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In a previous study we found that a Tay-Sachs disease (TSD) causing mutation in the intron 9 donor splice site of the HEXA gene occurs at high frequency in non-Jewish patients and carriers from the British Isles. It was found more frequently in subjects of Irish, Scottish, and Welsh origin compared with English origin (63% and 31% respectively). We have now tested, in a blind study, 26 American TSD carriers and 28 non-carriers who have British ancestry for the intron 9 splice site mutation. Six of the carriers and none of the controls were positive for the mutation. All six had Irish ancestry, compared with nine of the 20 other (intron 9 mutation negative) TSD carriers (p < 0.05). These results confirm the previously found high frequency of the intron 9 mutation in non-Jewish TSD families of British Isles, particularly Irish, origin, and reinforce the need to screen such families for this mutation.

Objective: To report experience with brucellosis among expatriate hospital employees in an area of the world where brucellosis is endemic., Design: Review of cases from the viewpoints of direct supervisor and treating physician, including epidemiologic interviews and clinical follow-up., Setting: Tertiary care hospital center in a developing country that increased from 125 beds to 450 beds during the period studied., Patients: Employees with clinical findings suggesting brucellosis and in whom a positive blood culture or significantly elevated serologic test confirmed the diagnosis., Results: Nine hospital employees from nonendemic areas developed brucellosis. Five were from England and four from North America. Seven were bacteriology technologists, one was a nurse, and one was an obstetrician. Each had an acute febrile illness with malaise, arthralgia, or headache. Brucella titers were > or = 1:1,280. Five were bacteremic with positive Brucella cultures. All responded to anti-Brucella therapy. Three patients had relapses, but there were no complications., Conclusions: Among Saudi patients, brucellosis is generally attributable to drinking infected milk or contacting infected animals. On the other hand, among expatriate hospital employees, the infection is likely due to processing Brucella cultures or dealing with infected body fluids. In 1988, the laboratory began stricter infection control measures. Since then, there has been only one case of brucellosis among the hospital employees.

We present six cases of imported malaria in Spanish and foreign patients who had visited or lived in areas of malaria endemic. Two patients presented deficit of erythrocytic glucose-6-phosphate dehydrogenase. The main aspects of these two pathologies are analyzed, stressing their similar geographic distribution and the mechanisms by which such deficit protects against the malaria infection. In addition, we describe the problems that may arise with the use of anti-malaria in carriers of this enzymatic deficit; in our patients, the use of chloroquine did not raise any problem.

A new scale for the evaluation of feelings of guilt is described. Two types of guilt feeling were of potential interest: 'delusional' guilt or shame (experienced in relation to one's actions), and 'affective' guilt (a more general feeling of unworthiness). Reliability and validity analyses for the first (15-item) version of the scale were performed in three separate and contrasting clinical samples. The second and final (seven-item) version was tested in another sample of major depressives and in normal controls. The HRSD was used as a measure of severity throughout. The BDI and Widlöcher psychomotor retardation scale were also used as external criteria for the seven-item scale. Exploratory factor analysis of this sample yielded two factors--'cognitive/attitudinal' and 'mood/feeling'--of which only the first correlated with scores for psychomotor retardation. It is suggested that these two factors represent two forms of guilt, but that only the former is related to a putative dopaminergic disorder. Guilt scores and measures of severity were not correlated. It is suggested that feelings of guilt should be considered as a behavioural marker for a subtype of depression.

Within the context of marked increases in suicide rates in the UK among men between 1974 and 1988, the rate among those aged 15-24 years rose more than that of any other age band. The UK suicide rate among young men also worsened compared with those of most other countries in the EC. Rises in the general male suicide rate were statistically associated with rises in unemployment in most of the EC.

The opportunity and need for surgical training overseas changes with time. In the past, young surgeons in Australia and England completed their training with periods spent in the UK or USA respectively. Recent times have however seen a dramatic reduction in the numbers going abroad. This is in part due to concern about the ability to return to the domestic system in either Australia or the UK and in part due to a lack of knowledge about opportunities that exist not only in the English speaking medical community but also those on mainland Europe. We have been fortunate in having been able to work as members of the Department of Surgery in Rennes with Professor B. Launois (G. M.) and in Paris with Professor H. Bismuth (A. D.) and together in Berne Switzerland with Professor L. H. Blumgart. This experience has furthered our training in hepato-biliary surgery in non-English speaking environments. Supervisors and surgeons in training may wish to consider the possibility of additional experience in Europe rather than the UK or USA.

Ileosigmoid knotting, or compound volvulus, has not been reported previously in Australia. A 41 year old woman of Anglo-Saxon origin presented with a short history of extreme abdominal pain that was out of proportion to her physical findings. At operation it was found that her entire ileum was tightly knotted around the redundant, twisted sigmoid colon. Both closed loops were gangrenous and it was impossible to unravel the bowel. She recovered uneventfully following resection and primary anastomosis of both portions of the intestine. Most patients with this uncommon condition have been reported from Finland and eastern Africa. An arrangement of the small bowel and sigmoid colon on long, narrow mesenteries would appear to be a prerequisite. The brevity of the history and the severity of the abdominal pain call for early laparotomy. Prolonged attempts to untie the knot are dangerous. It is safer to divide the ileum at the knot and resect it in order to release the sigmoid colon. Primary anastomosis is feasible where the history is short and the uninvolved intestine is clean and collapsed.

Health visitor, Val Rose, won a Florence Nightingale memorial fund scholarship to travel to the Navajo Indian reservation in north America. The health problems of the Navajo are similar to those affecting the traveller population on her own caseload, forced by changing circumstances and legislation to settle on local authority sites in England. Here she describes some of the health problems arising from the settlement of nomadic people.

