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Background In low- and middle-income countries (LMIC), it is uncertain whether a “dedicated” approach to integrating mental health care (wherein a community health worker (CHW) has the sole responsibility of delivering mental health care) or a “designated” approach (wherein a CHW provides this service in addition to usual responsibilities) is most effective and cost-effective. This study aims to compare the effectiveness and cost-effectiveness of these two models of service integration relative to treatment as usual (TAU) for improving mental health and chronic disease outcomes among patients with HIV or diabetes. Methods/Design This is a cluster randomised trial. We will randomise 24 primary health care facilities in the Western Cape Province of South Africa to one of three study arms. Within each cluster, we will recruit 25 patients from HIV and 25 from diabetes services for a total sample of 1200 participants. Eligible patients will be aged 18 years or older, take medication for HIV or diabetes, and screen positive on the Alcohol Use Disorder Identification Test for hazardous/harmful alcohol use or depression on the Centre for Epidemiology Scale on Depression. Participants recruited in clinics assigned to the designated or dedicated approach will receive three sessions of motivational interviewing and problem-solving therapy, while those recruited at TAU-assigned clinics will be referred for further assessment. Participants will complete an interviewer-administered questionnaire at baseline, and at 6 and 12 months post-enrolment to assess change in self-reported outcomes. At these end points, we will test HIV RNA viral load for participants with HIV and HbA1c levels for participants with diabetes. Primary outcomes are reductions in self-reported hazardous/harmful alcohol use and risk of depression. Secondary outcomes are improvements in adherence to chronic disease treatment, biomarkers of chronic disease outcomes, and health-related quality of life. Mixed-effect linear regression models will model the effect of the interventions on primary and secondary outcomes. The cost-effectiveness of each approach will be assessed using incremental cost-effectiveness ratios. Discussion Study findings will guide decision-making around how best to integrate mental health counselling into chronic disease care in a LMIC setting. Trial registration Pan African Clinical Trials Registry, Trial registration number: ACTR201610001825403 . Registered 17 October 2016.

Objectives Medication non-adherence is a significant problem in treatment of severe mental disorders and is associated with poor clinical outcomes and increased demand on services. Task-shifting interventions incorporating mobile health may improve adherence in mental health service users in low- and middle-income countries. Seventy-seven participants were recruited from a psychiatric hospital in Cape Town, with 42 randomized to receive the intervention and 35 to treatment as usual. Intervention pairs underwent treatment-partner contracting and psychoeducation, and received monthly text message reminders of clinic appointments. Primary outcomes were intervention acceptability and feasibility. Secondary outcome for efficacy were adherence to clinic visit; relapse; quality of life; symptomatic relief and medication adherence. Results Treatment partner and psychoeducation components were acceptable and feasible. The text message component was acceptable but not feasible in its current form. Efficacy outcomes favoured the intervention but did not reach statistical significance. A treatment-partner intervention is acceptable and feasible in a low- and middle-income setting. Work is needed to ensure that additional components of such interventions are tailored to the local context. Appropriately powered efficacy studies are needed. Trial Registration PACTR PACTR201610001830190, Registered 21 October 2016 (Retrospectively registered)

Clostridium perfringens food poisoning can be fatal in patients with chronic constipation. We report the investigation and management of a probable outbreak of C. perfringens food poisoning among psychiatric patients in Cape Town, South Africa, in 2013.

Bronwyn Myers,1,2 John A Joska,3 Crick Lund,4,5 Naomi S Levitt,6 Christopher C Butler,7 Tracey Naledi,8,9 Peter Milligan,10 Dan J Stein,11,12 Katherine Sorsdahl4 1Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa; 2Division of Addiction Psychiatry, Psychiatry and Mental Health, 3HIV and Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, 4Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; 5Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK; 6Division for Diabetes and Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa; 7Nuffield Department of Primary Care Health Services, Oxford University, Oxford, UK; 8Western Cape Department of Health, Cape Town, South Africa; 9Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; 10KwaZulu-Natal Department of Health, KwaZulu-Natal, South Africa; 11Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; 12SAMRC Unit on Anxiety and Stress Disorders, Cape Town, South Africa Purpose: To describe patient perceptions of the acceptability of integrating mental health counseling within primary care facilities in the Western Cape province of South Africa and their preferences for the way in which this care is delivered. Patients and methods: Qualitative interviews with 30 purposively selected patients receiving treatment for HIV or diabetes within primary care facilities who screened positive for depression using the Center for Epidemiological Studies Depression Scale or hazardous alcohol use through the Alcohol Use Disorders Identification Test. Results: Participants articulated high levels of unmet need for mental health services and strong associations between poor mental health and the challenges of living with a chronic disease. Consequently, they considered it acceptable to offer screening and mental health counseling within the context of chronic disease care. They thought counseling would be highly relevant if it helped patients develop adaptive strategies for coping with stress and negative emotions. Irrespective of chronic disease, patients indicated a preference for lay counselors rather than existing clinicians as potential delivery agents, supporting a task-shared approach to mental health counseling delivery in primary care settings. Some expressed concern about the feasibility of using lay counselors already present in facilities to deliver this service, suggesting that additional counselors might be needed. Conclusion: Findings demonstrate a need for mental health counseling within the context of chronic disease care in South Africa. Task-shared approaches, using lay counselors, seem acceptable to patients – provided counselors are selected to ensure they possess the qualities associated with effective counselors. Findings have informed the design of a task-shared mental health program that is responsive to the preferences of patients with chronic diseases. Keywords: integration, mental health, chronic disease care, counseling preferences, primary health care, South Africa, global mental health, task sharing, alcohol, depression

