Can health visitors prevent fractures in elderly people? To assess whether intervention by a health visitor could reduce the number of fractures, over a four year period, in those aged 70 and over. Randomised, controlled trial; randomisation by household. General practice in a market town. Of 863 patients aged 70 and over on the practice records, 674 were traced and successfully interviewed; 350 were assigned to the intervention group, 324 as controls. The people in the intervention group were allocated to the care of a health visitor. The approach was four pronged: assessment and correction of nutritional deficiencies, including reducing smoking and alcohol intake; assessment and referral of medical conditions such as heart block or inappropriate medication; assessment and correction of environmental hazards in the home such as poor lighting; assessment and improvement of fitness--for example, exercise classes for the moderately fit. The intervention continued for four years. Fracture rate over four years. The incidence of fractures was 5% (16/350) in the intervention group and 4% (14/324) in the control group (difference not significant). A health visitor visiting a group of people aged 70 and over and using simple preventive measures had no effect on the incidence of fractures.


Risk of second primary cancers after Hodgkin's disease by type of treatment: analysis of 2846 patients in the British National Lymphoma Investigation. To analyse the risk of second primary cancers during long term follow up of patients with Hodgkin's disease. Cohort study. The British National Lymphoma Investigation (a collaborative group of over 60 participating centres in Britain treating lymphomas). 2846 patients first treated for Hodgkin's disease during 1970-87, for whom follow up was complete in 99.8%. Second primary cancers; uniform pathology reviews confirmed the diagnosis of Hodgkin's disease and of second primary non-Hodgkin's lymphomas. 113 second primary cancers occurred. Relative risk of cancer other than Hodgkin's disease was 2.7 (95% confidence interval 2.3 to 3.3) compared with the general population, with significant risk of leukaemia (16.0(9.1 to 26.0)); non-Hodgkin's lymphoma (16.8(9.8 to 26.9)); and cancers of the colon (3.2 (1.4 to 6.2)), lung (3.8 (2.6 to 5.4)), bone (15.1 (1.8 to 54.7)), and thyroid (9.4 (1.1 to 33.9)). Absolute excess risk associated with treatment was greater for solid tumours than for leukaemia and lymphomas. Relative risk of leukaemia increased soon after treatment, reaching a peak after five to nine years. It was increased substantially after chemotherapy (27.9 (12.7 to 52.9)), combined treatment with radiotherapy and chemotherapy (21.5 (7.9 to 46.8)), and relative to number of courses of chemotherapy but was not significantly increased after radiotherapy (2.5 (0.1 to 14.1)). Relative risk of non-Hodgkin's lymphoma increased in the first five years after treatment and remained high but showed no clear relation with type or extent of treatment. Relative risk of solid tumours was less raised initially but increased throughout follow up and for lung cancer 10 years or more after entry was 8.3 (4.0 to 15.3). The risk of solid tumours increased after treatments including radiotherapy and after chemotherapy alone. The risk after chemotherapy increased significantly with time since first treatment. The risk of solid cancer, not of leukaemia, is the major long term hazard of treatment for Hodgkin's disease, and this seemed to apply after chemotherapy as well as after radiotherapy. These risks of second cancers are important in choice of treatment and in follow up of patients, but they are small compared with the great improvements in survival which have been brought about by modern therapeutic methods for Hodgkin's disease.


Drowning and near drowning in children in the United Kingdom: lessons for prevention. To determine the pattern of drowning and near drowning of children in Britain and identify means of prevention. Study of drowned and nearly drowned children under 15 years old. United Kingdom, 1988 and 1989. Children under 15 years either drowning or admitted to hospital after a submersion incident. Number of nearly drowned children, obtained from consultant paediatricians returning monthly notification cards through the British Paediatric Surveillance Unit. Number of drowned children notified by the Office of Population Censuses and Surveys and other national epidemiological offices; information from coroners. 306 children had confirmed submersion incidents: 149 died and 157 survived after near drowning. The annual incidence in England and Wales was 1.5/100,000, and mortality 0.7/100,000. Mortality was lowest in public pools 6% (2/32) and highest in rivers, canals, and lakes (78%, 56/73). Most of the children (263, 83%) were unsupervised at the time of the accident. 208 (68%) children were under 5 years old. Drowning and near drowning of children are problems in the British Isles. Appropriate supervision and safety barriers seem important for preventing such accidents. Improving information on dangers of drowning given to parents through the child surveillance programmes, encouraging fencing or draining of garden ponds and domestic swimming pools, and increasing supervision of swimming in lakes, rivers, and beaches should reduce the number of accidents.


Predicting psychiatric admission rates.

Predicting psychiatric admission rates. To determine the numbers of actual and expected psychiatric admissions for the residents of the district health authorities of England and to develop a model to indicate which social, health status, and service provision factors best explain the variation of the actual from the expected psychiatric admissions; to use this model to predict psychiatric admission for district health authorities as an aid to resource allocation. The actual psychiatric admission for district health authority residents were extracted from data of the 1986 Mental Health Enquiry. Expected admissions were calculated using the age, sex, and marital status structure of each district health authority and the national psychiatric admission rates related to age, sex, and marital status. Standardised psychiatric admission ratios were calculated as the ratios of the numbers of actual to expected psychiatric admissions. A wide range of social, health status, and service provision data were used as the explanatory variables in regression analyses to determine which combination of factors best explained the variation between districts of standardised psychiatric admission ratios. The 168,652 psychiatric admissions recorded for the 1986 Mental Health Enquiry, after exclusion of mental handicap and psychogeriatric admissions. The actual number of psychiatric admissions varied from 79% above to 54% below the expected number of admissions from age, sex, and marital status for the districts of England. The most powerful variables to explain this variation were the rate of notification of drug misusers, standardised mortality ratios, and levels of illegitimacy in each district. A complex model was developed which could be used to predict district psychiatric admissions as an aid to resource allocation. A simpler model was also developed (which was less powerful than the more complex model) based on the underprivileged area score. One advantage of this model was that it could be used at the level of electoral wards as well as district health authorities.


Short term treatment of dermatophyte onychomycosis with terbinafine. To evaluate the effect of short term treatment with terbinafine on dermatophytosis. Multicentre, randomised, double blind placebo controlled trial of 250 mg/day terbinafine for 12 weeks in dermatophyte onychomycosis. Eight dermatology centres in the United Kingdom. 112 patients (mean age 44, range 19-78), 99 with mycologically proved toenail infections and 13 with fingernail infections, of whom eight were subsequently excluded and 19 failed to complete the study. Terbinafine 250 mg daily or placebo for 12 weeks. Follow up for 36 weeks after stopping treatment. Mycological cure (negative results on microscopy and culture) and clinical cure at the end of follow up, adverse events, and biochemical and haematological variables at monthly intervals during treatment. After follow up 82% (37/45) (95% confidence interval 68% to 92%) mycological cure and 69% clinical cure were recorded for evaluable patients treated with terbinafine for toenail infection and 71% (5/7) (30% to 96%) mycological cure and clinical cure for those treated for fingernail infection. The corresponding values for those treated with placebo were 12% (3% to 31%) mycological cure and no clinical cure for toenail infections and 33% (1% to 91%) mycological cure and no clinical cure for fingernail infections. On an intention to treat basis for toenail infections the figures were 73% (38/52) (58% to 85%) mycological cure for terbinafine compared with 6% (0% to 30%) for placebo (p less than 0.007). Two withdrawals were related to adverse events with terbinafine, and there were no significant abnormal laboratory test results. 12 weeks' terbinafine is effective and safe treatment for nail dermatophytosis.


Current uses of ophthalmic lasers.

Current uses of ophthalmic lasers. Current laser treatments are quick, relatively painless, and well tolerated. Some ophthalmic techniques can be performed only by laser while others have a lower morbidity than alternative treatments. Peripheral retinal photocoagulation and focal photocoagulation now offer greatly improved visual prognosis for diabetic patients with proliferative diabetic retinopathy or diabetic macular disease. Selected cases of macular degeneration may be treated by focal laser photocoagulation. The role of lasers in treating sub-retinal neovascular membranes is limited by the extent and location of the membrane at presentation and the high risk of recurrence after treatment. Patients with distorted vision must be referred urgently for specialist ophthalmic assessment. Flat retinal holes and tears may be sealed by laser therapy, thus preventing retinal detachment. Short pulsed neodymium-YAG photodisruptive capsulotomy effectively clears the visual axis of thickened posterior lens capsule after cataract surgery. Short pulsed neodymium-YAG photodisruptive iridotomy may be used to treat and prevent angle closure glaucoma. Laser trabeculoplasty aids the control of open angle glaucoma. Research is continuing into the role of other lasers in managing open angle glaucoma and of photoablative lasers in treating refractive errors and superficial corneal disorders.


Erythrocyte sodium-lithium countertransport and blood pressure in identical twin pairs discordant for insulin dependent diabetes. To investigate whether insulin dependent diabetes is responsible for the abnormal behaviour of the carrier in sodium-lithium countertransport and whether the diabetic state is associated with rise in blood pressure. Case-control study. London teaching hospital. 44 twin pairs discordant for insulin dependent diabetes living in United Kingdom and 44 healthy control subjects matched for age, sex, and body mass index. None of the twin pairs or the controls had evidence of microalbuminuria. Sodium-lithium countertransport activity in erythrocytes and arterial blood pressure. The mean (95% confidence interval) sodium-lithium countertransport activity (mmol Li per litre of red blood cells per h) of the diabetic twins (0.291 (0.244 to 0.338)) was similar to that of their non-diabetic cotwins (0.247 (0.204 to 0.290)); both values were significantly higher than that of the controls (0.187 (0.157 to 0.216); p < 0.05). In addition, systolic blood pressure was higher in those twins with diabetes (127 (122 to 133) mm Hg) than in the non-diabetic cotwins (122 (117 to 127) mm Hg; p < 0.01). There were no significant differences in mean diastolic blood pressure between any of the groups studied. The raised erythrocyte sodium-lithium countertransport activity in the diabetic twins compared with the controls seems to be inherited rather than a consequence of overt diabetes. The higher systolic blood pressure in diabetic twins than non-diabetic cotwins indicates that insulin dependent diabetes does exert a small influence on systolic blood pressure.