October 31 1989: Two hours in the city of Toronto and already I had been visited by six ghosts, three goblins, a warlock and several witches! No, these were not the latest British nurses bound for the Toronto hospitals but the local kids demanding "Trick or Treat". I had arrived in North America!

Watford health visitor June Mitchell visited north east Pakistan and Azad Kashmir last year. Many health visitors have clients with close ties to Azad Kashmir. She describes three health initiatives she observed there.

A socio-dental investigation was carried out in Southampton among 195 Asians of Indian, Pakistani or Bangladeshi origin, aged 55 years and over, in order to assess their oral health status and identify factors which might affect their uptake of dental services. The majority of subjects (70%) were dentate; 69% were in need of periodontal treatment and 29% required extractions due to advanced periodontal involvement. Despite the fact that many subjects held positive attitudes towards dental health, less than 15% attended the dentist on a regular basis. The remaining subjects felt that it was not necessary to do so unless they were in pain or required new dentures.

Objective: To examine mortality from ischaemic heart disease and cerebrovascular disease in England and Wales by country of birth of the deceased., Design: Standardised mortality ratios were computed by country of birth groups for ischaemic heart disease and cerebrovascular disease for 1979-83 and 1970-2 by using the five year age-sex specific rates for England and Wales for 1979-83 as standard., Setting: England and Wales 1970-2 and 1979-83., Results: In 1979-83 mortality from ischaemic heart disease was highest in men and women born in the Indian subcontinent (standardised mortality ratio 136 and 146 respectively). Young Indian men suffered the greatest excess (313 at ages 20-29). Other groups with raised mortality included Irish, Scottish, and Polish born immigrants. Those born in the Caribbean, the old Commonwealth, west Europe, and the United States had low death rates. In England and Wales mortality from ischaemic heart disease declined by 5% in men and 1% in women between 1970-2 and 1979-83, with greatest percentage declines in immigrants born in the United States, South Africa, the old Commonwealth, the Caribbean, and France. immigrant groups with raised mortality in the earlier period showed little improvement, and mortality from ischaemic heart disease increased among Indians (6% in men and 13% in women). In 1979-83 mortality from cerebrovascular disease was highest in Caribbeans (standardised mortality ratios 176 in men and 210 in women), followed by Africans, Indians, and Irish. Rates were low in west Europeans. Mortality from stroke declined by 28% overall in this period, a rate of decline shared by most groups. Men from the Indian subcontinent showed a decline of only 3%., Conclusion: In the 1980s mortality from ischaemic heart disease and cerebrovascular disease differed significantly between ethnic groups in England and Wales. In general, ethnic groups that experienced lower mortality from ischaemic heart disease in the 1970s showed the greatest improvement over the following decade.

While several investigators have reported relationships between ethnic background and expression of pain, such relationships are in fact highly problematical. Few studies of pain and ethnicity have used quantitative measures of pain combined with multivariate methods of data analysis. Most have focussed on populations which, unlike many in the United States today, are characterized by highly distinct ethnic groups. The study reported here interviewed 536 persons recently treated for forms of cancer known to cause significant pain. Pain was assessed using standard, well validated instruments, including Graphic Rating Scales anchored in several alternative time-frames and the McGill Pain Questionnaire. The study took place in an area with a low proportion of recent immigrants and only small concentrations of distinct ethnic minorities. No statistically significant relationships were observed between ethnic identity and measures of pain sensation. However, pain described in affective terms according to the McGill Pain Questionnaire did vary among ethnicities. This observation suggests that cultures associated with specific ethnic identities still condition individual expression of pain despite the high degree of assimilation that has occurred among ethnic groups in the United States.

Investigations of ethnic differences in pain experience have been largely confined to the hospital or laboratory. Such studies are limited by the potentially confounding effects of the expectation of pain in the former and of little or no pain in the latter. The present investigation overcomes some of these methodological problems by studying ethnic differences in pain experience following ear-piercing. Afro-West Indian, Anglo-Saxon and Asian subjects (n = 84) completed a pain questionnaire and two rating scales after ear-piercing. Half the subjects were told the study was about pain and half that it was concerned with sensation. There were highly significant ethnic differences in pain ratings. The pain condition produced higher ratings than the sensation condition but there were no significant sex differences. The results are discussed in the context of subjects' ratings of their parents' attitudes to minor injury and their own ability to cope with pain. It is argued that investigation of the bases of ethnic differences in pain experience is important in order to develop maximally efficient pain control regimes for all sections of the populations.

Cancer incidence in migrants to New South Wales (NSW) from individual countries within the British Isles has been compared with that in the Australian-born population using data from the NSW Central Cancer Registry for the period 1972-84. Indirectly age-standardised incidence ratios (SIR) showed that, for cancer at all sites combined, Scottish migrants had a significantly higher, and English migrants a lower, incidence than the native-born Australians. Melanoma of skin was less common in migrants from all four countries while lung cancer was more common. In all except the Irish migrants, stomach cancer was more frequent than in the Australian-born. Raised SIRs for bladder cancer were found in men from all the countries and for breast cancer in all except the Irish women but only in the English migrants were these ratios significant. English migrants differed from those from Wales, Scotland and Ireland in that, compared with the Australian-born, they had significantly lower SIRs for cancer of the colon (both sexes), head and neck, larynx and prostate (men), gallbladder and kidney (women), and a higher SIR for ovarian cancer. Bone cancer was relatively more common in men born in Wales. 'Other genital' cancers (penis and scrotum; vulva and vagina) tended to be more frequent in migrants from each country than in the Australian-born.