The NHS White paper (The new NHS modern dependable) was published in December 1997. This strategic document, endorsed by a new Government, promotes integrated care, national standards of care and easier and swifter access to the NHS, in a ten year programme which proposes that local doctors and nurses will shape local primary and secondary care services. The opinions of a small group of General Practitioners were surveyed from a structured questionnaire as part of a seminar / discussion session. The GPs' knowledge and views of the White Paper were obtained, together with data on their own practices' clinical performance, their priorities and their use of information. The differences between their views and experience and the national strategy identify constraints to change in the extent of collaboration, of clinical consistency, and of information use. The findings are important because an effective national health strategy relies on full support from those whose work is affected, especially general practitioners, and these proposals will involve them in more planning and management than is currently the case. The currently little collaboration reported between GPs and other care agencies conflicts with the Government proposals. GPs also said that they did not use information much in planning and delivering services. They were not confident in accessing, analysing and understanding information, and felt that there was insufficient relevant information to help them plan and deliver services to major patient care groups. It is hoped that exposure to, and support with, information management methods should increase the amount of shared relevant information, and the use to which it is put. GPs' current focus on their individual practice, rather than on the envisaged larger, multiprofessional PCGs, may limit the preparation of agreed rational plans and the introduction of effective collaboration.

In the present study, we attempted to replicate the finding of an increased frequency of HLA-A2 in men with early-onset (less-than-or-equal-to 60 years) Alzheimer disease (AD). HLA data obtained on 167 patients (including 19 men with early-onset AD) from three geographic regions (North Carolina. Great Britain, and Finland) failed to replicate the result. A recent prospective study from Oregon, however, confirmed the association. Studies demonstrating the association suggest its presence in sporadic rather than familial AD. These results indicate a variable HLA/AD association, with some factor such as geographic region or disease familiality contributing to this variability.

AN epidemiological study of injury and poisoning deaths has revealed differing patterns of mortality in the regional health authorities of England and the district health authorities of Yorkshire. The implica tions of these findings for health promotion are explored, and it is concluded that the identification and monitoring of local patterns of mortality are essential in any campaign to reduce deaths from injury and poisoning, if limited resources are to be used efficiently and effectively.

Synopsis The case histories of the patients newly admitted to the Retreat Asylum in York between 1880–1884 were examined. Most patients were aged under 50 years, single and non-Quaker, and a majority satisfied the Research Diagnostic Criteria for a diagnosis of schizophrenia or affective disorder. It was found that 72·9% of the patients were deluded, the most common delusions being of persecution, grandeur and guilt; in 34·9% of the deluded patients, the delusion had a religious content. Suicidal ideation was recorded in the case records of 31·4% of the patients. Drug therapy was commonly prescribed, a history of assault on other patients or asylum staff was recorded in 38·1% of the patients, and 11% of patients were force fed at some stage during their illness. Within a year of admission 49·1% of the patients were discharged, the prognosis being better for patients with an affective illness than for schizophrenia, but 31·4% remained in the asylum for five or more years. The characteristics, alleged causes of mental illness, and treatment and outcome of the Retreat patients were compared with those of patients admitted during the same period to the two other York asylums which served different socio-economic groups of the population. Mortality rates were higher in the asylum admitting mainly pauper patients, and possible reasons for this are explored.

Currently, resources for acute mental illness services are allocated on the basis of the age, sex and marital status profiles of the catchment population. However, it has been argued (Hirsch, 1988) that mental illness budgets and bed provision should also be weighted according to the socio-demographic characteristics of the local population.

The geographical distributions and causes of deaths occurring in Leeds residents aged 15–64, during 1985 and 1986, were studied. The results were used to construct an epidemiological map showing the standardised mortality ratios (SMRs) for males and females in each postal district. SMRs ranged from 67 to 171 in men and from 63 to 157 in women, and high SMRs were not confined to postal districts covering inner city areas. Potentially avoidable deaths accounted for 57.6% of the male and 36.9% of the female deaths, and some postal districts had three times the proportion of avoidable deaths than others. Although no firm conclusions can be drawn from the results of a single study, the wide variations in mortality observed point to a need for health education to reduce such disparities. It is suggested that the compilation of an epidemiological map to show the distribution and nature of premature deaths within a health district, is a useful first step in planning a local health promotion campaign, which can be updated annually to identify temporal trends.