Background There is a shortage of trained mental health workers in spite of the significant contribution of psychiatric disorders to the global disease burden. Task shifting, through the delegation of health care tasks to less specialised health workers such as community health workers (CHWs), is a promising approach to address the human resource shortage. CHWs in the Western Cape province of South Africa provide comprehensive chronic support which includes that for mental illness, but have thus far not received standardized mental health training. It is unknown whether a structured mental health training programme would be acceptable and feasible, and result improved knowledge, confidence and attitudes amongst CHWs. Methods We developed and piloted a mental health training programme for CHWs, in line with the UNESCO guidelines; the WHO Mental Health Gap Action Programme and the South African National framework for CHW training. In our quasi-experimental (before-after) cohort intervention study we measured outcomes at the start and end of training included: 1) Mental health knowledge, measured through the use of case vignettes and the Mental Health Knowledge Schedule; 2) confidence, measured with the Mental Health Nurse Clinical Confidence Scale; and 3) attitudes, measured with the Community Attitudes towards the Mentally Ill Scale. Knowledge measures were repeated 3 months later. Acceptability data were obtained from daily evaluation questionnaires and a training evaluation questionnaire, while feasibility was measured by participant attendance at training sessions. Results Fifty-eight CHWs received the training, with most (n = 56, 97.0%) attending at least 7 of the 8 sessions. Most participants (n = 29, 63.04%) demonstrated significant improvement in knowledge, which was sustained at 3-months. There was significant improvement in confidence, along with changes in attitude, indicating improved benevolence, reduced social restrictiveness, and increased tolerance to rehabilitation of the mentally ill in the community but there was no change in authoritarian attitudes. The training was acceptable and feasible. Conclusions Mental health training was successful in improving knowledge, confidence and attitudes amongst trained CHWs. The training was acceptable and feasible. Further controlled studies are required to evaluate the impact of such training on patient health outcomes. Trial registration PACTR PACTR201610001834198 , Registered 26 October 2016.

The main purpose of this study was to describe the nature of the relationship between hamstring muscle activity and anterior knee laxity. This was a cross-sectional study. Anterior knee laxity was measured at 133N and manual maximal forces using the KT2000 knee arthrometer, in 8 ACL-injured and 13 uninjured individuals. Electromyographic activity of the lateral hamstrings was measured during laxity testing. Subjects contracted the hamstrings during anterior knee laxity testing at eight predetermined levels of maximal voluntary isometric contraction. Volitional contraction of the lateral hamstrings reduced anterior knee laxity logarithmically for both the 133N and manual maximal tests in both the ACL-injured and uninjured knees. A simple linear regression model, with the log of percentage of maximum lateral hamstrings activity as the sole predictor, explained approximately 70–80 % of the variation in anterior knee laxity. Both ACL-injured and uninjured subjects reduced anterior knee laxity at the same rate with increases in muscle activity. However, initial lateral hamstrings muscle activity had a greater effect on percentage anterior knee laxity scores in the ACL-injured as compared to the uninjured knee. Lateral hamstrings activity reduces anterior knee laxity in a nonlinear manner, whereby the initial lower level of activation produces the greatest change in anterior knee laxity. Therefore, hamstrings muscle activity must be monitored during anterior knee laxity testing.

