Incidence and viral aetiologies of acute respiratory illnesses (ARIs) in the United States: a population-based study.

We conducted prospective, community-wide surveillance for acute respiratory illnesses (ARIs) in Rochester, NY and Marshfield, WI during a 3-month period in winter 2011. We estimated the incidence of ARIs in each community, tested for viruses, and determined the proportion of ARIs associated with healthcare visits. We used a rolling cross-sectional design to sample participants, conducted telephone interviews to assess ARI symptoms (defined as a current illness with feverishness or cough within the past 7 days), collected nasal/throat swabs to identify viruses, and extracted healthcare utilization from outpatient/inpatient records. Of 6492 individuals, 321 reported an ARI within 7 days (4·9% total, 5·7% in Rochester, 4·4% in Marshfield); swabs were collected from 208 subjects. The cumulative ARI incidence for the entire 3-month period was 52% in Rochester [95% confidence interval (CI) 42-63] and 35% in Marshfield (95% CI 28-42). A specific virus was identified in 39% of specimens: human coronavirus (13% of samples), rhinovirus (12%), RSV (7%), influenza virus (4%), human metapneumovirus (4%), and adenovirus (1%). Only 39/200 (20%) had a healthcare visit (2/9 individuals with influenza). ARI incidence was ~5% per week during winter.

Monitoring the occurrence of wound infections after cardiac surgery.

The aim of this study was to demonstrate the use of a graphical method for real-time monitoring of the occurrence of surgical wound infection following cardiac surgery. This included developing and incorporating a risk scoring system so that variations in case-mix could be duly accounted for in the monitoring process. We analysed routinely collected data from a London teaching hospital. These data consisted of records for 2146 patients who had undergone cardiac surgery between April 2000 and March 2004 and whose surgical wounds were followed up as part of the local surveillance programme. The risk model was developed using logistic regression analysis with surgical wound infection diagnosed before hospital discharge as the outcome measure. Factors included in the model were the number of surgical wounds, patient age, operations that combined bypass surgery and valve replacement, renal disease and the number of days between hospital admission and surgery. The model was a good predictor of outcomes recorded within an independent data set (Chi-squared=3.81, P=0.58) and we incorporated it into a graphical tool for monitoring outcomes. The risk model and the associated graphical monitoring method could be valuable tools to assist with infection management. If used in real-time, problems with the care process can be quickly identified allowing timely remedial action to be taken.

Is hydrotherapy cost-effective? A randomised controlled trial of combined hydrotherapy programmes compared with physiotherapy land techniques in children with juvenile idiopathic arthritis.

OBJECTIVES: To compare the effects of combined hydrotherapy and land-based physiotherapy (combined) with land-based physiotherapy only (land) on cost, health-related quality of life (HRQoL) and outcome of disease in children with juvenile idiopathic arthritis (JIA). Also to determine the cost-effectiveness of combined hydrotherapy and land-based physiotherapy in JIA. DESIGN: A multicentre randomised controlled, partially blinded trial was designed with 100 patients in a control arm receiving land-based physiotherapy only (land group) and 100 patients in an intervention arm receiving a combination of hydrotherapy and land-based physiotherapy (combined group). SETTING: Three tertiary centres in the UK. PARTICIPANTS: Patients aged 4-19 years diagnosed more than 3 months with idiopathic arthritides, onset before their 16th birthday, stable on medication with at least one active joint. INTERVENTIONS: Patients in the combined and land groups received 16 1-hour treatment sessions over 2 weeks followed by local physiotherapy attendances for 2 months. MAIN OUTCOME MEASURES: Disease improvement defined as a decrease of > or =30% in any three of six core set variables without there being a 30% increase in more than one of the remaining three variables was used as the primary outcome measure and assessed at 2 months following completion of intervention. Health services resource use (in- and outpatient care, GP visits, drugs, interventions, and investigations) and productivity costs (parents' time away from paid work) were collected at 6 months follow-up. HRQoL was measured at baseline and 2 and 6 months following intervention using the EQ-5D, and quality-adjusted life-years (QALYs) were calculated. Secondary outcome measures at 2 and 6 months included cardiovascular fitness, pain, isometric muscle strength and patient satisfaction. RESULTS: Seventy-eight patients were recruited into the trial and received treatment. Two months after intervention 47% patients in the combined group and 61% patients in the land group had improved disease with 11 and 5% with worsened disease, respectively. The analysis showed no significant differences in mean costs and QALYs between the two groups. The combined group had slightly lower mean costs (-6.91 pounds Sterling) and lower mean QALYs (-0.0478, 95% confidence interval -0.11294 to 0.0163 based on 1000 bootstrap replications). All secondary measures demonstrated a mean improvement in both groups, with the combined group showing greater improvements in physical aspects of HRQoL and cardiovascular fitness. CONCLUSIONS: JIA is a disease in which a cure is not available. This research demonstrates a beneficial effect from both combined hydrotherapy and land-based physiotherapy treatment and land-based physiotherapy treatment alone in JIA without any exacerbation of disease, indicating that treatments are safe. The caveat to the results of the cost-effectiveness and clinical efficacy analysis is that the restricted sample size could have prevented a true difference being detected between the groups. Nevertheless, there appears to be no evidence to justify the costs of building pools or initiating new services specifically for use in this disease. However, this conclusion may not apply to patients with unremitting active disease who could not be entered into the trial because of specified exclusion criteria. For this group, hydrotherapy or combined treatment may still be the only physiotherapy option. Further research is suggested into: the investigation and development of appropriate and sensitive outcome measures for use in future hydrotherapy and physiotherapy trials of JIA; preliminary studies of methodologies in complex interventions such as physiotherapy and hydrotherapy to improve recruitment and ensure protocol is acceptable to patients and carers; hydrotherapy in the most common paediatric user group, children with neurological dysfunction, ensuring appropriate outcome measures are available and methodologies previously tried; patient satisfaction and compliance in land-based physiotherapy and hydrotherapy and European studies of hydrotherapy in rare disorders such as JIA.