Impact of HIV infection on mortality in young men in a London health authority. To determine the number of deaths attributable to HIV infection among men aged 15-64 in a geographically defined population in the United Kingdom. Retrospective review of death certificates and linkage with local and national HIV and AIDS surveillance data. Riverside District Health Authority, London. Numbers of deaths attributed to HIV infection in male residents of Riverside aged 15-64 and 15-44 over a six month period. Proportion of attributed deaths were (i) identified from death certificates by the Office of Population Censuses and Surveys as being due to HIV infection and (ii) reported as cases of AIDS or HIV related deaths to the Public Health Laboratory Service Communicable Disease Surveillance Centre. 34 of 213 (16%) deaths in men aged 15-64 and 27 of 69 (39%) deaths in men aged 15-44 were attributed to HIV infection. Six of 33 (18%) attributed deaths were identified by the Office of Population Censuses and Surveys and 32/34 (94%) were reported to the Communicable Disease Surveillance Centre. HIV infection was the leading cause of death in male residents of Riverside aged 15-44 and the third commonest cause of death in those aged 15-64. Most individuals dying of known HIV infection were reported to the Communicable Disease Surveillance Centre but identification of the true cause of death from the process of death certification was poor. Measures to improve the certification of HIV and AIDS or the use of AIDS surveillance information correctly to code the cause of death needs to be considered to ensure that the true impact of HIV infection is reflected in routine mortality statistics.


Evidence of transmission of tuberculosis by DNA fingerprinting. To determine whether a subject who had died of tuberculous meningitis had been infected by a neighbour. Retrospective comparison of isolates of Mycobacterium tuberculosis from the two cases and from 10 controls by DNA fingerprinting. Public Health Service Reference Laboratory for Mycobacteria and bacterial molecular genetics unit of the London School of Hygiene and Tropical Medicine. Deceased and neighbour; 10 controls from the same city, from whom isolates had been collected over three months before the subject's death. Identity and similarity values (SAB) between fingerprint patterns from different isolates obtained by hybridisation of restriction fragments produced by PvuII with a probe from the insertion element IS6110/986, present in multiple copies throughout the genome of M tuberculosis. Isolates from the two cases under investigation had identical fingerprints whereas those from the controls were all distinct. Two clusters of isolates with a similarity coefficient > 0.25 were identified: in one, four out of five patients were born in the midlands (the birth place of the fifth was not known) and in the other all three patients were born in the Indian subcontinent. The data are consistent with, but do not prove, transmission of tuberculosis from the neighbour to the deceased. Geographical separation of the pools of infection may have led to the evolution of distinct clusters of fingerprint patterns. DNA fingerprinting of M tuberculosis is a powerful new tool for study of the epidemiology and pathogenesis of tuberculosis.


Choosing the preventive workload in general practice: practical application of the Coronary Prevention Group guidelines and Dundee coronary risk-disk. To determine the workload implications for general practice of the Coronary Prevention Group and British Heart Foundation action plan for preventing heart disease. Computer simulation of plan, including calculation of Dundee risk scores, with data from OXCHECK trial. 4759 patients aged 35-64 who had health checks during 1989-91. Effect of using different risk scores as thresholds on workload and coverage of patients at known risk. Thresholds of 6-20 were used for cholesterol screening (nearset) and 4-16 for special care (preset). On the basis of workload a nearset of 8 and preset of 12 would be reasonable. This implies cholesterol measurement in 1794 (37.7%) patients and special care in 1074 (22.6%). However, many patients with single risk factors were not allocated to special care at these thresholds: 11 (37.9%) patients with cholesterol concentrations > or = 10 mmol/l, 21 (33.9%) with systolic pressure > or = 180 mm Hg, and 213 (40.7%) heavy smokers (> 20 cigarettes/day) were missed. The distribution of scores was similar in those at established clinical risk, those with family history of heart disease, and others. The guidelines may help to make best use of resources within specific age-sex groups but sound protocols for unifactorial risk assessment and modification remain essential.


Bone density parathyroid hormone and 25-hydroxyvitamin D concentrations in middle aged women. To examine the relation between bone density and indices of calcium metabolism including parathyroid hormone and 25-hydroxyvitamin D concentrations in middle aged women. A cross sectional study. 138 women volunteers aged 45-65 with no known osteoporosis and unselected for disease status recruited for a dietary assessment study from the community using general practice registers. Volunteer rate was 20%. Bone mineral density measured with dual energy x ray absorptiometry. Bone density at the lumbar spine and neck and trochanteric regions of the femur was inversely related to serum intact parathyroid hormone concentrations and positively related to serum 25-hydroxyvitamin D concentrations. These associations were independent of possible confounding factors, including age, body mass index, cigarette smoking habit, menopausal status, and use of diuretics and postmenopausal hormone replacement therapy. These associations were apparent throughout the whole distribution of bone density and 25-hydroxyvitamin D and parathyroid hormone concentrations within the normal range, suggesting a physiological relation. The findings are consistent with the hypothesis that parathyroid hormone and 25-hydroxyvitamin D concentrations influence bone density in middle aged women. Findings from this study together with other work suggest that the role of vitamin D in osteoporosis should not be neglected. The associations with parathyroid hormone also indicate plausible biological mechanisms. The roughly 5-10% difference in bone density between top and bottom tertiles of serum 25-hydroxyvitamin D concentrations, though not large in magnitude, may have considerable public health implications in terms of prevention of osteoporosis and its sequelae, fractures.


Low serum cholesterol concentration and short term mortality from injuries in men and women. To determine whether total serum cholesterol concentration predicts mortality from injuries including suicide. Cohort study of men and women who had their serum cholesterol concentration measured as part of a general health survey in Värmland, Sweden in 1964 or 1965 and were followed up for an average of 20.5 years. Adults participating in health screening in 1964-5 (26,693 men and 27,692 women). The study sample was restricted to subjects aged 45-74 years during any of the 20.5 years of follow-up. Serum cholesterol concentration. Deaths from all injuries and suicides during three periods of follow up (0-6 years, 7-13 years, and 14-21 years) according to the Swedish mortality register in subjects aged 45-74. Adjustment was made for prevalent cancer (identified from the Swedish cancer register) at the time of a suicide. A strong negative relation between cholesterol concentration and mortality from injuries was found in men during the first seven years of follow up. The relative risk in the lowest 25% of the cholesterol distribution was 2.8 (95% confidence interval 1.52 to 4.96) compared with the top 25%. Most of the excess risk was caused by suicide with a corresponding relative risk of 4.2 (p for trend = 0.001). Correction for prevalent cancer did not change the results. Events occurring during the latter two thirds of the 20.5 years of follow up were not predicted. In women no relation between cholesterol concentration and mortality from injuries was found. Together with observations from intervention trials the findings support the existence of a relation between serum cholesterol concentration and suicide. The causality of such a relation is, however, not resolved.


Central serotonin receptors and delayed gastric emptying in non-ulcer dyspepsia. To determine whether central serotonin receptors are involved in the pathophysiology of non-ulcer dyspepsia. Between subjects study of solid phase gastric emptying and prolactin response to buspirone challenge. 12 patients fulfilling criteria for non-ulcer dyspepsia and 12 age and sex matched controls. Solid phase gastric emptying measured by scintigraphic assessment of the movement of a standard meal labelled with technetium-99m and indium-111; responsiveness of central serotonin 1A receptors measured by the prolactin release following challenge with oral buspirone 60 mg. Solid phase gastric emptying was significantly delayed in the patients with non-ulcer dyspepsia (t 1/2 = 90.6 (SD 14.5) minutes in patients and 54.6 (10.7) minutes in controls; 95% confidence interval 24.7 to 46.7 minutes, p < 0.001). Prolactin release was significantly greater in patients compared with controls (1272.7 (1039.9) mU/l v 292.9 (136.1) mU/l; 352.1 to 1607.5 mU/l, p < 0.01). Gastric emptying and prolactin release were significantly correlated (r = 0.59, p = 0.04) in the patients but not in the controls (r = 0.23). Central serotonin 1A receptors may have a role in the pathophysiology of non-ulcer dyspepsia of the dysmotility subtype.


Health service support of breast feeding--are we practising what we preach? To ascertain the attitudes of health professionals and breast feeding mothers to breast feeding and their views on current practice. Questionnaire to all midwives and health visitors and to breast feeding mothers in Newcastle upon Tyne. Maternity units and community in Newcastle upon Tyne. 127 hospital midwives, 23 community midwives, 63 health visitors, and 50 first time breast feeding mothers. Optimum practice guidelines were not followed. 30 (60%) mothers said they were separated from their babies on the first night after birth. 82 (42%) professionals said that breast fed babies were frequently given water to drink. 28 (56%) babies in the mothers survey had received food or water other than breast milk; 19 of these had been given water. Professionals expressed mainly positive attitudes towards breast feeding in general but less positive attitudes to specific issues such as the beneficial effects on child health and the value of voluntary organisations in breast feeding promotion and management. Although many health workers are in favour of breast feeding there is conflict among the professions working most closely with breast feeding mothers. Good breast feeding support requires closer attention to monitoring hospital practices and continued training on good lactation management.