ObjectiveTo assess understanding of the Department of Health weaning guidelines and weaning influences in a self-selected sample of black and minority ethnic (BME) parents, residing in London.DesignA face-to-face, questionnaire-facilitated survey among Black African, Black Caribbean and South Asian parents.SettingAn opportunistic sample of parents was recruited from Sure Start centres, churches and play groups across key London boroughs.SubjectsThree hundred and forty-nine interviews were included; 107 Black African, fifty-four Black Caribbean, 120 South Asian and sixty-four of Black mixed-race ethnicity.ResultsFifty-two per cent of Black and 66 % of South Asian parents had accurate understanding of the guidelines. Inaccurate knowledge of the guidelines was associated with weaning before 17 weeks (P < 0·001); 36 % of Black Africans and 31 % of Black Caribbeans were weaned before 4 months compared with 16 % of South Asians. All BME groups were most influenced by weaning information from the previous generations of mothers in their families, which was associated with earlier weaning (21·5 (sd 6·5) v. 24·1 (sd 4·2) weeks; F(2,328) = 5·79, P = 0·003), and less so by professional infant feeding advice, which was associated with a later weaning age (23·7 (sd 5·1) v. 20·7 (sd 5·7) weeks; F(1,344) = 34·7, P < 0·001).ConclusionsLack of awareness of the Department of Health weaning guidelines is common among these BME populations, whose weaning behaviour is strongly influenced by informal advice. Further research is necessary to elucidate the influences on weaning in these populations and to facilitate the development of infant feeding support which is salient for BME groups in the UK.

Background Orofacial granulomatosis (OFG) is a chronic granulomatous condition of the mouth, face and lips. Recent work demonstrates a high rate of atopy and silver birch sensitisation from skin prick testing (SPT). Oral allergy syndrome (OAS) is an acute oro-pharyngeal IgE mediated reaction, triggered by foods that cross react with pollens, most commonly silver birch. The aim of this study was to determine if patients with OFG and positive SPT to common OAS associated pollens responded to avoidance of cross reactive foods. Methods Patients with OFG and positive SPT to silver birch, grass, mugwort, ragweed and latex were required to avoid cross reacting foods, for 6 weeks and, in those who responded, for a total of 12 weeks. All had standardized oral examinations and were given severity scores (SS) at each appointment. Results Twenty two of 47 (47%) patients had one or more positive SPT and 13/22 completed 6 weeks on the diet. No difference was seen in SS between weeks 0 (14.62 ± 11.16) and 6 (13.31 ± 10.33; P = 0.656). Six of 14 (43%) had significantly improved SS (week 0; 19.17 ± 12.95, week 6; 10.83 ± 4.99, P = 0.027). Five completed 12 weeks and no further improvement was seen (week 6; 11 ± 5.57, week 12; 10.4 ± 9.94; P = 0.068). Two patients required no further treatments. Conclusions On an intention to treat basis, only 2/14 patients improved and required no further intervention. Whilst this diet cannot be recommended routinely, the improvement seen in some patients raises questions about the role of OAS in patients with OFG.

The UK weaning guidelines recommend the introduction of solid food at or around 6 months. The evidence suggests that knowledge of the guidelines is high, although only a small minority of parents wait until 6 months to wean. The aim of this study was to assess understanding of the UK weaning guidelines in a sample of UK parents and investigate the associations of this understanding with weaning timing, and in comparison to other influencing factors. This study conducted an online survey of UK parents. Eligible participants had weaned a child since the introduction of the current guidelines. Of 3607 participants, 86% accurately understood the guidelines. Eighty-seven per cent of health visitors were reported to have advised weaning at or around 6 months. Knowledge of the guidelines was associated with later weaning (independently of demographic factors) (P < 0.001) but did not ensure compliance: 80% of mothers who weaned before 24 weeks and 65% who weaned before 17 weeks were aware of the guidelines. Younger mothers (P < 0.001), those receiving benefits (P < 0.001), those educated only to 16 (P < 0.001) and minority ethnic groups (P < 0.001) had lower levels of awareness. Poor understanding of the guidelines was the most reliable predictor of early weaning (P = 0.021) together with young maternal age (P = 0.014). Following the baby-led weaning approach was the most reliable predictor of those weaning at 26 weeks, together with the Internet being the most influential source of advice. Understanding of the current weaning guidelines is high and is a key independent predictor of weaning age in this population.

ObjectiveThe aim of the present study was to explore knowledge of the UK weaning guidelines and the sources of weaning advice used by UK first-time mothers.DesignAn online survey of UK parents; analysed using mixed methods.SettingParticipants were recruited from a selection of parenting websites that hosted a link to the survey.SubjectsIn total, 1348 UK first-time mothers were included in the analysis.ResultsKnowledge of the guidelines was high (86 %) and associated with later weaning (P < 0·001), although 43 % of this sample weaned before 24 weeks. The majority of parents used multiple sources of information, the most influential being the health visitor (26 %), the Internet (25 %) and books (18 %). Fifty-six per cent said they received conflicting advice. Younger mothers and those of lower educational attainment were more likely to be influenced by advice from family, which was likely to be to wean earlier. Furthermore, those most influenced by their mother/grandmother were less likely to have accurate knowledge of the guidelines. In this population the Internet was used for weaning advice across all sociodemographic groups and was associated with a later weaning age, independently of sociodemographic factors (P < 0·001). Data from responses to a free-text question are used in illustration.ConclusionsThe study suggests that first-time mothers have a good understanding of the weaning guidelines but seek weaning information from multiple sources, much of which is conflicting. Informal sources of weaning advice appear most influential in younger mothers and those of lower educational attainment, and result in earlier weaning.

