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In view of the increasing cost of general practice of drug prescribing, it is important to look at ways of reducing drug wastage and thereby improve the cost-effectiveness of prescribing.To determine the costs and cost savings to the NHS of instalment dispensing for newly prescribed medicines and to quantify the extra costs incurred by patients.Patients were randomized to receive either a normal (n = 103) or an instalment (n = 101) prescription.The difference between prescribed and dispensed drug costs in the intervention group was 0.98 UK pounds per patient (95% confidence interval 0.14-1.82 UK pounds), giving a 7% reduction in drug costs. The costs of the additional pharmacy time required to implement the intervention was calculated to be 5.02 UK pounds per patient.Introduction of a system of instalment dispensing produced savings in the general practice of drugs bill, but these were not large enough to offset additional costs for pharmacists.

Abstarct Aim To determine the effectiveness of serial influenza vaccination. Scope Studied in a Scottish GP population, the overall seroresponse rate increased with annual influenza vaccinations and after 5 years it increased from 45.1% to 93.3% for influenza virus A (H1) and from 48.4% to 98.3% for influenza virus A (H3). However, there was little boosting effect with further doses after becoming a seroresponder. The pre-vaccination titres were significantly higher in previous year's seroresponders compared to non-responders. Conclusions The policy of annual vaccination is supported by our data in order to increase the disappointing response rate after one dose. However, the lack of a boosting response with subsequent doses and the significant residual immunity after becoming a seroresponder suggests a prior serological immunity check in order to better direct the vaccine supply (in the years of no antigenic drift), to those who need it most.

Cement pressurization is critical to achieving optimal results in cemented arthroplasty of the hip. An in vitro experiment using plastic femoral models (10 per group) was undertaken to measure the pressures developed by 3 cementing systems: the Howmedica Mark 1 (Stryker Howmedica, Limerick, Ireland) and DePuy Cemvac retrograde cementation systems (DePuy CMW, Blackpool, UK), and a novel antegrade system consisting of a 60-mL catheter-tipped syringe and a Miller proximal femoral seal (Zimmer Ltd, Swindon, UK). The mean pressure was higher for the syringe system (161.45 +/- 28.9 kPa) than the Mark 1 (103.51 +/- 22.0 kPa) or Cemvac (92.65 +/- 30.7 kPa) systems (P = .0001). In addition, fewer cement mantle defects were seen with the syringe system (1, interquartile range [IQR] 1-2) than the Mark 1 (3, IQR 2-4) or Cemvac (3, IQR 1-3) systems (P = .0256).

BackgroundA higher risk of suicide has been associated with low birth weight in one study, but not yet replicated. Higher birth order has been associated with self-harm, but not with suicide.AimsTo examine the relationship between perinatal circumstances and subsequent young adult suicide in Scotland.MethodUsing linked data from the Scottish Morbidity Record and Scottish death records, a birth cohort of 1 061 830 people was followed-up for a mean of 25.1 years. Data were analysed using Cox regression.ResultsHigher maternal parity, younger maternal age (ConclusionsOur findings provide support for the influence of maternal circumstance and foetal experience on subsequent mental health.

BACKGROUND: In Nigeria, urbanisation and increasing life expectancy are likely to increase the incidence of non-communicable diseases. As the epidemic of diabetes matures, visual loss from diabetic retinopathy (DR) will increase unless mechanisms for early detection and treatment improve, and health systems respond to the growing burden of non-communicable diseases. METHODS: A nationally-representative population-based sample of 13,591 participants aged ≥40 years selected by multistage-stratified-cluster-random-sampling with probability-proportional-to-size procedures were examined in 305 clusters in Nigeria between January 2005 to June 2007. All were asked about history of diabetes and underwent basic eye examination. Visual acuity (VA) was measured using logMAR E-chart. Participants with VA11.1mmol/l or had DR. Data in the subsample were used to estimate the prevalence and to analyse risk factors for diabetes and DR using multivariable logistic regression. Additional information on the types of DR was obtained from participants not in the subsample. RESULTS: In the subsample, 164 participants were excluded due to missing data; and 1,595 analysed. 52/1,595 had diabetes, a prevalence of 3.3% (95%CI 2.5-4.3%); and 25/52(48%) did not know. Media opacity in 8/52 precluded retinal examination. 9/44(20.5%) had DR. Higher prevalence of diabetes was associated with urban residence (Odds ratio [OR]1.87) and overweight/obesity (OR3.02/4.43 respectively). Although not statistically significant, DR was associated with hypertension (OR3.49) and RBG>15.0mmol/L (OR8.10). Persons with diabetes had 3 times greater odds of blindness. Of 11,832 other participants in the study sample, 175(1.5%) had history of diabetes; 28 had DR. Types of DR (total=37) included 10.8% proliferative, 51.4% macular oedema. CONCLUSION: The age-adjusted prevalence of diabetes in Nigeria was 3.25% (95%CI 2.50-4.30) and over 10% of people with diabetes aged ≥40 years had sight-threatening-DR. These data will enable the development of better public health strategies for the control of diabetes and planning services for DR to prevent vision loss.

