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Haploinsufficiency of the transcription factor short stature homeobox (SHOX) manifests as a spectrum of clinical phenotypes, ranging from disproportionate short stature and Madelung deformity to isolated short stature. Here, we describe five infants with molecularly confirmed diagnoses of SHOX haploinsufficiency who presented in utero with short long bones during routine antenatal scanning from as early as 19 weeks gestation. Other foetal growth parameters were normal. The molecular basis of SHOX haploinsufficiency was distinct in each case. In four cases, SHOX haploinsufficiency was inherited from a previously undiagnosed parent. In our de novo case, SHOX haploinsufficiency reflected the formation of a derivative sex chromosome during paternal meiosis. Final adult height in the SHOX-deficient parents ranged from -1.9 to -1.2 SDS. All affected parents had disproportionately short limbs and two affected mothers had bilateral Madelung deformity. To our knowledge, SHOX haploinsufficiency has not previously been reported to present in utero. Our experience illustrates that SHOX deficiency should form part of the differential diagnosis of foetal short long bones and suggests a low threshold for genetic testing. This should be particularly targeted at, but not limited to, families with a history of features suggestive of SHOX deficiency. Data on the postnatal growth of our index cases is presented which demonstrates that antenatal presentation of SHOX haploinsufficiency is not indicative of severe postnatal growth restriction. Early identification of SHOX deficiency will enable accurate genetic counselling reflecting a good postnatal outcome and facilitate optimal initiation of growth hormone therapy.

Objective: Various treatment options are available for the management of psoriasis; however, there remains a scarcity of literature regarding satisfaction levels among these patients. Given that treatment dissatisfaction is associated with lower levels of adherence, the objective of the present study was to establish satisfaction levels among patients with psoriasis., Design: A modified version of a previously validated satisfaction questionnaire was completed by patients., Setting: Dermatology outpatient department (Solihull, United Kingdom)., Participants: Thirty-eight patients with psoriasis (median age 43)., Measurements: The questionnaire addressed various domains of satisfaction including satisfaction with safety, convenience, information provision, and finally global satisfaction with 1) topical treatments, 2) phototherapy, and 3) systemic treatments., Results: Mean global satisfaction with phototherapy and systemic treatments was significantly higher than with topical treatments. The authors' findings also showed that 20 percent of patients receiving topical treatment were dissatisfied with the convenience of the treatment. Interestingly, the only domain causing dissatisfaction among patients receiving systemic therapies (largely biologies) was safety. Despite this, satisfaction with both systemic treatment and phototherapy was higher than has been previously reported., Conclusion: The findings of this study indicate that levels of satisfaction with phototherapy and systemic treatments are high, which is encouraging for both clinicians and patients. However, there are undoubtedly higher levels of dissatisfaction with topical treatments. Given that topical treatments have the greatest safety profile, they will continue to be the first-line treatment for psoriasis. Advances that focus on patient concerns should become a priority in order to improve compliance and reduce the need for more costly intervention.

