Search

Objective: A variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital. Methods: This paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments. Results: Our preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes. Conclusion: The choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated. [ABSTRACT FROM AUTHOR]

Toxocara infection occurs through ingestion of parasite eggs excreted by dogs and cats, and can cause severe morbidity. The burden of disease in England and Wales is not well described, and the impact of public health campaigns conducted in the mid-1990s is uncertain. This paper uses data from two extensive databases to explore the trends in this disease in England and Wales from the 1970s to 2009. [ABSTRACT FROM AUTHOR]

The article investigates assessment and treatment trends for adult snoring available at otolaryngology departments in England. Topics discussed include management methods offered by the departments to patients, difference in the approaches to managing snoring between Trusts and otolaryngology departments and inconsistencies in terms of surgery commissioning across the country. Also discussed are recommendations to improve British National Health Service (NHS) methods for managing snoring.

This paper presents the experimental validation of a coupled periodic finite element–boundary element model for the prediction of subway induced vibrations. The model fully accounts for the dynamic interaction between the train, the track, the tunnel and the soil. The periodicity or invariance of the tunnel and the soil in the longitudinal direction is exploited using the Floquet transformation, which allows for an efficient formulation in the frequency–wavenumber domain. A general analytical formulation is used to compute the response of three-dimensional invariant or periodic media that are excited by moving loads. The numerical model is validated by means of several experiments that have been performed at a site in Regent's Park on the Bakerloo line of London Underground. Vibration measurements have been performed on the axle boxes of the train, on the rail, the tunnel invert and the tunnel wall, and in the free field, both at the surface and at a depth of 15m. Prior to these vibration measurements, the dynamic soil characteristics and the track characteristics have been determined. The Bakerloo line tunnel of London Underground has been modelled using the coupled periodic finite element–boundary element approach and free field vibrations due to the passage of a train at different speeds have been predicted and compared to the measurements. The correspondence between the predicted and measured response in the tunnel is reasonably good, although some differences are observed in the free field. The discrepancies are explained on the basis of various uncertainties involved in the problem. The variation in the response with train speed is similar for the measurements as well as the predictions. This study demonstrates the applicability of the coupled periodic finite element–boundary element model to make realistic predictions of the vibrations from underground railways. [Copyright &y& Elsevier]

Background Rates and time trends in mortality from pancreatic cancer vary considerably between countries. Aim To examine trends and patterns in the incidence of, and the survival and mortality from, pancreatic cancer in England and Wales from 1975 to 2000; in particular, whether incidence and survival rates are related to socio-economic deprivation. Methods We calculated annual age-specific and overall age-standardized incidence and mortality rates by sex for pancreatic cancer in total, and by subsite. We also estimated survival by sex and age group and by subsite. Results In males, the age-standardized rate fluctuated in the late 1970s, to peak at 13.0 per 100 000 in 1979, declined steadily by an average of 1.3% per year to around 10.3 per 100 000 in the mid-1990s and then levelled off. For females, the rate peaked at 8.4 per 100 000 in the late 1980s before declining and fluctuating around 7.7 per 100 000 in the late 1990s. Patterns and trends in mortality rates were closely similar to those in incidence, due to the very low survival rates: only 2–3% at 5 years from diagnosis. Survival rates improved only minimally over the period 1971–99. Incidence and mortality rates were slightly higher in both males and females living in the most deprived areas, but survival was not consistently related to socio-economic deprivation. Conclusions The incidence of, and mortality from, pancreatic cancer in England and Wales have fallen from peak levels observed in the 1970s and 1980s, and levelled off in the 1990s for both sexes; survival rates remain very low. [ABSTRACT FROM AUTHOR]

