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Human immunodeficiency virus (HIV-1) can be detected in the cerebrospinal fluid (CSF) throughout the course of HIV infection, although at lower concentrations than in blood.1 Opportunistic meningeal infections, such as Cryptococcus neoformans and Mycobacterium tuberculosis can enhance HIV replication in vitro,2-4 and during such infections, HIV-1 viral load (VL) in CSF is found to be raised,5 either as a result of this direct enhancement of replication, and/or increased HIV-1 replication due to a pro-inflammatory immune response and the influx of leucocytes.6 Thus, treatment of the opportunistic infection might lead to a more rapid decline of the HIV-1 VL in the compartment of infection than systemically. To examine the changes in CSF and plasma HIV-1 VL during treatment of cryptococcal meningitis, we measured the levels of HIV-1 RNA in CSF and plasma before and after 2 weeks of treatment of cryptococcal meningitis in 63 Thai patients enrolled in a trial of amphotericin B-based therapy.7 Baseline cryptococcal organism load was determined by quantitative CSF cultures, as were CSF cell count and differential and CSF and plasma cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12p70, IL-13, IL-17, G-CSF, GM-CSF, MCP-1, MIP-1β, IFN-γ, and TNF-α)8 to investigate any association of CSF immune parameters with CSF HIV-1 RNA concentrations. CSF was available from 57 patients at baseline and 47 at day 14. Plasma was available from 62 patients at baseline and 49 at day 14. Paired CSF/plasma samples were available of 57 patients at baseline, and 46 at day 14. CSF and plasma samples were centrifuged at 3000 rpm for 10 minutes at 4°C and supernatants were stored at −80°C. The mean time from lumbar puncture to storage at −80°C was less than 3 hours. After collecting all samples, HIV RNA quantification in the cell-free CSF and plasma was performed with the Roche Amplicor Monitor Test (version 1.5, Roche Diagnostic Systems, Hoffman-La Roche, Basel, Switzerland). We compared median log10 HIV-1 RNA concentrations using Wilcoxon matched pairs signed-rank test and the Mann Whitney U test. Correlation between variables was tested using Spearman's rank correlation. Median log10 HIV-1 VL was significantly lower in CSF compared to plasma at baseline and at day 14 (p < 0.001 for both comparisons). There was a significant decrease in HIV-1 VL in both CSF and plasma during the first two weeks of treatment of cryptococcal meningitis (Table). However, the CSF/Plasma HIV-1 VL ratio did not change over time. Baseline CSF HIV-1 VL correlated with CSF lymphocyte count (r=0.5, P=0.0002). At baseline, there was a positive correlation between CSF IL-10 and CSF HIV-1 VL (r=0.6, P

Young people are increasingly required to demonstrate civic engagement in their communities and help deliver the aspirations of localism and Big Society. Using an ecological systems approach this paper explores the experiences of different groups of young people living in areas of socio-economic disadvantage. Using volunteering as an example of civic engagement it is shown that barriers and motivators for young people stem from within the micro, meso, exo and macrosystems, and that these interact with each other, and with bio-psychological factors within individuals, to bring about differential opportunities and outcomes for young people. Through examining the experiences of three different groups of young people placed within socio-economically disadvantaged communities, considerable variation in levels of civic engagement are identified and it is suggested that some young people's lived experiences are resulting in decisions to civically disengage. It is argued that young people need to benefit...

