies reviewed: 19 out of 21 eligible trials that had data available on non-illness mortality. Interventions reviewed: Dietary modification, drug treatment, or partial ileal bypass surgery for 1-10 years Main outcome measure: Deaths from suicides, accidents, and violence in treatment groups compared with control groups. Results: Across all trials, the odds ratio of non-illness mortality in the treated groups, relative to control groups, was 1.18 (95% confidence interval 0.91 to 1.52; P=0.20). The odds ratios were 1.28 (0.94 to 1.74; P=0.12) for primary prevention trials and 1.00 (0.65 to 1.55; P=0.98) for secondary prevention trials. Randomised clinical trials using statins did not show a treatment related rise in non-illness mortality (0.84, 0.50 to 1.41; P=0.50), whereas a trend toward increased deaths from suicide and violence was observed in trials of dietary interventions and non-statin drugs (1.32, 0.98 to 1.77; P=0.06). No relation was found between the magnitude of cholesterol reduction and non-illness mortality (P=0.23). Conclusion: Currently available evidence does not indicate that non-illness mortality is increased significantly by cholesterol lowering treatments. A modest increase may occur with dietary interventions and non-statin drugs.

Objective To examine the association of state income inequality and individual household income with the mental and physical health of women with young children. Design Cross sectional study. Individual level data (outcomes, income, and other sociodemographic covariates) from a 1991 follow up survey of a birth cohort established in 1988. State level income inequality calculated from the income distribution of each state from 1990 US census. Setting United States, 1991. Participants Nationally representative stratified random sample of 8060 women who gave birth in 1988 and were successfully contacted (89%) in 1991. Main outcome measures Depressive symptoms (Center for Epidemiologic Studies depression score > 15) and self rated health Results 19% of women reported depressive symptoms, and 7.5% reported fair or poor health. Compared with women in the highest fifth of distribution of household income, women in the lowest fifth were more likely to report depressive symptoms (33% v 9%, P < 0.001) and fair or poor health (15% v 2%, P < 0.001). Compared with low income women in states with low income inequality, low income women in states with high income inequality had a higher risk of depressive symptoms (odds ratio 1.6, 95% confidence interval 1.0 to 2.6) and fair or poor health (1.8, 0.9 to 3.5). Conclusions High income inequality confers an increased risk of poor mental and physical health, particularly among the poorest women. Both income inequality and household income are important for health in this population.

Objectives: To study whether fracture risk before and after surgery was increased in patients with primary hyperparathyroidism. Design: Cohort study. Setting: Three Danish university hospitals. Participants: 674 consecutive patients with primary hyperparathyroidism (median age 61, range 13–89 years) operated on during the period 1 January 1979 to 31 December 1997; 2021 age and sex matched controls from national patient register. Main outcome measure: Fractures. Results: The cases had an increased relative rate of fractures compared with the controls before surgery (1.8, 95% confidence interval 1.3 to 2.3) but not after surgery (1.0, 0.8 to 1.3). The risk of fracture was increased for the vertebrae (3.5, 1.3 to 9.7), the distal part of the lower leg and ankles (2.3, 1.2 to 4.3), and the non-distal part of the forearm (4.0, 1.5 to 10.6) before surgery but not after. The increase in risk of fracture began about 10 years before surgery. Risk peaked 5–6 years before surgery and remained raised, although at a lower level, in the five years immediately before surgery. A small increase in risk of fracture of the distal forearm emerged more than 10 years after surgery (2.9, 1.3 to 6.7). Conclusions: Risk of fracture is increased up to 10 years before surgery in patients with primary hyperparathyroidism. The risk returns to normal after surgery.

Objectives: To describe changes in the prevalence of cigarette smoking in the middle income country of Mauritius from 1987 to 1998, and to relate these changes to legislative and health promotion efforts over the same period. Design: Questionnaire survey. Setting: Mauritius, an island in the Indian Ocean with a population of about 1.2 million (about 70% south Asian, 2% Chinese, and 28% Creole). Participants: Data were obtained from 5072 participants in 1987, 6573 in 1992, and 6281 in 1998. Main outcome measures: Prevalence of current smoking in 1987, 1992, and 1998, sales of cigarettes in Mauritius, and information on activities for control of tobacco. Results: Self reported cigarette smoking has been decreasing in Mauritius since 1987, with the largest decrease between 1987 and 1992. From 1987 to 1998 smoking prevalence decreased by 23% in men and 61% in women. Smoking decreased across all age and ethnic groups and across different levels of income and education. Sales of cigarettes also decreased in line with smoking prevalence. Conclusions: The introduction of cigarette taxes, a limited health promotion programme, and the absence of massive promotional campaigns by the sole tobacco company on Mauritius have led to a striking and continued decrease in smoking prevalence and cigarette consumption on the island.

Objective and design: To relate UK national trends since 1950 in smoking, in smoking cessation, and in lung cancer to the contrasting results from two large case-control studies centred around 1950 and 1990. Setting: United Kingdom. Participants: Hospital patients under 75 years of age with and without lung cancer in 1950 and 1990, plus, in 1990, a matched sample of the local population: 1465 case-control pairs in the 1950 study, and 982 cases plus 3185 controls in the 1990 study. Main outcome measures: Smoking prevalence and lung cancer. Results: For men in early middle age in the United Kingdom the prevalence of smoking halved between 1950 and 1990 but the death rate from lung cancer at ages 35–54 fell even more rapidly, indicating some reduction in the risk among continuing smokers. In contrast, women and older men who were still current smokers in 1990 were more likely than those in 1950 to have been persistent cigarette smokers throughout adult life and so had higher lung cancer rates than current smokers in 1950. The cumulative risk of death from lung cancer by age 75 (in the absence of other causes of death) rose from 6% at 1950 rates to 16% at 1990 rates in male cigarette smokers, and from 1% to 10% in female cigarette smokers. Among both men and women in 1990, however, the former smokers had only a fraction of the lung cancer rate of continuing smokers, and this fraction fell steeply with time since stopping. By 1990 cessation had almost halved the number of lung cancers that would have been expected if the former smokers had continued. For men who stopped at ages 60, 50, 40, and 30 the cumulative risks of lung cancer by age 75 were 10%, 6%, 3%, and 2%. Conclusions: People who stop smoking, even well into middle age, avoid most of their subsequent risk of lung cancer, and stopping before middle age avoids more than 90% of the risk attributable to tobacco. Mortality in the near future and throughout the first half of the 21st century could be substantially reduced by current smokers giving up the habit. In contrast, the extent to which young people henceforth become persistent smokers will affect mortality rates chiefly in the middle or second half of the 21st century.