Nutrient intake and cataract extraction in women: a prospective study. To examine prospectively the association between dietary intake of vitamins C and E, carotene, and riboflavin and cataract extraction in women. Prospective cohort study beginning in 1980 with eight years of follow up. 11 states of the United States. Female registered nurses who were 45 to 67 years of age. 50,828 women were included in 1980 and others were added as they became 45 years of age. Incidence of extraction of senile cataracts. 493 cataracts were extracted during 470,302 person years of follow up. Intake of carotene and vitamin A was inversely associated with cataract: in multivariate analyses, women in the highest fifth of total vitamin A intake (excluding supplements) had a 39% lower risk of cataract relative to women in the lowest fifth (relative risk 0.61; 95% confidence interval 0.45 to 0.81). Neither riboflavin nor dietary vitamins E or C were associated with cataract in a multivariate analysis. Among specific food items spinach (rather than carrots, the greatest source of beta carotene) was most consistently associated with a lower relative risk. The risk of cataract was 45% lower among women who used vitamin C supplements for 10 or more years(relative risk 0.55 (0.32 to 0.96)), but no association was noted for multivitamin intake. Dietary carotenoids, although not necessarily beta carotene, and long term vitamin C supplementation may decrease the risk of cataracts severe enough to require extraction.


Case holding in patients with tuberculosis in Botswana. To evaluate the effectiveness of daily supervised short course chemotherapy in a national tuberculosis programme. Observation of programme during 1984-90. In October 1986 short course chemotherapy was introduced with patients receiving treatment daily from staff in their nearest health facility. Botswana national tuberculosis programme. All patients with tuberculosis. Proportions of patients complying with and defaulting from treatment (missing > or = 43 days' treatment). 2938 cases of tuberculosis were recorded in 1990, 1528 of which were of sputum positive pulmonary disease. 2711 (92.3%) patients complied with treatment and 227 (7.7%) defaulted. Before introduction of short course chemotherapy compliance was about 60% compared with over 90% in 1987-90. A programme using daily supervised short course chemotherapy integrated into the primary health care system is an effective method of treating tuberculosis. The costs of the programme need to be evaluated.


Childhood cancer, intramuscular vitamin K, and pethidine given during labour. To assess unexpected associations between childhood cancer and pethidine given in labour and the neonatal administration of vitamin K that had emerged in a study performed in the 1970 national birth cohort. 195 children with cancer diagnosed in 1971-March 1991 and born in the two major Bristol maternity hospitals in 1965-87 were compared with 558 controls identified from the delivery books for the use of pethidine during labour and administration of vitamin K. Odds ratios for cancer in the presence of administration of pethidine or of intramuscular vitamin K. Both logistic regression and Mantel-Haenszel techniques were used for statistical analyses. Children of mothers given pethidine in labour were not at increased risk of cancer (odds ratio 1.05, 95% confidence interval 0.7 to 1.5) after allowing for year and hospital of delivery, but there was a significant association (p = 0.002) with intramuscular vitamin K (odds ratio 1.97, 95% confidence interval 1.3 to 3.0) when compared with oral vitamin K or no vitamin K. There was no significantly increased risk for children who had been given oral vitamin K when compared with no vitamin K (odds ratio 1.15, 95% confidence interval 0.5 to 2.7). These results could not be accounted for by other factors associated with administration of intramuscular vitamin K, such as type of delivery or admission to a special care baby unit. The only two studies so far to have examined the relation between childhood cancer and intramuscular vitamin K have shown similar results, and the relation is biologically plausible. The prophylactic benefits against haemorrhagic disease are unlikely to exceed the potential adverse effects from intramuscular vitamin K. Since oral vitamin K has major benefits but no obvious adverse effects this could be the prophylaxis of choice.


Health status of the temporarily homeless population and residents of North West Thames region. To survey the health status of the temporarily homeless population of North West Thames region and make comparisons with regional residents. Direct interview with standardised questionnaires. Temporarily homeless people resident in hotels in the London boroughs in the North West Thames region and a random sample of regional residents. 137 hotels thought to be providing accommodation to homeless people selected at random from a list of 295. 113 (82%) participated in the study, and 319 (61%) of 522 homeless people approached participated. The study was restricted to adults aged 16 and over selected at random. The homeless population was predominantly female (195/319; 61%), young (229 (72%) aged 16-34), and poor, 54% (172/319) receiving income support. 207 subjects (65%) had dependent children aged 16 and under. Rates of acute illness among homeless people (32 cases; 10%) were similar to those reported by regional residents. The prevalence of longstanding limiting illness (108 cases; 34%) was similar to that for regional residents, but the prevalence of mental morbidity was twice that for the region as a whole (145 cases (45%) v 1485 (18%)). Utilisation of general practitioner services, accident and emergency departments, and inpatient admission was much higher by the homeless population than by regional residents. General practitioner registration rates were above 90% for the homeless sample. Survey data provide empirical evidence about the nature and characteristics of the temporarily homeless population. The high service utilisation recorded may, in part, have resulted from the higher morbidity in this sample of homeless people. The concentration of homeless people into specific locations may suggest that additional funding should be provided to the district which provides care to this group. However, such funding should not necessarily be used for additional acute care but should be used to purchase appropriate services which meet the health needs of this very young, poor and vulnerable group.


Laparoscopic cholecystectomy as a safe and effective treatment for severe acute cholecystitis. To evaluate the feasibility and safety of laparoscopic cholecystectomy in severe acute cholecystitis. Analysis of data collected prospectively from a consecutive series of 350 laparoscopic operations. Two general surgical units in a teaching hospital. 31 patients with a diagnosis of severe acute cholecystitis based on clinical examination, investigation results, and operative findings. Initial intravenous fluids and broad spectrum antibiotics followed by laparoscopic cholecystectomy within 72 hours of presentation. Failure to complete the operation laparoscopically, length of postoperative stay in hospital, early postoperative morbidity, interval from operation to full activity, and return to work. Laparoscopic cholecystectomy was attempted in 19 patients with empyema of the gall bladder and 12 who had severe cholecystitis which failed to settle on medical management. A total of 29 operations were successfully completed with two conversions to open surgery. Two minor postoperative complications occurred, and one case of retained common bile duct stones with jaundice was treated by endoscopic retrograde cholangiopancreatography and papillotomy. Median postoperative hospital stay was two days, with return to normal activity in seven days and to work in two weeks. There were no deaths related to the operation. In the presence of severe acute cholecystitis laparoscopic cholecystectomy is feasible in most patients, with minimal risk of injury to surrounding structures and considerable benefits. It is recommended that laparoscopic cholecystectomy should be attempted in these patients when appropriate surgical skill is available.


General practice partnerships: till death us do part? To investigate applications for general practice partnership vacancies by established general practitioner principals, the reasons for changing partnerships, and the disincentives to these moves. Confidential postal questionnaire. Applicants to 367 general practices in the United Kingdom advertising for a new full time partner. The proportion of job applications containing at least one application from established principals, proportion of principals appointed as new partners, incentives and disincentives to changing partnership. Of 325 replies (89% response rate) received, 292 were suitable for further analysis. 210/241 (87%) of all applications contained some applications from at least one established principal. 12% of all applications were made by principals. 41/296 (14%) of the newly appointed partners had previously been an established principal. The main reasons for leaving the previous partnership were a desire to move locality or not getting on with previous partners. The disincentives to changing partnerships were largely financial, including the cost of the move and loss of income. It is possible for established principals in general practice to overcome the disincentives and to change partnerships. There did not seem to be any overall prejudice against appointing principals, in contrast to previously published views.


Discomfort and pain during mammography: description, prediction, and prevention. To identify the nature of pain and discomfort experienced during mammography and how it can be ameliorated. Questionnaire survey before invitation for mammography and immediately after mammography. Responses before screening were related to experience of discomfort. Health district in South East Thames region. 1160 women aged 50-64 invited routinely for screening; 774 completed first questionnaire, of whom 617 had mammography. 597 completed the second questionnaire. Reported discomfort and pain, comparisons of discomfort with that experienced during other medical procedures, qualitative description of pain with adjective checklist. 35% (206/597) of the women reported discomfort and 6% (37/595) pain. 10 minutes after mammography these figures were 4% (24/595) and 0.7% (4/595) respectively. More than two thirds of women ranked having a tooth drilled, having a smear test, and giving blood as more uncomfortable than mammography. The most important predictor of discomfort was previous expectation of pain (discomfort was reported by 21/32 (66%) women who expected pain and 186/531 (35%) who did not). Discomfort had little effect on satisfaction or intention to reattend. The low levels of reported pain and discomfort shortly after mammography and the favourable comparisons with other investigations suggest that current procedures are acceptable. Since two thirds of the women experienced less pain than expected health education and promotion must ensure that accurate information is made available and publicized.