Wetland habitat continues to be lost in many watersheds across Canada and new program tools are needed to help restore drained wetlands. We used a reverse auction to restore drained wetlands in the Assiniboine River Watershed (ARW) of east-central Saskatchewan which is an important target area for wetland restoration in the North American Waterfowl Management Plan (NAWMP). The reverse auction format was discriminative, with sealed bids and two rounds of bidding. Bidders could submit bids for 12-year term agreements and/or perpetual conservation easements, and bids were submitted by quarter section (160 acres). Bids could be either in cultivated cropland or perennial forage, and were evaluated using an environmental benefits index based on the incremental increase in predicted hatched waterfowl nests relative to bid price. Potential bidders were solicited via contacts with existing conservation project cooperators, and a public media campaign. In the first round, 20 bidders submitted 118 bids to restore 713 wetlands totaling 670 acres at a price of $837,000. All bids were for 12-year term agreements. Bid prices to restore drained wetlands within cultivated land were higher than for perennial forage. In the second round, 30 bids from seven bidders were approved to restore 211 wetlands totaling 211 acres in perennial forage at a price of $182,000. The price of successful bids varied from $20.83 to $391.22 per acre per year (average $118.52). The reverse auction provided information on cost variability and funding required for achieving NAWMP wetland restoration objectives in the ARW. La perte d'habitats humides dans de nombreux bassins hydrographiques du Canada se poursuit, d'ou la necessite d'elaborer de nouveaux programmes et outils pour favoriser la restauration des milieux humides qui ont ete draines. Nous avons procedea une enchere inversee en ligne pour restaurer les milieux humides draines dans le bassin hydrographique de la riviere Assiniboine dans la partie du centre-est de la Saskatchewan, qui constitue une zone cible importante de la restauration des milieux humides dans le Plan nord-americain de la gestion de la sauvagine (PNAGS). L'enchere inversee en ligne etait discriminatoire et comprenait des offres secretes et deux tours d'enchere. Les encherisseurs pouvaient soumettre des offres soit pour des ententes d'une duree de douze ans, soit pour des servitudes de conservation perpetuelles, pour une superficie de un quart de section (160 acres) dans les deux cas. Les offres, qui pouvaient comprendre des terres cultivees ou des terres couvertes de plantes fourrageres vivaces, ont eteevaluees a l'aide d'un indice des avantages environnementaux fonde sur l'augmentation progressive du nombre prevu d'œufs eclos dans les nids de sauvagine par rapport au prix offert. Nous avons joint des encherisseurs potentiels par l'intermediaire des coordinateurs de projets de conservation existants et de campagnes de publicite-medias. Au premier tour, 20 encherisseurs ont soumis 118 offres pour restaurer 713 milieux humides totalisant 670 acres, au prix de 837 000$. Toutes les offres visaient des ententes de douze ans. Le prix des offres pour restaurer les milieux humides draines a l'interieur des terres cultivees etait plus eleve que le prix des offres pour restaurer les milieux humides draines a l'interieur des terres couvertes de plantes fourrageres vivaces. Au deuxieme tour, trente offres soumises par sept encherisseurs ont ete retenues pour restaurer 211 milieux humides totalisant 211 acres de terres couvertes de plantes fourrageres vivaces, au prix de 182 000$. Le prix des offres retenues variait de 20,83$a 391,22$ l'acre par annee (moyenne de 118,52$). L'enchere inversee en ligne a permis d'obtenir de l'information sur la variabilite des couts et le financement necessaire pour atteindre les objectifs de restauration des milieux humides du PNAGS dans le bassin hydrographique de la riviere Assiniboine.

Objective To investigate the histopathology of the arachnoid granulations in patients with HIV-associated cryptococcal meningitis and correlate the findings with clinical data, in particular cerebrospinal fluid (CSF) opening pressure. Design Case series. Methods Postmortems were requested on patients dying during initial hospitalization with HIV-associated cryptococcal meningitis. Results Five postmortems were performed. Large numbers of cryptococcal cells were seen within the arachnoid granulations. The number of fungal cells correlated with CSF pressure. Inflammatory cell infiltrates and disruption of the normal architecture of the granulations were also observed. Conclusion The study provides the first direct evidence supporting the obstruction to CSF reabsorption at the level of the arachnoid granulations as the main mechanism underlying the development of raised CSF pressure in HIV-associated cryptococcal meningitis.

SummaryThis article offers an introduction to advocacy on behalf of people with mental disorders and/or intellectual disabilities. It concentrates mainly on the issues related to independent specialist advocacy, but refers to other forms also. The term is itself contentious, having different meanings in different contexts. Some of these controversies are outlined here. Inevitably, diverse interpretations imply varying practices, and these too are illustrated briefly. Legislation and concordance of expectations are both contributing to a set of standards to which most advocates in the UK and Ireland will adhere. The requirements that such legislation makes of mental healthcare staff working with independent specialist advocates are outlined, and the ethical dimension of mental health advocacy is noted.