Background: Given the high prevalence of chronic conditions and multimorbidity in the elderly, there is a need to determine which chronic conditions have the greatest impact on health-related quality of life (HRQL) and identify where additional intervention may be required., Objective: To explore the impact of a range of common chronic conditions on HRQL in a community-based population aged 65 years or more in the UK., Methods: Secondary analysis of data derived from a large (n = 5849) cross-sectional study. HRQL was assessed using the EuroQoL EQ-5D. Multivariable models were used to estimate the relative effect of 15 individual common chronic conditions and combinations of these conditions on HRQL., Results: Mean age of participants was 74.6 years, 49.2% were male. The mean EQ-5D index score was 0.78 (standard deviation 0.2), range -0.43 to 1.00. Overall, 53% (n = 3078) of the cohort reported problems with pain, 39% (n = 2273) with mobility and 9% (n = 529) with self-care. Multivariate modelling demonstrated that impaired HRQL was significantly associated with 13 of the 15 common chronic conditions studied. Clinically meaningful reductions in EQ-5D index scores were observed for osteoarthritis (-0.081, P = 0.0006), neurological disease (-0.172, P < 0.0001) and depression (-0.269, P < 0.001)., Conclusions: This study quantifies the relative impact of 13 common chronic conditions on HRQL in a UK-based community-dwelling ageing population. Findings indicate that osteoarthritis, depression and neurological disease have a strong clinically important negative effect on HRQL. These findings may help clinical decision making and priority setting for management of individuals with multimorbidity., (© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Evidence is emerging that rates of adverse events in patients taking warfarin may vary with ethnicity. This study investigated the rates of bleeds and thromboembolic events, the international normalised ratio (INR) status and the relationship between INR and bleeding events in Malaysia. Patients attending INR clinic at the Heart Centre, Sarawak General Hospital were enrolled on an ad hoc basis from May 2010 and followed up for 1 year. At each routine visit, INR was recorded and screening for bleeding or thromboembolism occurred. Variables relating to INR control were used as predictors of bleeds in logistic regression models. 125 patients contributed to 140 person-years of follow-up. The rates of major bleed, thromboembolic event and minor bleed per 100 person-years of follow-up were 1.4, 0.75 and 34.3. The median time at target range calculated using the Rosendaal method was 61.6% (IQR 44.6–74.1%). Of the out-of-range readings, 30.0% were below range and 15.4% were above. INR variability, (standard deviation of individuals’ mean INR), was the best predictor of bleeding events, with an odds ratio of 3.21 (95% CI 1.10–9.38). Low rates of both major bleeds and thromboembolic events were recorded, in addition to a substantial number of INR readings under the recommended target range. This may suggest that the recommended INR ranges may not represent the optimal warfarin intensity for this population and that a lower intensity of therapy, as observed in this cohort, could be beneficial in preventing adverse events.

Background: In the United Kingdom, rates of deliberate self-harm (DSH) are rising. Alongside this, there has been an increase in the number of websites available with DSH content, and the Internet is known as a valuable resource for those who feel isolated by their condition(s). However, there is little and contradictory evidence available on the effects of using such websites. Further research is therefore required to examine the use and effects of DSH websites., Objective: Our objectives were to explore (1) the reasons people engage in the use of self-harm forums/websites, (2) the beliefs of users of self-harm forums regarding the role of such websites, (3) how the use of self-harm forums/websites modulates self-harm behaviors, and (4) other ways that self-harm forums affect the lives of individuals who use them., Methods: Data were collected by a questionnaire hosted on 20 websites with self-harm content. Participants were self-selected from users of these sites. Results were analyzed using descriptive statistics and simple thematic analysis., Results: In total, 329 responses were received with 91.8% (302/329) from female site users. The majority of participants (65.6%, 187/285) visited these sites at least twice per week, and most participants used the sites to find information (78.2%, 223/285) or participate in the forums (68.4%, 195/285). Positive effects of website use such as gaining help and support, isolation reduction, and a reduction in self-harm behaviors were reported by a large number of participants. However, smaller but important numbers reported negative effects including worsened self-harm, being triggered to self-harm, and additional negative physical and psychological effects., Conclusions: This is the first multisite study to explore DSH website use in depth. There are clear and important benefits to engaging in website use for many individuals; however, these are not experienced by all website users. Negative effects were experienced by moderate numbers following website use, and clinicians should consider the impact of a patient's website use when consulting.

The frequency distribution of serum thyroid stimulating hormone (TSH) shows a skewed pattern that may change with age. The set point of the hypothalamic-pituitary-thyroid axis for an individual is thought to be genetically determined and has been described as a log-linear relationship of serum TSH to free thyroxine (T4); however, the validity of this hypothesis has yet to be established in older people. The aim of the study was to describe the relationship between serum TSH and free T4 in older people and define factors influencing this relationship. We conducted a cross-sectional, observational study of thyroid function in a community population of older subjects over 65 years of age. The relationship between serum TSH and free T4 was not linear as previously described, but is best described as a fourth-order polynomial. Both gender and smoking status affected the relationship. This suggests that more complex modelling is required when investigating the hypothalamic-pituitary-thyroid axis.

