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Objectives: To quantify the effects of rurality and socio-economic disadvantage on prior evidence of need for total hip joint replacement and use of health services after adjusting for age and gender. Design: Self-completion validated questionnaire mailed directly to subjects. Settings: Geographical areas covered by Wiltshire and Sheffield Health Authorities in England. Participants: Random stratified sample of 15,000 aged 65 years and over taken from the central age-sex registers. Main outcome measure: Prior need for hip joint replacement surgery and whether general practice and hospital services were being used as assessed by the questionnaire. Results: The response rate was 78% after three mailings. Prevalence of need for total hip replacement in the over 64s was 3.4% (95% confidence interval is 3.0% to 3.8%) and in those without co-morbidity 5.4% (95% confidence interval is 4.8% to 6.0%). There were inequalities demonstrated due to age, geography, and deprivation, but not rurality in accessing general practice and hospital services. People who were poor had more need. Older people in need were less likely to be accessing health services. Conclusions: There is an important unmet need for hip joint replacement in older people with marked inequalities in levels of need and use of services. The use of numbers of people waiting as a performance indicator is perverse for this procedure. We have urgently to expand orthopaedic services and the training of orthopaedic surgeons in England. Received 19 March 2002. Accepted 13 November 2002.

Objectives: To quantify the effects of socioeconomic deprivation and rurality on evidence of need for total knee joint replacement and the use of health services, after adjusting for age and sex. Methods: A random stratified sample of 15 000 people aged ⩾65 years taken from central age/sex registers for the geographical areas covered by the previous Sheffield and Wiltshire Health Authorities. A self completion validated questionnaire was then mailed directly to subjects to assess need for knee joint replacement surgery and whether general practice and hospital services were being used. Subjects were followed up for 18 months to evaluate access to surgery. Results: The response rate was 78% after three mailings. In those aged 65 years and over (with and without comorbidity), the proportion with no comorbid factors and in need of knee replacement was 5.1%; the rate of need among subjects without comorbidity was 7.9%. There were inequalities in health and access to health related to age, sex, geography, and deprivation but not rurality. People who were more deprived had greater need. Older and deprived people were less likely to access health services. Only 6.4% of eligible people received knee replacement surgery after 18 months of follow up. Conclusions: There is an important unmet need in older people, with significant age, sex, geographical, and deprivation inequalities in levels of need and access to services. The use of waiting list numbers as a performance indicator is perverse for this procedure. There is urgent need to expand orthopaedic services and training.

OBJECTIVES--To examine the relationship between specific types of morbidity, measured by validated survey questions, and hospital service use and mortality to see if the latter two could act as a proxy in health needs assessment, health service planning, and resource allocation in a typical health district. DESIGN--A postal questionnaire was used to provide information about depression, digestive disorders, musculo-skeletal disorders, obesity, respiratory disease, and hip and knee pain. The questions were from survey instruments that have been widely used to derive information about these conditions. The relationships between the prevalence of these specific types of morbidity and appropriate admission and mortality rates were explored using linear regression and Pearson correlation analysis. SETTING--The population of Rotherham health district, England. SUBJECTS--A simple random sample of the residents of each of the 22 electoral wards in Rotherham health district. RESULTS--Responses were obtained from 78% of the 5000 sampled (82% after excluding people who had moved house or died). Significant, positive correlations were found between the prevalence of respiratory disease and the hospital admission and mortality rates for respiratory problems (r = 0.68, p < 0.01 and r = 0.54, p < 0.01) and the prevalence of depression and the admission rate for depression (r = 0.52, p < 0.05). No such relations were found for digestive disease, musculo-skeletal disease, and obesity. For the conditions examined here, hospital service use was a more useful measure than mortality. CONCLUSIONS--Only two diseases (respiratory disease and depression) out of the seven diseases or procedures investigated showed a positive correlation between hospital admission and disease prevalence. But even for these two, the correlations explained less than 50% of the variance. Caution must be exercised when hospital service use is being considered as a proxy for morbidity.

OBJECTIVE--To audit avoidable deaths from stroke and hypertensive disease. DESIGN--Details of care before death were obtained from general practitioners and other doctors, anonymised, and assessed by two experts against agreed minimum standards of good practice for detecting and managing hypertension. SETTING--Health authority with population of 250,000. SUBJECTS--All patients under 75 years who died of stroke, hypertensive disease, or hypertension related causes during November 1990 to October 1991. MAIN OUTCOME MEASURES--Presence of important avoidable factors and departures from minimum standards of good practice. RESULTS--Adequate information was obtained for 88% (123/139) of eligible cases. Agreement between the assessors was mostly satisfactory. 29% (36/123, 95% confidence interval 21% to 37%) of all cases and 44% (36/81, 34% to 55%) of those with definite hypertension had avoidable factors that may have contributed to death. These were most commonly failures of follow up and continuing smoking. Assessment against standards of minimum good practice showed that care was inadequate but not necessarily deemed to have contributed to death, in a large proportion of patients with definite hypertension. Common shortcomings were inadequate follow up, clinical investigation, and recording of smoking and other relevant risk behaviours. CONCLUSIONS--This method of audit can identify shortcomings in care of patients dying of hypertension related disease.