In order to understand better the way in which the emerging field of citizenship education is being characterised we reflect on work emerging from a higher education network (citizED) for citizenship education. Three of the four authors of this article are closely involved in that network. CitizED was established with funding from the Teacher Training Agency (TTA) (now the Training and Development Agency for Schools, TDA) in order to establish a network and provide resources to support the initial training of citizenship teachers. We analysed download data from the network's website, a sample of the resources produced by the network, and interviewed a sample of users and developers. In this article we identify who is using the resources, how they are using them and what form of citizenship education is developing as a result. We argue that there is now a clear citizenship teacher education community that uses common resources for a variety of purposes. We suggest that there is some consensus in relation t...

The history of psychiatric therapeutic communities is complex and obscure. Nevertheless, one can make a reasonable case for saying that the first true therapeutic community was created at Northfield Military Hospital, Birmingham, England, in 1945. That community had its origins in the thought and practice of two British psychoanalysts, John Rickman and Wilfred Ruprecht Bion. Accordingly, in the present article their careers and the social and intellectual influences bearing on them are discussed. The article then continues by describing Rickman's work as a military psychiatrist, Bion's prototype of a therapeutic community, and the therapeutic community that was eventually created at Northfield. It is hoped that the article will provide some of the groundwork for an adequate history of the therapeutic community.

In this article I use a case study of the relationship between an international non-government development organisation (NGO) and one of its local partner NGOs to question the desirability of basing NGO partnerships on the principle of subsidiarity. I argue that devolving maximum control to the local NGO in accordance with the principle of subsidiarity would have conflicted with the interests and expectations of both the international NGO and its local partner. As a result, there was occasional but significant contestation between these organisations about what sort of relationship was most compatible with the principle of partnership and what role each party should play within that relationship. I argue that such contestation over what constitutes partnership has the potential to contribute to the realisation of this value-laden term by involving all parties in defining the nature of their relationship. Copyright © 2007 John Wiley & Sons, Ltd.

Background: Psychiatrists commonly take on a range of leadership roles. These responsibilities are complex because of an environment which is ever-changing, lack of training and competition between disciplines. Aims: This article outlines some of the issues facing the psychiatrist within the multidisciplinary team and describes a leadership programme initiated in the West Midlands. Method: A programme of in-house leadership training and increased delegation of leadership roles within one NHS Trust. Results: These initiatives have been favourably received; but it is recognised that the approach can be further developed. Conclusion: This basic strategy should be enhanced and delivered more widely.

PurposeThis paper aims to offer a commentary on Psychologically Informed Services: A Good Practice Guide, a recently published operational guidance document on developing psychologically informed environments (PIEs) in services for homeless people.Design/methodology/approachThe paper is an invited opinion piece and comment, based on the specialist experience and viewpoint of the author as a rehabilitation psychiatrist, a medical historian of the therapeutic community movement, and a member of the “enabling environments” development group.FindingsThe new operational guidance is welcomed, with some provisos. Specifically, the author is concerned that, in the prevailing commissioning culture, and the individual pathology‐based presumptions of the “medical model”, a focus on the “psychological” may be taken to mean a stress on individual psychology and therapeutic techniques derived from individual therapy. This may distract attention from the need to work with the whole social environment, with peer support and with recognition of the importance of informal interactions, as opportunities for growth, if services are to work with the whole person.Originality/valueServices that wish to develop as PIEs need to take care to work with the whole person, and their social selves, and to develop enabling environments that recognise and work with the importance of all relationships.

