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Internal systems for quality and safety were assessed in 89 hospitals in six European states, by external teams using standardised criteria and procedures, as part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) project. The assessments were made primarily to identify the current use of quality management systems in the sample hospitals, and also to demonstrate a potential tool for comparable assessment of hospitals in general. The large majority of the hospitals had a formal, documented infrastructure to manage quality and safety, but a significant minority had no designated mission, programme or coordination. In two-thirds of hospitals, the governing body was active in defining policy and programmes for improvement, and received reports on quality, safety and patient satisfaction at least once a year. The brief on-site assessments identified systematic variations, within and between countries, in structures and processes of governance and to document the uptake of best practice. Unacceptable variations in practice could be reduced, to the benefit of consumers and providers, by developing and publishing basic organisational standards relevant to all European states. The simple assessment criteria designed for this project could be developed into a practical tool for self-assessment, peer review or benchmarking of hospitals across national borders. This assessment, combined with explicit, relevant and achievable standards, could provide a vehicle to promote the voluntary uptake of best practice and consistency in quality and safety among hospitals in Europe.

It is common practice for captive birds to be kept under fluorescent lighting, which typically flickers at either 100Hz (UK) or 120 Hz (USA). Such lighting was developed for human vision and it is thought that birds may be able to detect higher frequencies of flicker than humans. For humans, 100Hz fluorescent lighting has been linked to eyestrain, headaches and migraine, even though this rate of flicker is above the human perceptual flicker-fusion frequency of around 60 Hz. Keeping birds under 100 Hz lighting is therefore potentially detrimental to their welfare. We studied the preferences of wild-caught European starlings, Sturnus vulgaris, for high-frequency (HF, >30 kHz) fluorescent lighting versus conventional low-frequency (LF, 100 Hz) fluorescent lighting. The flicker frequency of the HF lighting would be undetectable to the nervous system of any animal. We also exposed starlings to either HF or LF light for 2 weeks, and investigated the degree of stress caused by each environment by monitoring their behaviour and plasma corticosterone levels. Groups of starlings showed a preference for HF lighting over LF lighting (P < 0.001), which indicates that they can detect a difference between the two lighting conditions and find the HF lighting preferable. However, there were no measurable differences in behaviour or plasma corticosterone levels when the birds were housed under either HF or LF for 2 weeks, thus providing initial evidence that housing starlings under 100Hz lighting may not be detrimental to the welfare of starlings during early captivity. (C) 2003 Elsevier B.V. All rights reserved.

Placental transfer of nutrients and secretion of hormones is essential for normal fetal development.To determine whether biotin supply affects biotin homeostasis, proliferation rates, and progesterone secretion in placenta cells.JAr choriocarcinoma cells were cultured in media containing deficient (25 pmol/L), physiological (250 pmol/L), or pharmacological concentrations (10,000 pmol/L) of biotin for three weeks; markers for biotin homeostasis, proliferation, and hormone secretion were quantified.Biotin concentrations in culture media correlated negatively with expression of the biotin transporter SMVT, as judged by cellular transport rates of biotin, abundance of SMVT protein, and transcriptional activity of SMVT reporter-gene constructs. Notwithstanding this homeostatic mechanism, biotin concentrations in media correlated positively with activities of biotin-dependent propionyl-CoA carboxylase, abundance of biotinylated carboxylases, and with biotinylation of histones. Biotin deficiency was associated with decreased rates of thymidine uptake into JAr cells [pmol thymidine/( 10(6) cells x 24 h)]: 1.6 +/- 0.1 (25 pmol/L biotin) versus 2.3 +/- 0.2 (250 pmol/L biotin) versus 3.7 +/- 0.4 (10,000 pmol/L biotin), suggesting that cell proliferation depends on biotin. Secretion of progesterone was reduced in biotin-deficient cells; this effect was caused by reduced generation of new cells in deficient media rather than by an immediate effect of biotin on progesterone secretion at the singlecell-level.This study provides evidence that choriocarcinoma cells cannot maintain normal activities of biotin-dependent metabolic pathways if biotin concentrations in culture media are low. It is uncertain whether activities of biotin-dependent pathways in placenta affect fetal development in vivo.