Objective: To determine the frequency of disability in young people and adults admitted to hospital with a head injury and to estimate the annual incidence in the community. Design: Prospective, hospital based cohort study, with one year follow up of sample stratified by coma score. Setting: Five acute hospitals in Glasgow. Subjects: 2962 patients (aged 14 years or more) with head injury; 549 (71%) of the 769 patients selected for follow up participated. Main outcome measures: Glasgow outcome scale and problem orientated questionnaire. Results: Survival with moderate or severe disability was common after mild head injury (47%, 95% confidence interval 42% to 52%) and similar to that after moderate (45%, 35% to 56%) or severe injury (48%, 36% to 60%). By extrapolation from the population identified (90% of whom had mild injuries), it was estimated that annually in Glasgow (population 909 498) 1400 young people and adults are still disabled one year after head injury. Conclusion: The incidence of disability in young people and adults admitted with a head injury is higher than expected. This reflects the high rate of sequelae previously unrecognised in the large number of patients admitted to hospital with an apparently mild head injury.

To investigate the influence of weight reduction on obese patients with asthma.Open study, two randomised parallel groups.Private outpatients centre, Helsinki, Finland.Two groups of 19 obese patients with asthma (body mass index (kg/m(2)) 30 to 42) recruited through newspaper advertisements.Supervised weight reduction programme including 8 week very low energy diet.Body weight, morning peak expiratory flow (PEF), forced vital capacity (FVC), forced expiratory volume in one second (FEV(1)); and also asthma symptoms, number of acute episodes, courses of oral steroids, health status (quality of life).At the end of the weight reducing programme, the participants in the treatment group had lost a mean of 14.5% of their pretreatment weight, the controls 0.3%. The corresponding figures after one year were 11.3% and a weight gain of 2.2%. After the 8 week dieting period the difference in changes in percentage of predicted FEV(1) from baseline in the treatment and control groups was 7.2% (95% confidence interval 1.9% to 12.5%, P=0. 009). The corresponding difference in the changes in FVC was 8.6% (4. 8% to 12.5%, P0.0001). After one year the differences in the changes in the two groups were still significant: 7.6% for FEV(1) (1. 5% to 13.8%, P=0.02) and 7.6% for FVC (3.5% to 11.8%, P=0.001). By the end of the weight reduction programme, reduction in dyspnoea was 13 mm (on a visual analogue scale 0 mm to 100 mm) in the treatment group and 1 mm in the control group (P=0.02). The reduction of rescue medication was 1.2 and 0.1 doses respectively (P=0.03). After one year the differences in the changes between the two groups were -12 for symptom scores (range -1 to -22, P=0.04) and -10 for total scores (-18 to -1, P=0.02). The median number of exacerbations in the treatment group was 1 (0-4) and in the controls 4 (0-7), P=0.001.Weight reduction in obese patients with asthma improves lung function, symptoms, morbidity, and health status.

To examine the accuracy of a new version of the Sheffield table designed to aid decisions on lipids screening and detect thresholds for risk of coronary heart disease needed to implement current guidelines for primary prevention of cardiovascular disease.Comparison of decisions made on the basis of the table with absolute risk of coronary heart disease or cardiovascular disease calculated by the Framingham risk function. The decisions related to statin treatment when coronary risk is/=30% over 10 years; aspirin treatment when the risk is/=15% over 10 years; and the treatment of mild hypertension when the cardiovascular risk is/=20% over 10 years.The table is designed for use in general practice.Random sample of 1000 people aged 35-64 years from the 1995 Scottish health survey.Sensitivity, specificity, and positive and negative predictive values of the table.13% of people had a coronary risk of/=15%, and 2. 2% a risk of/=30%, over 10 years. 22% had mild hypertension (systolic blood pressure 140-159 mm Hg). The table indicated lipids screening for everyone with a coronary risk of/=15% over 10 years, for 95% of people with a ratio of total cholesterol to high density lipoprotein cholesterol of/=8.0, but for50% with a coronary risk of5% over 10 years. Sensitivity and specificity were 97% and 95% respectively for a coronary risk of/=15% over 10 years; 82% and 99% for a coronary risk of/=30% over 10 years; and 88% and 90% for a cardiovascular risk of/=20% over 10 years in mild hypertension.The table identifies all high risk people for lipids screening, reduces screening of low risk people by more than half, and ensures that treatments are prescribed appropriately to those at high risk, while avoiding inappropriate treatment of people at low risk.

Objective: To evaluate the relation between midline episiotomy and postpartum anal incontinence. Design: Retrospective cohort study with three study arms and six months of follow up. Setting: University teaching hospital. Participants: Primiparous women who vaginally delivered a live full term, singleton baby between 1 August 1996 and 8 February 1997: 209 who received an episiotomy; 206 who did not receive an episiotomy but experienced a second, third, or fourth degree spontaneous perineal laceration; and 211 who experienced either no laceration or a first degree perineal laceration. Main outcome measures: Self reported faecal and flatus incontinence at three and six months postpartum. Results: Women who had episiotomies had a higher risk of faecal incontinence at three (odds ratio 5.5, 95% confidence interval 1.8 to 16.2) and six (3.7, 0.9 to 15.6) months postpartum compared with women with an intact perineum. Compared with women with a spontaneous laceration, episiotomy tripled the risk of faecal incontinence at three months (95% confidence interval 1.3 to 7.9) and six months (0.7 to 11.2) postpartum, and doubled the risk of flatus incontinence at three months (1.3 to 3.4) and six months (1.2 to 3.7) postpartum. A non-extending episiotomy (that is, second degree surgical incision) tripled the risk of faecal incontinence (1.1 to 9.0) and nearly doubled the risk of flatus incontinence (1.0 to 3.0) at three months postpartum compared with women who had a second degree spontaneous tear. The effect of episiotomy was independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour. Conclusions: Midline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence.