This work was made possible by funding from the Wellcome Trust (WT088148MF), the Medical Research Council (MR/J008176/1), the NIHR Surgical Reconstruction and Microbiology Research Centre and the Lister Institute for Preventive Medicine (to R.C. May), and a Wellcome Trust Intermediate fellowship (089966, to T. Bicanic). The C. neoformans isolates were collected within clinical trials funded by the British Infection Society (fellowship to T. Bicanic), the Wellcome Trust (research training fellowships WT069991, to A.E. Brouwer and WT081794, to J.N. Jarvis), and the Medical Research Council, United Kingdom (76201). Background. Cryptococcal meningitis (CM) is a leading cause of HIV-associated mortality globally. High fungal burden in cerebrospinal fluid (CSF) at diagnosis and poor fungal clearance during treatment are recognized adverse prognostic markers; however, the underlying pathogenic factors that drive these clinical manifestations are incompletely understood. We profiled a large set of clinical isolates for established cryptococcal virulence traits to evaluate the contribution of C. neoformans phenotypic diversity to clinical presentation and outcome in human cryptococcosis. Methods. Sixty-five C. neoformans isolates from clinical trial patients with matched clinical data were assayed in vitro to determine murine macrophage uptake, intracellular proliferation rate (IPR), capsule induction, and laccase activity. Analysis of the correlation between prognostic clinical and host immune parameters and fungal phenotypes was performed using Spearman's r, while the fungal-dependent impact on long-term survival was determined by Cox regression analysis. Results. High levels of fungal uptake by macrophages in vitro, but not the IPR, were associated with CSF fungal burden (r = 0.38, P = 0.002) and long-term patient survival (hazard ratio [HR] 2.6, 95% CI 1.2-5.5, P = 0.012). High-uptake strains were hypocapsular (r = -0.28, P = 0.05) and exhibited enhanced laccase activity (r = 0.36, P = 0.003). Fungal isolates with greater laccase activity exhibited heightened survival ex vivo in purified CSF (r = 0.49, P P = 0.05) and exhibited enhanced laccase activity (r = 0.36, P = 0.003). Fungal isolates with greater laccase activity exhibited heightened survival ex vivo in purified CSF (r = 0.49, P < 0.0001) and resistance to clearance following patient antifungal treatment (r = 0.39, P = 0.003). Conclusion. These findings underscore the contribution of cryptococcal-phagocyte interactions and laccase-dependent melanin pathways to human clinical presentation and outcome. Furthermore, characterization of fungal-specific pathways that drive clinical manifestation provide potential targets for the development of therapeutics and the management of CM. Publisher PDF

Successful pharmaceutical companies are rich in intellectual property. Historically, this property has taken the form of patents, and a company's skill in acquiring such assets has been instrumental in driving its share price. But with the huge increase in public interest in and access to hitherto restricted pharmaceutical products and information, it is clear that the industry's approach to marketing must change. Couple this with the increasing elusiveness of breakthrough new products, and it becomes clear that the fundamental business model of the leading companies must change too. Strong brands, which help support a product's market position long after its patent has lapsed — or provide a platform for the OTC arena — can add layers of sustainable value because they ‘connect’ with doctors, patients and consumers alike. Thus careful brand management will play an increasingly important role in the future of value creation in the pharmaceutical industry — much as it does in the majority of industries where...

The systematic involvement of service users (patients or clients; McGuire-Snieckus et al, 2003) and carers in an active educational role in psychiatric training is a relatively recent development. The National Service Framework for Mental Health states that ‘Service users and carers should be involved in planning, providing and evaluating training for all health care professionals' (Department of Health, 1999). The Royal College of Psychiatrists declared that from June 2005 all psychiatric trainees must have training from service users or carers. This is a sizeable shift away from traditional medical teaching, where patients have been involved only in a passive way, as the possessor of symptoms and signs, with teaching delivered by experienced clinicians and academics. The reasons behind these changes have been discussed frequently in recent medical literature (Livingston & Cooper, 2004). The primary arguments for this initiative are that service users have a unique understanding of their illness and are best placed to judge trainees on their empathy and communication skills. Increasingly, service users' views are being taken into account in training and examination of medical students and doctors (Vijayakrishnan et al, 2006).

This case study aims to draw attention to the impact of work-related stress on psychiatrists. The first author's account of his own experience is supplemented by accounts from his secretary and wife. The aims of this report are to assist others to recognise the effects of work-related stress in themselves, to point out the impact on others, and to propose that doctors in training should be made aware of the issues.

First records of the myrmecophilous species Lomechusoides strumosus Fabricius, 1793 and Lomechusa paradoxa Gravenhorst, 1806 are reported for Bulgaria. Lomechusoides strumosus is the only member of the genus in Bulgaria while Lomechusa paradoxa joins L. emarginata (Paykull, 1789) as the second member of the genus Lomechusa. Both beetle species were found in nests of Formica ants.