Aims: To explore associations of deprivation and smoking, with prevalence of asthma, wheeze, and quality of life. Methods: Survey, using International Study of Asthma and Allergies in Childhood (ISAAC) methodology, of children aged 13–14 years attending Scottish schools previously surveyed in 1995. Results: 4665/5247 (89%) pupils completed questionnaires. 3656/4665 (78.4%) had missed school for any reason in the last 12 months, 587 (12.6%) because of asthma or wheeze. Compared to children with 1–3 wheeze attacks per year, those with >12 attacks in the last year were more likely to have missed school, twice as likely to have missed physical education in the last month, to report interference with home activities, or to have visited accident and emergency departments, and three times more likely to have been hospitalised. Deprivation was not independently associated with self-reported asthma or wheeze, but was associated with school absence, either for any reason or specifically for asthma or wheeze, but not with use of services such as accident and emergency visits, doctor visits, or hospital admissions. Active smoking was associated with wheezy symptoms, and active and passive smoking with use of medical services. These associations were independent of wheeze severity, treatment taken, and other associated atopic conditions. Smoking also had an impact on school absence and home and school activities. Conclusions: Deprivation does not affect the prevalence of asthma or wheeze. Exposure to cigarette smoke was associated with the increased use of services. Deprivation and smoking have independent adverse effects on the quality of life in subjects with asthma or wheeze.

The impact on health status of hypnosis was investigated in a primary care NHS GP surgery clinic, with referrals from a Local Health Care Cooperative (LHCC) with 85,000 patients. The Medical Outcomes Study Short Form-36 Health Survey (SF36) pre and post treatment was completed by patients referred with mental health problems, medical problems and for smoking cessation. One hundred and fifteen patients successfully completed SF36 questionnaires before and six weeks after the intervention. Categories of treatment were smoking cessation, mental health, and medical. In the case of referrals for smoking cessation there were no significant changes in mental, social or physical function six weeks after the intervention. In the case of mental health referrals, which were predominantly anxiety related, there was a large and significant effect on the SF-36 in emotional role and mental role and a moderate effect on social role and mental health. Self-hypnosis was in widespread use after treatment, even in those whose perceived problem appeared not to have improved. The results suggest that simple hypnosis techniques could have a significant impact on mental health. This could have implications for promoting mental health as well as for treating mental illness, and needs to be tested further by a randomized, controlled trial.

BACKGROUND: Health professionals in rural primary care could gain more from eHealth initiatives than their urban counterparts, yet little is known about eHealth in geographically isolated areas of the UK. OBJECTIVE: To elicit current use of, and attitudes towards eHealth of professionals in primary care in remote areas of Scotland. METHODS: In 2002, a questionnaire was sent to all general practitioners (n=154) in Scotland's 82 inducement practices, and to 67 nurses. Outcome measures included reported experience of computer use; access to, and experience of eHealth and quality of that experience; views of the potential usefulness of eHealth and perceived barriers to the uptake of eHealth. RESULTS: Response rate was 87%. Ninety-five percent of respondents had used either the Internet or email. The proportions of respondents who reported access to ISDN line, scanner, digital camera, and videoconferencing unit were 71%, 48%, 40% and 36%, respectively. Use of eHealth was lower among nurses than GPs. Aspects of experience that were rated positively were 'clinical usefulness', 'functioning of equipment' and 'ease of use of equipment' (76%, 74%, and 74%, respectively). The most important barriers were 'lack of suitable training' (55%), 'high cost of buying telemedicine equipment' (54%), and 'increase in GP/nurse workload' (43%). Professionals were concerned about the impact of tele-consulting on patient privacy and on the consultation itself. CONCLUSIONS: Although primary healthcare professionals recognize the general benefits of eHealth, uptake is low. By acknowledging barriers to the uptake of eHealth in geographically isolated settings, broader policies on its implementation in primary care may be informed.

Background. Several local anaesthetic techniques are available for cataract surgery. Recently, topical anaesthesia has gained in popularity. A randomized trial was designed to compare patient discomfort and intraoperative complications following routine cataract surgery under topical or sub-Tenon's anaesthesia. Methods. A randomized double-blinded placebo-controlled clinical trial of 210 patients assigned to either a sub-Tenon's group (sub-Tenon's anaesthesia with placebo topical balanced salt solution, n=140) or a topical anaesthesia group (topical anaesthesia with placebo sub-Tenon's injection of balanced salt solution, n=70) was carried out. All patients underwent phacoemulsification with intraocular lens implantation. Patients in the sub-Tenon's group received a single injection (3 ml) of a combination of lidocaine 2% (2 ml) and bupivacaine 0.75% (1 ml), and four doses of topical placebo (balanced salt solution). Patients in the topical anaesthesia group received four doses of topical proxymethocaine 0.5% and a placebo sub-Tenon's injection (3 ml) of balanced salt solution. No intracameral injection of local anaesthetic was given. A 10-point visual analogue pain scale was used preoperatively and for postoperative pain assessment immediately after the operation and 30 min postoperatively. The intraoperative complications in the two groups were recorded. Results. The mean pain score immediately after surgery was 2.42 ( sd 2.2) in the sub-Tenon's group and 3.44 (2.3) in the topical anaesthesia group (P=0.0043). The mean pain score 30 min after surgery was 1.24 (1.7) in the sub-Tenon's group and 2.25 (2.2) in the topical anaesthesia group (P=0.0009). Conclusions. Patients undergoing cataract surgery under topical anaesthesia experience more postoperative discomfort than patients receiving sub-Tenon's anaesthesia. Surgery-related complications were similar in both groups.