Introduction: Undiagnosed underlying cognitive issues have an impact on progression with rehabilitation. Early diagnosis of these is beneficial to the patient as it can offer them early treatment and advance planning for their future care. Methods: Patients transferred to our rehabilitation wards from other specialities often do not have a routine cognitive assessment done. This has a negative impact on their rehabilitation goals and discharge planning. We hence routinely assessed cognition for all the patients transferred to our rehabilitation unit across two sites for 3 months. In the weekly MDT, we discussed in detail the cognition of each patient, taking into account not only the doctor’s view, but also nursing and therapists. Once a concern was raised, we investigated them fully with blood tests, imaging and MOCA or ACE-R. Results: 56 patients were diagnosed as having cognitive issues. Average age was 81.67 years. Of them 32.14%were from surgical specialities and the rest from other sub-specialities of medicine. In the MDT cognitive concerns were raised 73.2% by therapists, 66.1%by nurses and 60.7% by doctors. Of the concerns raised, 87.4% of patients were diagnosed with some form of underlying dementia or cognitive impairment. 55.4% were started on treatment. Remaining was either palliative deemed unsuitable for treatment or needed more detailed input from community psychiatry team on discharge. 75% were for follow up with the mental health team on discharge, 7.14% by the Parkinson’s specialist and the rest by the own GP. All diagnosis was notified to the patient, next-of-kin and the GP Conclusions: Routine multidisciplinary approach to cognitive assessment helps us in new and prompt diagnosis of dementia, offer appropriate treatment and plan ahead for the future. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article about schizophrenia in ethnic groups in the December 1993 issue.

Introduction: Surgeons and allied professionals have been quick to respond to the need for evidence during the COVID-19 pandemic. The Royal College of Surgeons of England (RCS England) has provided formal recognition, support and guidance to all members of its interdisciplinary collaborative COVID Research Group (RCS CRG). We describe research conducted by members of this group, initial findings and lessons for clinical practice so far., Methods: Members of the more than 50 projects included so far in the RCS CRG portfolio were invited to provide a summary of their project and findings to date. The 26 summaries received were collated and broad themes identified to produce this summary document., Results: Wide-ranging projects have been conducted by members of the RCS CRG, rapidly yielding crucial insights into the behaviour of the SARS-CoV-2 pathogen, its impact on patients and staff, the challenges it presents to surgical practice and investigation into methods to adapt and overcome such challenges., Conclusions: The response of the surgical research community to COVID-19 has been rapid and well-organised. Early establishment of a formal network under the auspices of RCS England has assisted efficient research collaboration and delivery, while avoiding academic duplication between groups. This has led to a high research output, directly informing and substantially influencing practice throughout and beyond the pandemic.

SARS-CoV-2 IgG screening of 1,000 antenatal serum samples in the Oxford area, United Kingdom, between 14 April and 15 June 2020, yielded a 5.3% seroprevalence, mirroring contemporaneous regional data. Among the 53 positive samples, 39 showed in vitro neutralisation activity, correlating with IgG titre (Pearson's correlation p<0.0001). While SARS-CoV-2 seroprevalence in pregnancy cohorts could potentially inform population surveillance, clinical correlates of infection and immunity in pregnancy, and antenatal epidemiology evolution over time need further study.

Background: Cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) can provide unique data on the transmural extent of scar/viability. We assessed the prevalence of dysfunctional myocardium, including partial thickness scar, which could contribute to left ventricular contractile dysfunction in patients with heart failure and ischaemic heart disease who denied angina symptoms., Methods: We invited patients with ischaemic heart disease and a left ventricular ejection fraction < 50% by echocardiography to have LGE CMR. Myocardial contractility and transmural extent of scar were assessed using a 17-segment model., Results: The median age of the 193 patients enrolled was 70 (interquartile range: 63-76) years and 167 (87%) were men. Of 3281 myocardial segments assessed, 1759 (54%) were dysfunctional, of which 581 (33%) showed no scar, 623 (35%) had scar affecting ≤50% of wall thickness and 555 (32%) had scar affecting > 50% of wall thickness. Of 1522 segments with normal contractile function, only 98 (6%) had evidence of scar on CMR. Overall, 182 (94%) patients had ≥1 and 107 (55%) patients had ≥5 segments with contractile dysfunction that had no scar or ≤50% transmural scar suggesting viability., Conclusions: In this cohort of patients with left ventricular systolic dysfunction and ischaemic heart disease, about half of all segments had contractile dysfunction but only one third of these had > 50% of the wall thickness affected by scar, suggesting that most dysfunctional segments could improve in response to an appropriate intervention.