Objectives: To investigate the association between suicide and area based measures of deprivation and social fragmentation. Design: Ecological study. Setting: 633 parliamentary constituencies of Great Britain as defined in 1991. Main outcome measures: Age and sex specific mortality rates for suicide and all other causes for 1981-92. Results: Mortality from suicide and all other causes increased with increasing Townsend deprivation score, social fragmentation score, and abstention from voting in all age and sex groups. Suicide mortality was most strongly related to social fragmentation, whereas deaths from other causes were more closely associated with Townsend score. Constituencies with absolute increases in social fragmentation and Townsend scores between 1981 and 1991 tended to have greater increases in suicide rates over the same period. The relation between change in social fragmentation and suicide was largely independent of Townsend score, whereas the association with Townsend score was generally reduced after adjustment for social fragmentation. Conclusions: Suicide rates are more strongly associated with measures of social fragmentation than with poverty at a constituency level. Key messages Place of residence may affect health, and mortality from most common diseases tends to be higher in areas characterised by low socioeconomic position Research dating back over 100 years suggests that social fragmentation may influence suicide In the 1980s and 1990s, parliamentary constituencies with high levels of social fragmentation had high rates of suicide, independent of deprivation Constituencies with the greatest increases in social fragmentation between 1981 and 1991 also had the greatest increases in suicide rates over the same period Any targeting of suicide prevention may be more effective if aimed at socially fragmented rather than deprived areas

Objective: To study the influence of zygosity on the metabolic variables involved in the pathophysiology of type 2 diabetes. Design: Population based cross sectional study. Setting: Odense University Hospital, Denmark Participants: 125 monozygotic twin pairs and 178 dizygotic twin pairs of the same sex born between 1921 and 1940. Main outcome measures: Clinical characteristics of monozygotic and dizygotic twins with or without a family history of type 2 diabetes Results: Absolute prevalences of type 2 diabetes and impaired glucose tolerance according to the World Health Organisation criteria were similar in both the monozygotic and the dizygotic twins as were measurements of height, weight, body mass index, waist to hip ratio, and fasting plasma glucose and insulin concentrations. During the oral glucose tolerance test, monozygotic twins had a higher incremental plasma insulin area under the curve than dizygotic twins (10.05 (SD 0.68) v 9.89 (0.72) pmol/l×minutes, P Conclusion: Zygosity influences both plasma glucose and plasma insulin concentrations during an oral glucose tolerance test. This supports an intrauterine influence on glucose homeostasis and perhaps on insulin resistance in humans. Key messages Zygosity affects glucose homeostasis and insulin resistance but has no influence on body weight and fat distribution Differences in glucose metabolism between monozygotic and dizygotic twins are independent of a family history of type 2 diabetes The validity of causal conclusions from classic twin studies may be questioned

Objective: To examine the outcome of a population of long stay psychiatric patients resettled in the community. Design: Prospective study with 5 year follow up. Setting: Over 140 residential settings in north London. Subjects: 670 long stay patients from two London hospitals (Friern and Claybury) discharged to the community from 1985 to 1993. Main outcome measures: Continuity and quality of residential care, readmission to hospital, mortality, crime, and vagrancy. Results: Of the 523 patients who survived the 5 year follow up period, 469 (89.6%) were living in the community by the end of follow up, 310 (59.2%) in their original community placement. A third (210) of all patients were readmitted at least once. Crime and homelessness presented few problems. Standardised mortality ratios for the group were comparable with those reported for similar populations. Conclusions: When carefully planned and adequately resourced, community care for long stay psychiatric patients is beneficial to most individuals and has minimal detrimental effects on society. Key messages Replacing a psychiatric hospital with full residential facilities in the community has worked well for most long stay psychiatric patients Recurrent and sporadic readmissions to hospital are inevitable for high risk patients regardless of their living conditions Fears are unfounded that former hospital inmates are destined to neglect, high mortality, and homelessness, or that they pose a threat to the public

Objectives: To relate alcohol consumption to mortality. Design: Prospective cohort study. Setting: 27 workplaces in the west of Scotland. Participants: 5766 men aged 35-64 when screened in 1970-3 who answered questions on their usual weekly alcohol consumption. Main outcome measures: Mortality from all causes, coronary heart disease, stroke, and alcohol related causes over 21 years of follow up related to units of alcohol consumed per week. Results: Risk for all cause mortality was similar for non-drinkers and men drinking up to 14 units a week. Mortality risk then showed a graded association with alcohol consumption (relative rate compared with non-drinkers 1.34 (95% confidence interval 1.14 to 1.58) for 15-21 units a week, 1.49 (1.27 to 1.75) for 22-34 units, 1.74 (1.47 to 2.06) for 35 or more units). Adjustment for risk factors attenuated the increased relative risks, but they remained significantly above 1 for men drinking 22 or more units a week. There was no strong relation between alcohol consumption and mortality from coronary heart disease after adjustment. A strong positive relation was seen between alcohol consumption and risk of mortality from stroke, with men drinking 35 or more units having double the risk of non-drinkers, even after adjustment. Conclusions: The overall association between alcohol consumption and mortality is unfavourable for men drinking over 22 units a week, and there is no clear evidence of any protective effect for men drinking less than this.

Objective: To evaluate the influence of preoperative abstinence on postoperative outcome in alcohol misusers with no symptoms who were drinking the equivalent of at least 60 g ethanol/day. Design: Randomised controlled trial. Setting: Copenhagen, Denmark. Subjects: 42 alcoholic patients without liver disease admitted for elective colorectal surgery. Interventions: Withdrawal from alcohol consumption for 1month before operation (disulfiram controlled) compared with continuous drinking. Main outcome measures: Postoperative complications requiring treatment within the first month after surgery. Perioperative immunosuppression measured by delayed type hypersensitivity; myocardial ischaemia and arrhythmias measured by Holter tape recording; episodes of hypoxaemia measured by pulse oximetry. Response to stress during the operation were assessed by heart rate, blood pressure, serum concentration of cortisol, and plasma concentrations of glucose, interleukin 6, and catecholamines. Results: The intervention group developed significantly fewer postoperative complications than the continuous drinkers (31% v 74%, P=0.02). Delayed type hypersensitivity responses were better in the intervention group before (37 mm2v 12 mm2, P=0.04), but not after surgery (3 mm2v 3 mm2). Development of postoperative myocardial ischaemia (23% v 85%) and arrhythmias (33% v 86%) on the second postoperative day as well as nightly hypoxaemic episodes (4 v 18 on the second postoperative night) occurred significantly less often in the intervention group. Surgical stress responses were lower in the intervention group (P≤0.05). Conclusions: One month of preoperative abstinence reduces postoperative morbidity in alcohol abusers. The mechanism is probably reduced preclinical organ dysfunction and reduction of the exaggerated response to surgical stress.

