The natural history of schizophrenia: a five-year follow-up study of outcome and prediction in a representative sample of schizophrenics

Longitudinal studies of schizophrenia based on at least 70 subjects and a minimum five-year follow-up period are reviewed in respect of the requirements of adequate method. A cohort of 121, PSE-diagnosed, schizophrenic admissions from a defined population was identified. The sex-distribution of the subjects was almost equal. Forty per cent were first admissions; 65% of the men and 24% women were unmarried; the mean age of onset for men was 28.6 years, for women 33.2 years. Almost half (48%) were continuously employed (including house and child care) for 2 years prior to admissions. First rank symptoms of schizophrenia were present in 79% of the men and 86% of the women. Comprehensive, standardized assessments of clinical state and social function were made on discharge from hospital and at follow-up by home interview of patient and relative(s). Outcome was also assessed by duration and frequency of readmission and by duration of employment. First admissions were analysed separately from the whole cohort. There were 49 first admissions generating an incidence of 7.4 per 100,000 general population per annum. Sixty-nine per cent of men and 13% of women were unmarried. The mean age of admission for men was 30.8 years, women 40.3 years and the mean age of onset 30.7 and 38.6 respectively. After 5 years first rank symptoms were present in 46% of the males and 35% of the females. The proportion showing depressive symptoms fell from 39% at intake to 22% at five years. In terms of a combination of symptoms and readmissions there was a good outcome in 50% of men and 65% of women, a trend comparable to that found in the whole cohort. For the whole cohort a combination of the number of symptoms and admissions disclosed a good outcome for 48%. The mean total duration of readmissions during the five years for men was 76 weeks and for women 27 weeks. Depressive symptoms were present in 38% at intake and 21% after 5 years. An overall rating of social functioning at 5 years showed no more than mild impairment for 47% of men and 74% of women, although individual items were more impaired. However, 38% of the group showed no more than mild impairment in any aspect of social functioning rated. Clinical and social outcome were, in general, closely correlated. The difference in outcome between men and women and the relations between clinical and social outcome are discussed. By means of an application of measures of association between independent and dependent variables to the onset data the clinical and social categories of pathology and impairment at 5 years were forecast.(ABSTRACT TRUNCATED AT 400 WORDS)

A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project

OBJECTIVE

To compare the clinical and psychological effectiveness of the traditional British antenatal visit schedule (traditional care) with a reduced schedule of visits (new style care) for low risk women, together with maternal and professional satisfaction with care.

DESIGN

Randomised controlled trial.

SETTING

Places in south east London providing antenatal care for women receiving shared care and planning to deliver in one of three hospitals or at home.

SUBJECT

2794 women at low risk fulfilling the trial's inclusion criteria between June 1993 and July 1994.

MAIN OUTCOME MEASURES

Measures of fetal and maternal morbidity, health service use, psychosocial outcomes, and maternal and professional satisfaction.

RESULTS

Pregnant women allocated to new style care had fewer day admissions (0.8 v 1.0; P=0.002) and ultrasound scans (1.6 v 1.7; P=0.003) and were less often suspected of carrying fetuses that were small for gestational age (odds ratio 0.73; 95% confidence interval 0.54 to 0.99). They also had some poorer psychosocial outcomes; for example, they were more worried about fetal wellbeing antenatally and coping with the baby postnatally, and they had more negative attitudes to their babies, both in pregnancy and postnatally. These women were also more dissatisfied with the number of visits they received (odds ratio 2.50; 2.00 to 3.11).

CONCLUSIONS

Patterns of antenatal care involving fewer routine visits for women at low risk may lead to reduced psychosocial effectiveness and dissatisfaction with frequency of visits. The number of antenatal day admissions and ultrasound scans performed may also be reduced. For the variables reported, the visit schedules studied are similar in their clinical effectiveness. Uncertainty remains as to the clinical effectiveness of reduced visit schedules for rare pregnancy problems.