Background: As the number of female GPs increases, the need to understand delivery of maternity care to this group becomes increasingly important. Previous literature suggests doctors face additional barriers in utilizing health care compared to other patients, but little is known about GPs' maternal health care experiences and whether their occupation facilitates or compromises care., Objective: To explore female GPs' personal experiences of maternal health care and how occupation affects care received., Methods: Female GPs with children aged 6 months to 5 years were recruited from South Birmingham Primary Care Trust with subsequent snowballing. Data were obtained using semi-structured interviews and constant comparison analysis was applied to develop themes and categories., Results: Fourteen GPs participated and no new themes emerged after interview 10 suggesting data saturation was achieved. Overall, GPs felt they received better care due to their occupation and where established relationships between the GP and the health care professional existed, communication and care satisfaction was enhanced. However, assumptions about knowledge led to reduced information provision and some problems in care provision, especially during labour and early motherhood when women were most vulnerable and unable to rely on work skills to address information deficits., Conclusion: This research supports the growing body of evidence that there are unique problems facing doctor-patients and clinicians treating them. However, contrary to expectations derived from anecdotal evidence, GPs indicated that care was enhanced due to their occupation. This study raises awareness of areas for consideration when female GPs approach pregnancy and health care professionals deliver maternal health care.

Background: Abuse of ambulance services is high, and there is concern among healthcare professionals that misuse of ambulances places stress on services, which may jeopardise patient care. This study aims to determine the proportion of people who correctly identify appropriate situations to call for an ambulance, and determine the characteristics of those most likely to call inappropriately., Methods: An online questionnaire presented 12 common scenarios that may require medical attention and required participants to identify when they would request an ambulance. Proportions correctly responding to each scenario were calculated and each respondent was given a total score. t-Tests compared mean scores between groups (with and without first aid (FA) training), and χ(2) tests compared between-group proportions of correct answers for scenarios. Backwards stepwise logistic regression analyses determined the characteristics of those most likely to call inappropriately., Results: 150 respondents completed the questionnaire. 5.2-47.8% responded with an inappropriate answer, depending on the scenario. Almost all participants identified the need for an ambulance in 3/5 scenarios when it was required; however, fewer (74.8%) respondents identified the need for an ambulance to a suspected stroke. The majority correctly identified an ambulance was not required in only 2/7 scenarios. Those with FA training were less likely to call inappropriately in all scenarios (significant in three situations). However, no participant characteristics were predictive of calling an ambulance inappropriately once confounders were taken into account., Conclusions: The majority would call for an ambulance appropriately when a real emergency occurred, and most inappropriate classification occurs when an ambulance is not required.

Background: World Health Organization (WHO) immunological and clinical criteria for monitoring first-line antiretroviral treatment (ART) offer low accuracy for predicting viral failure. Targeting viral load assays to those at high risk has been recommended and a system to do this has been developed in Cambodia. Systems for use in sub-Saharan African populations were evaluated., Methods: A new Ugandan-based scoring system for targeting viral load assays was developed from data from the first 4 years of a Ugandan cohort (N = 559) receiving first-line ART. The accuracy of this, the Cambodian system and the WHO criteria to predict viral failure, through targeting viral load assays, were compared in a separate population of 496 Ugandans., Results: The new Ugandan scoring system included CD4 cell count, mean cell volume, adherence, and HIV-associated clinical events as predictors of viral failure. In the validation population, the Ugandan system undertook viral load assays in 61 (12.3%) cases offering 20.5% sensitivity and 100% positive predictive value (PPV) to predict viral failure. The Cambodian system undertook viral load assays in 33 (6.7%) cases producing 23.1% sensitivity and 90.0% PPV. WHO criteria recommended viral load assays in 72 (14.5%) cases offering 30.8% sensitivity and 100% PPV., Conclusion: Locally developed algorithms based on clinical and immunological criteria may offer little additional accuracy over WHO criteria for targeting viral load assays. When possible, confirming viral load before switching therapy is recommended. Scoring systems are more flexible than WHO criteria in allowing ART providers to choose the proportion of the population that undergo targeted viral load testing.