Objective: To describe the clinical circumstances in which psychiatric patients commit suicide. Design: National clinical survey. Setting: England and Wales. Subjects: A two year sample of people who had committed suicide, in particular those who had been in contact with mental health services in the 12 months before death. Main outcome measures: Proportion of suicides in people who had had recent contact with mental health services; proportion of suicides in inpatients; proportion of people committing suicide and timing of suicide within three months of hospital discharge; proportion receiving high priority under the care programme approach; proportion who were recently non-compliant and not attending. Results: 10 040 suicides were notified to the study between April 1996 and March 1998, of whom 2370 (24%; 95% confidence interval 23% to 24%) had had contact with mental health services in the year before death. Data were obtained on 2177, a response rate of 92%. In general these subjects had broad social and clinical needs. Alcohol and drug misuse were common. 358 (16%; 15% to 18%) were psychiatric inpatients at the time of death, 21% (17% to 25%) of whom were under special observation. Difficulties in observing patients because of ward design and nursing shortages were both reported in around a quarter of inpatient suicides. 519 (24%; 22% to 26%) suicides occurred within three months of hospital discharge, the highest number occurring in the first week after discharge. 914 (43%; 40% to 44%) were in the highest priority category for community care. 488 (26% excluding people whose compliance was unknown; 24% to 28%) were non-compliant with drug treatment while 486 (28%; 26% to 30%) community patients had lost contact with services. Most people who committed suicide were thought to have been at no or low immediate risk at the final service contact. Mental health teams believed suicide could have been prevented in 423 (22%; 20% to 24%) cases. Conclusions: Several suicide prevention measures in mental health services are implied by these findings, including measures to improve compliance and prevent loss of contact with services. Inpatient facilities should remove structural difficulties in observing patients and fixtures that can be used in hanging. Prevention of suicide after discharge may require earlier follow up in the community. Better suicide prevention in psychiatric patients is likely to need measures to improve the safety of mental health services as a whole, rather than specific measures for people known to be at high risk.

Objective : To compare tacrolimus with cyclosporin for immunosuppression in renal transplantation. Design : Meta-analysis of randomised trials of two treatments after kidney transplantation. Identification : Four studies involving 1037 patients. Trials were included if they were randomised, the intervention group received tacrolimus, the control group received cyclosporin, the patients were followed for a minimum of 12 months, and patient survival, graft survival, incidence of acute rejection, need for antilymphocyte treatment, or the prevalence of diabetes mellitus after transplant was reported. Main outcome measures : Pooled estimates of patient mortality, allograft loss, and episodes of acute rejection 1 year after transplantation. Results : The odds ratio for loss of allograft with tacrolimus compared with cyclosporin was 0.95 (95% confidence interval 0.65 to 1.40). The odds ratio for mortality with tacrolimus was 1.07 (0.47 to 2.48). Treatment with tacrolimus was associated with a reduction in episodes of acute rejection (0.52; 0.36 to 0.75), a reduction in the use of antilymphocyte antibodies to treat rejection (0.37; 0.25 to 0.56), and an increased prevalence of diabetes mellitus after transplantation (5.03; 2.04 to 12.36) compared with treatment with cyclosporin. Conclusions : After renal transplantation, immunosuppression with tacrolimus results in a significant reduction in acute rejection compared with cyclosporin. Follow up studies of high methodological quality are needed to determine whether tacrolimus improves long term renal graft survival.

To identify ethnic differences in the incidence of first ever stroke.A prospective community stroke register (1995-6) with multiple notification sources. Pathological classification of stroke in all cases was based on brain imaging or necropsy data. Rates were standardised to European and world populations and adjusted for age, sex, and social class in multivariate analysis.A multi-ethnic population of 234 533 in south London, of whom 21% are black.612 strokes were registered. The crude annual incidence rate was 1.3 strokes per 1000 population per year (95% confidence interval 1.20 to 1.41) and 1.25 per 1000 population per year (1.15 to 1.35) age adjusted to the standard European population. Incidence rates adjusted for age and sex were significantly higher in black compared with white people (P0.0001), with an incidence rate ratio of 2.21 (1.77 to 2.76). In multivariable analysis increasing age (P0.0001), male sex (P0.003), black ethnic group (P0.0001), and lower social class (P0.0001) in people aged 35-64 were independently associated with an increased incidence of stroke.Incidence rates of stroke are higher in the black population; this is not explained by confounders such as social class, age, and sex. Ethnic differences in genetic, physiological, and behavioural risk factors for stroke require further elucidation to aid development of effective strategies for stroke prevention in multi-ethnic communities.

Financial relationships among industry and academic institutions are diverse and common.1 These interests can influence authors' conclusions2 and readers' perceptions of published studies.3 We report the effects on reader perceptions of different statements of competing interests for two manuscripts. We used computer generated random numbers from the British Medical Association's membership database (to select 900 BMJ readers). We randomised 450 to be sent a paper about the use of problem lists in letters between hospital doctors and general practitioners4 (problem lists paper) and 450 to be sent a paper indicating that the impact of pain from herpes zoster on patients' daily functioning may be substantial (herpes paper).5 We previously reported a study using the herpes paper,3 and we have incorporated the results from that study in this paper. For each of the papers, 150 readers received the paper with no competing interests declared, 150 with a financial statement, and 150 with a statement that the author was a recipient of funding for studentships and research grants. The competing interest statements for each group were as follows. For both papers, when the type of competing interest was “none,” the phrasing of …

Objective :To compare the effect of pelvic floor exercises, electrical stimulation,vaginal cones, and no treatment for genuine stress incontinence. Design :Stratified, single blind, randomised controlled trial. Setting :Multicentre. Participants : 107 women with clinically and urodynamically proved genuine stress incontinence. Mean (range) age was 49.5 (24-70) years, and mean (range) duration of symptoms 10.8 (1-45) years. Interventions : Pelvic floor exercise (n=25) comprised 8-12 contractions 3 times a day and exercise in groups with skilled physical therapists once a week. The electrical stimulation group (n=25) used vaginal intermittent stimulation with the MS 106 Twin at 50 Hz 30 minutes a day. The vaginal cones group (n=27) used cones for 20 minutes a day. The untreated control group (n=30) was offered the use of a continence guard. Muscle strength was measured by vaginal squeeze pressure once a month. Main outcome measures : Pad test with standardised bladder volume, and self report of severity. Results :Improvement in muscle strength was significantly greater (P=0.03) after pelvic floor exercises (11.0 cm H 2 O (95% confidence interval 7.7 to 14.3) before v 19.2 cm H 2 O (15.3 to 23.1) after) than either electrical stimulation (14.8 cm H 2 O (10.9 to 18.7) v 18.6 cm H 2 O (13.3 to 23.9)) or vaginal cones (11.8 cm H 2 O (8.5 to 15.1) v 15.4 cm H 2 O (11.1 to 19.7)). Reduction in leakage on pad test was greater in the exercise group (−30.2 g; −43.3 to 16.9) than in the electrical stimulation group (−7.4 g; −20.9 to 6.1) and the vaginal cones group (−14.7 g; −27.6 to −1.8). On completion of the trial one participant in the control group, 14 in the pelvic floor exercise group, three in the electrical stimulation group, and two in the vaginal cones group no longer considered themselves as having a problem. Conclusion : Training of the pelvic floor muscles is superior to electrical stimulation and vaginal cones in the treatment of genuine stress incontinence.