Time delays in provision of thrombolytic treatment in six district hospitals. Joint Audit Committee of the British Cardiac Society and a Cardiology Committee of Royal College of Physicians of London. To measure the delays between onset of symptoms and admission to hospital and provision of thrombolysis in patients with possible acute myocardial infarction. Observational study of patients admitted with suspected myocardial infarction during six months. Six district general hospitals in Britain. 1934 patients admitted with suspected myocardial infarction. Route of admission to hospital and time to admission and thrombolysis. Patients who made emergency calls did so sooner after onset of symptoms than those who called their doctor (median time 40 (95% confidence interval 30 to 52) minutes v 70 (60 to 90) minutes). General practitioners took a median of 20 (20 to 25) minutes to visit patients, rising to 30 (20 to 30) minutes during 0800-1200. The median time from call to arrival in hospital was 41 (38 to 47) minutes for patients who called an ambulance from home and 90 (90 to 94) minutes for those who contacted their doctor. The median time from arrival at hospital to thrombolysis was 80 (75 to 85) minutes for patients who were treated in the cardiac care unit and 31 (25 to 35) minutes for those treated in the accident and emergency department. The time from onset of symptoms to thrombolysis could be reduced substantially by more effective use of emergency services and faster provision of thrombolysis in accident and emergency departments.


Predicting mortality from cervical cancer after negative smear test results. To assess the relative protection against death from cervical cancer after two or more negative smear test results and compare it with the protection against invasive cancer estimated by an International Agency for Research on Cancer (IARC) working group in an analysis of data from 10 large screening programmes. Comparison of risk of death from cervical cancer after two or more negative smear results with the risk in unscreened women by using a model constructed with data from the British Columbia screening programme. Mortality from and incidence of invasive cancer. In women with two negative smear results estimates of protection against cervical cancer were about 50% higher when lethal invasive cancer was used as the criterion rather than all invasive cancer. This difference was due to these women being more likely to attend for further tests at which invasive cancer could be detected: screen detected cancer has a better prognosis than clinically diagnosed cancer. Screening intervals could be longer than three years: screening women aged 35-64 every five years was predicted to result in a 90% reduction in mortality from cervical cancer. Because protection from mortality is higher than protection from disease and because of the high costs and negative side effects of frequent screening, screening intervals should be longer than three years.


BCG immunisation in England and Wales: a survey of policy and practice in schoolchildren and neonates. To determine the policy and practice of district health authorities in England and Wales for BCG immunisation in schoolchildren and neonates. Self completion postal questionnaire survey. District immunisation coordinators. 199 district health authorities in England and Wales. Questionnaires were received from 186 districts, a response rate of 94%. Considerable uniformity was observed in many aspects of BCG immunisation policy and practice but some important variations were found. 15 districts no longer carry out a routine schools programme. 148 districts offer BCG to selected groups of neonates and five to all neonates, but 31 districts do not offer BCG to this age group. The recommended action in response to different levels of tuberculin sensitivity in schoolchildren and neonates varied among districts. Despite the recommendations of the Joint Committee on Vaccination and Immunisation some districts do not offer BCG immunisation to neonates at high risk of tuberculosis and there are important variations in other aspects of BCG policy.


Randomised controlled trial of short term treatment to eradicate Helicobacter pylori in patients with duodenal ulcer. To determine whether one week's drug treatment is sufficient to eradicate Helicobacter pylori in patients with duodenal ulcer. Single blind, randomised controlled trial. Specialised ulcer clinic in a teaching hospital. 155 patients with H pylori and a duodenal ulcer verified endoscopically which had either bled within the previous 24 hours or was causing dyspepsia. Patients were allocated randomly to receive either omeprazole for four weeks plus bismuth 120 mg, tetracycline 500 mg, and metronidazole 400 mg (all four times a day) for the first week (n = 78), or omeprazole alone for four weeks (n = 77). Further endoscopy was performed four weeks after cessation of all drugs. Presence or absence of H pylori (by urease testing, microscopy, and culture of antral biopsy specimens), duodenal ulcer, and side effects. Eradication of H pylori occurred in 70 (95%) patients taking the four drugs (95% confidence interval 86% to 97%) compared with three (4%) patients taking omeprazole alone (1% to 11%). Duodenal ulcers were found in four (5%) patients taking the four drugs (2% to 12%) and in 16 (22%) patients taking omeprazole alone (14% to 32%). Mild dizziness was the only reported side effect (six patients in each group) and did not affect compliance. A one week regimen of bismuth, tetracycline, and metronidazole is safe and effective in eradicating H pylori and reduces the number of duodenal ulcers four weeks after completing treatment.


Social effects of wheeze in childhood: a 25 year follow up. To determine the outcome of childhood wheeze in terms of education, employment, housing, and social class. 25 year follow up study. Community study based at the department of thoracic medicine, Aberdeen Royal Infirmary. Three groups of subjects who had been identified in a random community survey in 1964: those who had had asthma in childhood (n = 97), those who had wheezed only in the presence of upper respiratory tract infections (n = 132), and a comparison group who had had no respiratory symptoms as children (n = 131). Subjects were aged 34 to 40 years at the time of the current study. Interview and questionnaire data on education, employment, housing and social class, ventilatory function, and peak flow rate. Pulmonary function testing showed that only the "asthmatic" group had airways obstruction; this group showed greater peak flow variation than the "wheezy" group, which did not differ from the comparison group. The asthmatic subjects were more likely to have experienced respiratory problems during their school years and associated with their work. Despite these problems, educational attainment, employment, housing, and eventual social class were similar for all three groups. Childhood wheeze did not adversely affect education, employment, housing, or social class in this population.


Feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners: Grampian region early anistreplase trial. GREAT Group. To assess the feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners. Randomised double blind parallel group trial of anistreplase 30 units intravenously and placebo given either at home or in hospital. 29 rural practices in Grampian admitting patients to teaching hospitals in Aberdeen (average distance 36 (range 16-62) miles). 311 patients with suspected acute myocardial infarction and no contraindications to thrombolytic therapy seen at home within four hours of onset of symptoms. Time saving, adverse events, Q wave infarction, left ventricular function. Anistreplase was administered at home 101 minutes after onset of symptoms, while anistreplase was given in hospital 240 minutes after onset of symptoms (median times). Adverse events after thrombolysis were infrequent and, apart from cardiac arrest, not a serious problem when they occurred in the community: seven of 13 patients were resuscitated after cardiac arrest out of hospital. By three months after trial entry the relative reduction of deaths from all causes in patients given thrombolytic therapy at home was 49% (13/163 (8.0%) v 23/148 (15.5%); difference -7.6% (95% confidence interval -14.7% to -0.4%), p = 0.04). Full thickness Q wave infarction was less common in patients with confirmed infarction receiving treatment at home (65/122 (53.3%) v 76/112 (67.9%); difference -14.6% (95% confidence interval -27.0% to -2.2%), p = 0.02). General practitioners provided rapid pre-hospital coronary care of a high standard. Compared with later administration in hospital, giving anistreplase at home resulted in reduction in mortality, fewer cardiac arrests, fewer Q wave infarcts, and better left ventricular function. Benefits were most marked where thrombolytic therapy was administered within two hours of the onset of symptoms.


Safety of early pain relief for acute abdominal pain. (a) to determine the efficacy of papaveretum in treating pain when administered early to patients presenting with acute abdominal pain and (b) to assess its effect on subsequent diagnosis and management. Prospective, randomised, placebo controlled study. Walsgrave Hospital, Coventry. 100 consecutive patients with clinically significant abdominal pain who were admitted as emergencies to a surgical firm. Intramuscular injection of up to 20 mg papaveretum or an equivalent volume of saline. Pain and tenderness scores, assessment of patient comfort, accuracy of diagnosis, and management decisions. Median pain and tenderness scores were lower after papaveretum (pain score 8.3 in control group and 3.1 in treatment group, p < 0.0001; tenderness score 8.1 in control group and 5.1 in treatment group, p < 0.0001). Forty eight patients were deemed to be comfortable after papaveretum compared with nine after saline. Incorrect diagnoses and management decisions applied to two patients after papaveretum compared with nine patients after saline. Early administration of opiate analgesia to patients with acute abdominal pain can greatly reduce their pain. This does not interfere with diagnosis, which may even be facilitated despite a reduction in the severity of physical signs. These patients should not be denied effective treatment.


Effect of salcatonin given intranasally on bone mass and fracture rates in established osteoporosis: a dose-response study. To study the dose related response of salmon calcitonin (salcatonin) given intranasally on bone mass and bone turnover and the effect of salcatonin on rates of fracture in elderly women with moderate osteoporosis. Double blind, placebo controlled, randomised group comparison. Outpatient clinic for research into osteoporosis. 208 healthy women aged 68-72 years who had a bone mineral content of the distal forearm on average 30% below the mean value for healthy premenopausal women. The 208 women were allocated randomly in blocks of four to two years of treatment with either salcatonin 50 IU, 100 IU, or 200 IU given intranasally or placebo. All groups received a calcium supplement of 500 mg. 32 of the women left the study before its end and 164 women complied with the study criteria throughout. Bone mineral content of the distal forearm and lumbar spine and rates of vertebral and peripheral fractures after two years of treatment. The average changes in bone mineral content of the spine showed positive outcomes of 1% (95% confidence interval -0.1% to 1.5%) in the group treated with calcium (placebo) and 3% (1.8% to 4.2%) in the group treated with salcatonin 200 IU. There was a significant dose related response to salcatonin, manifested by an increase of 1.0%/100 IU (0.2% to 1.7%, p = 0.008). The rate of patients with new fractures was reduced significantly in the women treated with salcatonin to about one third of that in the non-salcatonin treated women (relative risk 0.23 (0.07 to 0.77)). The results suggest that, compared with calcium alone, salcatonin given intranasally reduces the rates of fracture by two thirds in elderly women with moderate osteoporosis. Furthermore, it increases spinal bone mass in a dose dependent manner.