Background The prevalence of childhood asthma in Scotland is one of the highest in the world. The morbidity secondary to allergic diseases is significant in terms of costs to the nation and effects on the family including the child. Aims The aims of this study were to describe the prevalence of asthma, eczema and hay fever in the Highlands of Scotland and in the Shetland Isles and to examine factors in relation to quality of life and social deprivation. Method A total population survey of 12 year old children using a parent completed questionnaire. Results 86.3% (2658/3080) returned questionnaires. Of the 2549 questionnaires analysed, 476 (18.7%) reported asthma ever, 362 (14.2%) wheeze in last 12 months, 508 (19.9%) reported hay fever ever and 555 (21.8%) reported eczema ever. Of the children reporting asthma or wheeze, 35.4% (229/647) had missed school because of asthma or wheeze, 38.0% (246/647) had missed physical education. 62.5% (354/566) of subjects with wheeze ever reported sleep disturbance. Deprivation measured by DEPCAT scores was associated with maternal smoking and bronchitis in the child but not with allergic diseases. Conclusion Compared with previous studies, the prevalence of asthma was unchanged but eczema has increased in Highland adolescents. Allergic disease has a significant impact on school attendance and physical activity. Deprivation was associated with maternal smoking and bronchitis in the child but not with allergic diseases. The impact of allergic diseases in rural areas may be different from urban areas.

BACKGROUND: This pragmatic randomised, controlled trial investigated annual review of patients with sleep apnea/hypopnea syndrome (SAHS). Clinical outcomes and costs were compared for consultant clinic review versus specialist nurse home visit. METHOD: One hundred and seventy-four patients were randomised to annual review by consultant clinic appointment or by specialist nurse home visit. SAHS symptoms, Epworth score, hospital anxiety and depression scale (HADS), Short Form-36 (SF-36) and hours of use of constant positive airway pressure (CPAP) were measured before and 3 months after review. The costs and patient preference for review were determined. RESULTS: After review, both groups significantly increased CPAP use (mean (SD) increase: nurse, 0.66 (1.71) h; consultant, 0.45 (1.69) h) and reduced symptom scores (nurse, -2 (7); consultant, -3 (9)), compared to baseline. There were no differences between groups in these improvements, or in HADS or SF-36 scores. Average duration of a nurse home visit, excluding travel time, was 26 (6) min. Total NHS cost per visit was 52.26 UK pounds (49.85) ($83.62 (79.76)), of which 6.57 UK pounds (1.43) ($10.51 (2.29)) reflected time spent with the patient and the remainder was travel cost. Average duration of consultant review was 10 (6) min, total NHS cost 6.21 UK pounds (3.99) ($9.94 (6.38)). However, the cost to the patient of attending the clinic was 23.63 UK pounds (23.21) ($37.81 (37.13)). Patient preference for review was nurse 16%, consultant 19%, and no preference 65%. CONCLUSION: Following annual review, use of CPAP increased and symptoms improved. Outcomes were similar for consultant and nurse led review. Home visits were expensive for the healthcare provider, whereas clinic attendance incurred substantial costs to the patient. The majority of patients would accept nurse review for their sleep apnea management.

Background Inexperience predisposes skiers, snowboarders, and skiboarders to a higher risk of injury. Hypothesis Individuals on their very 1st day's experience of skiing, snowboarding, or skiboarding are at greater risk of injury. Study Design Case control study. Methods All individuals injured at the three largest ski areas in Scotland during the three winter seasons 1999-2000 through 2001-2002 were included. First-day participants were identified. Individual demographic details and snow sports–related parameters were recorded. Control data were collected from uninjured individuals. Factors associated with injury were explored in univariate and multivariate analyses. Results First-day participants were overrepresented in the injured population by a factor of 2.2. Participant age younger than 17 years or older than 26 years, snowboarding, taking professional instruction, and the use of rented or borrowed gear were all independently associated with increased injury risk among 1st-day participants. Conclusions First-day participants are at increased risk of injury. Several independent risk factors for injury have been identified. Clinical Relevance First-day participants should be targeted in any future educational programs with emphasis on gear selection, use of protective gear, and the risks of exceeding the limits of their ability.