Aim: To explore how irritable bowel syndrome (IBS) impacts on patients' lives in order to explain the reported reduction in quality of life (QOL)., Background: IBS affects 10-20% of the population and over half of the people with the condition consult in primary care, with many consultations ending unsatisfactorily. IBS is known to have a detrimental effect on the QOL, though the mechanisms through which this is affected are poorly understood. A greater understanding of the patient experience of IBS would facilitate better healthcare provision., Methods: Eighteen semi-structured, in-depth interviews were undertaken in the West Midlands, United Kingdom from August 2006 to March 2008. Interviews were carried out until data saturation was achieved. All interviewees had previously taken part in one of the two recent primary care-based IBS studies and were long-term sufferers of IBS. Participants were purposively sampled to capture a range of experiences and included both genders, a range of ages, symptom severity scores and IBS sub-types., Findings: In contrast to the previously reported 'worried well' label, participants reported integration of the disease into their lives to the extent that it became a part of their identity. Even so, IBS did at times prevent their participation in everyday activities. Strategies used by participants to manage symptoms were an integral part of daily living and events which threatened routine coping strategies caused stress and exacerbated symptoms. Both adaptive and maladaptive coping strategies were identified. These were in part patient created, but for many incorporated advice or medication provided by their doctor. The findings not only confirm the extensive impact of IBS on daily living but also expose the additional impacts of IBS on emotional well-being and self-identity. The reduced QOL reported in previous studies may be an underestimate of the impact of IBS on patients' lives as patients integrate coping mechanisms completely into daily living.

Context: Previous research has shown that general practitioners (GPs) hold negative attitudes towards patients with schizophrenia, which do not simply reflect the nature or chronic aspects of the illness. This study aimed to describe the attitudes and predicted behaviour of medical students towards patients with mental illness in a primary care setting and to investigate whether these were affected by the students' level of training., Methods: A sample of 1239 students from the University of Birmingham Medical School were each given one of four case vignettes, all of which were identical except that the patient involved was described as having a previous diagnosis of, respectively, schizophrenia, depression, diabetes or no illness. Students rated their level of agreement with 12 attitudinal statements relating to the vignette., Results: A total of 1081 (88%) students responded to the questionnaire. Students were generally less favourable in their responses to patients with either schizophrenia or depression. They would not be as happy to have them on their list, believed they would consume more time and considered they would be less likely to comply with advice and treatment. They expressed more concern about the risk of violence, the potential welfare of children and the possibility of illegal drug and excessive alcohol use. General clinical and psychiatric training had little effect on these reactions., Conclusions: Patients with mental illness provoke less favourable responses in medical students, which are not altered by furthering education. Undergraduate primary care-based mental health education should be re-evaluated to ensure that students develop an empathetic and positive approach to mental health patients and their treatment.

Background: Education is integral to reducing stigma toward the mentally ill. Medical educators have a key role in delivering education that reduces that stigma. Undergraduate psychiatric training and specific education programs are both effective in reducing stigma. However, many students are exposed to concepts of mental illness at a much earlier stage in their education. No previous study has explored the effect of intervention such as role-play on student attitudinal development., Objectives: This study's objective was to identify whether undergraduate role-play exercises featuring mental illness influenced development of attitudes toward the mentally ill., Methods: A randomized controlled trial was used to compare attitudinal scores between students exposed to a mental illness role-play as part of routine teaching and a control group that did not receive the teaching., Results: A total of 332 students provided data. There were no between-group differences for any attitudinal scores, although gender (being female) and experience of mental illness were associated with more positive attitudinal scores., Conclusions: Single high-intensity routine teaching sessions such as role-play involving metal illness do not influence student attitudes.

Introduction: A number of men have extreme castration ideations. Many only fantasize about castration; others actualize their fantasies., Aims: We wish to identify factors that distinguish those who merely fantasize about being castrated from those who are at the greatest risk of genital mutilation., Methods: Seven hundred thirty-one individuals, who were not castrated, responded to a survey posted on http://www.eunuch.org. We compared the responses of these "wannabes" to those of 92 men who were voluntarily castrated and responded to a companion survey. Main Outcome Measures. Respondents answered the questionnaire items relating to demographics, origin of interest in castration, and ambition toward eunuchdom., Results: Two categories of wannabes emerged. A large proportion ( approximately 40%) of wannabes' interest in castration was singularly of a fetishistic nature, and these men appeared to be at a relatively low risk of irreversible genital mutilation. Approximately 20% of the men, however, appeared to be at great risk of genital mutilation. They showed a greater desire to reduce libido, change their genital appearance, transition out of male, and prevent sexually offensive behavior. Nineteen percent of all wannabes have attempted self-castration, yet only 10% have sought medical assistance., Conclusions: We identify several motivating factors for extreme castration ideations and provide a classification for reasons why some males desire orchiectomies. Castration ideations fall under several categories of the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV), most notably a Gender Identity Disorder other than male-to-female (MtF) transsexual (i.e., male-to-eunuch) and a Body Identity Integrity Disorder. Physicians need to be aware of males who have strong desires for emasculation without a traditional MtF transsexual identity.