Factors predictive of difficulty of mandibular third molar surgery

AIM

Historically the difficulty of third molar surgery has been judged using radiologically assessed dental factors specifically tooth morphology and position. This study investigated additional factors that have a bearing on the difficulty of extraction.

STUDY DESIGN

A prospective study undertaken by three clinical assistant grade surgeons who removed 354 single mandibular third molar teeth under day case anaesthesia over the 4-year period (1994-1998).

METHOD

Data relating to patient, dental and surgical variables were collected contemporaneously as the patients were treated. The difficulty of extraction was estimated by the surgeons pre-operatively using dental radiographic features and compared by the same surgeon within the actual surgical difficulty encountered at surgery. Operation time strongly related to both pre and post treatment assessments of difficulty and proved to be the best measure of surgical difficulty.

RESULTS

Univariate analysis identified increased patient age, ethnic background, male gender, increased weight, bone impaction, horizontal angulation, depth of application, unfavourable root formation, proximity to inferior alveolar canal and surgeon as factors increasing operative time. Multivariate analysis showed that increasing age (P = 0.014), patient weight (P = 0.024), ethnicity (P = 0.019), application depth (P = 0.001), bone impaction (p=0.008) and unfavourable root formation (P = 0.009) were independent predictors for difficulty of extraction.

CONCLUSIONS

Half of the six independent factors that predicted surgical difficulty of third molar extraction were patient variables.

Hip dysplasia in bilateral cerebral palsy: incidence and natural history in children aged 18 months to 5 years

Children with bilateral cerebral palsy (CP) born during 1989 to 1992 (n=346) to a geographically defined population were ascertained and followed up to age 5 years. The aims of the study were to monitor hip development by serial X-rays; to record gross locomotor development, aspects of physical management, and any hip-related orthotics or surgery; to learn more of the natural history of hip development in this condition; and to provide guidelines for a surveillance protocol for those clinically managing children with bilateral CP. Children were X-rayed at 18, 24, 30, 48, and 60 months. X-rays were taken in a standardized position and measured to record migration percentage, acetabular index, Sharp's angle, and Smith's diaphyseal ratios. Relationships between the measures were investigated and a natural history of the children's hip development suggested. At as early as 18 months, migration percentages were significantly greater than in the normally developing population, although no measured CP factor could be identified to be the cause of this early change. Two possible factors affecting early hip development are described, neither of which is clinically apparent: the first separates the bilateral CP population as a whole from the normal population; but there is an additional presdisposing factor affecting some children only which in the presence of the motor disorder, has a significant influence on early hip development and subsequent dysplasia. The study confirms that, when measured correctly, migration percentage is the best guide to hip surveillance and the need for treatment. It is suggested that all children with bilateral CP should be X-rayed in a standardized position at 30 months (corrected for gestational age).

Long axis excursion in aortic stenosis

OBJECTIVES

To examine long axis excursion in patients with all grades of aortic stenosis and preserved transverse systolic function, and to compare long axis excursion in symptomatic with that in asymptomatic severe aortic stenosis.

DESIGN

Prospective comparative study.

SETTING

Regional cardiothoracic centre.

PATIENTS

78 patients with all grades of aortic stenosis and normal fractional shortening and ejection fraction were studied. There were two comparison groups, 10 age matched normal subjects and 14 patients with aortic stenosis and fractional shortening < 26%.

METHODS

Aortic valve function and left ventricular mass were assessed echocardiographically. M mode measurements of long axis excursion at the septal and lateral sides of the mitral annulus were taken.

RESULTS

There were significant differences between the groups in long axis excursion at both the septal (p < 0.0001) and lateral sides of the mitral annulus (p = 0.002 by analysis of variance). Long axis excursion was independently related to both left ventricular mass index (p = 0.001) and the grade of aortic stenosis (p = 0.002). Comparing patients with severe aortic stenosis with and without symptoms, there were significant differences in effective orifice area (p = 0.02 ) and long axis excursion at the lateral side of the mitral annulus (p = 0.04), but not in fractional shortening, ejection fraction, or peak or mean pressure difference.

