Objective -To review available evidence on the problems facing rural health care in the UK. In particular, to determine whether the health of rural populations is worse than that of town dwellers and how the quality of health care is influenced by rurality. Criteria for inclusion and exclusion of articles -A wide variety of publications and data sources were used. A number of computerised databases with different specialisations (for example medical, health care management) were used to identify relevant published articles. In addition, reports, reviews, and surveys produced by agencies for local circulation were identified by approaching academic, service, and voluntary bodies thought likely to have an interest in rural health. Although this "grey" literature is not subject to peer review, the relative lack of relevant UK publications made it a useful data source for illustrative purposes. Similarly, published articles based on rural health in other developed countries were used when UK data were lacking. Conclusions -Although the evidence concerning the health and health care of the UK rural populations is suggestive, it is very general and further research is needed. Levels of urban health seem to be generally worse than in rural areas, but contradictions do exist. The evidence on quality of care suggests that service accessibility is a central problem, and rural populations have poorer access than others. Within rural populations, such disadvantage is not uniformly experienced -it affects some groups more than others. In addition, the NHS does not seem to have a consistent policy about whether rurality should influence resource allocation, and how it should be incorporated. (J Epidemiol Community Health 1994;48:16-21) While the health and health care of rural populations are seen as specific concerns in many other developed and developing countries,1 concern in Britain has focused mainly on the problems of towns.2
The diagnosis of Whipple's disease in the absence of intestinal involvement is difficult and often overlooked. We describe five patients aged 8-71 years with normal jejunal biopsies and disparate clinical features, previously unrecognized in Whipple's; all were investigated at a single institution over a period of 18 months. Routine histological examination for periodic acid-Schiff (PAS) positive macrophages and polymerase chain reaction (PCR) analysis for Tropheryma whippelii was performed on the small intestine in all patients. PCR analysis was also performed on various tissues including peripheral blood, lymph node, muscle, synovium and spleen in individual patients. Patients 1, 2, 4 and 5 had unusual presenting features not previously associated with Whipple's: intractable immune thrombocytopenic purpura (ITP), juvenile chronic arthritis, isolated muscle weakness and quadriparesis, respectively. Patient 3 presented with pyrexia of unknown origin. All patients had histologically normal small-bowel biopsies with no evidence of PAS positive macrophages. PCR for T. whippelii was positive in all patients in one or more tissues: peripheral blood, intestine, muscle, lymph node and synovium. PAS-positive macrophages were found in 4/5 patients in various sites: lymph node, muscle, spinal cord. Whipple's disease presents with protean clinical features and should be considered in granulomatous disorders of unknown aetiology even in the absence of gastrointestinal involvement.
The usefulness of proliferation marker MIB1 in predicting recurrences in cranial meningiomas when other clinical and pathological factors are considered was assessed. Data from 65 patients with meningiomas were analysed and their clinical notes reviewed to define the Simpson grade of surgical excision, the location of tumour, amongst other clinical factors. The diagnosis was reviewed; immunohistochemical staining for a proliferation marker MIB1 was carried out on archival formalin-fixed, paraffin-embedded tumour and a labelling index for MIB1 (MIB1 L1) calculated. Analysis was undertaken of the impact of histology, grade of excision, tumour location and proliferation index on the risk of recurrence. The grade of surgical resection and histology type were the most important factors likely to predict recurrence. MIB1 LI was not considered useful in predicting tumour recurrence.
Mast cells are closely associated with nerves in the mucosa of the appendix vermiformis, and obliteration of the appendiceal lumen by fibrous tissue is accompanied by neurogenous hyperplasia. However, changes in the density of mast cells in this process have not been reported. Accordingly, fibrosis was graded in haematoxylin and eosin sections from 46 samples of human appendix. This was compared with mast cell number in toluidine blue-stained slides and nerve density in PGP9.5-immunoreactive sections. In the mucosa, the mast cell number in the samples with minimal fibrosis was three times greater than in those classified as normal (P less than 0.0001), and this declined in the more fibrotic samples. The mucosal nerve scores paralleled the mucosal mast cell changes, and stereological analysis revealed a correlation of mast cell number and nerve density within the lamina propria of the same specimens (r = 0.49-0.90). In the submucosa, mast cell numbers and nerve scores were not significantly different in the different histological grades and obliterated samples resembled normal submucosa, except that a dense axial block of nerve staining was often present. The progressive fibrotic changes in appendices provide a human model for studying the relationships of nerves, mast cells, and fibrosis in the gastrointestinal tract.
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