Introduction: There are men in the Western world who are voluntarily castrated and are not male-to-female transsexuals., Aims: We surveyed members of this group to understand their responses to androgen deprivation (AD) and how their experiences matched their expectations of AD., Methods: We posted a questionnaire on the Eunuch Archive (http://www.eunuch.org) that received responses from 92 voluntarily orchiectomized males who identified as eunuchs. Data from this questionnaire were supplemented with interviews with 19 of the eunuchs., Main Outcome Measures: Participants completed questionnaire items regarding: (i) the side effects they expected and experienced; (ii) their current physical and psychological condition; (iii) their level of regret; (iv) what they appreciated most about their castrated status; and (v) who performed their orchiectomies., Results: The most appreciated aspect of castration was the sense of control over sexual urges and appetite (52%). The major side effects experienced were loss of libido (66%), hot flashes (63%), and genital shrinkage (55%). The population had high self-rated sociability, and mental and physical health. Although there was an insignificant reduction in depression after castration, the overall level of self-reported obsessive-compulsive disorders decreased significantly (P < 0.01). Twenty-two percent of the population reported a change in sexual orientation. Many respondents (60%) took supplemental hormone treatments to counteract the side effects of AD. The use of both supplemental testosterone and high-dose estrogen correlated with a significant increase in self-reported sexual desire and activity above the agonadal level (P < 0.001). The majority of the castrations (53%) were not performed by medical professionals., Conclusion: The medical community needs to be aware of men at risk of unsafe castrations in order to provide them with more information on the side effects of AD and access to safe orchiectomies.

Introduction: Some males desire to be emasculated for no medical reason. These individuals are often secretive about their desires and little is known about their background and motivation., Aims: We sought to characterize these modern eunuchs and to identify risk factors for genital self-mutilation or self-administered chemical castration., Methods: We posted a questionnaire on the Eunuch Archive ( http://www.eunuch.org) that was responded to by 135 voluntarily castrated males. Questionnaire data were supplemented by accompanying narrative responses and several personal interviews., Main Outcome Measures: Participants answered questionnaire items pertaining to their knowledge about androgen deprivation, the nature of their castration, and the length of time between initial presentation of castration paraphilia and castration. These questionnaire data allowed us to compare and contrast voluntary chemical and physical eunuchs., Results: The physical castrations were largely premeditated, with an average of 18 years from the time that an individual developed interest in being a eunuch to the time of their actual castration. We identified four factors that may promote castration ideations: (i) abuse sustained during childhood, including parental threats of castration; (ii) homosexuality; (iii) exposure to animal castration during youth; and (iv) religious condemnation of sexuality. Chemical eunuchs were more likely to have sought castration for libido control or to advance transition from male to female (P < 0.05). Physical eunuchs had a nonsignificant tendency to have masochistic paraphilia involving genital mutilation in advance of their castration (P < 0.1). Both Body Integrity Identity Disorder and Gender Identity Disorders occur among those who self-identify as eunuch., Conclusions: We present evidence that the majority of self-identified voluntary eunuchs are not male-to-female transsexuals. Whereas the majority identify as male, many view themselves as in an alternate nonmale, nonfemale, gender space. We therefore suggest that male-to-eunuch is a valid transgender identity.

