Sexual dysfunction in men with lower urinary tract symptoms.

The conventional view that sexual function is not adversely affected by lower urinary tract symptoms (LUTS), assumed to be caused by enlargement secondary to benign prostatic hyperplasia (BPH), was investigated in this study of 423 men aged 40 years and over in a community population in the UK and 1271 urology clinic attenders aged 45 years and over in 12 countries, using the ICSmale and ICSsex questionnaires. Sexual dysfunction was found to be common: in the community, age standardized prevalences of reduced rigidity of erections were 53%, reduced ejaculation 47%, and pain on ejaculation 5%; in clinic men, age standardized prevalences of reduced rigidity of erections were 60%, reduced ejaculation 62%, and pain on ejaculation 17%. Sex lives were reported to be spoiled by LUTS in 8% of community men and 46% in the clinic. There were negative trends for age in the extent to which clinic men were bothered by these symptoms, although older men were still very concerned. Significantly raised odds ratios of sexual dysfunction were found in those with LUTS, especially storage symptoms associated with incontinence. Urinary flow rates were not associated with sexual symptoms. Sexual dysfunction is, therefore, strongly associated with LUTS, is a matter of concern to the men affected, and should be taken into account when managing patients with LUTS.

Randomised trial of effectiveness of second eye cataract surgery.

BACKGROUND: The effectiveness of cataract surgery on one eye is well established, but concerns over health-care expenditure have called into question the value of cataract surgery on the second eye. We examined the effects of second eye surgery in terms of patient perceptions as well as through visual acuity, contrast sensitivity, and stereoacuity tests. METHODS: 208 otherwise healthy patients awaiting second eye cataract surgery were recruited into our randomised trial. At randomisation participants were allocated expedited surgery (planned to take place within 6 weeks) or routine surgery (routine waiting time, 7-12 months). Assessments were made at randomisation and again at review after about 6 months. Eight primary trial outcomes consisted of four questionnaire items and four visual function tests, done with both eyes open. FINDINGS: Traditional clinical tests of success in cataract surgery (visual acuity and contrast sensitivity) showed only slight differences in binocular vision in favour of the expedited-surgery group. There were major benefits for the expedited-surgery group in terms of reported visual symptoms and effects on quality of life. At review, differences in self-reported vision related difficulties between the two groups ranged from 11% (95% CI 4.4-17%, activities) to 30% (19-41%, reading). Stereoacuity was better in the expedited surgery group, the difference between the groups for the proportions with stereoacuity of 3000 s of arc or worse was 58% (47-69%). INTERPRETATION: This trial has shown that there is a clear benefit from second eye cataract surgery.

Socio-economic and dietary influences on leg length and trunk length in childhood: a reanalysis of the Carnegie (Boyd Orr) survey of diet and health in prewar Britain (1937-39).

Social class differences in height have been recognised for many centuries. However, few studies have examined the extent to which these differences are made up of differences in leg length or trunk length. This paper reanalyses cross-sectional information on children examined in Britain in the 1930s. We assess associations between socio-economic status and diet and the components of childhood stature. The analyses were based on the records of 2990 children aged 2 years to 14 years 9 months who were examined in the Carnegie (Boyd Orr) survey of diet and health (1937-39). z-Scores for the measures of childhood stature were calculated using polynomial regression techniques with the study population as the standard. Univariable and multivariable statistical techniques were used to assess the relationships between childhood height, leg length and trunk length, and dietary and socio-economic factors measured at the level of the household. Leg length was the component of stature most strongly associated with measures of childhood diet and socio-economic status. A greater part of the difference in stature between socio-economic groups was caused by differences in leg length rather than trunk length. In multiple regression analyses, district of residence and family food expenditure were generally the two factors most strongly related to stature. In a subsample of the surveyed children, for whom birthweight information was available, trunk length and leg length were equally strongly related to birthweight. Leg length appears to be a particularly sensitive indicator of childhood socio-economic circumstances. Although contemporary studies highlight the importance of biological factors in determining childhood height, the data analysed in this study suggest that socio-economic circumstances were also important in explaining height differentials in prewar Britain.

Childhood obesity and adult cardiovascular mortality: a 57-y follow-up study based on the Boyd Orr cohort.

Few studies have examined associations between childhood overweight and adult disease. We examined the relation between BMI measured in childhood and adult all-cause and cardiovascular mortality in a 57-y follow-up of a cohort study based on the Carnegie (Boyd Orr) Survey of Family Diet and Health in prewar Britain (1937-1939). Complete baseline and follow-up data were available for 1165 males and 1234 females who were aged between 2 y and 14 y 9 mo when they were examined. All-cause and cardiovascular mortality were associated with higher childhood BMIs. Compared with those with BMIs between the 25th and 49th centiles, the hazard ratio (95% CI) for all-cause mortality in those above the 75th BMI centile for their age and sex was 1.5 (1.1, 2.2) and for ischemic heart disease it was 2.0 (1.0, 3.9). There was also a suggestion of a nonlinear association with overall mortality; those in the 25-49th centile of the BMI distribution had the lowest mortality rates. The linear associations may be due in part to the tracking of BMI between childhood and adulthood. High BMI in adults is known to be associated with raised blood pressure and abnormal lipid profiles. The relative contributions of adult and childhood overweight to the observed mortality patterns are uncertain. From the public health perspective, strategies aimed at reducing weight in childhood are important but may only affect adult health if such weight reduction persists into adulthood.