Objectives: To investigate why invasive cervical cancers developed in a high-risk urban population with an established screening programme and to place cancers in the context of high-grade cervical intraepithelial neoplasia (CIN) and cervical glandular intraepithelial neoplasia (CGIN) diagnosed during the same period of time., Study Design: Observational study of CIN2+ (CGIN, CIN3 and CIN2) and invasive cervical cancer diagnosed at Guy's and St Thomas' NHS Foundation Trust in 1999-01, 2002-04 and 2005-07 and audit of screening histories of women with invasive cancer analysed according to route to diagnosis, histological type and International Federation of Obstetrics and Gynecology (FIGO) stage., Results: There were 133 invasive cancers, 53 CGIN, 1502 CIN3 and 1472 CIN2. Screen-detected cancers in asymptomatic women comprised 48.9% of cancers and were successively more likely to be in younger age groups (P = 0.03); all except one were stage IA or IB1. Screen-detected IA cancers were more likely (P < 0.001) to be in women screened within 0.5-5.0 years (80.5%) than screen-detected fully invasive (58.3%) or symptomatic cancers (35.3%). Seventy-one (53.4%) women had been screened within 0.5-5.0 years; 11 had negative cytology within 0.5-3.5 years and two tests within 10 years. The other 60 had negative tests less frequently or had previous abnormal cytology, colposcopy or treatment. Potentially avoidable factors were often multiple, including false-negative cytology, high-grade cytology reported as low-grade and lapses in attendance either for routine or repeat screening, or for colposcopy or treatment., Conclusion: While often potentially avoidable, cancers in previously screened women tended to be early stage, detected by cytology and rare when compared with high-grade CIN.

Objective: To examine screening histories of women with invasive cervical cancer in a 12-year period during the introduction of organised screening to assess its effectiveness., Study Design: Screening histories were classified into six categories: no cytology record (1), previous cytology more than 5 years before diagnosis (2) and previous cytology within 5 years of diagnosis (3-6). Categories 3-6 were described as interval cancers and comprised previous negative cytology (3), previous repeats for low-grade cytology (4), previous recommendations for investigation (5) and previous treatment (6)., Setting: Southampton and South West Hampshire (SSWH)., Population: Women resident in SSWH registered with invasive cervical carcinoma between 1985 and 1996., Methods: Data were held for analysis on an anonymous spreadsheet., Main Outcome Measures: Association of screening history categories with 3-year time period, age group, type and stage of cancer and route to diagnosis; incidence per 100,000 women aged 25-64 years screened and not screened within 5 years in 1991-93 and 1994-96., Results: Interval cancers increased as a proportion of all cancers from 31.5% in 1985-87 to 48.6% in 1994-96 (P= 0.002) and showed a peak in 1991-93. Their incidence decreased from 20.1 to 10.9 per 100 000 eligible women aged 25-64 years screened within 5 years (P= 0.008) between 1991-93 and 1994-96, while incidence in women not screened within 5 years was unchanged (44.2 and 40.4). Factors other than previous negative smears were recorded in 50.9% of interval cancers. Interval cancers were more likely to be low stage, screen detected and were diagnosed in younger women (P < 0.00001)., Conclusions: Interval cancers should be assessed as a proportion of eligible women screened within the same period of time and not as a proportion of all cancers. This audit demonstrates the importance of accurate cytology, appropriate follow up, prompt investigation and effective treatment of high-grade precancerous lesions.