Aim: To determine whether image analysis of ploidy status and immunohistochemical analysis of p57 KIP2 (a paternally imprinted, maternally expressed gene) can be used to refine the diagnosis of molar pregnancy. Methods and results: The original histological diagnosis in 40 randomly selected cases of hydatidiform mole was reviewed and confirmed in 38 cases (22 complete moles, 16 partial moles). These cases were anonymized and submitted for further analysis. Tissue from each case was submitted for flow cytometric assessment of DNA ploidy using a FACSort flow cytometer and for automated image cytometric assessment using a novel digital imaging system. Tissue sections from each case were immunostained with a monoclonal mouse antibody to p57 KIP2 . Correlations between the histopathological diagnosis, image cytometry. flow cytometry and p57 KIP2 immunohistochemistry were determined using K statistics. The concordance between histological diagnosis and p57 KIP2 was very good (κ= 0.89). Twenty of the 22 (90.9%) complete moles showed no immunoreactivity for p57 KIP2 . The remaining two cases showed nuclear immunoreactivity in villous cytotrophoblast. In one of these, the pattern of staining resembled that of a partial mole. In the other, the staining pattern supported the diagnosis of a twin molar/non-molar pregnancy. All 16 partial moles were p57 KIP2 immunoreactive. On flow cytometry, all 22 complete moles were diploid and 12/16 partial moles were triploid (the remaining four cases originally diagnosed as partial moles were found to be diploid). On image cytometry, one case originally diagnosed as complete mole was found to contain a triploid population. Thus, by using a combination of image cytometry and p57 KIP2 status we were able to refine the diagnosis of molar pregnancy in five (13%) of the cases studied. Conclusions: Automated image cytometry is a readily performed investigation which is comparable to, but more sensitive than, flow cytometry. Complementary use of ploidy analysis and p57 KIP2 status can now help to distinguish a diploid hydropic miscarriage (p57 KIP2 -positive), diploid complete mole (p57 KIP2 -negative) and triploid partial mole (p57 KIP2 -positive).

Objective We studied the long-term outcomes of intractable anorexia nervosa treated with leukotomy and specialized psychotherapy over 20 years ago. Method All traceable subjects were interviewed using the Eating Disorders Examination (EDE) and the Structured Clinical Interview for DSM-III-R (SCID). They also completed questionnaires. Detailed histories were taken. Results Four of five female subjects were traced. Their cases had been severe, with failure of previous intensive psychotherapy and now with high risk of death from terminal inanition. One patient had committed suicide, whereas the others enjoyed a reasonable quality of life. Persistent core psychopathology was evident, but patients had not succumbed to weight loss. All suffered depression and anxiety-related disorders, but endorsed their treatment, which had allowed sustained weight gain by release of appetitive behavior, provision of a license to change, and alleviation of phobic anxiety, allowing psychotherapeutic engagement. Discussion We argue that these outcomes are relatively favorable and would not have been possible without this latter engagement in specialist psychotherapy to address burgeoning panic at unavoidable weight gain. © 2000 by John Wiley & Sons, Inc. Int J Eat Disord 27: 249–258, 2000.

Summary A third of a million adults in the UK sleepwalk while a million suffer from night terrors. In both conditions the individual is unaware of the fullness of their surroundings and is totally focussed in their concern or activity. Doctors are only likely to become involved if the individual comes to harm or seeks help or if other people are inconvenienced or threatened. The constitutional basis of the disorder is beyond doubt, although the actual expression may be related to stressful life-events resulting from an individual’s personality, relationships and circumstances. Treatment may include the provision of a secure environment, counselling, and the use of benzodiazepines and serotonin re-uptake inhibitors.

A woman aged 80 years had suffered with anorexia nervosa in adolescence and the condition was rekindled after 50 years of remission. The remission was seen in the light of affective disorder and a chronic grief reaction.