Background: Orofacial granulomatosis (OFG) is a rare chronic inflammatory disease of unknown etiology sharing histological features with Crohn's disease (CD). This study aimed to 1) define the clinical presentation of OFG, 2) establish differentiating features for those with CD, 3) examine if onset of OFG is predictive of CD, and 4) establish differentiating features for children. Methods: Data were extracted from medical notes (n = 207) for demographics, clinical features, blood parameters, diagnosis of CD, and treatment's for patients with OFG. Results: Ninety-seven patients (47%) were female. The lips (184/203; 91%) and buccal mucosa (151/203; 74%) were mainly affected. Forty-six (22%) had intestinal CD. Ulcers (24/46; 46% versus 29/159; 15%, P =

ObjectivesTo examine the feasibility and acceptability of integrating a ‘designated’ approach to community health worker (CHW)-delivered mental health counselling (where existing CHWs deliver counselling in addition to usual duties) and a ‘dedicated’ approach (where additional CHWs have the sole responsibility of delivering mental health counselling) into chronic disease care.DesignA feasibility test of a designated and dedicated approach to CHW-delivered counselling and qualitative interviews of CHWs delivering the counselling.SettingFour primary healthcare clinics in the Western Cape, South Africa allocated to either a designated or dedicated approach and stratified by urban/rural status.ParticipantsForty chronic disease patients (20 with HIV, 20 with diabetes) reporting hazardous alcohol use or depression. Interviews with seven CHWs.InterventionThree sessions of structured mental health counselling.Main outcome measuresWe assessed feasibility by examining the proportion of patients who were willing to be screened, met inclusion criteria, provided consent, completed counselling and were retained in the study. Acceptability of these delivery approaches was assessed through qualitative interviews of CHWs.ResultsRegardless of approach, a fair proportion (67%) of eligible patients were willing to receive mental health counselling. Patients who screened positive for depression were more likely to be interested in counselling than those with hazardous alcohol only. Retention in counselling (85%) and the study (90%) was good and did not differ by approach. Both dedicated and designated CHWs viewed the counselling package as highly acceptable but requested additional training and support to facilitate implementation.ConclusionsDedicated and designated approaches to CHW-delivered mental health counselling were matched in terms of their feasibility and acceptability. A comparative efficacy trial of these approaches is justified, with some adjustments to the training and implementation protocols to provide further support to CHWs.

Objective To test the hypothesis that children with sickle cell disease (SCD) who experienced an acute chest syndrome (ACS) hospitalization episode would have worse lung function than children with SCD without ACS episodes. Study design Forced expiratory volume in 1 second (FEV 1 ); forced vital capacity (FVC); FEV 1 /FVC ratio; peak expiratory flow (PEF); forced expiratory flow at 25% (FEF 25 ), 50% (FEF 50 ), and 75% (FEF 75 ) of FVC; airway resistance (Raw); and lung volumes were compared in 20 children with ACS and 20 aged-matched children without ACS (median age, 11 years; range, 6 to 16 years). Fourteen age-matched pairs were assessed before and after bronchodilator use. Results The mean Raw ( P = .03), TLC ( P = .01), and RV ( P = .003) were significantly higher in the group with ACS than in the group without ACS. There were no significant differences in the changes in lung function test results in response to bronchodilator administration between the 2 groups, but the children with ACS had a lower FEF 25 ( P = .04) and FEF 75 ( P = .03) pre–bronchodilator use and a lower mean FEV 1 /FVC ratio ( P = .03) and FEF 75 ( P = .03) post–bronchodilator use. Conclusions Children with SCD who experienced an ACS hospitalization episode had significant differences in lung function compared with those who did not experience ACS episodes. Our results are compatible with the hypothesis that ACS episodes predispose children to increased airway obstruction.