CONCLUSION

In patients with aortic stenosis, long axis excursion is reduced even in the presence of normal fractional shortening or ejection fraction. It is lower in patients with symptomatic compared with asymptomatic severe aortic stenosis and may be of use in predicting the onset of symptoms.

A randomized controlled trial of mite allergen-impermeable bed covers in adult mite-sensitized asthmatics

BACKGROUND

Mite-allergic patients with allergic disease should benefit from avoiding mite allergens. Many physicians, however, are yet to be convinced that allergen avoidance can make a significant contribution to asthma management in these patients. Many allergen-avoidance regimes include multiple measures of allergen reduction, but as mite exposure in the home is most likely to be greatest in bed dust, bedding is usually the first target for intervention.

OBJECTIVE

This study selected adult patients considered to be most likely to benefit from avoiding mite allergens, namely diagnosed asthmatics, sensitized to house dust mites and exposed to mite allergen in their mattresses. Patients were randomized into a placebo-controlled trial of the use of allergen-impermeable bed covers for 12 months, without any other form of mite-reduction measures.

METHODS

Adults with asthma were selected from general practices and asthma clinics in south-east London. Their serum IgE to mite allergens and allergen content of mattress dust samples were measured. Those with >0.70 kU/L mite-specific IgE and >2 microg/g Der p 1 were randomized into active or placebo treatments. Information was collected on allergic symptoms and medication use and quarterly peak flow diaries were kept throughout the trial. Dog or cat allergic patients were excluded if they had a pet at home to which they were sensitized.

RESULTS

The mean decrease in microg/g Der p 1 was 25.7 (95% CI 8.9, 74.1) in the active group and 4.5 (95% CI 1.8, 11.5) in the placebo group. Der p 1 concentrations in the active and placebo groups at the end of the trial were not significantly different. There was no effect on peak flow or asthma symptoms in a simple comparison of the treatment and placebo groups.

CONCLUSION

In this group of patients, mite allergen avoidance in the bed by the use of allergen-impermeable bedding alone cannot be recommended as an effective way of relieving asthma symptoms.

Comparative study of chest pain characteristics in patients with normal and abnormal coronary angiograms

OBJECTIVE

To improve the characterisation of chest pain by comparing symptoms in patients with normal and abnormal coronary angiograms.

STUDY DESIGN

Prospective case-control study.

SETTING

Single tertiary cardiac referral centre.

PATIENTS

65 consecutive patients with chest pain and completely normal coronary angiograms recruited over a period of one year, and 65 sex matched patients with significant stenoses at angiography.

MAIN OUTCOME MEASURES

Standardised chest pain questionnaires.

RESULTS

61 of 65 patients (94%) and every control reported chest pain on exertion. There were no important differences in the site, quality, and radiation of pain but three symptoms had discriminatory value expressed in binary fashion ("typical" v "atypical"): the consistency with which pain was reproduced by exercise (typical, score index 10/10), the duration of pain episodes (typical, five minutes), and the frequency of pain at rest (typical, 10% all pain episodes). All three symptoms were atypical in 21 (32%) patients with normal coronary angiograms, but only one patient with an abnormal coronary angiogram. Patients with no typical features had a 2% chance of an abnormal coronary angiogram if aged under 55 years or 12% if aged 55 years or more. The additional impact of exercise stress testing was low.

CONCLUSIONS

Chest pain characteristics which separate patients with normal coronary angiograms from patients with obstructive coronary heart disease can be defined objectively. This may allow improvements in referral patterns for specialist opinion or angiography, and in characterisation of patients in research studies.

Women's satisfaction with traditional and reduced antenatal visit schedules

OBJECTIVE

to ascertain: (i) which demographic, obstetric, maternity care, practical and attitudinal variables, and which variables relating to social support and life problems predict satisfaction with traditional antenatal visit schedules; and (ii) which of these variables predict satisfaction with reduced antenatal visit schedules.