Objective: To assess the clinical significance of screen-detected cancer compared with symptomatic cervical cancer during the introduction of organized screening., Study Design: Screen-detected and symptomatic cancers were analysed according to International Federation of Obstetrics and Gynecology stage and histological type of cancer and age of women during four 3-year periods., Setting: Southampton and South West Hampshire (SSWH)., Population: Women resident in SSWH registered with invasive cervical carcinoma between 1985 and 1996., Methods: Screen-detected and symptomatic cancers were defined on the basis of clinical information obtained at the time of diagnosis and recorded together with date of diagnosis, age group, histology and cytology results. Data were held for analysis on an anonymous spreadsheet., Main Outcome Measures: Incidence of screen-detected and symptomatic cancers per 100 000 women; association between route to diagnosis, age group, stage of cancer and screening history during four 3-year periods., Results: Of 382 cancers, 256 were symptomatic, 78 screen-detected fully invasive and 48 screen-detected microinvasive. Incidence of symptomatic cancers fell from 13.0 to 6.4 per 100 000 total female population (P = 0.0005), and there was a trend towards screen-detected cancers as a proportion of all cancers (P = 0.002). By the latest period of the study (1994-96), the likelihood of cancers being screen-detected was strongly associated with younger age groups (P = 0.001). Screen-detected fully invasive cancers were significantly less likely (P = 0.001) to be diagnosed at stage II or above (16.6%) compared with symptomatic cancers (63.3%). Women with screen-detected microinvasive cancers were significantly more likely (P < 0.001) to have been screened within 5 years (83.3%) than screen-detected fully invasive cancers (60.2%) or symptomatic cancers (33.6%)., Conclusion: Screen-detected cancers were more likely to be diagnosed at an earlier stage, in younger women and in women who had previously been screened and became relatively more frequent as symptomatic cancers declined.

Objective: To study the effect of different levels of pressure support ventilation (PSV) on respiratory parameters in preterm infants during the weaning phase of mechanical ventilation., Design/methods: In this quasi-experimental crossover study, a total of 19 154 breaths were analysed from 10 ventilated infants of <32 weeks' gestation. Breath-to-breath data on minute ventilation, tidal volume, respiratory rate, peak inspiratory pressure and mean airway pressure were collected during three study epochs: synchronised intermittent mandatory ventilation (SIMV) alone, SIMV with partial PSV (PS(min)), and SIMV with full PSV (PS(max)). PS(min) was set to provide an exhaled tidal volume (V(Te)) between 2.5-4 ml/kg and PS(max) 5-8 ml/kg V(Te). Statistical analyses were performed using analysis of variance (ANOVA) for repeated measures., Results: The addition of full PSV (PS(max)) was associated with a significant increase in total minute ventilation as compared with SIMV alone (392 ml/kg/min vs 270 ml/kg/min, respectively; p<0.05). This difference in minute ventilation was still present when PS(min) was used (332 ml/kg/min as compared with 270 ml/kg/min in SIMV; p<0.05). There was also a concomitant decrease in the respiratory rate with both PS(max) (59 breaths per minute) and PS(min) (65 breaths per minute) compared with SIMV alone (72 breaths per min) (p<0.05)., Conclusions: Pressure support ventilation increases total minute ventilation and stabilises breathing in proportion to the level of pressure support used. This may be advantageous and provide a useful ventilation strategy for use during weaning stages of mechanical ventilation in preterm infants.

Megaflood events involving sudden discharges of exceptionally large volumes of water are rare, but can significantly affect landscape evolution, continental-scale drainage patterns and climate change. It has been proposed that a significant flood event eroded a network of large ancient valleys on the floor of the English Channel-the narrow seaway between England and France. This hypothesis has remained untested through lack of direct evidence, and alternative non-catastrophist ideas have been entertained for valley formation. Here we analyse a new regional bathymetric map of part of the English Channel derived from high-resolution sonar data, which shows the morphology of the valley in unprecedented detail. We observe a large bedrock-floored valley that contains a distinct assemblage of landforms, including streamlined islands and longitudinal erosional grooves, which are indicative of large-scale subaerial erosion by high-magnitude water discharges. Our observations support the megaflood model, in which breaching of a rock dam at the Dover Strait instigated catastrophic drainage of a large pro-glacial lake in the southern North Sea basin. We suggest that megaflooding provides an explanation for the permanent isolation of Britain from mainland Europe during interglacial high-sea-level stands, and consequently for patterns of early human colonisation of Britain together with the large-scale reorganization of palaeodrainage in northwest Europe.