Simulation model for planning renal services in a district health authority. To investigate the use of a computer simulation model in planning and budgeting for renal replacement services. Regional renal unit. The simulation provided projections that accurately reflected the actual numbers of people maintained on different forms of renal replacement therapy in previous years. Projections up to the end of the century showed that with no change in the demand for the service the total number of people on the renal replacement programme would increase by 40%. Increasing the uptake of new patients from 40 per million to 55 per million would mean an increase of 66% in patient numbers over the same period. Similarly, at present day prices the cost of providing the service would rise by 31% with no change in demand and by twice this with the greater uptake of new patients. Increasing the number of transplant operations was shown to offer little prospect of a reduction in these costs. The simulation program could be used by individual renal units to evaluate different treatment policies and to budget for resource use. Even at current demand levels resource requirements for renal replacement therapy will continue to grow until after the end of the century.


Evidence for decreasing quality of semen during past 50 years. To investigate whether semen quality has changed during the past 50 years. Review of publications on semen quality in men without a history of infertility selected by means of Cumulated Index Medicus and Current List (1930-1965) and MEDLINE Silver Platter database (1966-August 1991). 14,947 men included in a total of 61 papers published between 1938 and 1991. Mean sperm density and mean seminal volume. Linear regression of data weighted by number of men in each study showed a significant decrease in mean sperm count from 113 x 10(6)/ml in 1940 to 66 x 10(6)/ml in 1990 (p < 0.0001) and in seminal volume from 3.40 ml to 2.75 ml (p = 0.027), indicating an even more pronounced decrease in sperm production than expressed by the decline in sperm density. There has been a genuine decline in semen quality over the past 50 years. As male fertility is to some extent correlated with sperm count the results may reflect an overall reduction in male fertility. The biological significance of these changes is emphasised by a concomitant increase in the incidence of genitourinary abnormalities such as testicular cancer and possibly also cryptorchidism and hypospadias, suggesting a growing impact of factors with serious effects on male gonadal function.


Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports. To examine the possible contribution of sedation with propofol in the deaths of children who were intubated and required intensive care. Case note review. Three intensive care units. Five children with upper respiratory tract infections aged between 4 weeks and 6 years. Four patients had laryngotracheo-bronchitis and one had bronchiolitis. All were sedated with propofol. The clinical course in all five cases was remarkably similar: an increasing metabolic acidosis was associated with brady-arrhythmia and progressive myocardial failure, which did not respond to resuscitative measures. All children developed lipaemic serum after starting propofol. These features are not usually associated with respiratory tract infections. No evidence was found of viral myocarditis, which was considered as a possible cause of death. Although the exact cause of death in these children could not be defined, propofol may have been a contributing factor.


Warming lignocaine to reduce pain associated with injection. To investigate the effect of warming lignocaine on the pain associated with subcutaneous injection. Double blind, randomised, crossover study. Hospital clinic. 40 healthy volunteers. Subcutaneous injection with 1 ml of 1% lignocaine at 20 degrees C and 1 ml of 1% lignocaine at 37 degrees C. Pain assessed by linear analogue pain scores and subjects' comparison of pain on injection. 25 subjects (89%; 95% confidence interval 72% to 98%) thought that lignocaine at 20 degrees C was more painful and 3 (11%; 2% to 28%) thought that lignocaine at 37 degrees C was more painful (p < 0.0001); 12 subjects did not express a difference. Median pain score for injection at 20 degrees C was 11.00 and at 37 degrees C was 3.25 (p < 0.001). Median difference was 8.25 (4.00 to 13.50). The simple procedure of warming to 37 degrees C reduced the pain associated with subcutaneous injection of lignocaine.


Health checks on patients 75 years and over in Nottinghamshire after the new GP contract. To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. 20 general practices in one family health services authority. Patients of 75 years and over in 20 general practices. Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. The way health checks were performed varied greatly, both in their organisation and the practices' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.


Assessment of patients aged over 75 in general practice. To evaluate the assessment scheme for people aged 75, to establish doctors' and nurses' views on the value of the assessment scheme, and to seek patients' opinions on elderly assessments. Data on the assessment process were collected from individual practices. Questionnaires were sent to doctors and practice nurses undertaking assessments and to a sample of elderly patients. 31,565 patients aged 75 and over and all doctors registered with Wiltshire Family Health Services Authority, as well as practice nurses assessing elderly patients. A 2% random sample of elderly patients was selected to answer questions on patient satisfaction. Numbers of patients accepting the invitation for assessment, who carried out the assessments and where, what unmet needs were identified, and by whom. 20,192 patients (64%) accepted the assessment offer. Doctors carried out 8786 assessments and nurses 10,779. Although 12,317 (61%) were carried out in the home, nurses did most domiciliary assessments (7122/11,883). Nurses with extra qualifications identified the highest number of unmet needs (400/1000 visits). 155 of 228 (68%) doctors thought assessments unnecessary whereas 25 of 48 (52%) of nurses thought them important. 93% of patients found assessment useful. Doctors see no merit in the scheme; most undertake assessments opportunistically and pick up few new problems. Nurses who see it as important require further training to fit them to do home visits confidently. Patients who were assessed found it worth while. The case for developing a specialist community nurse for elderly people should be investigated.


Retinal blood flow in diabetic retinopathy. (a) To report on the basic parameters of retinal blood flow in a population of diabetic patients with and without retinopathy and non-diabetic controls; (b) to formulate a haemodynamic model for the pathogenesis of diabetic retinopathy from this and other studies. Laser-Doppler velocimetry and computerised image analysis to determine retinal blood flow in a large cross sectional study. Diabetic retinopathy outpatient clinic. 24 non-diabetic controls and 76 diabetic subjects were studied (63 patients with insulin dependent diabetes, 13 with non-insulin dependent diabetes). Of the diabetic subjects, 12 had no diabetic retinopathy, 27 had background retinopathy, 13 had pre-proliferative retinopathy, 12 had proliferative retinopathy, and 12 had had pan-retinal photocoagulation for proliferative retinopathy. Retinal blood flow (microliters/min) and conductance (rate of flow per unit of perfusion pressure). In comparison with non-diabetic controls (9.52 microliters/min) and diabetic patients with no diabetic retinopathy (9.12 microliters/min) retinal blood flow was significantly increased in all grades of untreated diabetic retinopathy (background 12.13 microliters/min, pre-proliferative 15.27 microliters/min, proliferative 13.88 microliters/min). There was a significant decrease in flow after pan-retinal photocoagulation in comparison with all the other groups studied (4.48 microliters/min). Conductance of the retinal circulation was higher in the untreated diabetic retinopathy groups. These results were independent of age, sex, type of diabetes, duration of diabetes, glycated haemoglobin concentration, blood glucose concentration, blood pressure, and intraocular pressure. Retinal blood flow is significantly increased in diabetic retinopathy in comparison with non-diabetic controls and diabetic subjects with no retinopathy. This has implications for controlling hypertension and hyperglycaemia as a strategy in reducing morbidity from diabetic retinopathy.


Social class differences in infant mortality in Sweden: comparison with England and Wales. To investigate social class differences in infant mortality in Sweden in the mid-1980s and to compare their magnitude with that of those found in England and Wales. Analysis of risk of infant death by social class in aggregated routine data for the mid-1980s, which included the linkage of Swedish births to the 1985 census. Sweden and England and Wales. All live births in Sweden (1985-6) and England and Wales (1983-5) and corresponding infant deaths were analysed. The Swedish data were coded to the British registrar general's social class schema. Risk of death in the neonatal and postneonatal period. Taking the non-manual classes as the reference group, in the neonatal period in Sweden the manual social classes had a relative risk for mortality of 1.20 (95% confidence interval 1.02 to 1.43) and those not classified into a social class a relative risk of 1.08 (0.88 to 1.33). In the postneonatal period the equivalent relative risks were 1.38 (1.08 to 1.77) for manual classes and 2.14 (1.65 to 2.79) for the residual; these are similar to those for England and Wales (1.43 (1.36 to 1.51) for manual classes, 2.62 (2.45 to 2.81) for the residual). The existence of an equitable health care system and a strong social welfare policy in Sweden has not eliminated inequalities in post-neonatal mortality. Furthermore, the very low risk of infant death in the Swedish non-manual group (4.8/1000 live births) represents a target towards which public health interventions should aim. If this rate prevailed in England and Wales, 63% of postneonatal deaths would be avoided.


Changes in drug treatment after discharge from hospital in geriatric patients. To ascertain changes in drug treatment of elderly patients after discharge from hospital and to identify areas of communication which may require improvement. Follow up of patients six to 14 days after discharge, when the drugs supplied by the hospital should have run out and a further supply obtained from the general practitioner. Patients were also asked about information supplied to them by health care professionals during their hospital stay. 50 elderly patients discharged from five geriatric wards (mean age 76.9 years). Sunderland District Health Authority. Drugs taken after discharge from hospital. After returning home the drug regimen of 45 patients differed from that prescribed on discharge from hospital, with 11 patients taking a different dose, 10 having stopped drugs, and 20 taking new drugs. Possible influencing factors included an incomplete drug history, the continuation of drugs taken before hospital admission, and changes in the prescription not attributable to a conscious clinical decision. Lack of information also contributed; 46 patients could not recall being told when to take drugs before discharge. Closer communication is needed between hospital and community health care professionals to ensure that patients are informed about their discharge prescription and continuation of treatment.


Cyclin B is associated with centrosomes in Drosophila mitotic cells. We have studied by way of confocal laser scanning microscopy the subcellular localization of cyclin B in Drosophila-cultured cells and report here evidence that a part of the cyclin B cell pool is closely associated with the centrosome. This cyclin B centrosomal signal is strong in prophase and metaphase but disappears during anaphase. Moreover, the signal is absent in the acentriolar Drosophila cell line 1182-4. These results put forward additional arguments suggesting that the centrosome plays an important role in the control of the cell cycle.