The use of electricity in British psychiatry during the second half of the 19th century is examined. An account is given of the clinical and theoretical aspects of electrical therapy. Factors leading to its use and eventual decline are considered.

Serum antibody titres to Adenovirus, Chlamydia Group B, Coxiella burnettii, Cytomegalovirus, Herpes simplex virus, Influenza A, Influenza B, Measles and Mycoplasma pneumoniae were measured in 33 patients with a clinical diagnosis of Alzheimer's disease, and in 28 non-demented controls suffering from functional psychiatric disorders. No statistically significant differences were found between the patients and controls, and it is concluded that these agents play no role in the aetiology of Alzheimer's disease.

The case of an 82-year-old woman with delusional infestation and senile dementia of the Alzheimer type is reported. Her symptoms of infestation ceased dramatically with pimozide given for 5 weeks, and did not recur during follow-up over 9 months. The importance of organic factors in patients with this disorder is emphasised.

A case of folie à deux in a 29 year-old man with Down's syndrome, whose mother had a paranoid psychosis, is described. Successful treatment of the mother's illness also resulted in full recovery of the son without the need for medication.

In genetically proven identical female twins, discordant for presenile dementia of the Alzheimer type, the affected twin began to dement at the age of 49, and died 15 years later; the diagnosis was confirmed at post-mortem. The surviving twin remains clinically unaffected 20 years after the onset of dementia in her sister. Environmental aetiological factors are postulated to account for this discordance.

measures aimed at bringing the hospital medical staffing structure into balance over the next 10 earss' This initiative has been endorsed by the Central Committee for Hospital Medical Services and the Hospital Junior StaffCommittee. If the proposals are agreed implementation will start on 1 January 1987 and will result in major changes to the junior hospital doctors' career structure. This study reports the views on the proposals of junior hospital medical staff working in a teaching district. As the document

Dr MARK HARRIES (Northwick Park Hospital and Clinical Research Centre, Harrow, Middlesex HAl 3UJ) writes: Drs G A R Morgan and R J Winter (9 August, p 395) make an important point which deserves highlighting. Fracture dislocation of the cervical spine complicating near drowning is a rare event in Britain but is seen more commonly in Australia, where body surfing is a popular sport. The advice given to rescuers in Britain is that any unconscious patient found in standing depth water should be handled as though he or she had suffered fracture dislocation of the neck. It is possible on occasions to ventilate adequately without extending the neck, but if this is not the case then the rescuer has no alternative but to tilt the head back.

ABO and rhesus (Rh) blood groups were examined in 124 patients with presenile dementia of the Alzheimer type (PDAT) and senile dementia of the Alzheimer type (SDAT), and their distribution was compared with controls. No significant associations between these blood groups and Alzheimer's disease (AD) were found after statistical correction for multiple comparisons.

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Serum antibody titres to cytomegalovirus (CMV) were measured in 113 patients with Alzheimer's disease (AD), and 39 non-demented controls suffering from chronic functional psychoses. AD patients and controls had similar CMV antibody titres, and conventional CMV activity was not detected in post-mortem samples from eight AD patients. It is therefore unlikely that the CMV play any causal role in most cases of AD. The possession of the histocompatibility antigen HLA-B15 was significantly correlated with raised levels of CMV antibody in the AD patients, which suggests that HLA-B15 may be associated with an enhanced immune response to CMV.

Synopsis Histocompatibility antigens were examined in 124 patients with Alzheimer's disease (AD), and the frequency of HLA-B15 was found to be significantly increased over controls. Pooling of data from the present and similar studies suggests that AD is not strongly associated with any particular HLA antigen, although there may be a weak association with HLA-A2, B15 and Cw3. In a family study of 34 patients with AD, secondary cases of AD were identified in 9·7% of the first-degree relatives, and cases of presenile dementia and senile dementia of the Alzheimer type were found to occur within individual families.