The 1967 Abortion Act and the 1990 Human Fertilisation and Embryology Act amendment allow abortions in acute hospitals or licensed premises only. Provision of abortions in community unlicensed premises is unlicensed and not legal. At abortion assessment, counselling, chlamydia testing and/or treatment/partner notification and a contraceptive package is included. This works towards the overall aim of reducing unwanted pregnancies and reducing the burden of sexually transmitted infections in the community, thus removing the silo approach to abortion. A 92% completed abortion outcome was achieved. Route of administration of misoprostol will be reconsidered. Efficacy could be improved by vaginal administration. The findings support the introduction of an early medical abortion service in collaboration with a partner organisation. Our experience provides useful preliminary data for others contemplating a similar service, with room for improvement.

Objective: To determine the timings of regional transfer for emergency neurosurgery and intensive care after severe head injury in children, and the effective operational range of a regional service., Design: Prospective observational study of admissions to a regional paediatric intensive care unit (PICU)., Setting: East Anglia region in England, January 2000 to December 2001, where 18 referring hospitals are within two hours road transit time from the centre., Patients: 69 severely head injured children (52 boys and 17 girls, aged 8.4 (3.6 to 12.5) years)., Main Outcome Measures: Time interval between injury and arrival at first hospital (primary transfer); timing between arrival at first hospital and arrival in PICU or the operating theatre (secondary transfer)., Results: Arrival in one of the 19 accident and emergency departments occurred (median, IQR) within 48 (35 to 70) minutes of the accident. After arrival, the interval of secondary transfer was 4.4 (3.2 to 5.8) hours. Children rarely received their surgery within four hours of injury; for this to occur, the geographical range of this regional practice would need to be restricted to those hospitals within about 45 minute road transit time from the centre., Conclusions: Good evidence supporting the recommendation that acute neurosurgery for the evacuation of a haematoma within four hours of injury is still scarce. The timings of care after an accident suggest that this guideline is unworkable in regions covering areas with road distance travel times in excess of 45 minutes.

Objective: To look for any differences in attitudes to menopause and hormone replacement therapy (HRT) between Asian and Caucasian women standardised for educational background, socio-economic status and access to medical information., Method: Self administered postal questionnaire sent to 144 women doctors (general practitioners) in defined geographical areas., Results: The overall response rate was 61%. Both Asian and Caucasian women responded in a similar manner for most aspects. A high proportion of these women doctors (over 75%) would seek HRT at the climacteric. More Asian respondents reported a fear of breast cancer (P=0.001), and that a woman feels less of a woman after the menopause (P=0.02). More Caucasian respondents felt positively about the potential for HRT to enhance enjoyment of life (P=0.01)., Conclusions: The lack of major differences between the ethnic groups in our sample suggests that variations reported elsewhere may be due to lack of knowledge and/or differences in socio-economic status.

This paper describes a national surveillance scheme, began in 1995, designed to monitor immunosuppression associated with HIV infection in adults in England and Wales. Currently 60 out of 64 (94%) laboratories performing CD4 cell counts participate in the scheme. The database contains over 42,000 patient records with over 300,000 counts, taken between April 1984 and March 2000. Approximately half of the patient records in the CD4 database match with patient records in the UK database of diagnosed HIV infections; a large proportion of the unmatched patients in the CD4 database may not be HIV-infected. Close to 50% of both men who have sex with men and injecting drug users and two-thirds of those who acquired their infection heterosexually had CD4 cell counts below 350 cells/mm3 at the time of HIV diagnosis. The National CD4 Surveillance Scheme provides important information regarding the epidemiology of HIV infection such as the changes in patterns of early and late diagnosis. It should continue to be used in conjunction with the other HIV surveillance systems to present as complete a picture of the epidemic as possible.