Summary The free movement of doctors within the European Community demands harmonization of standards of medical practice and carries major implications of an undergraduate and postgraduate educational kind. These have begun to be addressed by the first three Medical Directives and also by a series of reports produced by the Advisory Committee on Medical Training to the European Community. This Committee was established in 1975 in order to provide informed agreed advice to the Commission. Many tasks remain to be tackled. A system of mutual inspection of the examination processes and standards in Member States should be established. Control must be exercised over the numbers of doctors produced since educational resources, including numbers of patients available for study, are limited. Thus, excellent standards of medical practice can only be developed and maintained if the primacy of clinical skills derived from the study of patients is recognized as essential in this respect. In some Member States at the present time there are many unemployed and therefore presumably deskilled doctors.

It is a paradox that many areas of specialised and highly specialised practice in psychiatry are commonplace within medical practice in general. Problems of mother and baby psychia try, chronic pain, psychiatric aspects of brain injury and related rehabilitation, resistant affective disorder, personality disorder, disor ders of eating, sleeping and sexual dysfunction, all judged to have major psychopathological elements, are ubiquitous, many throughout the life-span. Certain treatment approaches such as behavioural and cognitive psychother apy and family psychotherapy fall into the same category. All of them have generated one or more National Health Service (NHS)services within the UK under the umbrella of psychia try. Some of them impinge on Health of the Nation concerns. Many of them also fall into the realm of human biology rather than neuropathology which is often a more mainstream interest within psychiatry. Yet many of them also significantly overlap with and sometimes un derlie mainstream psychiatric illnesses. The specialised services have a definite stand ing in our College. In contrast, the highly specialised services usually develop under the wing of academic clinical psychiatry and are fragile. A senior clinical academic retires and the service must be picked up by an NHS appointee if it is to survive. These days it must be obviously financially viable for it to stand a chance ofbeing considered it must earn its keep including around 30% for management costs. For those of us working in these apparent fringes, the evidence of the last few years has been depressing. Some highly specialised services have disappeared abruptly before serious consideration could be given to their merits in terms of wider clinical need, profes sional development and other teaching and research potential. If this haemorrhage is to be staunched, then certain steps had best be taken now. A nation-wide identification of existing highly specialised services

Eighteen psychiatric trainees from St George's Hospital were placed in three local general practices for periods of six months each. The aim was to broaden their postgraduate education by an experience of primary care and to test the feasibility of such a scheme. Their assessments of the placement were canvassed by postal questionnaire. All considered the experiment a success but there were a number of problems. Resistance among the trainees was much greater than expected. Some of the relationships in practice posed problems for them and the ongoing demands of their psychiatric training exceeded the practices' expectations. Supervision by the GP trainers was rated very highly and old knowledge returned rapidly.

Within medicine, psychiatry is seen as a specialist subject, especially insofar as it deals with psychosis and other severe mental illness. Accordingly, it is often taught in medical schools alongside other so-called specialist subjects such as paediatrics and obstetrics and gynaecology. These are seen to contrast to generalist subjects such as medicine and surgery, but which them selves are usually taught within the framework of highly specialised firms concentrating on one or two organs or systems within the body. Within psychiatry there are specialist areas of practice. Some of these are recognised formally by our College and by the health service, e.g. child and adolescent psychiatry, psychiatry of addictive behaviour, psychiatry of learning dis ability, and forensic psychiatry. Others are less generally recognised and are more likely to be the consequence of idiosyncratic service or research developments, e.g. disorders of eating, sleeping and sexual function, neuropsychiatry, and puerperal disorders. This applies also to certain treatment approaches. For instance, milieu therapy and behavioural psychotherapy are less universally developed in psychiatric practice within the health service than is dynamic psychotherapy. Paradoxically it is some such categories of highly specialist practice which reflect more commonplace disorders within the general population. Psychiatric teaching to undergraduates often focuses on the major illnesses and their treat ment and management. All students clearly need to know how to identify the major psychoses and to know, in broad terms, about their long-term management, both in respect of compliance problems, and the importance of teamwork, management skills and working in the com munity alongside primary care systems. Psy chiatry provides a most useful and potentially well structured opportunity for medical students to experience working in the community. Medical students also especially need to know in a thorough way about the protean expressions of depression and how to assess suicide risk. However, other subject areas are equally impor tant for the medical student, and psychiatry is often turned to as a discipline that might be able to contribute to and take the lead in such teaching. One such area which psychiatrists themselves have a variety of views about their competence to spearhead in this way is 'communication skills'.