Interaction of the Golgi membranes isolated from rabbit liver with microtubules in vitro. We have developed a reconstituted model system to study the interaction of the Golgi membranes isolated from rabbit liver with taxol-stabilized bovine-brain microtubules without microtubule-associated proteins (MAPs). The Golgi membranes are associated with microtubules. The sheets of vesicles and the membranous tubules are observed along microtubules by direct visualization using differential-interference-contrast, dark field, or fluorescence microscopy. The monoclonal antibody against Golgi membranes suggests that the Golgi membranes, but not the contaminating vesicles, are interacting with microtubules. The degree of association is assayed quantitatively using rhodamine-labeled microtubules after separation of the complex from unbound microtubules by centrifugation upon sucrose gradient. The association is inhibited by crude MAPs, purified MAP2, or 1.0 mM ATP. However, the association neither requires the cytosol from rat liver or bovine brain nor N-ethylmaleimide, brefeldin A, or GTP-gamma-S. The association is mediated by trypsin-sensitive peripheral protein(s) on the Golgi membranes.


Alterations in erythrocyte membrane fluidity in children with trisomy 21: a fluorescence study. Membrane fluidity of erythrocytes obtained from 15 children with trisomy 21 and 20 healthy controls were studied by measuring steady-state fluorescence anisotropy and fluorescence lifetime of 1,6-diphenyl-1,3,5-hexatriene (DPH) and 1-(4-trimethylammoniumphenyl)-6-phenyl-1,3,5-hexatriene (TMA-DPH) incorporated in hemoglobin-free erythrocyte membranes. Our results demonstrate a significant decrease in DPH fluorescence anisotropy and a significant increase in TMA-DPH fluorescence anistropy in erythrocytes from subjects with trisomy 21. No significant differences between the two groups were observed in the fluorescence lifetime of DPH and TMA-DPH. These data suggest an increase in membrane fluidity in the interior part of the membrane and a decrease in fluidity at the lipid-water interface region. This could be in part attributed to an increased oxidative damage in trisomy 21.


The calcium loading of secretory granules. A possible key event in stimulus-secretion coupling. The review focuses on calcium accumulation by secretory organelles. The observation that secretory granules contain variable and often important quantities of calcium (1-200 mM of total calcium) can be interpreted as a maturation index. A progressive loading with calcium would be permitted by a Ca2(+)-transport mechanism on the granular membrane and calcium-binding molecules in the granular core. The saturation of this store by the stimulus-induced calcium transient would permit in mature (calcium-loaded) granules the ionic crisis leading to exocytosis. The inside of secretory organelles being acidic, calcium influx into the granule can be driven by calcium-proton exchange. The calcium-proton exchanger could be a Ca2(+)-ATPase.


Probe-tube microphone measurements with very young infants. The practicalities of performing probe-tube microphone measurements in a clinical environment with unsedated infants were examined. External ear resonance curves (unaided response) were obtained for both ears of a group of infants aged 0-6 months and an adult comparison group. A repeat measure (with probe-tube repositioning) was made to estimate the test-retest reliability of these measures. Results showed that the mean infant resonance frequency (4200 Hz) occurred at a significantly (P less than 0.005) higher frequency than the mean adult resonance frequency (2950 Hz). Infants test-retest differences for resonance frequency (mean = 286 Hz, s.d. = 404 Hz) and size of peak (mean = 2.2 dB, s.d. = 2.6 dB) showed acceptable stability for the measurements. Size of resonance peak was found to vary positively with ear canal volume; however, estimation of ear canal volume from tympanometry did not provide a useful indicator of the size of the peak. The probe-microphone measurements were found to be feasible, repeatable and practical with these infants.


Acoustical changes of loudly spoken speech and their effects on speech recognition in hearing-impaired listeners. The level of speech is usually increased in conversations with unaided hearing-impaired listeners. However, the speaker may talk at conversational levels to aided hearing-impaired persons. In this case, the level of speech is electronically increased by the hearing aid. In the present study, the acoustical changes of loudly spoken speech and their effects on speech recognition were investigated in 20 patients with sensorineural hearing loss. Eight test words of the German Speech Intelligibility Test ('Freiburger Sprachtest') were recorded at original levels of 60 and 75 dB SPL by a male speaker. Both recordings were presented to hearing-impaired subjects at a playback level of 75 dB SPL. Thus, the level of the 60 dB SPL recording was increased electronically by 15 dB. For the 75 dB SPL recording, playback and recording levels were identical. The average whole-word score was 49% for the 60 dB SPL recording and 39% for the 75 dB SPL recording. This difference was statistically significant (0.002 less than P less than 0.005). The results of the speech recognition ability tests could be explained by the acoustical changes of the loudly spoken speech. In the 75 dB SPL recording, the levels of voiceless fricatives, nasals and plosives were significantly lower than in the 60 dB SPL recording. Spectrally, the fundamental frequency was increased and the configuration of the first formant was altered in the 75 dB SPL recording. The significance of the findings for clinical speech audiometry and hearing aid evaluation is discussed.


Acoustic evaluation of earmoulds in situ: a comparison of impression and earmould materials. Laboratory research has been carried out on the accuracy of both ear impression and earmould materials. The present work was undertaken to assess such materials in vivo. An objective clinical method of earmould evaluation was developed, based on estimation of the attenuation in the acoustic feedback path. The method was used to assess the acoustic performance of earmoulds made from three earmould materials of different texture, when prepared from two different impression materials. It was shown that the choice of impression material made a significant difference to earmould performance. For greatest accuracy, addition cured silicone impression materials are recommended.


Tactiling: a usable support system for speechreading? The purpose of this study was to find out whether deafened adults can take advantage of the extra information in speechreading given by the vibrational and motional patterns picked up by placing a hand on a speaker's throat and shoulder, and how valuable this tactile supplement is as a support system for speechreading. We have named this method--speechreading with tactile supplement--tactiling. Eight deafened adults participated in the study, conducted with a pre-test/post-test control group design. The experimental and the control groups took speechreading classes together. The experimental group received additional individual training in tactiling during six 1 h lessons. Both the experimental and the control groups were tested, before and after training, first by a familiar person and thereafter by an unfamiliar person. The results demonstrated two significant main effects. Tactiling is generally better than speechreading alone, and the results from the test given by the familiar speaker are better than with the unfamiliar speaker. The main effect of tactiling indicates that the method is worth pursuing as a communication system for the deafened adults. Possible reasons for the direct effect of tactiling are discussed, as well as modifications of this 'natural' device.


Early intervention in schizophrenia: theoretical background and clinical strategies. Clinical observation and retrospective studies have provided considerable information as to the nature of decompensation into acute schizophrenic illness. These themes have been further developed in studies designed to reduce overall exposure to neuroleptics whilst maintaining adequate prophylaxis against relapse. This review extracts from the literature information which could be harnessed to prevent, abort or ameliorate florid schizophrenic relapse. Emphasis is laid upon the coordination of psychological and medical approaches, describing in some detail both the theoretical background and practical intervention strategies in development, and exploring their implications for the role of clinical psychologists.


Treatment of depressive and obsessive-compulsive symptoms in OCD by imipramine and behaviour therapy. The efficacy of behavioural treatment of obsessive-compulsive disorder (OCD) has been well documented. However, severely depressed OCD patients showed fewer short- and long-term benefits than less depressed patients. The present study tested the hypothesis that reduction of depression by imipramine prior to behaviour therapy would enhance the effects of behavioural therapy on depressed OC patients. Thirty-eight patients were divided into highly and mildly depressed groups according to their scores on the Beck Depression Inventory; half of each group received imipramine and half received placebo for six weeks. All patients then received three weeks of daily behavioural treatment (exposure and response prevention) followed by 12 weekly sessions of supportive psychotherapy. Results indicated that although imipramine improved depressive symptoms in depressed patients, it did not affect OC symptoms. Behaviour therapy markedly reduced OC symptoms but, contrary to our hypothesis, imipramine did not potentiate the effects of behaviour therapy. No differences between highly depressed and mildly depressed patients on OC symptoms were found in their responses to behavioural or supportive therapy.


Sense of coherence, self-esteem, depression and hopelessness as correlates of reattempting suicide. Sense of coherence (SOC) has been proposed as a psychological factor that predicts good health and positive adjustment. The three components of SOC: manageability, comprehensibility and meaning were assessed together with depression, hopelessness and self-esteem as factors predicting future suicidal ideation and behaviour in parasuicides. One hundred and fifty hospitalized parasuicides were evaluated on these measures and followed up after six months to determine their current level of suicidal ideation and whether they had been readmitted for a further attempt or killed themselves in the intervening period. Suicidal ideation on admission was best predicted by a low score on the SOC meaning subscale and also significantly related to the other predictor variables. Suicidal ideation at the six-month follow-up was best predicted by the SOC subscales manageability and comprehensibility. These two SOC subscales also emerged as discriminators of suicidal behaviour over the six months following admission. Overall prediction of suicidal behaviour was enhanced by also including the background variables of age, a history of previous attempts, unemployment and whether the attempter was living alone. The study ends with a discussion of the importance of widening the focus when assessing and predicting suicidal risk to include not only predictions based on pathology but also psychological factors that promote adjustment.