It has been suggested that HIV incidence will decrease with the increased use of antiretroviral Therapy (ART) in HIV infected homosexual/bisexual men. HIV incidence was measured using a sensitive/less sensitive assay technique, at a time when combination ART was widespread. The Serological Testing Algorithm for Recent HIV Seroconversion (STARHS)13 technique was applied to syphilis test specimens collected from homosexual/bisexual men attending 15 sexually transmitted infections (STI) clinics which participated in an unlinked anonymous serosurvey of HIV infection during 1998. The HIV incidence rate was adjusted to compensate for patients who had a repeat syphilis test within the same year. Leftover syphilis test sera from 6202 men had been unlinked and anonymised, of which 415 were HIV positive. Sera from 412 (99.3%) patients were available. The STARHS assay showed 62 to have been recently infected with HIV (approximately in the last four months), giving an incidence of 3.33% per annum (95% CI: 2.06%-5.27%). The highest incidence was seen in those aged 35-44 years. About 46% of all HIV-infected homosexual/bisexual men were probably receiving combination ART at this time. If 10% of those on treatment were misclassified as recent infections the incidence would have been 2.58% per annum (95% CI: 1.53%-4.24%). In homosexual/bisexual men having syphilis tests at STI clinics in the UK during 1998 the incidence of HIV infection was between two and three per hundred per year. Treatment with combination ART of almost a half of homosexual/bisexual men who are HIV infected in the population is compatible with appreciable continuing HIV transmission among those at high behavioural risk. Public health surveillance systems for those at high risk for HIV infection should, as soon as possible, incorporate the STARHS methodology for monitoring recent HIV incidence.

Cigarette smoking causes acute blood pressure (BP) elevation, although some studies have found similar or lower BPs in smokers compared with nonsmokers. Cross-sectional data from 3 years (1994 to 1996) of the annual Health Survey for England were used to investigate any difference in BP between smokers and nonsmokers in a nationally representative sample of adults (>/=16 years old). Randomly selected adults (33 860; 47% men) with valid body mass index (BMI) and BP measurements provided data on smoking status (never, past, or current) and were stratified into younger (16 to 44 years old) and older (>/=45 years old) age groups. Analyses provided between 89% and 94% power to detect a difference of 2 mm Hg systolic BP between smokers and nonsmokers in the 4 age/gender strata (alpha=0.05). Older male smokers had higher systolic BP adjusted for age, BMI, social class, and alcohol intake than did nonsmoking men. No such differences were seen among younger men or for diastolic blood pressure in either age group. Among women, light smokers (1 to 9 cigarettes/d) tended to have lower BPs than heavier smokers and never smokers, significantly so for diastolic BP. Among men, a significant interaction between BMI and the BP-smoking association was observed. In women, BP differences between nonsmokers and light smokers were most marked in those who did not drink alcohol. These data show that any independent chronic effect of smoking on BP is small. Differences between men and women in this association are likely to be due to complex interrelations among smoking, alcohol intake, and BMI.

