The histories of exposure to sun through occupational, recreational and vacation activities of 595 patients with newly incident cutaneous melanoma excluding lentigo maligna and acral lentiginous melanoma, were compared to those of comparison subjects drawn randomly from the same population and matched for age, sex and province of residence in Western Canada. Significant increases in risk were seen with increasing amount of sun exposure through outdoor activities associated with recreation and vacations; activities likely to involve more intense sun exposure were associated with greater increases in risk. While a moderate amount of occupational exposure was associated with increased risk, greater occupational exposure resulted in no further increase; in men a decrease in risk was seen. These findings were independent of the effects of hair and skin colour, freckles, ethnic origin and socio-economic status. The results suggest that short-term exposure to unusually intense sunlight increases the risk of melanoma, while long-term constant exposure has no effect or may decrease risk. No simple relationship was seen between melanoma risk and total sunlight exposure. This study introduces new methods of assessing different types of sun exposure from retrospective data.

A case-control study of 374 patients with primary epithelial cancers of the oral cavity, oro- and hypopharynx, and larynx is reported, the controls being patients with selected other cancers, matched for age and sex. Of all eligible patients, 93% were interviewed. Increased risks were seen with alcohol consumption and, less strongly, with smoking, which for all sites could be adequately fitted by either a multiplicative or an additive model. However, the site-specific relationships were different, alcohol consumption being significantly associated only with oral cavity, pharyngeal and extrinsic laryngeal tumours, and smoking only with intrinsic laryngeal tumours. Increased risks were associated with low socio-economic status, the unmarried state, and poor dental care. No significant associations were seen with specific occupational exposures.

9 Bell GI, Karam JH. The polymorphic locus flanking the human insulin gene: is there an association with diabetes mellitus? In: Banbury report 14: applications of recombinant DNA in humnan disease. Cold Spring Harbor: Cold Spring Harbor Press (in press). 10 Owerbach D, Nerup J. Restriction fragment length polymorphism of the insulin gene in diabetes mellitus. Diabetes 1982;31:275-7. Rotwein PS, Chirgwin J, Province M, et al. Polymorphism in the 5'-flanking region of the human insulin gene: a genetic marker for non-insulin dependent diabetes. N EnglJ Med 1983;308:65-71. 12 Ullrich A, Dull TJ, Gray A, Philips JA, Peter S. Variation in the sequence and modification state of the human insulin gene flanking regions. Nucleic Acids Res 1982;10:2225-40. 31 WHO Expert Committee on Diabetes Mellitus. Second report. WHO Tech Rep Ser 1980;No 646. 14 Kunkel LM, Smith KD, Boyer SH, et al. Analysis of human Y chromosome specific reiterated DNA in chromosome variants. Proc Natl Acad Sci USA 1977;74:1245-9. 5 Southern EM. Detection of specific sequences among DNA fragments separated by gel electrophoresis.

A retrospective study of hearing in a female population exposed to weaving noise is described. The noise is believed to have remained substantially unaltered over periods of exposure ranging from less than 1-52 years. The deterioration of hearing due to noise has been assumed to be estimated by the difference between the recorded hearing level and the expected hearing level from other published presybcusis data. Patterns of deterioration of hearing are described for various audiometric frequencies. The most conspicuous feature is an initial deterioration in the first 10-15 years of exposure, followed by a period of about 10 years where deterioration attributable to noise is small. Thereafter, after 20-25 years of exposure, further deterioration occurs, especially marked at 2000 cps. The possible distribution of noise-induced threshold changes is briefly considered.

The general good health of varicose vein patients may justify the low priority given to their treatment, but the improvement in symptoms and general health that relatively simple surgery provides should ensure its continued provision as a health care service.