PURPOSE OF REVIEW: The epidemiology and pathogenesis of, and risk factors for, cryptococcal immune reconstitution inflammatory syndrome (CM-IRIS) are reviewed with an emphasis on how new insights inform a rational management approach and prevention strategies. RECENT FINDINGS: Risk factors for paradoxical CM-IRIS are a low inflammatory response and CD4 cell count at baseline, rapid immune restoration from this low baseline, and a high organism or antigen load at baseline and at antiretroviral therapy (ART) initiation. Detailed immune mechanisms are still unclear.Rapidly fungicidal induction therapy, allowing prompt initiation of ART (from around 3 weeks in resource-limited settings in the context of amphotericin B induction) at a time when organism and antigen loads are low, may reduce overall mortality without exacerbating paradoxical CM-IRIS, compared with initiation of ART at later time points. Recent cohorts suggest early recognition and management can reduce the mortality associated with paradoxical CM-IRIS. Unmasking CM-IRIS is preventable through screening for cryptococcal antigen prior to ART and preemptive antifungal treatment for those testing positive, although prospective studies are needed. SUMMARY: Optimal antifungal induction and judicious ART timing, together with early recognition and management of developing cases, with thorough exclusion of alternative diagnoses, should help reduce paradoxical CM-IRIS-related mortality. Unmasking CM-IRIS cases should be preventable.

Cuales son los temas clave en la educacion para la ciudadania hoy en dia? Este titulo anima a los estudiantes y profesores en ejercicio a participar y reflexionar sobre algunos de los temas, conceptos y debates clave que tendran que abordar a lo largo de su carrera. Situa el campo especializado de la Educacion para la Ciudadania en un contexto mas amplio y tiene como objetivo permitir a los profesores llegar a sus propios juicios informados y argumentar sus puntos de vista con un conocimiento y una comprension teoricos mas profundos. Teniendo en cuenta las politicas y las controversias recientes, los colaboradores expertos brindan un equilibrio de experiencia y perspectivas y cubren una amplia gama de temas clasicos y contemporaneos que incluyen: Perspectivas teoricas sobre educacion ciudadana; Perspectivas internacionales comparadas sobre educacion para la ciudadania; Educacion para la ciudadania, raza y cohesion comunitaria; Educacion sobre el cambio climatico y la ciudadania sostenible; TIC y Educacion para la Ciudadania; Educacion en Etica y Ciudadania; Evaluacion de la Educacion para la Ciudadania. Este libro es para todos los profesores en formacion y profesores en ejercicio que participan en DPC o estan interesados ​​en ampliar su comprension de la ensenanza en el area tematica. Esta coleccion, que incluye lecturas adicionales cuidadosamente anotadas y preguntas reflexivas para ayudar a dar forma a su propia investigacion y redaccion, proporciona una introduccion al pensamiento critico reciente y los debates contemporaneos dentro de la Educacion para la ciudadania.

Recently published WHO guidance recommends starting ART in HIV-infected adults with CD4 counts of ≤350 cells/μl [1]. There is mounting evidence that such a policy will lead to lower mortality among HIV-infected individuals [2]. Also modeling data suggests that expanded testing and earlier treatment will reduce HIV transmission [3]. In South Africa ART coverage is not meeting current needs, even using the CD4 count criteria of