The aim of the study was to examine the relationship between specific areas of morbidity measured using validated survey questions and deprivation indicators to see if the latter could act as a proxy in health needs assessment, health service planning and resource allocation in a typical health authority. A postal questionnaire was used to provide information about arthritis, depression, dyspepsia, obesity and respiratory symptoms in a simple random sample from the study population. The questions were from survey instruments that have been widely used to derive information about these conditions. The relationships between the prevalence of these specific areas of morbidity and both unemployment and the Jarman Underprivileged Areas Score were explored. Spearman's rank correlation coefficients were calculated and compared for each combination of measures. The study population was a random sample of the residents of each of the 22 electoral wards in Rotherham Health Authority. Responses were obtained from 82 per cent of the 5000 sampled. Although all morbidity measures showed positive correlations with both Jarman score and unemployment, some, notably those relating to respiratory disease and depression, were much more strongly correlated than others, such as obesity. There was no difference between unemployment and Jarman score in respect of the magnitude of the correlation coefficients. In conclusion, for some, but not all, conditions socio-economic measures are a good proxy for morbidity. Unemployment is just as useful a proxy as the Jarman score.

In 1989 the manual system of recording and analysing notifications of infectious disease in Sheffield was replaced by a computerized system based on the Epi Info software package. An analysis of the costs and benefits of this change shows that there has been a one-off cost of 780-930 h spent in developing the system. Offset against this is a continuing saving of time of around 400 h per annum. Other benefits which are harder to measure are enumerated and discussed. Costs of computer hardware and software are not substantial in comparison with the savings in staff time.

Axonal branching in the olivocerebellar projection was investigated using the retrograde fluorescent double-labelling method. Combinations of true blue and diamidino yellow injections (50 nl) were made in the cerebellar cortex of anaesthetized rats to investigate branching within single longitudinal zones and branching between such zones. The topographical arrangement of the projection was similar to that previously described, but additionally it was found that lateral parts of the inferior olive project more rostrally within a longitudinal zone and medial parts project more caudally in the same zone. Double-labelled olivary neurones, with axons branching rostrally and caudally within a single zone, were found to lie in an intermediate position between the two groups of single-labelled neurones. No such double-labelled neurones occurred when branching between zones was investigated. The correlation between these anatomical findings and earlier physiological work is discussed.

In 30 microns frozen sections of rat midbrain the retrograde axonal transport of diamidino yellow, a fluorescent tracer, was used to demonstrate a population of neurons in the substantia nigra. However, when visualisation was carried out using the routine Nissl method a significant proportion of neurons failed to stain. As the presence of the retrograde tracer did not affect Nissl staining of such cells, such incomplete staining, with consequent underestimation of neuronal populations, is probably a common error in similar material. Further investigation revealed that the proportion of such unstained neurons was greater when the staining time was short, when stain concentration was low, or when section thickness was increased. Some stains were worse in this respect than others. Cresyl fast violet resulted in the highest proportion of unstained neurons, thionin resulted in the lowest proportion. It was concluded that the rate of diffusion of the stain into the section was the main factor limiting the staining of neurons present. Staining with pure thionin at 0.1% concentration for at least 3 minutes and with sections no thicker than 30 microns is one regime which would avoid this problem.

The retrogradely transported fluorescent tracers True Blue and Diamidino Yellow were compared. They were found similar in the following respects: spread at injection sites; uptake from fibres of passage; fading of fluorescence and absence of retrograde transneuronal transport. Their fluorescence properties were, however, dissimilar and this, rather than differences in their sensitivity or efficiency, appears to account for their differences in respect of the intensities of fluorescence in such labelled neurones.

The projections to lobulus simplex and Crus I of the cerebellum from various brainstem nuclei have been examined in adult rats by using the retrograde fluorescent double labeling technique. True blue was injected into the lobulus simplex on one side and nuclear yellow on the other and the brainstem was examined for labeled neurons. The lateral reticular nucleus, pontine tegmental reticular nucleus, and nucleus praepositus hypoglossi were similar to the equivalent nuclei in other species but all contained double- as well as single-labeled neurons and it was concluded that these nuclei have neurons whose axons branch to both sides of the cerebellum. More neurons in the rostral part of the lateral reticular nucleus were bilaterally projecting than in the caudal and the significance of this in relation to its afferents is considered. The individual neurons in the pontine nuclei, inferior olivary nucleus, and cuneate nuclei only appear to project to one side and the recent evidence for axonal branching of pontine neurons in the cat is discussed.

A temperature controlled cell chamber is described which permits phase-contrast and fluorescence microscopy of living cells. It is shown how the cellular uptake of fluorochromes can be investigated both photographically and photometrically. Some sample results are presented for the uptake of Evans Blue.

The retrograde tracers true blue and diamidino yellow were injected into the caudate-putamen of adult rats which were allowed to survive for periods of 12 to 480 h after these injections. The retrograde axonal transport of these tracers was assessed by microphotometric measurement of the intensity of fluorescence in labelled neurones in the following three different sources of afferents to the caudate-putamen: the substantia nigra pars compacta; the parafascicular nucleus; and the dorsal raphe nucleus. It took respectively 12, 24 and 48 h for neurones in the substantia nigra, parafascicular nucleus and dorsal raphe nucleus to become retrogradely labelled. The average fluorescent intensity was greatest after 96-168 h but this highest value, and the subsequent decline, in fluorescence varied considerably between different tracers and different pathways. Neither axonal length nor neuronal activity correlate well with dynamics of build up and decline in fluorescence, but axonal collateralisation and diffuseness of terminals are associated with slower accumulation and more rapid removal of the tracers. Some neurones labelled with true blue retain their fluorescence better than those labelled with diamidino yellow but these differences are overshadowed by differences between different pathways in this respect.