Some of the proposals in Achieving a Balance (DHSS, 1987) seem to have developed with little regard for postgraduate training in psychiatry. In psychiatry it has become common practice for SHO posts to be incorporated in training schemes with registrar posts, allowing several years of overall basic specialist training in preparation for obtaining the MRCPsych. This is in accord with the GMC Education Committee's position (GMC, 1987a) that specialist training can, on the ‘fast track’, follow on immediately from satisfactory completion of pre-registration posts (general clinical training) and full registration. Achieving a Balance states clearly that specialist training begins at registrar level and that any doctors in SHO posts should be receiving further general training. There are few guidelines concerning the necessary nature of such general training.

AIM: To describe various symptoms other than pain among consecutive patients on the waiting list for possible coronary revascularisation in relation to estimated severity of chest pain. DESIGN: All patients were sent a postal questionnaire for symptom evaluation. SUBJECTS: All patients in western Sweden on the waiting list in September 1990 who had been referred for coronary angiography or coronary revascularisation (n = 904). RESULTS: 88% of the patients reported chest pain symptoms that limited their daily activities to a greater or lesser degree. Various psychological symptoms including anxiety and depression were strongly associated with the severity of pain (P < 0.001), as were sleep disturbances (P < 0.001), and dyspnoea and various psychosomatic symptoms (P < 0.001). Nevertheless only 44% of the patients reported chest pain as the major disruptive symptom, whereas the remaining 56% reported uncertainty about the future, fear, or unspecified symptoms as being the most disturbing. CONCLUSIONS: In a consecutive series of patients on the waiting list for possible coronary revascularisation, half the participants reported that uncertainty and fear were more disturbing than chest pain.

The theme of this book is the public's perception, often stigmatising, of mental illnesses and the impact this can have on compliance with pharmacological methods of treatment. This is considered in relation to strategies for tackling stigmatisation and related discrimination against medical

Records of ill people being stigmatised exist over the centuries, especially individuals with mental disorders and related mental health problems. Ingredients of such stigmatisation include a belief that such disorders are often self-inflicted and resistant to change. Also, the perceptions that those with them are dangerous and present major difficulties in social interaction (Hayward & Bright, 1997). Such stigmatisation then takes many behavioural forms, including abuse and social distancing. These same disorders are common and, overall, they comprise the largest group of health problems in the country today. For a century or more the public has been protected by the existence of mental hospitals. With their closure and the emphasis now on community care, public concern seems to be mounting and stigmatisation of those afflicted worsening.

In October 1991 the then Secretary of State for Health, William Waldegrave, appointed Sir Bernard Tomlinson to act as adviser on health services in London. Early on it was agreed that Sir Bernard would also take account of the role of these services in teaching and research. Previous reports have focused on one or other aspect, e.g. the Todd Report (1966) and Flowers Working Party Report (1979) primarily considered teaching and research while the report of the London Health Planning Consortium (1979) mainly addressed provision of services. While the former two reports have been followed by extensive change in the organisation of medical academic activities in London, there has been much less change in health care delivery. For instance, primary care and community care are still seriously deficient in parts of London while high technology hospital based medical practice, sometimes providing a nationwide service, has survived and sometimes continued to develop in an entrepreneurial way. The problem is riven by academic and professional concerns of nationwide relevance and importance.