Cryptococcal meningitis (CM) is a major cause of mortality in HIV-infected patients in much of the world, causing an estimated 504,000 deaths annually in sub-Saharan Africa alone (1). Despite rapid scale-up of antiretroviral therapy (ART) coverage in South Africa, the burden of CM is still high, because ART coverage is barely keeping pace with the number of new HIV-infected patients developing stage IV disease (2). As access to ART expands, increasing numbers of patients are presenting with CM after initiating ART, and CM has emerged as a major cause of morbidity and mortality in African ART programmes (3). Little data is available regarding the presentation and clinical features of CM in patients on ART, and evidence is conflicting on whether short-term outcomes are better in those already on ART at presentation when compared to ART-naive patients (4-6). We therefore examined these issues in a cohort of patients presenting with CM in Cape Town. The study was performed at GF Jooste Hospital, a public-sector adult referral hospital serving a population of 1.3 million. Cryptococcus is the commonest cause of meningitis at the hospital, accounting for 63% of microbiologically confirmed cases (7). All patients presenting with laboratory confirmed CM between 1st January 2007 and 31st December 2008 were prospectively identified, and clinical and laboratory data were collected with approval from the Research Ethics Committee of the University of Cape Town. Patients were classified according to whether they were taking ART at initial presentation, and the primary end-point of in-hospital mortality was recorded for all patients. During the study period the initial treatment of CM consisted of two weeks of induction therapy with amphotericin B (1mg/kg), followed by fluconazole 400mg daily for 8 weeks. As part of ongoing clinical studies 71 patients received additional induction treatment, all of whom were ART naive (61 received flucytosine, 39 received IFNγ, and 8 received fluconazole, all with amphotericin B). Statistical comparisons were made using the Kruskal-Wallis, χ2 or Fisher's exact tests. Odds ratios (OR) with 95% confidence intervals (CI) were calculated using logistic regression modeling adjusting for potential confounders (variables were included in the logistic regression model if they were significantly associated with the primary outcome in bivariate analysis (p

Cryptococcal meningitis and tuberculosis are leading causes of mortality in patients initiating antiretroviral therapy in Africa. We hypothesized that a history of tuberculosis may predispose to the development of cryptococcal meningitis and examined the association using multivariate logistic regression in a cohort of patients initiating antiretroviral therapy. History of pulmonary tuberculosis was independently associated with the development of cryptococcal meningitis (odds ratio = 6.6; 95% confidence interval = 1.3-32.7) after adjustment for covariates, including CD4 cell counts. A number of potential mechanisms may underlie this association.

Contains fulltext : 81687.pdf (Publisher’s version ) (Closed access) OBJECTIVES: To assess impact of serial lumbar punctures on association between cerebrospinal fluid (CSF) opening pressure and prognosis in HIV-associated cryptococcal meningitis; to explore time course and relationship of opening pressure with neurological findings, CSF fungal burden, immune response, and CD4 cell count. DESIGN: Evaluation of 163 HIV-positive ART-naive patients enrolled in three trials of amphotericin B-based therapy for cryptococcal meningitis in Thailand and South Africa. METHODS: Study protocols required four lumbar punctures with measurements of opening pressure over the first 2 weeks of treatment and additional lumbar punctures if opening pressure raised. Fungal burden and clearance, CSF immune parameters, CD4 cell count, neurological symptoms and signs, and outcome at 2 and 10 weeks were compared between groups categorized by opening pressure at cryptococcal meningitis diagnosis. RESULTS: Patients with higher baseline fungal burden had higher baseline opening pressure. High fungal burden appeared necessary but not sufficient for development of high pressure. Baseline opening pressure was not associated with CD4 cell count, CSF pro-inflammatory cytokines, or altered mental status. Day 14 opening pressure was associated with day 14 fungal burden. Overall mortality was 12% (20/162) at 2 weeks and 26% (42/160) at 10 weeks, with no significant differences between opening pressure groups. CONCLUSION: Studies are needed to define factors, in addition to fungal burden, associated with raised opening pressure. Aggressive management of raised opening pressure through repeated CSF drainage appeared to prevent any adverse impact of raised opening pressure on outcome in patients with cryptococcal meningitis. The results support increasing access to manometers in resource-poor settings and routine management of opening pressure in patients with cryptococcal meningitis.