Objectives: To examine the incidence and patterns of snow sports injuries at the three largest commercial ski areas in Scotland and to identify factors associated with injury risk. Methods: A prospective case-control study of all injured people at Cairngorm, Glenshee, and Nevis Range ski areas during the 1999–2000 winter season. Personal details, snow sports related variables, diagnosis, and treatment were recorded. Control data were collected at random from uninjured people at all three areas. Random counts were performed to analyse the composition of the on slope population. Results: A total of 732 injuries were recorded in 674 people. Control data were collected from 336 people. The injury rate for the study was 3.7 injuries per 1000 skier days. Alpine skiers comprised 67% of the on slope population, snowboarders 26%, skiboarders 4%, and telemark skiers 2%. Lower limb injuries and sprains were the commonest injuries in alpine skiers and skiboarders. Snowboarders sustained more injuries to the upper limb and axial areas. Skiboarders and snowboarders had a higher incidence of fractures. After adjustment for other variables, three factors were all independently associated with injury: snowboarding (odds ratio (OR) 4.07, 95% confidence interval (CI) 1.65 to 10.08), alpine skiing (OR 3.82, CI 1.6 to 9.13), and age

To assess the clinical outcomes of cataract surgery in rural southern India.Cluster sampling was used in randomly selecting a cross-sectional sample of persons 50 years of age or older for visual acuity measurement, refraction, and ocular examination in 1999. Subjects were queried as to the date and place of surgery for each cataract-operated eye. Surgical complications were noted and the principal cause of reduced vision was identified for eyes with presenting visual acuity worse than 6/18.Within the cataract-operated sample of 682 persons, 13.8% had presenting visual acuity worse than 6/60 in both eyes, 25.2% better than or equal to 6/18 in both eyes, and 37.8% were bilaterally operated on. For aphakic eyes, 50.5% presented with visual acuity better than or equal to 6/18; 82.6% with best-correction. For pseudophakic eyes, the corresponding percentages were 78.0% and 94.5%. Over one-third of all eyes were pseudophakic, and nearly three-fourths had been operated on in non-governmental facilities. Uncorrected aphakia and other refractive error were the main causes of vision impairment. In multiple logistic regression modeling, poor presenting visual acuity in aphakic eyes was associated with illiteracy, rural residence, and surgery in government facilities; gender and time period of surgery were not predictors of vision outcomes. None of these variables were associated with best-corrected outcomes in aphakic eyes, nor with presenting and best-corrected outcomes in pseudophakic eyes.Visual acuity outcomes in pseudophakic eyes were good. More attention must be given to needless vision impairment among the cataract-operated because of inadequate aphakic correction, especially among those operated on in government facilities, the illiterate, and those living in rural villages.

PURPOSE: Investigate prevalence and risk factors for lens opacities among a nationally representative sample of Nigerians aged ≥ 40 years. METHODS: Across 305 clusters, 13,591 adults were examined. Every seventh participant (n = 1722) was sampled systematically and examined in detail, including lens opacity grading. Lenses were examined at the slit-lamp with pupil dilation and graded using the World Health Organization (WHO) system. Significant opacities were defined as nuclear, cortical, or posterior subcapsular opacity of WHO grade >1, or hyper/mature cataract. The category "Any Opacity" included hyper/mature opacity and aphakia/pseudophakia/couching. Data were collected on sociodemographic and environmental factors, including height and weight. RESULTS: A total of 1631/1722 (95%) in the normative subsample had their lenses graded. Prevalence of "Any Opacity" was 19.8% (95% confidence interval [CI]: 7.9-21.7) the prevalence of all types increased with age, and was higher in females and those not literate. Prevalence of nuclear, cortical, and posterior subcapsular were 8.8% (95% CI: 7.5-10.1); 11.7% (95% CI: 10.0-13.3); and 2.9% (95% CI: 2.1-3.8), respectively. In multivariate analysis, age was an independent risk factor for all types. Nuclear opacity was also associated with female sex (odds ratio [OR] 2.4; 95% CI: 1.5-3.6); lean body mass index (BMI; OR 2.0; 95% CI: 1.1-3.5); and the Igbo ethnic group (OR 4.4; 95% CI: 2.3-8.4). Cortical opacity was also associated with female sex (OR 2.1; 95% CI: 1.5-3.0) and the Yoruba (OR 0.45; 95% CI: 0.3-0.8), but not with BMI. "Other Lens Opacities," which includes couching, was significantly lower in the Guinea savannah region (OR 0.4; 95% CI: 0.2-0.9), while living in rain forest areas was protective for posterior subcapsular cataracts (OR 0.3; 95% CI: 0.1-0.7). CONCLUSIONS: A fifth of Nigerian adults have some degree of lens opacity. Further studies are needed to investigate the role of ethnicity, climate variables, and other risk factors.

BACKGROUND—Visual acuity and vision related quality of life outcomes in cataract surgery were evaluated in a population based survey in two geographic zones in Nepal. METHODS—Case finding was based on random sampling using a stratified cluster design with door to door enumeration of people aged ⩾45 years followed by eye examinations at village sites. All aphakics/pseudophakics, those with visual acuity less than 6/60 in either eye, and a sample of those with normal visual acuity were administered visual functioning (VF) and quality of life (QOL) questionnaires. RESULTS—15% of the 159 cataract operated cases had presenting visual acuity ⩾6/18 in both eyes, 38% with best corrected visual acuity. 21% were still blind with presenting visual acuity