The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). Two studies are reported describing the development of a short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI) for use in circumstances where the full-form is inappropriate. Using item-remainder correlations, the most highly correlated anxiety-present and anxiety-absent items were combined, and correlated with scores obtained using the full-form of the STAI. Correlation coefficients greater than .90 were obtained using four and six items from the STAI. Acceptable reliability and validity were obtained using six items. The use of this six-item short-form produced scores similar to those obtained using the full-form. This was so for several groups of subjects manifesting a range of anxiety levels. This short-form of the STAI is therefore sensitive to fluctuations in state anxiety. When compared with the full-form of the STAI, the six-item version offers a briefer and just as acceptable scale for subjects while maintaining results that are comparable to those obtained using the full-form of the STAI.


Inhibition through negative priming with Stroop stimuli in schizophrenia. Stroop stimuli were used to measure the negative priming effect in eight positive and 10 negative schizophrenics, 21 depressive and 35 healthy control subjects in order to test hypotheses of insufficient versus persistent cognitive inhibition in schizophrenia. Data show that schizophrenics do not increase their response times to suppressor Stroop items compared to identical but neutral Stroop stimuli because the insufficiency of their inhibitory processes weakens the distractor-suppression effect. However, pre-exposure of the lexical distractor can compensate for insufficient inhibitory mechanisms in positive but not negative schizophrenics, suggesting more severe deterioration in the latter. Depressed subjects showed a slower development of cognitive inhibition. The results suggest important differences in the temporal evolution of inhibitory processes, and are discussed in terms of Hemsley's (1977) and Frith's (1979) theories.


Verbal fluency: a NART-based equation for the estimation of premorbid performance. A sample of 142 subjects free of neurological or psychiatric disorder were administered the National Adult Reading Test (NART) and a verbal fluency (VF) test. A highly significant correlation between the NART and VF was obtained indicating that premorbid ability should be taken into account when interpreting VF performance. A regression equation was built to estimate premorbid performance on VF from the NART. A highly significant difference between predicted and obtained VF was obtained in a sample of neurological patients (N = 38). For ease of use, a table converting NART errors to predicted VF scores is presented.


Predictors of outcome in the treatment of bulimia nervosa. Outcome predictors of a cognitive behavioural group treatment for bulimia nervosa were examined. Pre-treatment self-esteem, binge frequency and ineffectiveness, but not duration of disorder, significantly predicted outcome on at least one measure (binge frequency or overall eating pathology) at post-treatment and/or three-month follow-up. The results are related to previous studies and to theories of maintenance of the disorder.


Subscales of the Dysfunctional Attitude Scale. Eight subscales based on items drawn from the original 100-item Dysfunctional Attitude Scale (Weissman & Beck, 1978) were developed as potential markers of specific cognitive vulnerabilities (Beck, 1987). Six of the eight subscales were correlated with both depression and anxiety symptom measures, indicating that the 'vulnerabilities' represented by these subscales are unlikely to be specific to depression.


Factor structure of the Wechsler Adult Intelligence Scale-revised (WAIS-R): a clinical sample. Factor analysis was performed on a heterogeneous clinical sample of neurological patients. Both a two- and a three-factor model were extracted. The two-factor solution corresponded to Wechsler's categorization of verbal and performance subtests. The three-factor solution suggested a verbal comprehension factor, a perceptual organization and a third factor with highest loadings on digit span, arithmetic and digit symbol. Both models were consistent with factor models obtained from the standardization sample. As has previously been reported in neurologically impaired samples, the third factor was relatively more prominent than in the standardization sample. This study provides further evidence for the robustness of the WAIS-R factor structure across different populations and gives good support for the use of the WAIS-R in British clinical samples.


Representations of health, illness and medicines: coping strategies and health-promoting behaviour. This study focuses on the different representations of health, illness and medicines that are held by the population of the Basque Country. In addition, relationships between these representations and both coping strategies towards first symptoms of disease and health-promoting actions were studied. Three different representations were found: (a) an active/'against medicines' representation; (b) a 'magical/pro-medicines' representation; and (c) a representation that combines aspects of the previous representations. These representations were anchored in different social groups (defined by age, educational background, etc.) and were related to different coping strategies in the event of first symptoms of illness, and to differences in health-promoting behaviour.


Exhaustion as precursor of cardiac death. Excess fatigue is the most prevalent precursor of sudden cardiac death. This state may reflect prolonged tension or heart disease. In order to test the first explanation a prospective study was done among 3365 males, aged 45-59 years. This cohort was followed during an average period of 9.5 years. Exhaustion was assessed by the statement: 'At the end of the day I am completely exhausted mentally and physically'. Among those free of coronary heart disease at the beginning, 69 subjects died because of myocardial infarction. Data were analysed using Cox's regression analysis. The results showed a highly significant interaction between duration of follow-up and exhaustion upon the risk of cardiac death. The hazard ratios for exhaustion were 8.96, 6.33, 4.47 and 3.16 for the first 10, 20, 30 and 40 months of follow-up respectively. Thereafter the association between exhaustion and cardiac death is no more significant. It is argued that exhaustion before cardiac death does not reflect manifest heart disease but that an interaction between prolonged tension and subclinical levels of ischaemia may increase the risk of cardiac death.


Information giving in oncology: a preliminary study of tape-recorder use. This paper describes a pilot study of information giving in an oncology setting. This was achieved by randomly allocating patients to having their consultation tape-recorded or not. The results suggest that this approach increases the retention of information in patients as well as reducing their levels of anxiety. The method is cheap and easy to use, acceptable to patients and their families, and does not inhibit the consultation process.


Monitoring, medical fears and physical symptoms. In this study it was found that subjects with a high monitoring coping style had higher scores on the blood injury scale of the Fear Questionnaire and reported more physical symptoms on the Pennebaker Inventory of Limbic Languidness than those with a low monitoring style. Implications of these findings are briefly discussed.


Selective processing of eating, weight and shape related words in patients with eating disorders and dieters. The Stroop colour-naming task was used to investigate selective processing of eating, weight and shape related words in two groups of dieters, patients with anorexia nervosa, patients with bulimia nervosa and a group of non-dieting controls. 'Normal dieters' were not different from the non-dieting controls. Dieters with a history of features of an eating disorder but no diagnosis and the patients with anorexia nervosa, like the patients with bulimia nervosa, showed selective processing of information related to eating, weight and shape.


Pre-operative anxiety variables as possible predictors of post-operative stay in hospital. The extent to which measures of pre-operative anxiety predict post-operative hospital stay, over and above what is predicted by biographical, medical status and post-operative anxiety variables, was examined in 81 cholecystectomy patients. Hierarchical multiple regression analysis revealed that patients who were older, had lower health status and suffered from wound infection, had a longer post-operative hospital stay than others. None of the pre-operative anxiety measures had a significant incremental value in the prediction of the post-operative hospital stay.


Intercorrelation of lesions detected by magnetic resonance imaging after closed head injury. Forty-three patients with closed head injuries were followed up 5 to 12 months post-injury. Patients had magnetic resonance imaging (MRI) and performed a variety of neuropsychological tests. There were systematic relationships between lesions in different sites: depth of lesions in orbito-frontal regions, frontal regions, and temporal poles were particularly strongly intercorrelated. Depth of lesions in specific sites also correlated with an overall measure of brain damage: the number of areas with lesions present. After correcting for premorbid differences there were significant correlations between lesions in specific sites and scores on three out of five WAIS subtests. Scores on these three subtests also correlated significantly with overall brain damage. In general, hemispheric sites which were significantly related to neuropsychological measures also showed significant intercorrelations among themselves. The findings stress the importance of patterns of lesions in head injury, and emphasize the difficulty of showing differential localization of cerebral function in this population.


Effects of intensity of treatment and length of stay on rehabilitation outcomes. The combined effects of intensity of treatment and length of stay during inpatient rehabilitation hospitalization on the outcomes of 95 traumatic brain injury patients were examined. Outcome was assessed using the Rancho Scale and three measures of functional status--physical performance, higher-level cognitive skills, and cognitively mediated physical skills. The effects of intensity of treatment and length of stay were assessed using 2 x 2 analyses of variance with repeated measures. The results showed clearly that both length of stay and intensity of treatment affect outcomes. Patients in the long length of stay group consistently made more progress across all outcome variables than patients in the short length of stay group. However, the greater progress of the long length of stay patients was from a point significantly more disabled than that of the short length of stay patients, with improvement at discharge to the point at which the groups were now equal. The effect of intensity of treatment was significant or closely approached significance for higher-level cognitive skills and Rancho Level. In the long length of stay group, the two intensity groups were initially equivalent, but at discharge the high-intensity group surpassed the low-intensity group. The practical implications of the results are discussed.


Evaluating sensory regulation as a method to improve awareness in patients with altered states of consciousness: a pilot study. The status of sensory stimulation as a clinical procedure is still in some doubt. Recent papers have shown no significant clinical changes as a result of sensory intervention but this may be due to an inappropriate model on which these procedures were based. This paper outlines the results of a controlled pilot study, based on a sensory regulation model currently being tested at the Casa Colina Peninsula Rehabilitation Center, Los Angeles. The study contrasts the outcome of four patients treated in a sensory regulated environment with four who were exposed to sensory stimulation of an unregulated kind. The results are quite encouraging in favour of a sensory regulation approach.