introductionCardiovascular disease is more prevalent in patients with severe mental illness (SMI) than in the general population.MethodSeven geographically diverse centres were assigned a nurse to monitor the physical health of SMI patients in secondary care over a 2-year period in the “Well-being Support Programme” (WSP). A physical health screen was performed and patients were given individual weight and lifestyle advice including smoking cessation to reduce cardiovascular risk.ResultsNine hundred and sixty-six outpatients with SMI >2 years were enrolled. The completion rate at 2 years was 80%. Significant improvements were observed in levels of physical activity (p < 0.0001), smoking (p < 0.05) and diet (p < 0.0001). There were no changes in mean BMI although 42% lost weight over 2 years. Self-esteem improved significantly. Low self-esteem decreased from 43% at baseline to 15% at 2 years (p < 0.0001). At the end of the programme significant cardiovascular risk factors remained, 46% of subjects smoked, 26% had hypertension and 81% had BMI >25.ConclusionPhysical health problems are common in SMI subjects. Many patients completed 2 years follow up suggesting that this format of programme is an acceptable option for SMI patients. Cardiovascular risk factors were significantly improved. interventions such as the Well-being Support Programme should be made widely available to people with SMI.

A working party of specialists and GPs recently published their consensus on recommended treatments for chickenpox. These are the closest to recommended guidelines available in the UK. They offer a rational basis for targeting those groups most at risk of complications with antiviral treatment.The aim of the present study was to compare current practice by GPs in the management of chickenpox, particularly in targeting of antiviral therapy, with the working party recommendations.A questionnaire survey was conducted of all GP principals within a single London Health Authority Responses to nine chickenpox clinical scenarios were compared with the working party recommendations.The response rate was (69.2%) 227/328. In five of the nine scenarios, fewer than 70% of GPs selected the correct response according to the recommendations. There was both underuse and overuse of antivirals according to the recommendations, with only 42% (96/227) advising oral antivirals or referral for an asthmatic treated with oral steroids 1 month previously, and 24% (53/221) advising oral antivirals 3 days after the chickenpox rash appeared.The results suggest some high risk groups may be being undertreated with oral antivirals and there may be considerable use of oral antivirals in situations where they are of no proven benefit.

One could make the argument that pharmaceutical marketers have not produced any brands that occupy a consistent and compelling mindshare over time as consumer marketers have done. There is no pharmaceutical equivalent to Coke, ‘the number one cola’ for decades; to BMW, ‘the ultimate driving machine’; or to Burger King, ‘the best place to get a big burger’.

In this issue Park et al. from the Centers for Disease Control University of Alabama and Johannesburg South Africa have made the first attempt to estimate the global burden of HIV-associated cryptococcal infection. As clearly stated by the authors the estimates are exactly that -estimates which rely on the quality of the data on which they are based. Nevertheless the results are striking especially for sub-Saharan Africa where the estimated number of deaths associated with cryptococcal disease at half a million per year is comparable with the number attributed to tuberculosis a much more frequent infection but one for which we have much more effective and widely available therapy. So are these results credible? The data are sparse with just three incidence studies driving the estimates for sub- Saharan Africa (ruling out the possibility of evaluating or taking account of possible intraregional differences in incidence); and the reported incidences are variable resulting in wide ranges for the estimates of cases and associated deaths. However biases are as possible on the downside as on the upside. As the authors acknowledge the relatively low incidence estimate from a South African study with which some of the same authors were involved was likely affected by incomplete case ascertainment. (excerpt)

The Northfield Experiments took place at Hollymoor Hospital, Northfield, Birmingham, during World War II. The first experiment was conducted by Bion & Rickman. The second evolved gradually; many people contributed to its success, including Foulkes, Main and Bridger. The experiments were an important landmark in the evolution of theory and practice in group psychotherapy and in the therapeutic community movement. They were not carried out solely as responses to the need for mass treatment of neurotic disorders among army personnel; antecedent factors, the theoretical orientation of the practitioners and the nature of army life were equally important. The two experiments differed in pace and in recognition of the needs of higher-order systems, particularly the military hierarchy. They shared many underlying concepts, including responsibility to society, the therapeutic use of groups (including the hospital community) and an emphasis on process. Lessons learned at Northfield remain relevant to the practice of psychiatry today.

Regional Public Education Officers of the Royal College of Psychiatrists are strategically placed to influence and improve the coverage of mental health issues in the media. Their role needs to be enhanced and clarified, and a proposal is being put forward in the College to achieve this. One possible way of working locally is illustrated through the work of West Midlands Insight, which demonstrates the value of working with a wide group of people, including those who have experienced mental ill health.