BackgroundIn response to long waiting lists and problems with access to primary care physiotherapy, several Primary Care Trusts (PCTs) (now Clinical Commissioning Groups CCGs) developed physiotherapy-led telephone assessment and treatment services. The Medical Research Council (MRC) funded PhysioDirect trial was a randomised control trial (RCT) in four PCTs, with a total of 2252 patients that compared this approach with usual physiotherapy care. This nested qualitative study aimed to explore the acceptability of the PhysioDirect telephone assessment and advice service to patients with musculoskeletal conditions.MethodsWe conducted 57 semi-structured interviews with adults from 4 PCTs who were referred from general practice to physiotherapy with musculoskeletal conditions and were participating in the PhysioDirect trial. The Framework method was used to analyse the qualitative data.ResultsThe PhysioDirect service was largely viewed as acceptable although some saw it as a first step to subsequent face-to-face physiotherapy. Most participants found accessing the PhysioDirect service straightforward and smooth, and they valued the faster access to physiotherapy advice offered by the telephone service. Participants generally viewed both the PhysioDirect service and the physiotherapists providing the service as helpful. Participants’ preferences and priorities for treatment defined the acceptable features of PhysioDirect but the acceptable features were traded off against less acceptable features. Some participants felt that the PhysioDirect service was impersonal and impaired the development of a good relationship with their physiotherapist, which made the service feel remote and less valuable.ConclusionThe PhysioDirect service was broadly acceptable to participants since it provided faster access to physiotherapy advice for their musculoskeletal conditions. Participants felt that it is best placed as one method of accessing physiotherapy services, in addition to, rather than as a replacement for, more traditional face-to-face physiotherapy assessment and treatment.

This report should be referenced as follows: Salisbury C, Foster NE, Hopper C, Bishop A, Hollinghurst S, Coast J, et al. A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of 'PhysioDirect' telephone assessment and advice services for physiotherapy. Health Technol Assess 2013;17(2). This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (http://www.publicationethics.org/). Health Technology Assessment is indexed and abstracted inEditorial contact: nihredit@southampton.ac.ukThe full HTA archive is freely available to view online at http://www.hta.ac.uk/project/htapubs.asp. Print copies can be purchased from the individual report pages. Criteria for inclusion in the Health Technology Assessment journalReports are published in Health Technology Assessment (HTA) if (1) they have resulted from work for the HTA programme or, originally commissioned by the Medical Research Council (MRC) and now managed by the Efficacy and Mechanism Evaluation programme which is funded by the MRC and NIHR, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors.Reviews in Health Technology Assessment are termed 'systematic' when the account of the search appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others. HTA programmeThe HTA programme, part of the National Institute for Health Research (NIHR), was set up in 1993. It produces high-quality research information on the effectiveness, costs and broader impact of health technologies for those who use, manage and provide care in the NHS. 'Health technologies' are broadly defined as all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care.The research findings from the HTA programme directly influence decision-making bodies such as the National Institute for Health and Clinical Excellence (NICE) and the National Screening Committee (NSC). HTA programme findings also help to improve the quality of clinical practice in the NHS indirectly in that they form a key component of the 'National Knowledge Service'.For more information about the HTA programme please visit the website: http://www.hta.ac.uk/ This reportThis issue of Health Technology Assessment contains a project originally commissioned by the MRC but managed by the Efficacy and Mechanism Evaluation Programme. The EME programme was created as part of the National Institute for Health Research (NIHR) and the Medical Research Council (MRC) coordinated strategy for clinical trials. The EME programme is funded by the MRC and NIHR, with contributions from the CSO in Scotland and NISCHR in Wales and the HSC R&D, Public Health Agency in Northern Ireland. It is managed by the NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC) based at the University of Southampton.The authors have been wholly responsible for all data collection, analysis and interpretation, and for w...

Alcohol use and depression negatively impact adherence, retention in care, and HIV progression, and people living with HIV (PLWH) have disproportionately higher depression rates. In developing countries, more than 76% of people with mental health issues receive no treatment. We hypothesized that stepped-care mental health/HIV integration provided by multiple service professionals in Zimbabwe would be acceptable and feasible. A three-phase mixed-method design was used with a longitudinal cohort of 325 nurses, community health workers, and traditional medicine practitioners in nine communities. During Phase 3, 312 PLWH were screened by nurses for mental health symptoms; 28% were positive. Of 59 PLWH screened for harmful alcohol and substance use, 36% were positive. Community health workers and traditional medicine practitioners screened 123 PLWH; 54% were positive for mental health symptoms and 29% were positive for alcohol and substance abuse. Findings indicated that stepped-care was acceptable and feasible for all provider types.