Purpose: To compare the effects of extracapsular cataract extraction with posterior chamber intraocular lens (ECCE/PC-IOL) vs intracapsular cataract extraction with aphakic glasses (ICCEAG) on everyday visual functioning and quality of life. Methods: In a nonmasked randomized controlled clinical trial, 3,400 bilateral vision-impaired patients, aged 40 to 75 years, with operable cataract were randomly assigned to receive one of the two treatment options. One half in each group were randomly selected for interviewer administration of visual functioning and quality of life questionnaires before surgery and at 6 and 12 months after surgery. Results: Both ICCE-AG and ECCE/PC-IOL produced dramatic improvements in visual functioning and quality of life scores. Patients receiving ECCE/PC-IOL reported larger beneficial changes than did those receiving ICCE-AG, compatible with additional beneficial effects of a moderate magnitude for visual functioning and of a smaller beneficial magnitude for quality of life. All between-group differences were highly statistically significant ( P Conclusions: In this developing-country setting, ICCE-AG and ECCE/PC-IOL were associated with substantial benefits in improved everyday vision function and vision-related quality of life. Patients who received ECCE/PC-IOL reported greater benefits and fewer problems with vision than did patients who received ICCE-AG.

Purpose To define uveitis associated with leptospirosis in a clinical setting. Methods We present the clinical features of 73 consecutive cases of uveitis linked clinically to an outbreak of systemic leptospirosis in patients with antibodies to Leptospira species who were examined from January to September 1994. Results In 73 patients, the pattern of ocular involvement was unilateral in 35 and bilateral in 38. Panuveitis was seen in 106 eyes (95.5%), retinal periphlebitis in 57 eyes (51.4%), and hypopyon in 14 eyes (12.6%). Anterior uveitis alone without hypopyon was observed in three eyes (2.7%), whereas vitreous inflammatory reaction alone was seen in two eyes (1.8%). Sixty of 73 patients (82.2%) or 91 of 111 eyes (82.0%) were followed up for 8 months. Final visual acuity was 6/6 (20/20) in 47 eyes (52%) and improved during treatment, although not up to 6/6, in 15 eyes (16%). Twenty-eight eyes (31%) maintained same vision, and one eye showed deterioration of vision. Conclusion Uveitis associated with leptospirosis may manifest as unilateral or bilateral uveitis, anterior uveitis, or panuveitis. The prognosis is generally good in this entity, even when the inflammation is severe. Awareness of this disease in endemic areas is important in order to differentiate it from other uveitic entities, especially in young male patients in whom other immunologic uveitides are also common.

OBJECTIVE: Non-communicable diseases are now a global priority. We report on the prevalence of hypertension and its risk factors, including ethnicity, in a nationally representative sample of Nigerian adults recruited to a survey of visual impairment. METHODS: multi-stage, stratified, cluster random sample with probability proportional to size procedures was used to obtain a nationally representative sample of 13 591 subjects aged ≥ 40 years. Of these, 13 504 (99.4%) had a blood pressure measurement. RESULTS: The prevalence of hypertension was 44.9% [95% confidence interval (CI): 43.5-46.3% ]. Increasing age, gender, urban residence and body mass index were independent risk factors (p < 0.001). The Kanuri ethnic group had the highest prevalence of hypertension (77.5%, 95% CI: 71.0-84.0%). CONCLUSIONS: The high prevalence of hypertension in Nigeria is a cause for concern and suggests that it is inevitable that the impact of hypertension-related ill health is imminent, with the accompanying financial and societal costs to families and the state of Nigeria.

PURPOSE: To estimate prevalence and describe causes of functional low vision (FLV) among a nationally representative sample of Nigerian adults, assess socioeconomic risk factors, and estimate the number of adults in Nigeria who might benefit from low vision assessment or rehabilitation services. METHODS: Multistage, stratified, cluster random sampling with probability proportional to size procedures were used to identify a nationally representative sample of 15,027 persons aged 40 years or older. Distance vision was measured using a reduced logMAR tumbling E-chart. All participants with presenting acuity of

OBJECTIVE: To determine the prevalence and causes of visual loss in different ecological zones across Nigeria. METHODS: A population-based survey using multi-stage, stratified, cluster random sampling with probability proportional to size comprising a nationally representative sample of adults aged > or = 40 years from six ecological zones. OUTCOME MEASURES: Distance vision was measured using reduced logMAR charts. Clinical examination included basic eye examination for all respondents and a detailed examination including visual fields, gonioscopy and fundus photography for those who were visually impaired or blind (i.e. presenting vision < 20/40 in the better eye). A principal cause of visual loss was assigned to all respondents with presenting vision < 20/40 in the better eye. RESULTS: A total of 15 122 persons aged > or = 40 years were enumerated, 13 599 (89.9%) of whom were examined. The prevalence of blindness varied according to ecological zone, being highest in the Sahel region (6.6%; 95% confidence interval (CI) 4.2 - 10.4) and lowest in the rain forest region (3.23%; 95% CI 2.6 - 3.9). Age/ gender-adjusted analyses showed that risk of blindness was highest in Sahel (odds ratio (OR) 3.4; 95% CI 2.1 - 5.8). More than 80% of blindness in all ecological regions was avoidable. Trachoma was a significant cause only in the Sudan savannah belt. The prevalence of all major blinding conditions was highest in the Sahel. CONCLUSIONS: The findings of this national survey may be applicable to other countries in West and Central Africa that share similar ecological zones. Onchocerciasis and trachoma are not major causes of blindness in Nigeria, possibly reflecting successful control efforts for both these neglected tropical diseases.