In 1991 the Royal College of Psychiatrists organised two overseas teaching fellowships. In this paper we describe our visit to El Peral Hospital in Chile and discuss the value of our going there.

Many psychiatrists are deeply disturbed by the changing and challenging circumstances in which they are responsible for patient care. This became evident at a conference on the role of the consultant in the clinical team, held by the Health Services Manpower Review at the Royal Society of Medicine on 14 July 1988 and attended by an entirely medical audience. The need for the consultant to act as leader of the clinical team was emphasised without identifying the nature and extent of this task, resulting in the failure to develop any strategy to tackle the many problems identified.

J.G. Oosten, Peter Fuchs, Kult und Autorität: de Religion der Hadjerai. Dietrich Reimer Verlag, Berlin 1970. 395 S., 12 Karten, 38 Abb., 52 Photos. - J.P. Boendermaker, Björn Björnsson, The Lutheran doctrine of marriage in modern Icelandic society. Oslo, Reykjavik 1971. 250 p. - H.C.G. Schoenmaker, J. van Baal, Symbols for communication. An introduction to the anthropological study of religion. Van Gorcum & Comp. N.V. Assen, 1971. I-XII, 295 p. - Miriam de Beet-Sterman, Jean Hurault, Africains de Guyane. La vie matérielle et l’art des Noirs Réfugiés de Guyana. Mouton, La Haye-Paris 1970. 224 pp., 47 foto’s en illustraties. - Stephen Wild, Alan Lomax, Folk song style and culture. American Association for the Advancement of Science, Washington, D.C., 1968. xix, 308 pp., 3 appendices, bibliog., illus., maps. - Aidan Southall, A.H.J. Prins, Didemic Lamu: Social stratification and spatial structure in a Muslim maritime town. Instituut voor Culturele Antropologie der Rijksuniversiteit Groningen 1971. 68 pp., 4 diag., 4 figs., Map. - H.J.M. Claessen, Irving Goldman, Ancient Polynesian society. The University of Chicago Press. Chicago and London 1970. 625 pp., bibl., appendices, register. - J. van Baal, Paula Brown, The Chimbu: A study of change in the New Guinea Highlands. Schenkman Publishing Cy, Inc., Cambridge, Massachussets 1972, 151 + IX pp. - P. van de Velde, J. Peter White, Ol Tumbana - Archaeological excavations in the Eastern Central Highlands, Papua New Guinea. Terra Australis 2. Department of Pre-History, Research School of Pacific Studies, The Australian National University, Canberra, 1972. xx + 176 pp., 170 tables, 28 figs., 5 plates. - Ajatrohaedi, Tom Harrison, Gold and megalithic activity in prehistoric and recent West Borneo. New York, Southeast Asia Program, Department of Asian Studies. Cornell University, Data Paper number 77, 1970. XIV and 331 pp., map, ills., Stanley J. O’Connor (eds.) - David S. Moyer, James A. Tuck, Onondaga Iroquois Prehistory. Syracuse University Press, Syracuse 1971. xiii, 255 p. - Jeremy Boissevain, José Cutileiro, A Portugese rural society. The Clarendon Press, Oxford 1971. xi, 314 p., 10 plates, figs.

Yet however memorable as a picture of an English spring, especially in its birds, this lyric is least characteristic of the author. A few such allusions come direct from the poet, most from his characters. Irrespective of context most of his allusions reflect extensive and minute observation, though on occasion it is obvious that Browning used bird names without any knowledge of their owner. In this as in other phases of his art Browning delights in the unusual, the unappreciated, and the unexpected. The present purpose is to illustrate both the kinds of interest Browning possessed and the ways in which he regarded the world of birds as an aid to poetic ends. With Browning's peculiar fondness for animals,' it is not surprising to find his poetry filled with birds. Apart from compounds like brood-bird, night-bird, and the like, Browning uses bird and birds 162 times, and names 72 species,2 a dozen more than Tennyson, who is more widely recognized as

Three female Asian migrants to the United Kingdom presented with vomiting which was not of organic origin. Cultural, dynamic and other factors influenced the adop tion of vomiting as a manifestation of distress. Non-organic vomiting should be evaluated in terms of its symbolism, gains, and communicatory function for the individual.