To investigate the effect of different loads of knee extensor open kinetic chain resistance training on anterior knee laxity and function in the ACL-injured (ACLI) knee. Fifty-eight ACLI subjects were randomised to one of three (12-week duration) training groups. The STAND group trained according to a standardised rehabilitation protocol. Subjects in the LOW and HIGH group trained as did the STAND group but with the addition of seated knee extensor open kinetic chain resistance training at loads of 2 sets of 20 repetition maximum (RM) and 20 sets of 2RM, respectively. Anterior knee laxity and measurements of physical and subjective function were performed at baseline, 6 and 12 weeks. Thirty-six subjects were tested at both baseline and 12 weeks (STAND n = 13, LOW n = 11, HIGH n = 12). The LOW group demonstrated a reduction in 133 N anterior knee laxity between baseline and 12 weeks testing when compared to the HIGH and the STAND groups (p = 0.009). Specifically, the trained-untrained knee laxity decreased an average of approximately 5 mm in the LOW group while remaining the same in the other two groups. Twelve weeks of knee extensor open kinetic chain resistance training at loads of 2 sets of 20RM led to a reduction in anterior knee laxity in the ACLI knee. This reduction in laxity does not appear to offer any significant short-term functional advantages when compared to a standard rehabilitation protocol. These results indicate that knee laxity can be decreased with resistance training of the thigh muscles. Randomised controlled trial, Level II.

Previous studies have shown that community-pharmacy– based screening and brief intervention (SBI) for risky alcohol use is feasible. However, few studies have reported significant reductions in alcohol use following pharmacy-delivered BI. In this study, trained pharmacists (N = 29) at 28 community pharmacies in London, UK, offered BI from February-July 2010. Customers seeking alcohol-related medication and/or advice were targeted. Participating pharmacists used Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) scores (≥3 for women and ≥4 for men), a seven-day drinking diary, and feedback on a readiness to change form to identify people with risky drinking and to inform appropriate advice and feedback. One in four community pharmacy customers (n = 246) offered the alcohol BI were initially interested, and half of these (n = 134, 87 of whom were men) received the intervention. Of the 128 customers whose alcohol use was recorded, 16% (n = 21) were classified as high-risk drinkers, 56% (n = 72) as increasingrisk drinkers, and 27% (n = 35) as low-risk drinkers. Three months following BI, low- and increasing-risk drinkers were contacted by a member of the study team to obtain a post-BI AUDIT-C score and to assess past seven-day alcohol consumption. High-risk drinkers were contacted to ascertain whether they had accessed specialty alcohol services. Seventy-five customers were available for follow-up (response rate, 56%). Of the high-risk drinkers, 91% (n = 10) had seen their general practitioner (GP) and/or accessed specialty alcohol services. Increasing-risk drinkers were found to have significantly reduced their weekly consumption (average decrease, 84%; p = 0.004) and number of drinking days (p = 0.05), however, no significant change in AUDIT-C score was observed. As anticipated, no significant differences in consumption were observed for low-risk drinkers. In this study, community-pharmacy–based alcohol SBI was effective in reducing weekly alcohol use among increasing-risk drinkers and facilitated contact between high-risk drinkers and their GPs and/or specialty alcohol treatment services.

The objective of this study was to assess understanding of the weaning guidelines in a cross-sectional sample of UK parents and to investigate how this knowledge, together with other factors, may influence weaning timing. An on-line survey was carried out among 3607 UK parents, recruited from UK parenting web-sites. The survey consisted of twenty-one questions covering understanding of the guidelines, sources of weaning advice, ante-natal care and feeding choices. Ninty-nine percent of respondents were mothers. Sixty-two percentage understood the guidelines to be to introduce solid foods about 6 months, 24 % at 6 months (from 26 weeks), 7 % 4‐6 months, 6 % ‘when your baby showed signs of being ready’ and 1 % were not aware of any guidelines. Knowledge of the guidelines was associated with later weaning (independently of demographic factors) (P < 0.001) but did not ensure compliance as 80 % (n 1220) of mothers who weaned before 24 weeks and 65 % (n 250) who weaned before 17 weeks were aware of the guidelines. At least 70 % across all demographic groups accurately understood the guidelines, however younger mothers (P < 0.001), those receiving benefits (P < 0.001), those only educated to sixteen (P < 0.001) and ethnic minority groups (P < 0.001) were less likely to be aware of the guidelines. ANOVA modelling recognised that those who finished formal education at sixteen, weaned later when they were aware of the guidelines (P = 0.017). Poor understanding of the current weaning guidelines was the most reliable predictor of weaning inappropriately early (before 17 weeks) (P = 0.021, OR 2.52 (1.15‐5.52)) together with young maternal age (P = 0.014, OR 0.96 (0.93‐0.99)). Other factors associated with earlier weaning included low educational attainment*, being a single parent**, weaning in response to the baby waking at night* or not being satisfied by milk* and being most influenced by advice from friends and family** or previous experience*. Later weaning was associated with being influenced by advice from health visitors** and the internet*, attending ante-natal classes**, exclusive breastfeeding 0‐8 weeks* and being a first-time mother**. Following the baby-led weaning approach was the most reliable predictor of those weaning 26 weeks*. (*P < 0.001, ** P < 0.05). The complexity of factors associated with weaning timing was apparent from our analysis. Despite this, accurate knowledge of the recommendation to wean about 6 months is associated with later weaning, particularly among first-time mothers and may compensate for a tendency to wean early among those of lower educational attainment. The popularity of baby-led weaning was highlighted and merits further investigation given the lack of current research on this method of weaning.