Profiling outpatient workload: practice variations between consultant firms and hospitals in south west England.

OBJECTIVES: To describe the variation in outpatient new to old ratios between consultants and between providers for seven high volume specialties (four surgical, three medical). DESIGN: This was a descriptive study at consultant and provider unit level based upon patient administration system data from the South and West Regional Health Authority for the financial year 1992-93. Additional components of variance analysis was used to distinguish individual consultant effects from host institution effects. SETTING: The former South Western Regional Health Authority area from Gloucestershire to Cornwall. SUBJECTS: Altogether 345 consultant firms in seven specialties grouped into 13 provider unit groups. MAIN MEASURES: New to old ratio, omitting elective inpatients followed up as outpatients. RESULTS: Variation between consultants is greater in surgical than in medical specialties, while absolute levels of new to old ratios tend to be higher in surgical specialties than in medical. Variation between provider unit groups is also greater in surgical specialties. Analysis of variance shows that more total variance is attributable to provider unit group in gynaecology than in other specialties. CONCLUSIONS: Within individual specialties there is evidence of substantial variation that is not attributable to underlying differences in morbidity patterns. There is evidence of marked variation in terms of both individual consultants and institutions, a finding that provides the springboard for further analytical work. Published routine outpatient activity statistics should distinguish between new referrals, inpatient follow up, and clinic rebookings.

Palliative care services: what needs assessment?

A survey of all district health authorities in England was conducted in order to describe current patterns of needs assessment and contract setting for palliative care services. Outcome measures included the completion of needs assessments in the past five years, the type of data used for needs assessment, and recommendations for service development. Copies of contracts for palliative care services were requested and analysed according to duration of contract, and audit requirements. A 74% response rate was achieved. Over half the health authorities had not carried out a needs assessment or service review of palliative care services in the past five years. Of those that had undertaken needs assessment, about one-quarter were planning more review work, and most of the reports expressed the need for more information on many aspects of palliative care. Copies of contracts with specialist palliative care providers were supplied by 38 health authorities, with the majority being of only one year's duration. Although conducted within an English context, the study findings have wider implications for the process of effective health care purchasing.

Appropriateness of hospital utilization. The validity and reliability of the Intensity-Severity-Discharge Review System in a United Kingdom acute hospital setting.

Assessing the appropriateness of hospital utilization in the United Kingdom may yield practical solutions to problems faced by both purchasers and providers of health care in the National Health Service. It is, however, essential that such assessment is based on a method that is both valid and reliable--in particular, valid in the context in which it is applied. Whereas American methods for the assessment of appropriateness have been shown to be valid in the United States, it is pertinent to question whether the application of such methods to the National Health Service also is valid given the different circumstances, both cultural and financial, under which health care is provided. A study of the appropriateness of admission and hospital stay for a sample of admissions to a large acute hospital in the United Kingdom was carried out, and the assessment of appropriateness was made using the Intensity-Severity-Discharge Review System with Adult criteria (ISD-A). The validity and reliability of using the ISD-A for assessing hospital utilization in the United Kingdom was evaluated. The ISD-A was found to have high reliability and to be valid for assessing appropriateness in the United Kingdom when a full range of alternative forms of care are presumed to be available. It was not found to be valid currently, therefore, for routine assessment of hospital utilization within the National Health Service, when alternatives often are not available.

Prevalence of total hip replacement: how much demand has been met?

OBJECTIVE: To determine the prevalence of completed elective total hip replacements in a defined elderly population. DESIGN: Cross sectional postal questionnaire survey with additional data and validation from general practice and hospital records. SETTING: Six general practices in the English counties of Avon, Somerset, and Oxfordshire. SUBJECTS: A total of 7806 patients aged 65 years and over (94.7% response). RESULTS: The overall prevalence (95% confidence intervals) of elective total hip replacement was 5.3 (4.8,5.8)% Age and sex specific prevalences were 2.7 (2.0,3.5)% in men and 4.1 (3.3,4.9)% in women aged 65-74 years, and 5.2 (4.0,6.5)% in men and 8.8 (7.6,10.0)% in women aged 75 years and over. Of the 415 patients who had received elective total hip replacement, 28.2% had required bilateral surgery, 20% had received at least one operation privately, and 13% had required revision surgery. CONCLUSION: Our results show an increased level of satisfied demand for total hip replacement in elderly people compared with earlier estimates. The increasing prevalence of hip replacement is an indicator of increasing potential demand for revision procedures. Population based surveys are required to establish the level of unmet demand for primary procedures. Differences in past surgical activity may be important in interpreting the wide variation in current surgical rates.

Anti-IgA antibody associated reactions to intravenous gammaglobulin in a patient who tolerated intramuscular gammaglobulin.

A patient with common variable immunodeficiency syndrome tolerated intramuscular IgG (which contains IgA) and an initial infusion with intravenous (IV) IgG, but developed reactions to subsequent IV IgG. High-titre, class-specific anti-IgA antibodies were detected suggesting immunization by the IgA-contaminated IV immunoglobulin. Subsequent IgG replacement was achieved with IgA-deficient plasma infusions. Patients who tolerate intramuscular IgG may not tolerate the IV preparations.