DESIGN

a secondary analysis of data from the Antenatal Care Project (a randomised controlled trial comparing two schedules of routine antenatal visits).

SETTING

three hospitals and their community sites in south-east London.

PARTICIPANTS

1882 pregnant women, that is all those who took part in the Antenatal Care Project, on whom maternity record data were available, and who returned their antenatal questionnaire.

INTERVENTION

participants were randomly allocated to follow either the traditional schedule of 13 routine antenatal visits, or a reduced schedule of seven visits for nulliparous women and six visits for multiparous women.

MEASUREMENTS

a questionnaire developed specifically for the Antenatal Care Project. Also some data extracted from women's maternity records.

FINDINGS

women satisfied with reduced schedules were more likely to live in rented accommodation, and to have a caregiver who both listened and encourage them to ask questions than women not satisfied with reduced schedules. Women satisfied with the reduced schedules were less likely to be depressed in pregnancy than those not satisfied with reduced schedules. Women satisfied with the traditional schedule were more likely to have their general practitioner involved in their antenatal care, and to receive social support from relatives than those not satisfied with the traditional schedule. Initial preferences and expectations were also associated with satisfaction.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

(i) groups most likely to be satisfied with traditional or reduced antenatal visit schedules cannot be easily identified. It is therefore necessary to talk to women individually, and tailor care to their particular preferences; (ii) social support for depressed women needs to be safeguarded if reduced schedules are to be introduced; (iii) improving the psychosocial quality of antenatal care may be a good strategy for making reduced visit schedules more acceptable to pregnant women.

A survey of health professionals' views on possible changes in the provision and organisation of antenatal care

OBJECTIVE

To ascertain the views of midwives, obstetricians and general practitioners (GPs) on possible changes in the provision of antenatal care, and to describe any differences in attitude between the three professional groups.

DESIGN

survey using postal questionnaire.

SETTING

Three hospitals in south-east London.

PARTICIPANTS

The questionnaire was sent to 251 midwives, 50 obstetricians, and 438 GPs. The overall response rate was 70%.

MEASUREMENTS

A questionnaire asking whether the health professionals would like to see, were undecided, or would not like to see, 12 possible changes in the provision of antenatal care.

FINDINGS

The changes that most health professionals wanted to see were individualised visit schedules and an increase in continuity of care-giver. There were significant differences between the three professional groups for 11 of the 12 possible changes, with midwives being the group most keen, and GPs tending to be the least keen, to see change.

KEY CONCLUSIONS

It is important to recognise and address the different views of midwives, obstetricians and general practitioners at this time when major changes in the organisation of antenatal care are being planned or implemented.

IMPLICATIONS FOR PRACTICE

Differences in attitudes between health professionals need to be addressed when planning changes in the provision of antenatal care.

Variation of salivary flow rate in adolescents

Forty-three children living in North Wales, an area with a temperate climate, were involved in this study from September 1990 until June 1991 inclusive. By standardizing the method and timing of collection the effect of external factors on the salivary flow rate was minimized. Flow rate was assessed once a month. Of the original group of 43, 18 attended at each occasion; these were termed the "regular attendees". Repeated-measures analysis of variance indicated that unstimulated salivary flow rate varied within an individual over time in both the total (43, p < 0.001) and the regular groups (18, p < 0.001). This relation remained when the initial September and October measurements were excluded (p < 0.05, n = 43). When the subgroup, the regular attendees (n = 18), was considered, this relation almost reached statistical significance when September was excluded (p = 0.052) and when both months were omitted the association was no longer evident (p = 0.094). Similar to previously published results from a study of individuals in a subtropical climate, salivary flow-rate variation was inversely associated with ambient temperature in both the total (n = 43) and the subsection of regular attendees (n = 18) (p < 0.05).