PURPOSE: To provide data on prevalence and types of refractive error and the spectacle-wearing rate among adults in Nigeria and the degree to which the need for distance correction could be met by off-the-shelf spectacles. METHODS: Multistage, stratified, cluster random sampling with probability proportional to size was used to identify a nationally representative sample of 15,027 persons aged ≥40 years. Distance vision was measured using a reduced logMAR tumbling-E chart. All participants underwent autorefraction, and those with presenting acuity of

PURPOSE: Determine causes of blindness and visual impairment among adults aged >or=40 years. METHODS: Multistage, stratified, cluster random sampling with probability proportional to size procedures were used to identify a nationally representative sample of 15,027 persons >or=40 years of age. Distance vision was measured with a reduced logMAR tumbling E-chart. Clinical examination included a basic eye examination of all subjects and a more detailed examination of those who had presenting vision or=40 years who were enumerated, 13,599 (89.9%) were examined. In 84%, blindness was avoidable. Uncorrected refractive errors were responsible for 57.1% of moderate (40% over the next decade.

Background The configuration of rural health services is influenced by geography. Rural health practitioners provide a broader range of services to smaller populations scattered over wider areas or more difficult terrain than their urban counterparts. This has implications for training and quality assurance of outcomes. This exploratory study describes the development of a "clinical peripherality" indicator that has potential application to remote and rural general practice communities for planning and research purposes. Methods Profiles of general practice communities in Scotland were created from a variety of public data sources. Four candidate variables were chosen that described demographic and geographic characteristics of each practice: population density, number of patients on the practice list, travel time to nearest specialist led hospital and travel time to Health Board administrative headquarters. A clinical peripherality index, based on these variables, was derived using factor analysis. Relationships between the clinical peripherality index and services offered by the practices and the staff profile of the practices were explored in a series of univariate analyses. Results Factor analysis on the four candidate variables yielded a robust one-factor solution explaining 75% variance with factor loadings ranging from 0.83 to 0.89. Rural and remote areas had higher median values and a greater scatter of clinical peripherality indices among their practices than an urban comparison area. The range of services offered and the profile of staffing of practices was associated with the peripherality index. Conclusion Clinical peripherality is determined by the nature of the practice and its location relative to secondary care and administrative and educational facilities. It has features of both gravity model-based and travel time/accessibility indicators and has the potential to be applied to training of staff for rural and remote locations and to other aspects of health policy and planning. It may assist planners in conceptualising the effects on general practices of centralising specialist clinical services or administrative and educational facilities.

We presented all relevant results so that readers could decide for themselves whether their interpretation of our findings fits with ours. Brind thinks that the analysis in which both ever and never users lost to follow-up before the age of 38 were excluded (adjusted relative risk 0.95, 95% confidence interval 0.88 to 1.02) shows serious bias and invalidates the main dataset results in which only never users younger than 38 were excluded (0.88, 0.83 to 0.94). Since the total population in each analysis is different, their results should not be compared directly (in the same way that the results from the main and the general practitioner observation dataset should not be compared directly, as indicated in the footnote to table 2). Furthermore, the different standard populations inevitably result in some variation in the point estimates from each analysis. The point estimate of 0.95 from the “fully excluded” analysis is not materially different from that of 0.88 from the “partially excluded” analysis, although the latter is based on more data. In addition, the upper 95% confidence interval of the fully excluded point estimate was just above unity, suggesting no increased risk of overall cancer. The subgroup analyses of duration and time since last use of oral contraception included a large number of comparisons, some of which may have reached significance by chance. Although the relative risk of breast cancer was raised among ever users who had stopped 15-20 years previously, it was decreased in those who had stopped more than 20 years previously (0.54, 0.35 to 0.82) and the trend over time was not significant. We cannot explain the increased risk of central nervous system/pituitary cancer among ever users, although the number of women affected was small (49 of the 3877 cancers in the main dataset). We highlighted and discussed the increased risk of any cancer among women using oral contraception for more than eight years in the paper, press releases, and media interviews. Our interpretation remains that oral contraception was not associated with an overall increased risk of cancer—indeed it may even produce a net public health gain.

To describe the methodology and baseline data for the Antioxidants in Prevention of Cataracts (APC) study in South India.The APC study is a prospective, 5-year, randomized, triple-masked, placebo-controlled, field-based clinical trial to examine the effect of antioxidants (combination tablet of vitamins A, C, and E) on progression of cataract. The primary outcome variable is cataract progression (nuclear opalescence), evaluated with the slit-lamp biomicroscope by the Lens Opacification Classification System III method. Secondary outcome variables are progression in cortical and posterior subcapsular opacity and nuclear color, change in best corrected visual acuity, myopic shift, and treatment failure (progression to cataract surgery or best corrected vision worse than 20/400 in an eye). Inclusion criteria are age between 35 and 50 years and best-corrected visual acuity of 20/40 or better. Exclusion criteria are a diagnosis of diabetes mellitus or nonfasting blood glucose level7.8 mmol/L, history or presence of various ocular conditions or treatment forms, or current use of vitamin supplements. Baseline ophthalmic, demographic, and potential cataract risk factor data (such as smoking, sunlight, or alcohol exposure) were compared between groups on an intent-to-treat basis.Of 954 people screened, 798 were enrolled, a sample size which exceeded the required estimate. More than 80% of subjects had 20/20 or better vision in at least one eye, and baseline prevalence of significant cataract according to the LOCS III grading scale was high. The two treatment groups were comparable for all baseline measures except alcohol intake.The sample size and group baseline characteristics will provide sufficient power to detect a change in cataract progression within 5 years.