Background: Excess morbidity and mortality associated with schizophrenia is well established. Despite this, no previous multi-centre study has investigated whether patients with schizophrenia receive equitable physical healthcare within primary care., Objective: To determine whether patients with a diagnosis of schizophrenia receive the same levels of physical health care from primary care practitioners as patients without schizophrenia., Design: Case-matched retrospective case note review., Setting: Twenty-two general practices in the Birmingham area (UK)., Subjects: 195 patients with a diagnosis of schizophrenia, 390 matched controls with a diagnosis of asthma and 390 general control patients., Main Outcome Measures: Proportions of patients within each group having received six pre-defined routine health checks in a 3 year period. Conditional logistic regression models were used to identify differences between groups., Results: Patients with schizophrenia were half as likely as asthma controls to have blood pressure and cholesterol levels recorded (odds ratio 0.51; 95% confidence interval (CI) 1.35-0.73 and 0.50; 0.31-0.82, respectively) and were also less likely to have smoking status noted (0.60; 0.41-0.85). Similarly, patients with schizophrenia were significantly less likely than general population controls to have either blood pressure or cholesterol recorded (0.68; 0.47-0.97 and 0.58; 0.35-0.95). The significant differences observed were maintained after adjusting for potential confounders with the exception of cholesterol recording between the asthma and schizophrenia groups (0.57; 0.30-1.05)., Conclusions: Patients with a diagnosis of schizophrenia are less likely to receive some important general health checks than patients without schizophrenia.

Context: Population-based screening has been advocated for subclinical thyroid dysfunction in the elderly because the disorder is perceived to be common, and health benefits may be accrued by detection and treatment., Objective: The objective of the study was to determine the prevalence of subclinical thyroid dysfunction and unidentified overt thyroid dysfunction in an elderly population., Design, Setting, and Participants: A cross-sectional survey of a community sample of participants aged 65 yr and older registered with 20 family practices in the United Kingdom., Exclusions: Exclusions included current therapy for thyroid disease, thyroid surgery, or treatment within 12 months., Outcome Measure: Tests of thyroid function (TSH concentration and free T4 concentration in all, with measurement of free T3 in those with low TSH) were conducted. EXPLANATORY VARIABLES: These included all current medical diagnoses and drug therapies, age, gender, and socioeconomic deprivation (Index of Multiple Deprivation, 2004)., Analysis: Standardized prevalence rates were analyzed. Logistic regression modeling was used to determine factors associated with the presence of subclinical thyroid dysfunction., Results: A total of 5960 attended for screening. Using biochemical definitions, 94.2% [95% confidence interval (CI) 93.8-94.6%] were euthyroid. Unidentified overt hyper- and hypothyroidism were uncommon (0.3, 0.4%, respectively). Subclinical hyperthyroidism and hypothyroidism were identified with similar frequency (2.1%, 95% CI 1.8-2.3%; 2.9%, 95% CI 2.6-3.1%, respectively). Subclinical thyroid dysfunction was more common in females (P < 0.001) and with increasing age (P < 0.001). After allowing for comorbidities, concurrent drug therapies, age, and gender, an association between subclinical hyperthyroidism and a composite measure of socioeconomic deprivation remained., Conclusions: Undiagnosed overt thyroid dysfunction is uncommon. The prevalence of subclinical thyroid dysfunction is 5%. We have, for the first time, identified an independent association between the prevalence of subclinical thyroid dysfunction and deprivation that cannot be explained solely by the greater burden of chronic disease and/or consequent drug therapies in the deprived population.

Background: In western populations irritable bowel syndrome (IBS) affects between 10% and 30% of the population and has a significant effect on quality of life. It generates a substantial workload in both primary and secondary care and has significant cost implications. Gut-directed hypnotherapy has been demonstrated to alleviate symptoms and improve quality of life but has not been assessed outside of secondary and tertiary referral centres., Aim: To assess the effectiveness of gut-directed hypnotherapy as a complementary therapy in the management of IBS., Design of Study: Randomised controlled trial., Setting: Primary care patients aged 18-65 years inclusive, with a diagnosis of IBS of greater than 6 weeks' duration and having failed conventional management, located in South Staffordshire and North Birmingham, UK., Method: Intervention patients received five sessions of hypnotherapy in addition to their usual management. Control patients received usual management alone. Data regarding symptoms and quality of life were collected at baseline and again 3, 6, and 12 months post-randomisation., Results: Both groups demonstrated a significant improvement in all symptom dimensions and quality of life over 12 months. At 3 months the intervention group had significantly greater improvements in pain, diarrhoea and overall symptom scores (P<0.05). No significant differences between groups in quality of life were identified. No differences were maintained over time. Intervention patients, however, were significantly less likely to require medication, and the majority described an improvement in their condition., Conclusions: Gut-directed hypnotherapy benefits patients via symptom reduction and reduced medication usage, although the lack of significant difference between groups beyond 3 months prohibits its general introduction without additional evidence. A large trial incorporating robust economic analysis is, therefore, urgently recommended.