Objective: To define the relations between age, sex, lower limb symptoms, and the presence of trunk varicose veins on clinical examination. Design: Cross sectional population study. Setting: 12 general practices with catchment areas geographically and socioeconomically distributed throughout Edinburgh. Participants: An age stratified random sample of 1566 people (699 men and 867 women) aged 18-64 selected from the computerised age-sex registers of participating practices. Main outcome measures: Self administered questionnaire on the presence of lower limb symptoms and physical examination to determine the presence and severity of varicose veins. Results: Women were significantly more likely than men to report lower limb symptoms such as heaviness or tension, swelling, aching, restless legs, cramps, and itching. The prevalence of symptoms tended to increase with age in both sexes. In men, only itching was significantly related to the presence and severity of trunk varices (linear test for trend, P=0.011). In women there was a significant relation between trunk varices and the symptoms of heaviness or tension (P 0.001), aching (P 0.001), and itching (P 0.005). However, the level of agreement between the presence of symptoms and trunk varices was too low to be of clinical value, especially in men. Conclusions: Even in the presence of trunk varices, most lower limb symptoms probably have a non-venous cause. Surgical extirpation of trunk varices is unlikely to ameliorate such symptoms in most patients.

To determine the prevalence of workplace bullying in an NHS community trust; to examine the association between bullying and occupational health outcomes; and to investigate the relation between support at work and bullying.Questionnaire survey.NHS community trust in the south east of England.Trust employees.Measures included a 20 item inventory of bullying behaviours designed for the study, the job induced stress scale, the hospital anxiety and depression scale, the overall job satisfaction scale, the support at work scale, and the propensity to leave scale.1100 employees returned questionnaires-a response rate of 70%. 421 (38%) employees reported experiencing one or more types of bullying in the previous year. 460 (42%) had witnessed the bullying of others. When bullying occurred it was most likely to be by a manager. Two thirds of the victims of bullying had tried to take action when the bullying occurred, but most were dissatisfied with the outcome. Staff who had been bullied had significantly lower levels of job satisfaction (mean 10.5 (SD 2. 7) v 12.2 (2.3), P0.001) and higher levels of job induced stress (mean 22.5 (SD 6.1) v 16.9 (5.8), P0.001), depression (8% (33) v 1% (7), P0.001), anxiety (30% (125) v 9% (60), P0.001), and intention to leave the job (8.5 (2.9) v 7.0 (2.7), P0.001). Support at work seemed to protect people from some of the damaging effects of bullying.Bullying is a serious problem. Setting up systems for supporting staff and for dealing with interpersonal conflict may have benefits for both employers and staff.

Objective: To assess the relation between male and female medical leadership. Design: Cross sectional study on predictive factors for female medical leadership with data on sex, age, specialty, and occupational status of Norwegian physicians. Setting: Oslo,Norway. Subjects: 13844 non-retired Norwegian physicians. Main outcome measure: Medical leaders, defined as physicians holding a leading position in hospital medicine, public health, aacademic medicine, or private health care. Results: 14.6% (95% confidence interval 14.0% to 15.4%) of the men were leaders compared with 5.1% (4.4% to 5.9%) of the women. Adjusted for age men had a higher estimated probability of leadership in all categories of age and job, the highest being in academic medicine with 0.57(0.42to 0.72) for men aged over 54years compared with 0.39(0.21to 0.63) for women in the same category. Among female hospital physicians there was a positive relation between the proportion of women in their specialty and the probability of leadership. Conclusion: Women do not reach senior positions as easily as men. Medical specialties with high proportions of women have more female leaders.

Objective : To determine the contribution of psychological attributes (personality characteristics and coping styles) to the association between social class in childhood and adult health among men and women. Design : Partly retrospective, partly cross sectional study conducted in the framework of the Dutch GLOBE study. Subjects : Sample of general population from south east Netherlands consisting of 2174men and women aged 25-74years. Baseline self reported data from 1991provided information on childhood and adult social class, psychological attributes, and general health. Main outcome measure : Self rated poor health. Results : Independent of adult social class, low childhood social class was related to self rated poor health (odds ratio 1.67(95% confidence interval 1.02to 2.75) for subjects whose fathers were unskilled manual workers versus subjects whose fathers were higher grade professionals). Subjects whose fathers were manual workers generally had more unfavourable personality profiles and more negative coping styles. External locus of control, neuroticism, and the absence of active problem focused coping explained about half of the association between childhood social class and self rated poor health. The findings were independent of adult social class and height. Conclusions : A higher prevalence of negative personality profiles and adverse coping styles in subjects who grew up in lower social classes explains part of the association between social class in childhood and adult health. This finding underlines the importance of psychological mechanisms in the examination of the negative effects of adverse socioeconomic conditions in childhood.

Objective: To assess the value of carotid endarterectomy for prevention of stroke in patients with asymptomatic carotid stenosis. Design: Systematic review and meta-analysis of randomised controlled trials in patients with asymptomatic carotid stenosis in which subjects were allocated to carotid endarterectomy or to medical treatment alone. Subjects: Five trials enrolled 2440 patients with stenosis 50%. Main outcome measures: Stroke ipsilateral to the stenosis, all strokes, and perioperative complications (stroke or death). Results: In patients who underwent carotid endarterectomy (n=1215) there was a significant reduction in the odds of ipsilateral stroke plus perioperative stroke or death (odds ratio 0.62; 95% confidence interval 0.44 to 0.86), corresponding to a 2% absolute risk reduction over about 3.1 years. The prevalence of stroke in any location was also reduced (0.68; 0.51 to 0.9) in patients undergoing carotid endarterectomy. During the immediate postoperative period there was an increased prevalence of stroke or death among such patients (4.51; 2.36 to 8.64). Conclusion: Carotid endarterectomy in patients with asymptomatic carotid stenosis unequivocally reduces the incidence of ipsilateral stroke, though the absolute benefit is relatively small. Given the modest benefit of surgery for unselected patients with asymptomatic carotid artery stenosis carotid endarterectomy cannot be routinely recommended for these patients pending reliable identification of high risk subgroups, and medical management is a sensible alternative for most patients.