Background: A laboratory method has been developed that detects recent HIV infection and allows incidence to be estimated by testing single stored antibody-positive specimens. A theoretical exploration of the method's surveillance utility was carried out., Methods: Using various data sources, HIV incidence rates were postulated. The confidence intervals (CI) for these postulated incidences were calculated using the expected number of recent infections for each postulated incidence, the actual number tested for HIV, and the known number of HIV-1 positives. A test for trend was used to determine when an important change in incidence could be recognized., Results: If the incidence was 5% per annum (p.a.) in homosexual/bisexual men attending sexually transmitted diseases (STD) clinics in London, 64 recent infections would be expected in the 392 HIV-seropositive specimens and, if observed, would result in a 95% CI of 3.1-7.9% p.a. for the incidence rate. An incidence of 1% p.a. in pregnant women would be most unlikely as this would require detection of 193 recent infections, 26 more than the total 167 HIV-seropositive specimens found in 1997. In African women attending STD clinics in London, 30% of prevalent infections would be classified as recent if the incidence was 5% p.a. Further, if the incidence in homosexual/bisexual men were to fall by 50% over 3 years, a decrease of this magnitude would be recognized as significant within 2 years., Conclusions: The detuned assay will increase the information from HIV serosurveys even where prevalence and incidence are relatively low. Existing surveillance systems should be redesigned to take full advantage of the method.

Objectives: To describe the distribution and changes in CD4 cell counts (both initial and subsequent) in HIV-infected persons over time and determine the factors influencing these counts., Design: Reports were requested from laboratories measuring CD4 cell counts in England and Wales. Initial counts were analysed and median counts were followed over time., Methods: Time trends and the relationship between initial CD4 cell count and age, sex, and HIV risk category were studied using quantile regression methods or chi-square tests., Results: Between 1990 and 1998, 9553 adults were newly diagnosed with HIV infection and had a CD4 cell count within 6 months of HIV diagnosis. Over 50% of initial CD4 cell counts in each major risk category were below 350 cells/mm3. Older age (P < 0.001), male sex (P < 0.013) and heterosexual risk (P < 0.001) were independently associated with lower initial CD4 cell counts. For heterosexually infected adults, the median initial CD4 cell count was significantly negatively associated with the year of diagnosis (P = 0.03) and the median age increased through the time period examined (P < 0.001), whereas for men who have sex with men (MSM), there was no significant change in these values over time. For each year cohort of newly diagnosed individuals, the median CD4 cell count in subsequent years decreased until 1996 and then increased thereafter, consistent with a treatment effect., Conclusion: Across all major risk groups, a large proportion of HIV-infected adults are being diagnosed late in the course of HIV disease. For the heterosexually infected, the data suggest an ageing cohort effect, whereas for MSM the data are consistent with continuing transmission.

Aims: To investigate knowledge and attitudes towards intra-uterine contraception., Design: Anonymous postal survey of 441 GPs (153 female and 288 male GPs) from the FHSA register in Stockport and Manchester., Setting: General practices in Stockport and Manchester. Main outcome measure. Response to a series of questions concerning attitudes and knowledge of intra-uterine contraception., Results: One hundred and forty-two responses were received, giving a 35% response rate. Thirty-four percent of responding GPs did not fit intra-uterine devices (IUDs), with only 10% fitting more than 30 a year. There was a significant trend against IUD fitting by male GPs and GPs aged <40 years. Younger GPs with <10 years experience were significantly more aware of the reliability of intra-uterine contraception, but perceived IUD fitting as inconvenient for both the patient and the doctor. Female GPs had better knowledge and more positive attitudes to IUDs than male GPs., Conclusion: GPs may have difficulties in maintaining expertise. Primary care groups may opt to concentrate fittings in a few expert practices, or refer women to centrally based family planning clinics for IUD fitting.

This study was designed to evaluate the therapeutic response, as perceived by patients and their general practitioners, to a supraregional residential pain management programme (INPUT). Twenty patients who completed the INPUT programme and their general practitioners, were sent locally designed questionnaires. Eighteen patients and 16 general practitioners responded. Patients were assessed for the effects of the programme on a wide variety of treatment targets reflecting quality of life. General practitioners were questioned about changes in dependence upon healthcare services. The mean time from attending INPUT to assessment was 11.4 (5.7) months. Thirteen patients indicated a moderate or maximal improvement in quality of life. General practitioners reported a reduced use of healthcare services and improvement in quality of life. The majority of our patients attending INPUT gained benefits that improved their quality of life. Healthcare services appeared to benefit from the patients' greater independence in managing their symptoms.

