SummaryPostmortem examination offive institutionalised patients with Down's syndrome (DS) aged 40-66 years showed a complete absence of atheroma, while a similar number of mental defectives without DS were found to have mild or severe atheroma. Previous investigation of risk factors for atheroma in 70 patients with DS and 70 ageand sex-matched mental defectives living in the same institution showed significantly lower systolic and diastolic blood pressures in the DS group, with the exception of systolic pressure in men under 40. Fasting serum cholesterol and triglyceride concentrations were similar in the two groups, but triglyceride concentrations were significantly lower than in normal people without a history of vascular disease. These unexplained observations may be relevant in further studies of the pathogenesis of atheroma.

Study objective -Seasonality of coronary heart disease (CHD) was examined to determine whether fatal and non-fatal disease have the same annual rhythm. Design -Time series analysis was carried out on retrospective data over a 10 year period and analysed by age groups (<45 to >75 years) and gender. (under 45 years) admitted to hospital there was a dominant spring peak and an autumn trough. A bimodal pattern of spring and winter peaks was evident for hospital admissions in older male age groups: with increasing age the spring peak diminished and the winter peak increased. In contrast, female hospital admissions showed a dominant winter/summer pattern of seasonal variation. In male and female CHD deaths seasonal variation showed a dominant pattern of winter peaks and summer troughs, with the winter peak spreading into spring in the two youngest male age groups. CHD incidence in women showed a winter/summer rhythm, but in men the spring peak was dominant up to the age of 55. Conclusions -The male, age related spring peak in CHD hospital admissions suggests there is an androgenic risk factor for myocardial infarction operating through an unknown effector mechanism. As age advances and reproduction becomes less important, the well defined winter/summer pattern of seasonal variation in CHD is superimposed, and shows a close relationship with the environment, especially temperature, or the autumn and early winter fall in temperature. (J Epidemiol Community Health 1995;49:575-582) Studies of seasonal variation in coronary heart disease (CHD) are almost entirely based on data derived from national registers of deaths. Studies based on seasonal variation of CHD hospital admissions are few. Dunnigan et all found a bimodal pattern of seasonal variation with spring and winter peaks in a study of 47 281 admissions to all Scottish hospitals in 1962-66 in the diagnostic category ICD 420

The nature of the disorder in patients with familial lipodystrophy usually escapes recognition for many years and the syndrome is almost certainly much commoner than the few families described to date suggest.Before the description of the syndrome which forms the subject of the present communication, three clinical syndromes were recognised which share as their common distinguishing feature the partial or total absence of subcutaneous fat (lipoatrophy or lipodystrophy). In progressive ,partial lipodystrophy (Barraquer-Simon syndrome' ) fat is lost from the face and, in most cases, from the trunk with normal or excessive fat deposition on the pelvic girdle and lower limbs. Most affected subjects are female and show no other abnormality; a minority develop glomerulonephritis, diabetes, or hyperlipidaemia. The condition is usually sporadic. Seip3 and Berardinelli4 described congenital lipodystrophy in which total loss of subcutaneous fat was noted

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Patients with intellectual disability and neurological handicaps associated with swallowing difficulties are vulnerable to dehydration and undernutrition. Some patients are severely undernourished, a condition which is usually associated with recurrent food aspiration and respiratory infections. Underweight patients are usually provided with adequate dietary protein by carers: their low energy intakes reflect inadequate intakes of fat and carbohydrate. Many patients gain weight following the provision of easily assimilated energy-dense fat- and sugar-containing foods. Where these measures fail, the provision of a percutaneous endoscopic gastrostomy (PEG) tube may be life-saving. Optimal supervision of patients with severe nutrition/dysphagia problems requires a support network linking carers at home or in community care facilities with the primary health care team and the local district general hospital.

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