Acute bronchitis is a common disorder1usually assumed to be caused by a viral infection2with no beneficial effect resulting from antibiotic treatment.3 We examined whether acute bronchitis in a healthy individual should be regarded as an isolated event or a predictor of chronic lung disorders that has not yet clearly manifested itself clinically—that is, as bronchial hyperresponsiveness, asthma, or chronic bronchitis. In a previous study on the aetiology of acute bronchitis among adults in Gardabaer (7800 inhabitants), a suburban town south of Reykjavik, all patients diagnosed with acute bronchitis were included.4 The definition of acute bronchitis in that study was: cough (with or without expectoration) and rhonchi or coarse rales on auscultation in patients without any known underlying lung disease (according to the patients' medical records) or clinical signs of pneumonia. That prospective …

OBJECTIVE: To assess the hazards at an early phase of the growing epidemic of deaths from tobacco in China. DESIGN: Smoking habits before 1980 (obtained from family or other informants) of 0.7 million adults who had died of neoplastic, respiratory, or vascular causes were compared with those of a reference group of 0.2 million who had died of other causes. SETTING: 24 urban and 74 rural areas of China. SUBJECTS: One million people who had died during 1986-8 and whose families could be interviewed. MAIN OUTCOME MEASURES: Tobacco attributable mortality in middle or old age from neoplastic, respiratory, or vascular disease. RESULTS: Among male smokers aged 35-69 there was a 51% (SE 2) excess of neoplastic deaths, a 31% (2) excess of respiratory deaths, and a 15% (2) excess of vascular deaths. All three excesses were significant (P/70 there was a 39% (3) excess of neoplastic deaths, a 54% (2) excess of respiratory deaths, and a 6% (2) excess of vascular deaths. Fewer women smoked, but those who did had tobacco attributable risks of lung cancer and respiratory disease about the same as men. For both sexes, the lung cancer rates at ages 35-69 were about three times as great in smokers as in non-smokers, but because the rates among non-smokers in different parts of China varied widely the absolute excesses of lung cancer in smokers also varied. Of all deaths attributed to tobacco, 45% were due to chronic obstructive pulmonary disease and 15% to lung cancer; oesophageal cancer, stomach cancer, liver cancer, tuberculosis, stroke, and ischaemic heart disease each caused 5-8%. Tobacco caused about 0.6 million Chinese deaths in 1990 (0.5 million men). This will rise to 0.8 million in 2000 (0.4 million at ages 35-69) or to more if the tobacco attributed fractions increase. CONCLUSIONS: At current age specific death rates in smokers and non-smokers one in four smokers would be killed by tobacco, but as the epidemic grows this proportion will roughly double. If current smoking uptake rates persist in China (where about two thirds of men but few women become smokers) tobacco will kill about 100 million of the 0.3 billion males now aged 0-29, with half these deaths in middle age and half in old age.

Objectives : To investigate the association between suicide and socioeconomic status, unemployment, and chronic illness. Design : Longitudinal study. Setting : England and Wales. Subjects : Individuals from the Office for National Statistics longitudinal study for whom 1981 census data were available. The longitudinal study is a representative 1% sample of the population of England and Wales in which census variables are linked to mortality data. Main outcome measures : Suicide and undetermined deaths occurring between 1983 and 1992. Odds ratios estimated with logistic regression adjusted for attrition of cohort members. Results : There was a strong independent association between suicide and individuals who were unemployed (odds ratio 2.6; 95% confidence interval 2.0 to 3.4) and permanently sick (2.5; 1.6 to 4.0). Those without access to a car had an increased risk (1.3; 1.0 to 1.5), but other measures of socioeconomic status were not associated with suicide. Conclusions : The association between suicide and unemployment is more important than the association with other socioeconomic measures. Although some potentially important confounders were not adjusted for, the findings support the idea that unemployment or lack of job security increases the risk of suicide and that social and economic policies that reduce unemployment will also reduce the rate of suicide.

Patients' preferences in the provision of health care are an important consideration. Although several studies have investigated patients' preferences for male or female general practitioners,1–3 few studies have considered preference for male or female surgeons, and preference of women for male or female breast surgeons has not been reported. Until recently the small numbers of female consultant surgeons in Britain meant that patients did not have a choice of male or female surgeon. This will change, however, with increasing numbers of female consultants and may have implications for the staffing of specialist breast units. In September 1997 a female consultant surgeon became available at Victoria Infirmary's specialist breast clinic, …

Objective: To determine the long term relative survival of all patients who had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Design:Population based study. Setting:Western Australia. Subjects: All patients who had had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Main outcome measures: Morbidity and mortality data of patients admitted and surgically treated for abdominal aortic aneurysm in Western Australia during 1985-94. Elective, ruptured, and acute non-ruptured cases were analysed separately. Independent analyses for sex and patients aged 80 years or more were also undertaken. Postoperative (>30 days) relative survival was assessed against age and sex matched controls. Results: Overall, 1475 (1257 men, 218 women) cases were identified. The crude five year survival after elective surgery, including deaths within 30 days of surgery, was 79% for both men and women. When compared with a matched population the five year relative survival after elective surgery was 94.9% (95% confidence interval 89.9% to 99.9%) for men but only 88.0% (76.3% to 99.7%) for women. The five year relative survival of those aged 80 years and over was good: 116.6% (89.1% to 144.0%) compared with 92.4% (87.7% to 97.0%) for those under 80 years of age (men and women combined). Cardiovascular disease caused 57.8% of the 341 deaths after 30 days. Conclusion: In a condition such as abdominal aortic aneurysm, which occurs in elderly patients, relative survival is more clinically meaningful than crude survival. The five year relative survival in cases of elective and ruptured abdominal aortic aneurysm was better in men than in women. This is probably because of greater comorbidity in women with abdominal aortic aneurysm and this deserves more attention in the future. The long term survival outcome in octogenarians supports surgery in selected cases.

Objective: To clarify the extent to which working hours affect the risk of acute myocardial infarction, independent of established risk factors and occupational conditions. Design: Case-control study. Setting: University and general hospitals and routine medical examinations at workplaces in Japan. Subjects: Cases were 195 men aged 30-69 years admitted to hospital with acute myocardial infarction during 1990-3. Controls were 331 men matched at group level for age and occupation who were judged to be free of coronary heart diseases at routine medical examinations in the workplace. Main outcome measures: Odds ratios for myocardial infarction in relation to previous mean daily working hours in a month and changes in mean working hours during previous year. Results: Compared with men with mean working hours of >7-9 hours, the odds ratio of acute myocardial infarction (adjusted for age and occupation) for men with working hours of >11 hours was 2.44 (95% confidence interval 1.26 to 4.73) and for men with working hours of 7 hours was 3.07 (1.77 to 5.32). Compared with men who experienced an increase of 1 hour in mean working hours, the adjusted odds ratio of myocardial infarction for men who experienced an increase of >3 hours was 2.53 (1.34 to 4.77). No appreciable change was observed when odds ratios were adjusted for established and psychosocial risk factors for myocardial infarction. Conclusion: There was a U shaped relation between the mean working hours and the risk of acute myocardial infarction. There also seemed to be a trend for the risk of infarction to increase with greater increases in mean working hours.