Medical practice can be reframed in terms of research and teaching, possessing and using the relevant knowledge, skills and attitudes. The doctor's curiosity and the diagnostic challenges of medical practice (and in particular of psychiatry) demand a capacity to think systematically, measure comprehensively and accurately and analyse the information obtained within the consultation as a preamble to management and treatment. The word ‘doctor’ means ‘teacher’ and the same communication skills are essential to both professions. Psychiatric practice is especially dependent upon them. They are also often essential for good clinical research.

Disgust with ‘fatness' and a consequent preoccupation with body weight, coupled with an inability to reduce it to or sustain it at the desired low level, characterizes the abnormal normal weight control syndrome. Individuals remain sexually active in a biological sense and often also socially. Indeed their sexual behaviour may be as impulse ridden as is their eating behaviour, which often comprises phases of massive bingeing coupled with vomiting and/or purgation. The syndrome is unlike frank anorexia nervosa in that the latter involves a regression to a position of phobic avoidance of normal body weight and consequent low body weight control with inhibition of both biological and social sexual activity. In abnormal normal weight control there is a strong and sometimes desperate hedonistic and extrovert element that will often not be denied so long as body weight does not get too low. Individuals nevertheless feel desperately ‘out of control’ and insecure beneath their bravura. The syndrome is much more common in females than in males. There is a clinical overlap with anorexia nervosa and obesity in many cases as the disorder evolves. Depression, stealing, drug dependence (including alcohol) and acute self-poisoning and self-mutilation are common complications. Clinic cases probably only represent the tip of the iceberg of a much more widespread morbidity within the general population. Like anorexia nervosa and for the same reasons the disorder is probably more common than it used to be.

A significant relationship between nocturnal enuresis and motility is demonstrated in a 35 year old male patient who had chronic nocturnal enuresis. After further treatment this relationship disappeared and the enuresis progressively diminished.

Thirty out-patients with severe anorexia nervosa were randomly allocated to either 12 sessions of dietary advice or 12 sessions of combined individual and family psychotherapy. At one-year follow-up both groups showed significant overall improvement, and the dietary advice group showed significant weight gain. A similar mean weight gain for the psychotherapy patients did not reach statistical significance, but this group made significant improvements in sexual and social adjustment.

Although converting-enzyme inhibition is of established value in the management of patients with severe chronic congestive heart failure, troublesome adverse reactions occur frequently during the course of treatment and may cause physicians to interrupt effective therapy. The three most common adverse reactions that are seen in patients with heart failure following treatment with captopril and enalapril (symptomatic hypotension, functional renal insufficiency, hyperkalaemia) are predictable consequences of interfering with the homeostatic functions of the renin-angiotensin system, which evolved millions of years ago to preserve life in sodium-depleted states. It is not surprising, therefore, that these untoward effects can be prevented or reversed by increasing the dietary intake of salt or reducing the dose of concomitantly administered diuretics; their occurrence rarely requires discontinuation of drug therapy. Recognition of this link between sodium balance and the adverse effects of converting-enzyme inhibition is important, because most patients with severe heart failure who experience such untoward reactions can nevertheless be expected to improve clinically during long-term therapy, if effective treatment is not interrupted.

Summary The communication skills basic to good medical practice are, for many of us, unnatural. The authors attempt to address aspects of the matter with particular reference to communication across ethnic boundaries.

Summary Seventeen anorexia nervosa patients were examined dentally and their dietary histories and eating habits studied. Analysis of the data confirmed earlier observations dental deterioration associated with anorexia nervosa. The deterioration included a pattern of enamel dissolution in cases of vomiting, regurgitation, and/or the consumption of large amounts of citrus fruits; and an altered caries response due to abnormal carbohydrate consumption. Despite the patient's probably insistent denial of 'anorectic' eating habits, the general practitioner should consider the existence of anorexia nervosa in the presence of such abnormal features, especially in young women. The relationship of these findings to larger populations with similar eating habits is discussed.

I took up my present appointment at St. George's Hospital Medical School in 1967 and found myself with friendly colleagues and a tradition of undergraduate teaching of psychiatry extending back to the immediate post-war period. This tradition had also been expressed in the textbook Psychological Medicine, written and revised over successive years by Guttman, Curran and Partridge, and in more recent years by Peter Storey, currently a senior colleague here. The book is hallmarked by its clarity of expression and the richness of its clinical observation, and has for long been a favourite with both undergraduates and postgraduates.