Classification of mental disorder in primary care

This monograph describes a study designed to test how far the two major international systems of disease classification, International Classification of Diseases (ICD) and International Classification of Health Problems in Primary Care (ICHPPC), can be consistently applied by General Practitioners (GPs) to mental disorder presenting in primary care, and to identify sources of observer variation occurring at different stages of clinical judgement. A group of 27 senior GPs was exposed to a series of real life general practice consultations, either in the form of videotape or written case-vignette material, chosen to reflect a wide range of minor psychiatric problems, differing not only in respect of phenomenology but also of their associations with social stresses and supports, physical illness and personality features. The findings clearly indicate that neither ICD nor ICHPPC can be applied consistently by GPs. However, while the overall diagnostic concordance using ICD and ICHPPC proved to be disappointingly low, agreement on individual observations relating to psychological, physical, personality and social features was moderately good. It was also noted that participants, when given the opportunity, tended to incorporate several domains into their diagnostic conclusions, aiming for a multidimensional formulation, to which neither ICD nor ICHPPC lend themselves. It is, therefore, not surprising that if the principal diagnostic schemata are neither adequate in themselves nor readily applicable to primary care, then GPs are more likely to resort to symptomatic treatment and evade diagnosis when confronted with minor psychiatric morbidity. The consequence of this approach for National Morbidity Surveys and drug trials are discussed. The historical development of multiaxial schemata of classification is briefly traced, the problems associated with DSM-III are discussed, and a comprehensive model of classification is proposed which incorporates the notions of severity and duration as well as of category on the four dimensions of psychological illness, social stresses and supports, personality and physical illness.

Does reducing the frequency of routine antenatal visits have long term effects? Follow up of participants in a randomised controlled trial

1117 low risk women, who had been randomly allocated to either the traditional schedule of 13 antenatal visits or a reduced schedule of six to seven visits, were followed up 2.7 years after their delivery. Follow up was by means of a postal questionnaire (assessing the mother-child relationship, maternal psychological wellbeing, health service use, health-related behaviour and health beliefs), and patient record data on the frequency of contacts in general practice. There was no evidence of differences between the two groups for any of the outcomes examined. Offering a reduced schedule of routine antenatal visits to low risk women does not appear to have any long term effects.

Consultation for physical illnesses by patients diagnosed and treated for psychiatric disorders by a general practitioner: 20 year follow up study

Patterns of consultation for physical illness were analysed in a body of consultation data covering a continuous 20 year period from a single general practitioner in south London. Three groups of adult patients were identified: patients with a psychiatric disorder and a new prescription for a psychotropic drug; patients with a psychiatric disorder but no new prescription for a psychotropic drug; and a control group without psychiatric disorder. The percentages of patients having one or more consultation for physical illnesses were stable over the years studied, being roughly 90%, 85%, and 60% respectively. For groups identified in 1972 their patterns of consultation for physical illness were examined in 1957, 1962, and annually from 1967 to 1976. In every year studied except 1957 the group with a psychiatric disorder and a new prescription for a psychotropic drug exceeded both other groups in the percentage of patients having one or more consultations for physical illnesses. Both groups with psychiatric disorders had an excess of consultations over the control group; this excess halved in about four years for the group with a new prescription and in about one year for the group without a new prescription. Mental health care by general practitioners for patients with psychiatric disorders does not seem to have an offset effect on general health care of these patients.

A study of the classification of mental ill-health in general practice

An outline is provided of an experimental study of the classification of mental ill-health presented to general practitioners (GPs). Videotaped real-life consultations were assessed by 27 GPs for the purpose. A high degree of inter-observer variation was recorded. Some of the implications of the findings are discussed.

Does the use of low dose bupivacaine/opioid epidural infusion increase the normal delivery rate?