Objectives : To investigate the impact of the postcoital test on the pregnancy rate among subfertile couples and on the number of other diagnostic tests and treatments. Design : Randomised controlled study. Setting : A university and two non-university teaching hospitals in the Netherlands. Subjects : New couples at infertility clinics, 1 March 1993 to 1 October 1995; randomisation to an intervention group (series of infertility investigations that include the postcoital test) or to a control group (series excluding the test). Main outcome measure : Cumulative pregnancy rate. Results : Of 736 consecutive new couples, 444 fulfilled the inclusion criteria and consented to participate (intervention group, 227; control group, 217). Treatment was given more often in the intervention group than in the control group (54% v 41%; difference 13% (95% confidence interval 4% to 22%)). Yet cumulative pregnancy rates at 24 months in the intervention group (49% (42% to 55%)) and the control group (48% (42% to 55%)) were closely similar (difference 1% (−9.0% to 9.0%)). Conclusion : Routine use of the postcoital test in infertility investigations leads to more tests and treatments but has no significant effect on the pregnancy rate.

Objectives: To estimate the incidence of HIV and hepatitis C virus and risk factors for seroconversion among a cohort of injecting drug users. Design: Retrospective cohort study. Setting: Primary healthcare facility in central Sydney. Subjects: Injecting drug users tested for HIV-1 antibody (n=1179) and antibodies to hepatitis C virus (n=1078) from February 1992 to October 1995. Main outcome measures: Incidence of HIV-1 and hepatitis C virus among seronegative subjects who injected drugs and underwent repeat testing. Demographic and behavioural risk factors for hepatitis seroconversion. Results: Incidence of HIV-1 among 426 initially seronegative injecting drug users was 0.17/100 person years (two seroconversions) compared with an incidence of hepatitis C virus of 20.9/100 person years (31 seroconversions) among 152 injecting drug users initially negative for hepatitis C virus. Incidence of hepatitis C virus among injecting drug users aged less than 20 years was 75.6/100 person years. Independent risk factors for hepatitis C virus seroconversion were age less than 20 years and a history of imprisonment. Conclusions: In a setting where prevention measures have contributed to the maintenance of low prevalence and incidence of HIV-1, transmission of hepatitis C virus continues at extremely high levels, particularly among young injecting drug users. Key messages The prevalence and incidence of hepatitis C virus is high, while the prevalence and incidence of HIV remains low among injecting drug users Young age and history of imprisonment are risk factors for acquisition of hepatitis C virus infection HIV prevention strategies have been relatively ineffective in preventing hepatitis C virus infection in this population The role of imprisonment in the acquisition of hepatitis C infection should be further investigated

Objectives : To determine the demands on healthcare resources caused by different types of illnesses and variation with age and sex. Design: Information on healthcare use was obtained from all 22 healthcare sectors in the Netherlands. Most important sectors (hospitals, nursing homes, inpatient psychiatric care, institutions for mentally disabled people) have national registries. Total expenditures for each sector were subdivided into 21 age groups, sex, and 34 diagnostic groups. Setting: Netherlands, 1994. Main outcome measures: Proportion of healthcare budget spent on each category of disease and cost of health care per person at various ages. Results: After the first year of life, costs per person for children were lowest. Costs rose slowly throughout adult life and increased exponentially from age 50 onwards till the oldest age group (95). The top five areas of healthcare costs were mental retardation, musculoskeletal disease (predominantly joint disease and dorsopathy), dementia, a heterogeneous group of other mental disorders, and ill defined conditions. Stroke, all cancers combined, and coronary heart disease ranked 7, 8, and 10, respectively. Conclusions: The main determinants of healthcare use in the Netherlands are old age and disabling conditions, particularly mental disability. A large share of the healthcare budget is spent on long term nursing care, and this cost will inevitably increase further in an ageing population. Non-specific cost containment measures may endanger the quality of care for old and mentally disabled people. Key messages Little is known about demands for health care outside acute sectors In the Netherlands health costs are strongly age dependent, increasing exponentially after age 50 The five highest healthcare costs are for mental retardation, musculoskeletal disease, dementia, other mental disorders, and ill defined conditions Coronary heart disease, all cancers, and stroke accounted for only 9% of costs The main healthcare costs are for care not cure and costs are likely to increase rapidly in an ageing society

Objective: To detect changes in mortality after surgery, with allowance being made for variations in case mix. Design: Observational study of postoperative mortality from January 1992 to August 1995. Setting: Regional cardiothoracic unit. Subjects: 3983 patients aged 16 and over who had open heart operations. Main outcome measures: Preoperative risk factors and postoperative mortality in hospital within 30 days were recorded for all surgical heart operations. Mortality was adjusted for case mix using a preoperative estimate of risk based on additive Parsonnet factors. The number of operations required for statistical power to detect a doubling of mortality was examined, and control limits at a nominal significance level of P=0.01 for detection of an adverse trend were determined. Results: Total mortality of 7.0% was 26% below the Parsonnet predictor (P Conclusions: Hospital league tables for mortality from heart surgery will be of limited value because year to year differences in death rate can be large (odds ratio 1.5) even when the underlying risk or case mix does not change. Statistical quality control of a single series with adjustment for case mix is the only way to take into account recent performance when informing a patient of the risk of surgery at a particular hospital. If there is an increase in the number of deaths the chances of the next patient surviving surgery can be calculated from the last 16 deaths. Key messages Changes in the patient population affect a hospital9s annual death rate Year to year differences in death rate can be large even when there is no change in the underlying risk or case mix It takes surprisingly many operations before an increase in death rate can be distinguished from random fluctuation A formal inquiry should take place in a hospital if the death rate rises above control limits The chances of the next patient surviving surgery should be calculated using the surgeon9s most recent results

Objective: To investigate the association between social circumstances in childhood and mortality from various causes of death in adulthood. \ud Design: Prospective observational study. \ud Setting: 27 workplaces in the west of Scotland. \ud Subjects: 5645 men aged 35-64 years at the time of examination. \ud Main outcome measures: Death from various causes. \ud Results: Men whose fathers had manual occupations when they were children were more likely as adults to have manual jobs and be living in deprived areas. Gradients in mortality from coronary heart disease, stroke, lung cancer, stomach cancer, and respiratory disease were seen (all PConclusions: Adverse socioeconomic circumstances in childhood have a specific influence on mortality from stroke and stomach cancer in adulthood, which is not due to the continuity of social disadvantage throughout life. Deprivation in childhood influences risk of mortality from coronary heart disease and respiratory disease in adulthood, although an additive influence of adulthood circumstances is seen in these cases. Mortality from lung cancer, other cancer, and accidents and violence is predominantly influenced by risk factors that are related to social circumstances in adulthood.