Communication is a major aspect of medical practice in such areas as the consultation, counselling, team work, management duties, health education and teaching. Many communication skills essential to the clinical consultation are different from those used in everyday life. They require an understanding of the doctor/patient relationship and of the self as well as of others. They also require a subserving repertoire of specific behavioural skills. The present paper sets out to emphasize this pervasive importance of communication skills in medical practice and to suggest some educational goals and objectives for those skills of particular relevance to the consultation. It describes one attempt to pursue these within the author's own school despite the piecemeal nature of such teaching. In Britain great emphasis is placed on the importance of clinical skills and this is reflected in the priority given to them in the final professional examination, and yet their communication aspects are rarely well defined within the curriculum or directly assessed. The author advocates the teaching and assessment of communication skills as a continuous process throughout undergraduate and postgraduate medical education for clinical practice.

The clinical characteristics of a consecutive series of 36 male anorectics were compared with those of a similar series of 100 female cases. Social class background and mean age of onset were found to be similar as were the majority of clinical features at presentation. Anorexia nervosa was associated with diminished differences between the sexes in terms of physical, experiential and behavioural characteristics directly related to the condition, and in terms of general psychoneurotic characteristics. The condition is one within which the individual is sadly reduced to an existence rooted in the experience, behaviour and impulses of starvation including the impulse to ingest and the consequent defences against this latter propensity and its implication of weight gain. Only the 'choice' of defence relates to premorbid 'personality' characteristics and thereby continues to characterize the individual. Overall the same background and presentation factors in both sexes predict similar outcomes, though a vomiting defence at presentation predicts good outcome for males and poor outcome for females. The condition is very rare in the male and such presentations may help to shed light on its overall nature.

An hypothesis that migraine is the experience of a protective vascular response to cerebral information overload has been explored to a limited extent by examining the association between laterality of the attack and verbal and spatial performances under standard symptom-free conditions. The study was restricted to individuals with unilateral symptoms always presenting on the same side. It emerged that those with classical migraine do not always have prodromata referable to the same side as the pain. Indeed, in the present study, prodromata were almost exclusively referable to the left (dominant) cerebral hemisphere. A subgroup of those with speech disturbances as a feature of the prodromal symptoms was also found to have relatively impaired language abilities on routine testing. It is this finding that lends some support to the hypothesis. The findings also invite the refining proposition that information overload, as defined in the hypothesis, is almost always borne by the dominant (verbal) hemisphere in our species. Such overload might concurrently or sequentially also overtax a suggested limited right hemisphere language capacity, in terms of the hypothesis, accounting for the right-sided pain sometimes presenting in these cases. Otherwise, pain appears to be predominantly left-sided or midline. Perhaps the frequency of this particular syndrome is an indictment of the limitations of language as a basis for communication, as well as reflecting the possibility that most of our stressful transactions and their cerebral processing use a verbal substrate. The results also reveal the need for agreement on rules for classification of laterality in migraine.

Twenty-seven male anorexics have been followed up over 2–20 yr (mean 8 yr) and their outcome assessed. This has been compared with outcome in female patients with similar pictures at presentation ( Burns and Crisp , 1984). Features of the family and personal history and clinical aspects of the disease at presentation were compared with outcome and a number found to be significantly associated with it. Poor relationship with parents during childhood and the absence of normal adolescent sexual behavior and fantasy premorbidly were strongly predictive of a poor outcome. Long duration of illness, previous treatment and greater weight loss during illness were also associated with poor outcome, although no specific dietary behaviour was predictive. The remarkable similarity in outcome pattern between the male and female prompts re-evaluation of some theories of the nature of the role of sexual conflicts in anorexia nervosa.