In a population survey of 162 rural and 152 urban subjects aged 26-65 years at Moradabad, the findings are compared with existing data on Indian immigrants to Britain and United States. In comparison with rural subjects, urban subjects had a higher prevalence of coronary artery disease (8.6 vs. 3.0%) and diabetes (7.9 vs 2.5%), higher blood pressures, total and low density lipoprotein cholesterol, triglycerides and postprandial 2-h blood glucose and plasma insulin similar to observations made in UK in immigrants compared to Europeans. Fasting plasma insulin and high density lipoprotein cholesterol levels in urban subjects were comparable with rural subjects. Mean body weights were significantly higher in urban women, but not in men, than in rural subjects. However the body mass index (22.9 +/- 4.2 vs. 21.6 +/- 2.4 kg/m2) and waist-hip girth ratio (0.89 +/- 0.10 vs. 0.86 +/- 0.07) were significantly higher in urban men compared to rural men without such differences in women. Underlying these differences in risk factors, urban subjects had three times better socioeconomic status than rural subjects and were eating higher total and saturated fat, cholesterol and refined carbohydrates and lower total and complex carbohydrates compared to rural men and women. Energy expenditure during routine and spare time physical activity was significantly higher in rural compared to urban subjects. Those patients who had risk factors, showed lesser physical activity and had greater adverse factors in the diet compared to subjects without risk factors. Body mass index and waist-hip girth ratio in patients with risk factors were significantly higher than in subjects without risk factors. The findings suggest that decreased consumption of total and saturated fat and increased physical activity may be useful for prevention of coronary artery disease among urbans as well as in immigrants.

The paper presents preliminary findings from a follow-up study of 86 first-generation immigrants to the United Kingdom from the Indian sub-continent, and a matched indigenous English-born control group. All subjects had originally been seen at the Bethlem Royal and Maudsley Hospitals and had been diagnosed as suffering from a functional psychosis. Attempts to locate the patients 5-20 years later revealed that a significantly higher proportion of the immigrant group could not be traced to a general practitioner within the United Kingdom, or otherwise accounted for. Possible explanations for this finding are advanced; the fact itself has important implications for those concerned with the provision of care and services for mentally ill immigrants in this country.

This paper presents new analyses of data from two multicentre studies carried out by the WHO. The morbid risk of developing schizophrenia, as broadly defined by the Determinants of Outcome Study, was positively related to the mean daily range of temperature. The outcome of schizophrenia, as determined by the International Pilot Study of Schizophrenia, was found to be positively related to mean environmental temperature. Further studies are needed to examine the relationship of geographical and climatic variables to schizophrenia in order to complement what is already known about the role of sociocultural factors.

The incidence of schizophrenia is regarded as being similar between different cultures and times. However, several studies, mostly based on first-admission rates, have suggested that the incidence has declined over the past 10-15 years. Data from England and Wales for 1952-86 have been examined: there has been a substantial decrease, beginning in the mid-1960s, in the incidence of schizophrenia.

The response of plasma-25-hydroxyvitamin D (25[OH]D) to different exposures to ultraviolet irradiation has been studied in patients in long-stay geriatric wards. Increases sufficient to bring the plasma-25(OH)D into the normal range may be obtained with doses less than those required to produce erythema. The provision of such background irradiation may be a suitable method of preventing vitamin-D deficiency in elderly subjects who receive very little exposure to sunlight.

The vitamin D status of residents of an old people's home and long-stay patients was assessed by means of plasma 25-hydroxycholecalciferol (25-OHD) estimations. The residents of the old people's home had a higher mean plasma 25-OHD concentration than long-stay patients. Both groups had diets with vitamin D intakes of less than 2.5 micrograms (100 IU) per day and the conclusion is that solar exposure is the major determinant of the concentration of circulating 25-OHD.