Objective: The purpose of this study was to give a detailed description of recovery benchmarks that occur in patients whose therapy after partial meniscectomy knee arthroscopy consists of a home program of exercise. These benchmarks can be used as a basis for clinicians to compare improvements to individual patients who receive supervised care. Design: Thirty-nine patients (five females, mean age = 41) who underwent an uncomplicated arthroscopic partial meniscectomy were included. Test sessions occurred at 5 and 50 days after surgery. Outcome measures included: 1) Hughston Clinic knee self-assessment questionnaire; 2) EQ-5D Tariff for assessment of quality of life; 3) number of days taken to return to work after surgery; 4) knee passive range of motion; and 5) knee swelling assessed by evaluation of knee circumference. Stepwise regression analysis was used to evaluate factors that might have influenced the amount of pre- to posttest change in the outcome measures (the benchmarks) during the first 7 wks after surgery. The factors used in this analysis were: 1) age, 2) body mass index, 3) period from injury to surgery, and 4) the baseline value of the variable to be examined (except for return to work, where we used a score estimating the challenge to the knee offered by work). Results: None of the factors considered (age, body mass index, period from injury to surgery, stressfulness of the work on the knee) affected the number of days taken to return to work. Baseline scores affected change in all the other outcomes, and knee girth change was also affected by body mass index. Regression equations are presented where suitable for the benchmarks presented. Conclusions: Quick recovery occurs in these patients when only a home exercise program is given. This paper highlights the utility of using historical control group data instead of test-retest analysis of measurement error in evaluating patients whose recovery with a home exercise program is rapid. Of the variables analyzed in this study, quality of life and knee self-assessment changes offer the most useful benchmarks for evaluating treatment effectiveness.

Understanding how photoadaptation differs between individuals is important when considering susceptibility to the beneficial and harmful effects of sunlight exposure and when determining optimal phototherapy regimens. Most narrowband UVB (NB-UVB) regimens start with 70% of the minimal erythema dose (MED) with 20% increments at each treatment thereafter. We retrospectively studied 352 skin types I-IV psoriatic patients having twice weekly treatment with this regimen. Patients with high skin types tended to have high MEDs (P0.001). By session 20 the proportion of patients who had developed erythema was approximately 60% regardless of MED. Among patients who developed erythema, the number of treatments before erythema occurred did not differ between skin types (P=0.33). We conclude that patients with high skin types photoadapt approximately equally per physical unit of UVR in comparison to those with low skin types, but they have greater photoadaptation in absolute terms because they are able to tolerate a higher initial dose of radiation. Differences in skin type or MED are not associated with clinically important differences in tendency to erythema during a standard 70/20% NB-UVB twice-weekly regimen. This regimen is suitable for all skin types I-IV patients regardless of skin type or MED.

Lung volumes in healthy children differ according to their ethnic origin. We wished to determine if any differences in the lung volumes of Afro-Caribbean (AC) children from those predicted by Caucasian reference values disappeared if the results were related to sitting height or to 90% or 77% of lung volumes predicted for height from Caucasian reference values based on standing height. We took, as our working hypothesis, that it is inappropriate to use Caucasian reference values to interpret data from Afro-Caribbean children, and that ethnic-specific reference values are required. This was a prospective, observational study. Subjects included 80 AC children with a median age of 9 (range, 4.3–17.8) years. Standing and sitting height were measured. Lung volumes were measured by body plethysmography (total lung capacity, TLCpleth; functional residual capacity, FRCpleth; and vital capacity, VCpleth), helium gas dilution (functional residual capacity, (FRCHe), spirometry (forced expiratory volume in 1 sec, FEV1), and forced vital capacity (FVC). The lung volumes of AC children correlated significantly with standing height, but differed significantly from values predicted from Caucasian reference values based on standing height (P