For about 30 years electrical cardioversion has been routine for converting arrhythmias.1 Whether the application of shocks in the usual dosage is safe is still controversial as minimal myocardial cell injury cannot be excluded.2 If simultaneous muscle damage occurs the measurement of common cardiac markers, especially creatine kinase and its isoenzyme creatine kinase MB, lacks specificity. We therefore also measured the concentration of cardiac troponin T as this is the most sensitive and specific marker to date. Over the past three years in this unit 69 non-selected patients with atrial fibrillation (aged 21-87, mean 63.7 years) underwent elective countershock using a direct current. Serum samples were taken before and 24 hours after cardioversion. The concentrations of cardiac troponin T, …

To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis.Randomised controlled clinical trial with integrated cost minimisation economic evaluation.Rheumatic diseases unit at a teaching hospital between 1994 and 1996.118 consecutive patients with active rheumatoid arthritis randomised to receive either day care or inpatient care.Clinical assessments recorded on admission, discharge, and follow up at 12 months comprised: the health assessment questionnaire, Ritchie articular index, erythrocyte sedimentation rate, hospital anxiety and depression scale, and Steinbrocker functional class. Resource estimates were of the direct and indirect costs relating to treatment for rheumatoid arthritis. Secondary outcome measures (health utility) were ascertained by time trade off and with the quality of well being scale.Both groups had improvement in scores on the health assessment questionnaire and Ritchie index and erythrocyte sedimentation rate after hospital treatment (P0.0001) but clinical outcome did not differ significantly between the groups either at discharge or follow up. The mean hospital cost per patient for day care, 798 Pounds (95% confidence interval 705 Pounds to 888 Pounds), was lower than for inpatient care, 1253 Pounds (1155 Pounds to 1370 Pounds), but this difference was offset by higher community, travel, and readmission costs. The difference in total cost per patient between day care and inpatient care was small (1789 Pounds (1539 Pounds to 2027 Pounds) v 2021 Pounds (1834 Pounds to 2230 Pounds)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (374 Pounds; 639 Pounds to 109 Pounds).Day care and inpatient care for patients with uncomplicated active rheumatoid arthritis have equivalent clinical outcome with a small difference in overall resource cost in favour of day care. The choice of management strategy may depend increasingly on convenience, satisfaction, or more comprehensive health measures reflecting the preferences of patients, providers, and service commissioners.

Objective: To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms. Design: Follow up study. Setting: National Hospital for Neurology and Neurosurgery, London—a secondary and tertiary referral hospital for neurological disorders. Subjects: 73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia). Main outcome measures: Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview—the schedule for affective disorders and schizophrenia—conducted by a psychiatrist. Results: Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up. Conclusions: Unlike Slater9s study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients9 symptoms or disability was found. However, a high level of psychiatric comorbidity existed. Key messages Motor symptoms that remain unexplained medically despite thorough investigation are a common clinical problem, but the emergence of a subsequent organic explanation for these symptoms is rare The prevalence of coexistent affective and anxiety disorders is high and many patients also have a personality disorder Patients with a shorter duration of symptoms and coexistent anxiety or depression are likely to do better at follow up Reinvestigation of these patients is both expensive and potentially dangerous and should be avoided where no clear clinical indication exists

Objective: To evaluate the epidemiology and impact of mortality from chickenpox in England and Wales. Design: Review of death certificates from the Office for National Statistics on which codes for “chickenpox” or “varicella” were mentioned. Further information ascertained from certifying physician. Participants: Those certified as having died from chickenpox in England and Wales, 1995-7. Main outcome measures: Diagnosis and age and sex distributions of deaths from chickenpox. Results: On average, 25 people a year die from chickenpox. Overall case fatality was 9.22 per 100 000 consultations for chickenpox. Adults accounted for 81% of deaths and 19% of consultations. Deaths were twice as common in men as in women. More of those who died were born outside United Kingdom than expected (12% v 4%). Conclusions: Chickenpox is not a mild disease. Deaths in adults are increasing, both in number and proportion. What is already known on this topic Chickenpox can be fatal, especially in immunosuppressed people and adults The age distribution of cases has been shifting upwards for about 30 years What this study adds About 80% of deaths certified as due to chickenpox are due to chickenpox Chickenpox accounts for about 25 deaths annually in England and Wales, more than from measles, mumps, pertussis, and Hib meningitis combined Mortality in adults has been increasing for at least 30 years and now 80% of deaths from chickenpox are in adults Deaths were twice as common in men as in women

To compare the incidence of venous thromboembolism among women taking combined oral contraceptives before and after the October 1995 pill scare.Analysis of General Practice Research Database.United Kingdom, January 1993 to December 1998.Women aged 15-49 taking combined oral contraceptives.Incidence of venous thromboembolism.Use of so called "third generation" combined oral contraceptives fell from 53% during January 1993 to October 1995 to 14% during November 1995 to December 1998. There was no significant change in the incidence of venous thromboembolism between the two periods after age was adjusted for (incidence ratio 1.04, 95% confidence interval 0.78 to 1.39).The findings are not compatible with the assertion that third generation oral contraceptives are associated with a twofold increase in risk of venous thromboembolism compared with older progestogens.In October 1995 the UK Committee on Safety of Medicines advised that combined oral contraceptives (OCs) containing either gestodene or desogestrel were associated with twice the risk of venous thromboembolism compared with older products. This study was conducted to compare the incidence of venous thromboembolism among women taking combined OCs before and after the October 1995 pill scare. Using data from the General Practice Research Database, a total of 304 practices were analyzed. Overall, results show that use of third-generation combined OCs fell from 53% during the period of January 1993 to October 1995 to 14% during the period of November 1995 to December 1998. No significant change was noted in the incidence of venous thromboembolism between the two periods after age was adjusted for (incidence ratio, 1.04; 95% confidence interval, 0.78-1.39). Based on these findings, it is concluded that third-generation OCs are not associated with a twofold increase in risk of venous thromboembolism compared with older progestogens.