Rate of weight gain, together with metabolic rate before and after a glucose meal, were studied in a group of 15 female anorexia nervosa patients as their weight was being restored to normal levels. The previously obese anoretic patients gained weight more rapidly, on the same food intake, than those who were of normal weight before their illness began. The increase in metabolic rate (as treatment progressed) was less in the previously obese patients, who also showed a tendency for the metabolic rate to increase less after a glucose meal than the patients with no history of obesity. The thermic effect of glucose was greater in patients with anorexia nervosa than in a comparable control group of six female students.

Psychiatry has expanded rapidly as a medical discipline in the last two decades but has not always been able to recruit sufficient young doctors of ability to its ranks. In view of recent governmental and professional reports on future medical practice we set up a study group comprising members from academic, NHS, sub-specialty, community and in-training psychiatry to examine the present tasks, attractions and constraints within a career in psychiatry and propose possible improvements for further consideration. In marrying these views to foreseeable developments we are sensitive to the requirement to take into account both the needs of the community and the job satisfaction of the future psychiatrist. To this end we indicate briefly our views concerning the attractions that a career in psychiatry currently has for the good graduate and ways in which the provision of interest and stimulation, educationally and professionally, can be increased so as to attract psychiatrists of high calibre both to general adult psychiatry and to areas of the specialist services which are at present unpopular. Finally, we propose a pattern of psychiatric services which we believe will embody both a useful and an attractive specialized job and interesting educational goal for future medical practitioners.

Ninety-six out of 137 consultant psychiatrists working for the majority of their time in the London area outside academic units returned questionnaires concerning attitudes to their work. Analysis of the 88 fully completed questionnaires suggested the existence of four relatively discrete but overlapping patterns of psychiatric practice in the Regions concerned, of which two largely excluded individual psychotherapy. These findings are discussed in relation to the education in psychotherapy of trainee psychiatrists working in mental hospitals.

Ophthalmic outpatients without physical signs have been shown, as a group, to be significantly more anxious and depressed than a control group. They also have a higher incidence of somatic complaints of a kind commonly made by patients with psychiatric 'disorder'. There was a higher incidence of past psychiatric history in the proband group, and they also gave a greater subjective assessment of recent conscious life stress.

SummaryTwenty-seven consecutive male patients suffering from anorexia nervosa were fol lowed-up 2–20 years after presentation; 20 had been treated with an in-patient refeeding/psychotherapy regime. The outcome of the series compared very closely with a similar group of female anorectics: 12 (44%) had a good outcome, stable weight restoration and normal sexual functioning; seven (26%) had an intermediate outcome, and eight (30%) poor (weight more than 15% below normal, and poor or no sexual activity). No patient had died. Good outcome in terms of weight was associated with good psychological and social functioning, while poor outcome was clearly associated with a longer duration of illness, previous treatment, and greater weight-loss during illness, although not with any specific dietary behaviour. Poor relationship with parents during childhood and the absence of normal adolescent sexual behaviour premorbidly were also strongly predictive of poor outcome.

SummaryFor the past fifteen years we have been studying aspects of relationships between sleep, activity, nutrition and mood. This paper comprises a brief statement of some of this research and our views to date.

Summary The Eysenck Personality Inventory, the Middlesex Hospital questionnaire, and forearm blood-flow were used to measure aspects of psychological status in forty-one patients with the irritable bowel syndrome, who were compared in this respect with twenty-five matched psychoneurotic subjects and with a general population. The results show a positive association between psychoneurotic disorder and the irritable bowel syndrome.

Ophthalmologists of intelligence and experience should expect to play an active part in the educational life of their communities, by contributions to medical society programs, by sharing in discussions, or by talks before laymen. The writer or speaker who has no “literary phase” in his makeup will fail to present his testimony with due force. An interest in general literature of the better sort tends toward finer workmanship in medical writings. Robert Louis Stevenson, Michael Foster, and Thomas Henry Huxley are quoted as examples of elegance and clearness. The problems of ophthalmic journalism in the United States are discussed, and emphasis is laid upon the importance for physicians of training in literature and in foreign languages. Abbreviated from an address read before the Chicago Ophthalmological Society, January, 1928.