To investigate whether using low dose epidural infusion improves the normal delivery rate, outcome of labour was studied in women with singleton vertex presentations randomised to receive either 0.0625% bupivacaine opioid, or plain bupivacaine 0.125% for labour. The infusion rate was titrated to maintain analgesia and a sensory level to T10. Data were analysed using the unpaired t test, Mann-Whitney U test and for categorical variables chi2 test. Adjusted odds ratios for factors significantly associated with non-normal delivery were calculated using stepwise logistic regression. There were 291 women in the low dose and 296 in the plain bupivacaine group. There were no significant differences between groups in parity, race, induction of labour, use of augmentation, cervical dilatation at epidural insertion, duration of any stage of labour or duration or volume of infusion. Total dose of bupivacaine (126 +/- 47 mg versus 91 +/- 32 mg) and the proportion of women with motor block at the end of labour (45% versus 27%) were significantly greater in the plain bupivacaine than in the low dose group (P < 0.0001). The adjusted odds ratios (95% CI) for factors significantly associated with non-normal delivery were primiparity: 4.68 (2.78-7.88), older maternal age: 1.1 (1.05-1.14), longer active second stage of labour: 1.01 (1.005-1.017), total bupivacaine dose: 1.01 (1.005-1.016) and greater cervical dilatation at epidural insertion 1.22 (1.08-1.37). Treatment group and motor block at the end of labour had no significant effect. We found no increase in normal delivery rate with low dose infusions.

Identifying under-performing surgeons

OBJECTIVE

To estimate the likelihood of poor surgical results being explained by chance rather than under-performance.

METHODS

The 30-day mortality rates after radical cystectomy for bladder cancer were analysed theoretically. Surgical competence was defined as a mortality rate of 4%, excellence as 2% and under-performance as 8%, 12%, 20% or 40%. Four scenarios were explored for surgeons of different competence: first, the sample size required to show that a given level of under-performance is very unlikely to be due to chance; second, the likelihood of two or more consecutive deaths in a series of cases; third, the likelihood of clustering of deaths, defined as two deaths in five or in 10 cases; and last, the likelihood of outstanding surgical results (i.e. no deaths) being achieved in small cohorts by surgeons of differing competence.

RESULTS

For surgeons with a mortality rate of 8%, 12%, 20% or 40%, the sample sizes needed to prove under-performance are 211, 65, 21 and seven, respectively. For consecutive deaths, 0.4% of excellent, 1.4% of competent and 21% of surgeons with a mortality rate of 12% will experience two or more consecutive deaths in the next 10 cases. For clustered deaths, 1% of excellent, 5% of competent and 23% of seriously under-performing surgeons (mortality rates > or = 12%) will experience two deaths in their next 10 cases. Lastly, for the likelihood of outstanding results, only 3.6% of surgeons with an 8% mortality rate and < 1% of surgeons with a mortality rate > or = 12% will experience no deaths over 40 consecutive cases.

CONCLUSIONS

Very large cohorts are needed to confirm even significant under-performance. Consecutive deaths are very unlikely events for competent surgeons. Clustered deaths (two deaths in 10 cases) are very unlikely events for excellent surgeons but plausible for competent ones. Analysis of consecutive/clustered deaths is limited by low statistical sensitivity; only up to a quarter of seriously under-performing surgeons are identified. No deaths in 40 consecutive cases implies competence.

A chest pain score for stratifying the risk of coronary artery disease in patients having day case coronary angiography

'Typical' or 'atypical' are universally used descriptions of chest pain, but they are limited by subjectivity. This study tested the ability of a semi-objective chest pain score to predict the likelihood of coronary disease. A chest pain questionnaire was given to 250 patients with stable chest pain attending coronary angiography. The answers to three questions were defined as 'typical' or 'atypical' and summed to give a 'typical' score between 0 and 3. Logit analysis was performed based on an age cut-off of 55 years and 'typical' score. There were 96 (38%) patients with normal coronary arteries and 154 (62%) with coronary disease. In patients aged under 55 years, the likelihood of coronary disease by 'typical' score was 11% (score 0), 30% (score 1), 40% (score 2), 53% (score 3). Similar figures for age 55 years were 39% (score 0), 45% (score 1), 77% (score 2), and 85% (score 3). There is a direct relationship between 'typical' chest pain score and the likelihood of coronary artery disease. This scoring system may be useful in the clinical characterization of patients for research, for guiding referral to a cardiologist or for aiding the decision to perform coronary angiography.