OBJECTIVE IGF-I and IGF binding protein (IGFBP)-3 levels in man are positively regulated by GH status; in contrast, evidence suggests an inverse relationship between GH status and IGFBP-2. We investigated the effects of somatropin administration on the serum concentrations of these analytes, together with serum and urinary concentrations of GH, to evaluate their potential as markers in the development of a test for detecting doping with GH in sports competitors. DESIGN Somatropin was administered subcutaneously at a dose of 0.15 U/kg bodyweight/day at 1000 h for 3 days to eight healthy men (20–32 years old). MEASUREMENTS Serum concentrations of GH, IGF-I, IGFBP-2 and -3 were determined in blood samples collected at 1600 h on the days prior to (day −1), during (days 0, 1 and 2), and following administration (days 3 and 7). Urine was collected continuously from days −2 to 3 and then on day 7. RESULTS Serum and urinary concentrations of GH were only raised on the days of administration whereas, following cessation of somatropin, the increases in the serum concentrations of IGF-I and IGFBP-3 were sustained for at least 1 day (30 h). Serum IGFBP-2 decreased during the period of administration and was still suppressed on day 3. The concentration ratios of IGFBP-3 to IGFBP-2 and IGF-I to IGFBP-2 increased markedly with administration and both ratios were still significantly augmented compared with basal values 30 h after the last administration. CONCLUSION With acute administration of somatropin to healthy men the serum concentration of IGFBP-2 decreases and the ratios of serum IGF-I/IGFBP-2 and IGFBP-3/IGFBP-2 increase. These ratios should be considered in the development of a test for detecting somatropin administration in sport.