Background It is believed that total reported suicide rates tend to decrease during wartime. However, analysis of suicide rates during recent conflicts suggests a more complex picture, with increases in some age groups and changes in method choice. As few age and gender specific analyses of more distant conflicts have been conducted, it is not clear if these findings reflect a change in the epidemiology of suicide in wartime. Therefore, we examined suicide rates in Scotland before, during and after the Second World War to see if similar features were present. Methods Data on deaths in Scotland recorded as suicide during the period 1931 – 1952, and population estimates for each of these years, were obtained from the General Register Office for Scotland. Using computer spreadsheets, suicide rates by gender, age and method were calculated. Forward stepwise logistic regression was used to assess the effect of gender, war and year on suicide rates using SAS V8.2. Results The all-age suicide rate among both men and women declined during the period studied. However, when this long-term decline is taken into account, the likelihood of suicide during the Second World War was higher than during both the pre-War and post-War periods. Suicide rates among men aged 15–24 years rose during the Second World War, peaking at 148 per million (41 deaths) during 1942 before declining to 39 per million (10 deaths) by 1945, while the rate among men aged 25–34 years reached 199 per million (43 deaths) during 1943 before falling to 66 per million (23 deaths) by 1946. This was accompanied by an increase in male suicides attributable to firearms and explosives during the War years which decreased following its conclusion. Conclusion All age male and female suicide rates decreased in Scotland during World War II. However, once the general background decrease in suicide rates over the whole period is accounted for, the likelihood of suicide among the entire Scottish population during the Second World War was elevated. The overall decrease in suicide rates concealed large increases in younger male age groups during the War years, and an increase in male suicides recorded as due to the use of firearms. We conclude that the effects of war on younger people, reported in recent conflicts in Central Europe, were also seen in Scotland during the Second World War. The results support the findings of studies of recent conflicts which have found a heterogeneous picture with respect to age specific suicide rates during wartime.

Anecdotal reports suggested that farmers were sustaining significant injuries while ear tagging newborn calves or clipping cattle prior to slaughter.This national survey was designed for determining the incidence and nature of self-reported injuries to farmers that were sustained while tagging calves and clipping cattle.A cross-sectional, anonymous, postal questionnaire survey was sent to all members of the National Farmers Union of Scotland with beef or dairy cattle (n = 4495).In total, 2439 (54%) usable questionnaires were received and 1341 injuries were reported by 591 (24%) respondents. Tagging-related injuries were reported by 297 (12%) respondents. The most commonly described injury was bruising, but lacerations (3%) and fractures (3%) also occurred. Fifty-eight (20%) individuals lost time from work, with a median of 3 days [interquartile range (IQR) = 2-7 days]. Four hundred and eighteen (17%) respondents reported clipping-related injuries. The most common injury was bruising, but lacerations (6%) and fractures (7%) also occurred. Ninety-five (23%) individuals lost time from work, with a median of 4 days (IQR = 2-14 days). Tagging injuries more commonly affected lower limbs and the trunk, while clipping injuries affected the upper limbs. Tagging injuries were associated with working alone, in an open field and with a vehicle nearby, while clipping injuries were associated with working alone, with beef cattle and with younger age. Both types of injury were associated with injuries from livestock in other circumstances.Tagging calves and clipping cattle prior to slaughter are associated with a significant risk of injury, which may be severe, necessitating treatment and time lost from work. Policy makers, safety advisers and the farming community should reconsider whether these procedures are necessary and whether current guidelines should be modified in order to improve safety.

Objectives: To study the nature of CAM use in primary care attenders, the involvement of their NHS healthcare professionals in their CAM care and differences in characteristics between CAM users and non-users. Design: Postal questionnaire for primary care attenders and analysis of practice leaflets. Setting: Six Scottish GP practices with a range of practice size, CAM provision within practice, deprivation and rurality. Results: Five hundred and fourteen primary care attenders described 1194 incidences of CAM use and gave details about their main therapy. 37% had contact with a practitioner, the rest mainly self-prescribed. The perceived effectiveness of CAM was high. Patients used CAM for a variety of health problems, mainly as an adjuvant to orthodox medicine rather than an alternative. The involvement of the NHS in CAM delivery was small but there is a significant role to ensure patient safety, especially regarding herb–drug interactions. Disclosure rate of CAM use was low. CAM offered options in areas where the provision in the NHS is difficult, including musculo-skeletal and mental health problems. Provision of CAM by the GP is associated with higher CAM use in primary care attenders. Conclusions: It is recommended that healthcare professionals include patients’ use of CAM in history taking and clinical decision making.