A longitudinal study of general practitioner consultations for psychiatric disorders in adolescence

Patterns of psychiatric diagnoses given during adolescence to a group of individuals continuously registered with a single general practitioner in South London over 20 years were analysed first during 'early adolescence' and secondly during 'early adulthood'. Psychiatric diagnoses were found to be relatively common. Of the young adolescents who received a psychiatric diagnosis (almost one in ten of the group), 38% received a psychiatric diagnosis as young adults compared with only 16% of the remainder. Comorbidity was found to be very common--over 50% of young adults with a diagnosis of depression also had a diagnosis of anxiety and phobic neuroses. Young people with problems of a psychological nature therefore deserve more attention, particularly from the primary care team.

The identification of clustering in parasuicide

A straightforward test for detecting clustering in patterns of parasuicide in individual patients is described and applied to data from the Edinburgh Regional Poisoning Treatment Centre.

Is there a relationship between a mother's mental state and consulting the doctor by the family? A study in a military general practice

A total of 174 families of service personnel with children between 3 and 6 years of age were studied over a 6 month period. All contacts with the general practitioner, both in and out of hours together with the local casualty department were recorded. Mothers of the children were posted a specially designed questionnaire to measure how seriously they perceived various childhood symptoms to be and a copy of the general health questionnaire, 28 question version (GHQ 28). The perceived severity questionnaire had been piloted previously in a neighbouring practice. The overall response rate was 77%. Analyses of the data showed that the factors most significantly associated with a child's consultation frequency were the psychological state of the mother, the mother's own consultation frequency and the number of children in the family; the last being an inverse relationship. No evidence was found to suggest that the perception of the severity of illness varied with the psychological state of the mother. In addition, the childhood consultation rate was not influenced by the mother's perception of the severity of childhood illness as measured by the perceived severity questionnaire. Other factors such as the age of the mother or child, within the age range studied, were not found to be significantly related to the child's frequency of consulting. A mother's own consultation frequency was highly correlated with her GHQ 28 score, but more specifically with the subsections that scored for depression and somatic symptoms. From the study, doctors who see children should seriously consider the main reasons for a child's consultation.(ABSTRACT TRUNCATED AT 250 WORDS)

Long axis excursion in aortic stenosis

OBJECTIVES

To examine long axis excursion in patients with all grades of aortic stenosis and preserved transverse systolic function, and to compare long axis excursion in symptomatic with that in asymptomatic severe aortic stenosis.

DESIGN

Prospective comparative study.

SETTING

Regional cardiothoracic centre.

PATIENTS

78 patients with all grades of aortic stenosis and normal fractional shortening and ejection fraction were studied. There were two comparison groups, 10 age matched normal subjects and 14 patients with aortic stenosis and fractional shortening < 26%.

METHODS

Aortic valve function and left ventricular mass were assessed echocardiographically. M mode measurements of long axis excursion at the septal and lateral sides of the mitral annulus were taken.

RESULTS

There were significant differences between the groups in long axis excursion at both the septal (p < 0.0001) and lateral sides of the mitral annulus (p = 0.002 by analysis of variance). Long axis excursion was independently related to both left ventricular mass index (p = 0.001) and the grade of aortic stenosis (p = 0.002). Comparing patients with severe aortic stenosis with and without symptoms, there were significant differences in effective orifice area (p = 0.02 ) and long axis excursion at the lateral side of the mitral annulus (p = 0.04), but not in fractional shortening, ejection fraction, or peak or mean pressure difference.

CONCLUSION

In patients with aortic stenosis, long axis excursion is reduced even in the presence of normal fractional shortening or ejection fraction. It is lower in patients with symptomatic compared with asymptomatic severe aortic stenosis and may be of use in predicting the onset of symptoms.