Background: Irritable bowel syndrome (IBS) is a common health problem affecting a substantial proportion of the population. Many individuals with symptoms of IBS do not seek medical attention or have stopped consulting because of disillusionment with current treatment options. Such patients may choose to re-consult with the advent of new therapies with a resulting impact on health services., Aim: To generate reliable estimates of the prevalence of IBS by age, sex and symptom group., Design of Study: Postal survey., Setting: Patients selected from registers of eight general practices in north and west Birmingham., Method: Eight thousand six hundred and forty-six patients aged >or=18 years were randomly selected from practice lists. Selected patients received a questionnaire, which included diagnostic criteria for IBS. A second questionnaire, seeking more detailed information, was sent to those whose responses indicated the presence of IBS symptoms., Results: Of the 8386 patients surveyed 4807 (57.3%) useable replies were received. The community-based prevalence of IBS was 10.5% (6.6% of men and 14.0% of women). Overall the symptom profiles were characterised by diarrhoea (25.4%), constipation (24.1%) and alternating symptoms (46.7%). Over half (56%) of all patients had consulted their general practitioner within the past 6 months and 16% had seen a hospital specialist. A quarter of patients consulted more than twice and 16% were referred to secondary care; almost half were on prescribed medication. However, the majority of patients were self-treated. Less than half of those currently reporting symptoms of IBS according to the Rome II criteria had received a diagnosis of IBS. Reduced quality of life and a previous diagnosis of a stomach ulcer were identified as predictors of consultation., Conclusion: Quality of life was significantly reduced in patients with IBS. There is a substantial burden on primary healthcare services despite over half of those with symptoms also self- medicating. The Rome II diagnostic criteria identified those most affected by their symptoms and are a valid clinical tool. Population-based health surveys will need to supplement the Rome criteria with questions aiming to identify patients formally diagnosed but whose symptoms are currently under control if prevalence is to be reliably estimated.

Background: Patient-held records can improve communication across the primary-secondary interface. There has been no previous rigorous assessment of the utility of patient-held records for people with schizophrenia from a primary care perspective and their value for this population is unclear., Aim: To evaluate the effectiveness of a patient-held record for patients with schizophrenia receiving shared care., Design of Study: Cluster randomised controlled trial., Setting: Seventy-four general practices and six community mental health localities in Birmingham, England between June 1998 and June 1999., Method: A sample of 201 patients with schizophrenia (ICD-10 classification F20) was recruited; of these, 100 were intervention and 101 were control. Patient-held records were given to the intervention patients. At 12-month follow-up, all patients were accounted for and 191 (95%) were revisited. Primary outcomes were the Verona Service Satisfaction Scale-54 (VSSS-54) and the Krawiecka and Goldberg (K & G) rating scale of psychopathology at 12-month follow-up. Secondary outcomes were use of primary and secondary care services., Results: A total of 63/92 (68.5%) patients still had the patient-held record, 64/92 (69.6%) had used it, and 39 (60.9%) of the 64 who had used it said the patient-held record was regularly used by their keyworker. However the patient-held record had no significant effect on primary outcomes (VSSS-54: F1,116 = 0.06, P = 0.801, K & G: F1,116 = 0.6, P = 0.439) or on use of services. A higher symptom score was associated with not using the patient-held record., Conclusions: The trial provides no good evidence to suggest that patient-held records should be introduced as part of routine shared care for all patients with schizophrenia. However, the patient-held record was acceptable to patients with schizophrenia and acted as a communication tool, particularly between patients and keyworkers.