1. How can we maintain a sustainable private practice in the current political and economic climate?Eugene Allers2. SASOP Clinical guidelines, protocols and algorithms: Development of treatment guidelines for bipolar mood disorder and major depression Eugene Allers, Margaret Nair, Gerhard Grobler3. The revolving door phenomenon in psychiatry: Comparing low-frequency and high-frequency users of psychiatric inpatient services in a developing countryU A Botha, P Oosthuien, L Koen, J A Joska, J Parker, N Horn4. Neurophysiology of emotion and senses - The interface between psyche and somaEugene Allers5. Suicide prevention: From and beyond the psychiatrist's handsO Alonso Betanourt, M Morales Herrera6. Treatment of first-episod psychosis: Efficacy and toleabilty of a long-acting typical antipsychotic B Chiliza, R Schoeman, R Emsey, P Oosthuizen, L KOen, D Niehaus, S Hawkridge7. Treatment of attention deficit hyperactivity disorder in the young childHelen Clark8. Holistic/ Alternative treatment in psychiatry: The value of indigenous knowledge systems in cllaboration with moral, ethical and religious approaches in the military servicesJ Dill9. Treating Schizophrenia: Have we got it wrong?Robin Emsley10.Terminal questions in the elderlyMike Ewart Smith11. Mental Health Policy development and implementation in Ghana, South Africa, Uganda and ZambiaAlan J Flisher, Crick Lund, Michelle Frank, Arvin Bhana, Victor Doku, Natalie Drew, Fred N Kigozi, Martin Knapp, Mayeh Omar, Inge Petersen, Andrew Green andthe MHaPP Research Programme Consortium12. What indicators should be used to monitor progress in scaling uo services for people with mental disorders?Lancet Global Mental Health Group (Alan J Flisher, Dan Chisholm, Crick Lund, Vikram Patel, Shokhar Saxena, Graham Thornicroft, Mark Tomlinson)13. Does unipolar mania merit research in South Africa? A look at the literatureChristoffel Grobler14. Revisiting the Cartesian duality of mind and bodyOye Gureje15. Child and adolescent psychopharmacology: Current trends and complexitiesS M Hawkridge16. Integrating mental illness, suicide and religionVolker Hitzeroth17. Cost of acute inpatient mental health care in a 72-hour assessment uniyA B R Janse van Rensburg, W Jassat18. Management of Schizophrenia according to South African standard treatment guidelinesA B R Janse van Rensburg19. Structural brain imaging in the clinical management of psychiatric illnessF Y Jeenah20. ADHD: Change in symptoms from child to adulthoodS A Jeeva, A Turgay21. HIV-Positive psychiatric patients in antiretroviralsG Jonsson, F Y Jeenah, M Y H Moosa22. A one year review of patients admitted to tertiary HIV/Neuropsychiatry beds in the Western CapeJohn Joska, Paul Carey, Ian Lewis, Paul Magni, Don Wilson, Dan J Stein23. Star'd - Critical review and treatment implicationsAndre Joubert24. Options for treatment-resistent depression: Lessons from Star'd; an interactive sessionAndre Joubert25. My brain made me do it: How Neuroscience may change the insanity defenceSean Kaliski26. Child andadolescent mental health services in four African countriesSharon Kleintjies, Alan Flisher, Victoruia Campbell-Hall, Arvin Bhana, Phillippa Bird, Victor Doku, Natalie, Drew, Michelle Funk, Andrew Green, Fred Kigozi, Crick Lund, Angela Ofori-Atta, Mayeh Omar, Inge Petersen, Mental Health and Poverty Research Programme Consortium27. Individualistic theories of risk behaviourLiezl Kramer, Volker Hitzeroth28. Development and implementation of mental health poliy and law in South Africa: What is the impact of stigma?Ritsuko Kakuma, Sharon Kleintjes, Crick Lund, Alan J Flisher, Paula Goering, MHaPP Research Programme Consortium29. Factors contributing to community reintegration of long-term mental health crae users of Weskoppies HospitalCarri Lewis, Christa Kruger30. Mental health and poverty: A systematic review of the research in low- and middle-income countriesCrick Lund, Allison Breen, Allan J Flisher, Ritsuko Kakuma, Leslie Swartz, John Joska, Joanne Corrigall, Vikram Patel, MHaPP Research Programe Consortium31. The cost of scaling up mental health care in low- and middle-income countriesCrick Lund, Dan Chishlom, Shekhar Saxena32. 'Tikking'Clock: The impact of a methamphetamine epidemic at a psychiatric hospital in the Western CapeP Milligan, J S Parker33. Durban youth healh-sk behaviour: Prevalence f Violence-related behaviourD L Mkize34. Profile of morality of patients amitted Weskoppies Psychiatric Hospital in Sout frican over a 5-Year period (2001-2005)N M Moola, N Khamker, J L Roos, P Rheeder35. One flew over Psychiatry nestLeverne Mountany36. The ethical relationship betwe psychiatrists and the pharmaceutical indutryMargaret G Nair37. Developing the frameor of a postgraduate da programme in mental healthR J Nichol, B de Klerk, M M Nel, G van Zyl, J Hay38. An unfolding story: The experience with HIV-ve patients at a Psychiatric HospitalJ S Parker, P Milligan39. Task shifting: A practical strategy for scalingup mental health care in developing countriesVikram Patel40. Ethics: Informed consent and competency in the elderlyWillie Pienaar41. Confronting ommonmoral dilemmas. Celebrating uncertainty, while in search patient goodWillie Pienaar42. Moral dilemmas in the treatment and repatriation of patients with psychtorders while visiting our countryDuncan Ian Rodseth43. Geriatrics workshop (Psegal symposium): Medico-legal issuess in geriatric psyhiatryFelix Potocnik44. Brain stimulation techniques - update on recent researchP J Pretorius45. Holistic/Alternative treatments in psychiatryT Rangaka, J Dill46. Cognitive behaviour therapy and other brief interventions for management of substancesSolomon Rataemane47. A Transtheoretical view of changeNathan P Rogerson48. Profile of security breaches in longerm mental health care users at Weskoppies Hospital over a 6-month periodDeleyn Rema, Lindiwe Mthethwa, Christa Kruger49. Management of psychogenic and chronic pain - A novel approachM S Salduker50. Childhood ADHD and bipolar mood disorders: Differences and similaritiesL Scribante51. The choice of antipsychotic in HIV-infected patients and psychopharmacocal responses to antipsychotic medicationDinesh Singh, Karl Goodkin52. Pearls in clinical neuroscience: A teaching column in CNS SpectrumsDan J Stein53. Urinary Cortisol secretion and traumatics in a cohort of SA Metro policemen A longitudinal studyUgash Subramaney54. Canabis use in Psychiatric inpatientsM Talatala, G M Nair, D L Mkize55. Pathways to care and treatmt in first and multi-episodepsychosis: Findings fm a developing countryH S Teh, P P Oosthuizen56. Mental disorders in HIV-infected indivat various HIV Treatment sites in South AfricaRita Thom57. Attendanc ile of long-term mental health care users at ocupational therapy group sessions at Weskoppies HospitalRonel van der Westhuizen, Christa Kruger58. Epidemiological patterns of extra-medical drug use in South Africa: Results from the South African stress and health studyMargaretha S van Heerden, Anna Grimsrud, David Williams, Dan Stein59. Persocentred diagnosis: Where d ps and mental disorders fit in the International classificaton of diseases (ICD)?Werdie van Staden60. What every psychiatrist needs to know about scansHerman van Vuuren61. Psychiatric morbidity in health care workers withle drug-resistant erulosis (MDR-TB) A case seriesUrvashi Vasant, Dinesh Singh62. Association between uetrine artery pulsatility index and antenatal maternal psychological stressBavanisha Vythilingum, Lut Geerts, Annerine Roos, Sheila Faure, Dan J Stein63. Approaching the dual diagnosis dilemmaLize Weich64. Women's mental health: Onset of mood disturbance in midlife - Fact or fictionDenise White65. Failing or faking: Isses in the fiagnosis and treatment of adult ADHDDora Wynchank