To assess the prevalence of visual acuity impairment, blindness, and cataract surgery among older adults in rural southern India.Random selection of village- and urban-based clusters was used to identify a cross-sectional sample of persons 50 years of age or older from the Sivaganga district of Tamil Nadu. Subjects in 25 selected clusters were enumerated through a door-to-door survey and invited to examination sites for measurement of uncorrected, presenting, and best-corrected visual acuity and ocular examination in 1999. The principal cause was identified for eyes with presenting visual acuity worse than 6/18. Quality assurance monitoring of visual acuity measurements took place in five of the study clusters.A total of 5081 persons in 3517 households were enumerated, and 4642 (91.4%) were examined. Thirty-six percent presented with visual acuity worse than 6/18 in the better eye. The prevalence of blindness, based on visual acuity worse than 6/60 in both eyes, was 6.0% (95% confidence interval [CI]: 5.1% to 6.9%) with presenting vision, and 2.5% (95% CI: 1.8% to 3.1%) with best correction. Blindness with presenting visual acuity was associated with older age and illiteracy. Cataract was the principal cause of blindness in one or both eyes in 69.4% of those presenting blind, and uncorrected aphakia and other refractive error affected 35.6% in at least one eye. The prevalence of cataract surgery was 14.7% (95% CI: 13.0% to 16.4%); low surgical coverage among the cataract blind was associated with illiteracy.It appears that much has been done in the prevention of blindness in Sivaganga. Nevertheless, blindness remains an important public health problem, mainly because of cataract and refractive error. Prevention of blindness programs in the area should target these two causes, with special emphasis on the elderly and the illiterate.

PURPOSE: To compare the efficacy and safety of ofloxacin 0.3% ophthalmic solution with ciprofloxacin 0.3% ophthalmic solution in patients with culture-positive bacterial keratitis. METHODS: Patients with a microbiologic diagnosis of bacterial keratitis were included in this double-masked, parallel-group study and were randomized to treatment with either ofloxacin 0.3% or ciprofloxacin 0.3% ophthalmic solution. One drop of the study medication was instilled during the daytime according to the following schedule: every half-hour on study day 1, every hour on days 2 through 4, and every 2 hours on days 5 through 21. Healing, the primary outcome measure, was defined as complete reepithelialization, accompanied by nonprogression of stromal infiltrate for 2 days. Secondary outcome measures included signs and symptoms of infection. Patients were monitored throughout the study period for any adverse events. RESULTS: A total of 217 patients completed the study: 112 were treated with ofloxacin and 105 were treated with ciprofloxacin. Streptococcus pneumoniae was the most commonly encountered pathogen in all patients. Complete corneal reepithelialization occurred in 85% of those treated with ofloxacin and in 77% of those treated with ciprofloxacin (p = 0.32). The average time to corneal ulcer healing was 13.7 days in those treated with ofloxacin and 14.4 days in those treated with ciprofloxacin. Both treatments were well tolerated with no patient discontinuing the study because of side effects. CONCLUSION: Ofloxacin 0.3% and ciprofloxacin 0.3% ophthalmic solutions are effective and safe in the treatment of patients with culture-positive bacterial keratitis.

PURPOSE: To estimate the cumulative incidence of posterior capsule opacification 4 years after surgery in patients who participated in the Madurai Intraocular Lens Study and had extracapsular cataract extraction with posterior chamber intraocular lens implantation. METHODS: In the Madurai Intraocular Lens Study, 1,700 patients with best-corrected visual acuity 20/120 or worse in the better eye had extracapsular cataract extraction with posterior chamber intraocular lens implantation, and 1,474 (86.7%) of these completed the 1-year follow-up examination. From this group of 1,474 pseudophakic patients, 400 were randomly selected for reexamination 4 years after the original surgery. The eye that was operated on was examined by an ophthalmologist who was involved in the 1-year follow-up examinations and posterior capsule opacification grading. A grading of I to III was used to reflect the degree of opacification. With grades II and III, posterior capsule opacification detectable with an undilated pupil was present in the central axis. RESULTS: Three hundred twenty-seven (81.8%) of the selected population were examined between October 1997 and December 1998. Thirty-four (8.5%) were confirmed as being deceased, and 39 (9.8%) were unavailable for follow-up. The median age was 60 years, and 57.2% were women. The 4-year incidence of grade II or III posterior capsule opacification, including eyes already treated with laser capsulotomy, was 13.1% (95% confidence interval [CI], 9.7% to 17.3%). Each year of increased age was associated with a decreased risk of posterior capsule opacification (odds ratio, 0.96; 95% CI, 0.92 to 1.00). Based on best-corrected visual acuity of 20/40 or worse without co-existing pathology, the 4-year incidence of posterior capsule opacification was 13.5%. CONCLUSION: Because patients with relatively mature cataracts routinely receive extracapsular cataract extraction with posterior chamber intraocular lens implantation instead of the traditional intracapsular extraction, the subsequent need for laser capsulotomy may be less than that anticipated, based on previous reports.