Functional outcome of low-level traumatically brain-injured admitted to an acute rehabilitation programme. A retrospective analysis of functional status at discharge, disposition, Glasgow Outcome Scale (GOS) score at 6 months and 1 year was undertaken for 23 consecutive 'low-level' traumatic brain injury victims admitted in a state of complete dependency to an acute rehabilitation programme. All patients met criteria for extremely severe traumatic brain injury, with an average Glasgow Coma Scale score of 8.7 at admission to the rehabilitation facility (an average of 44 days post-injury). All but three patients made significant functional gains during the acute rehabilitation stay. Almost half of the study patients (48%) were discharged at home while the rest went to sub-acute rehabilitation programmes. At 6 months post-injury eight (35%) met GOS criteria for 'good' outcome or 'moderate disability'. A review of clinical features, categories of functional progress, and relationships of outcome and disposition to variables known to have predictive value in such a patient population is described. Analysis of variables related to admission selection criteria that have been used in this rehabilitation programme is presented and the basis and implications of selection criteria discussed.


Compensation neurosis rides again.

Compensation neurosis rides again. Compensation neurosis (CN), also known as accident neurosis, has generally not been considered to be a 'real' disorder. In 1961 it was seemingly laid to rest by Henry Miller, a distinguished neurologist, in a sharp article which appeared in the British Medical Journal. Miller's view of patients who presented psychological symptoms following accidents or traumas was suspicious. Compensated or not, his view seemed to be that they should have their legal process finished as quickly as possible and then they will miraculously convalescence. Miller's work, it appeared, was the coup de grâce for this ill-defined diagnosis. Today, however, compensation neurosis seems to ride again. After a prolonged silence in the psychiatric literature, new papers are emerging, strongly suggesting that this vanishing diagnosis be reconsidered. This new trend will be presented.


The effectiveness of directed multisensory stimulation versus non-directed stimulation in comatose CHI patients: pilot study of a single subject design. In view of the difficulties in finding control groups in sensory stimulation research, a single case methodology was explored. A pilot study was conducted on six comatose CHI patients in a neurosurgical intensive care unit. Each patient was given alternating weeks of directed multisensory stimulation (SDS) and non-directed stimulation (NDS) for half an hour a day in an ABAB single subject design. Eye movement, motor and vocal response to stimulation were recorded using the Sensory Stimulation Assessment Measure (Rader Scale). Comparisons of eye movement and motor responses on the Rader Scale appeared to indicate a greater degree of responsiveness to the SDS as compared with the NDS treatment. Overall improvement levels on the GCS, Rancho Scale and Western Neurosensory Stimulation Profile are discussed. The results are interpreted as indicative of the potential value of using single case methodology in this population, and future research directions are also discussed.


Differential effects of spinal cord injury and head injury on marital adjustment. Central nervous system (CNS) trauma can produce a multitude of physical and psychological sequelae, depending on the neurological level of injury. Clinicians have long recognized the adjustment difficulties posed in marriages of CNS trauma victims, yet there is little research documentation for this observation. The marital relationships of moderate (n = 31) and severe (n = 17) head injury (HI) groups and a spinal cord injury (SCI) group (n = 24) were assessed through spouses' self-reports in interview and through standardized questionnaires. Analyses indicated that the three groups were not statistically different in age, number of months post-injury, pre- and post-injury occupational status, and level of income. In the post-injury marital relationship, the severe HI group was significantly lower than the moderate HI and SCI groups on standardized and validated scales assessing affectional expression (p less than 0.002), dyadic satisfaction (p less than 0.001), dyadic cohesion (p less than 0.01), and total dyadic adjustment (p less than 0.001). On a scale of social role functioning, the severe HI group's performance was significantly lower than the moderate HI and SCI groups (p less than 0.005). These results empirically substantiate the clinical observation that adjustment difficulties may be more intense for wives of the severely head injured than the moderately injured or the SCI, as they must deal with neuropsychological as well as physical fall-out from the injury.


Delusional reduplication following closed-head injury. Somatic delusions following brain injury are not uncommon, and have been well documented in the literature. This study documents a case of somatic delusion which was seen in a patient following a head injury secondary to a motorcycle accident. Although perhaps not typical it serves to illustrate an interesting example of a somatic delusion following head trauma. On recovery from coma this patient reported the existence of a 'third arm' adjacent to the limb that had received the greatest impact in the accident. The patient was unreceptive to any counter-persuasions and in fact remained largely unconcerned about this addition to his anatomy. A thorough neuropsychological evaluation was carried out in an attempt to seek an explanation for this phenomenon. The results suggest that the phenomenon has at least a partly psychiatric aetiology rather than a purely neurological foundation.


Post-traumatic and emotional symptoms in different subgroups of patients with mild head injury. Post-concussional symptoms, such as headache, dizziness and irritability, are thought to result from the emotional stress associated with decreased cognitive performance after a head injury. A questionnaire-based investigation was carried out in 71 patients with mild head injury (MHI), using a heterogeneous item pool in order to study the interrelationships between traditional post-concussive complaints, cognitive problems, and more emotional and functional complaints. Factor analysis indicated that post-concussive symptoms loaded together with items on problems associated with decreased work performance and fatigability on a first factor, whereas psychovegetative and emotional complaints loaded together on a second factor. Two rating scales were constructed from the relevant items and were used to compare between subgroups of MHI patients and non-concussed controls. Patients with uncomplicated MHI had significantly higher scores than non-concussed subjects on the post-concussive-cognitive scale, but not on the emotional-vegetative scale. Patients with multiple head injuries or pre-existing emotional problems had higher scores on both the post-concussive-cognitive scale and the emotional-vegetative scale than MHI patients without a history of emotional problems. Reliable rating scales may be useful in multidiagnostic studies of MHI patients.


Prediction of motor status 3 and 6 months post severe traumatic brain injury: a preliminary study. The prediction of outcome following severe traumatic brain injury has received considerable attention in recent years. Previous prediction studies have focused on a long-term follow-up or prediction period. The reported outcome measures generally adopted a global approach (e.g. independent living) in terms of the prediction of physical function. The objective of the present study was to construct clinically useful predictive equations of motor system status, as represented by selected postural reactions (indicators of central nervous system function). Specifically, these equations would serve to predict the recovery of equilibrium and protective reactions both at 3 and 6 months post-injury, respectively. A stepwise multiple logistic regression analysis was performed, where nine predictive variables were considered using a multivariate approach. The results indicate that coma duration followed by age contribute significantly to the predictive capability of the models at both 3 and 6 months post-injury. Specifically, at 3 months, the predictive variables 'coma duration' and 'age' enabled an 84.62% correct prediction rate, whereas, at 6 months, 'coma duration' and 'age' enabled a 79.49% correct prediction rate. In addition, the exact probabilities (for given sample ages and coma durations) and associated 95% confidence intervals were calculated based on the predictive models obtained. The theoretical framework underlying these predictive models can form the basis for further studies. Furthermore, these preliminary predictive models have potential implications for early treatment planning and patient management.


Event-related potential measurement of deficits in information processing following moderate to severe closed head injury. Event-related potentials may offer more precision than behavioural measures for understanding the extent and timing of information processing difficulties that follow closed head injury (CHI). Behavioural tests consistently indicate a general reduction in cognitive function but lack adequate diagnostic or prognostic function. This study compares a group of seven CHI patients, in which time since injury varied between 1 and 5 years following injury, with 10 matched controls on a three-tone discrimination task. Abnormality in the processing of tones as early as 200 ms following their onset, as measured by the P2 and N2 components of the event-related potential, indicated a general difficulty with tone discrimination. This abnormality was obtained despite differing damage profiles over patients and is likely to be due to the diffuse aspects of damage normal in CHI. These results also indicate that functional deficits in CHI patients can extend up to 5 years or more. A correlation between P2/N2 amplitudes and time since injury, however, suggests that both these components normalize with the passage of time and offers the prospect of a sensitive, non-behavioural measure of recovery in cognitive processing.


Remediation of alexia without agraphia: a case study. Following a left temporoparietal-occipital haemorrhage and surgery, a 43-year-old, right-handed male exhibited alexia without agraphia. A remediation programme consisted of training in head turning to compensate for a right visual field defect, letter-by-letter reading aloud and covertly, drill with flash-cards to improve word recognition and practice in naming objects to improve dysnomia. The patient's reading improved markedly over a 6-week period and he was able to resume work as a respiratory therapy supervisor. A post-morbid depression resolved concomitantly with the patient's return to work. The training programme and the patient's post-training approach to reading are discussed in terms of hemispheric functioning as well as 'direct path' and 'indirect path' reading. The effectiveness of training is considered in the context of spontaneous recovery.


First documented outbreak of dengue in the Peruvian Amazon region. This article describes a classical dengue outbreak caused by dengue serotypes 1 and 4 that occurred from March to July 1990 in the city of Iquitos and surrounding areas of Loreto Department in the Peruvian Amazon. Epidemiologic data indicate that more than 150,000 persons may have been affected in Iquitos alone. Another dengue outbreak occurred in Tarapoto, a city in the neighboring department of San Martín. Laboratory data indicate that the same dengue serotypes were involved in both outbreaks. No cases of dengue hemorrhagic fever/shock syndrome appear to have occurred. Prior to this outbreak, no indigenous dengue cases had been documented in Peru.


Neuropsychiatric correlates of theta bursts in patients with closed head injury. Twenty-five head-injured patients with localized theta bursts on standard or 24 h ambulatory EEG were administered a standardized interview for neuropsychiatric symptoms associated with complex partial seizures (e.g. olfactory hallucinations, memory gaps) and a battery of neuropsychological tests. Although the formal neuropsychological test performances of these patients were relatively normal they reported an abundance of seizure-like behavioural symptoms. While the frequency of these symptoms was high, they did not occur in a stereotyped complex or sequence. These findings suggest that localized theta bursts may be diagnostic of an underlying neuroelectrical disorder.