Patient progress modelling for small cell lung cancer.

This paper describes the use of a mathematical technique called Patient Progress Modelling to reassess the results of an MRC trial on small cell lung cancer. The trial concerned patients treated initially with chemotherapy and radiotherapy and achieving at least a partial response. It compared the effects of giving maintenance chemotherapy with those of giving no maintenance therapy. The results of the MRC trial established that there was no significant survival difference between the two groups overall. However, it was observed that amongst patients achieving a complete response, those receiving maintenance chemotherapy had a small survival time advantage. The analysis described here suggests the hypothesis that this can be accounted for by differences in the pattern of deaths after relapse. There appeared to be little difference in the disease-free period.

Cytological screening and management of abnormalities in prevention of cervical cancer: an overview with stochastic modelling.

AIMS: To develop a mathematical model of the histological changes of precancer and the development of invasive cancer and how these are related to cytological findings. To use this to investigate the effects on incidence of cervical cancer, number of smear tests and colposcopies, of different schedules for cervical screening, and the clinical management policies for dyskaryosis. METHODS: A stochastic model was developed relating the available data on tissue progression to the cytological findings. Two strategies, A and B, were compared: under A, women with any abnormal smear receive immediate colposcopy and treatment; under B, women with mild or borderline dyskaryosis have repeated smears at six monthly intervals with colposcopy only for persistent abnormalities. RESULTS: The model predicted an incidence of invasive cervical cancer in an unscreened population of women aged over 18 years of 5.9 per 10,000 per year. With 70% coverage and three yearly screening under strategy A, the incidence fell to 2.00 and under B to 2.10. The number of smears required was similar but A required two to three times as many colposcopies as B. Raising the coverage to 90% reduced the incidence to around 1 per 10,000 per year but changing the screening interval, the specificity or sensitivity of cytology had much less effect. CONCLUSION: The model has been tested under a wide range of possible variations in natural history, specificity and sensitivity of cytology. For low grade smear abnormalities, open colposcopic referral is predicted to reduce invasive cancer only slightly more than repeat cytology, at the expense of much additional colposcopy. Improving cytological coverage is suggested as more effective in reducing invasive cancer than increased use of colposcopy or more frequent screening.

Identification of fetal growth retardation: comparison of Doppler waveform indices and serial ultrasound measurements of abdominal circumference and fetal weight.

OBJECTIVE: To compare the serial ultrasound assessment of abdominal circumference (AC) and fetal weight versus single values of umbilical artery pulsatility index (PI) and the aortic-middle cerebral PI ratio in the identification of fetal growth retardation (FGR). METHODS: Serial AC measurements and estimates of weight were obtained in 104 small fetuses in the third trimester of pregnancy. These serial values (expressed as a change in standard deviation [SD] scores) were compared with the final value of AC and estimated fetal weight (EFW), umbilical artery PI, and the aortic-middle cerebral artery PI ratio (all expressed as SD scores) for their ability to predict a reduced neonatal ponderal index, mid-arm circumference-head circumference (HC) ratio, and skinfold thickness. Receiver-operating characteristic (ROC) curves were derived and the ultrasound measurements evaluated by calculating the areas under the ROC curves. RESULTS: Serial estimates of fetal weight resulted in a significantly larger area under the ROC curve compared with the final aortic-middle cerebral PI ratio in the prediction of an abnormal mid-arm circumference-HC ratio and compared with the final AC, EFW, and umbilical artery PI in the prediction of all neonatal morphometric indices. CONCLUSION: In small fetuses, fetal growth failure as determined by the serial assessment of AC and EFW was superior to the final AC and EFW, umbilical artery PI, and the aortic-middle cerebral PI ratio in the prediction of abnormal neonatal morphometry indicative of FGR.

Ultrasonic estimation of fetal weight: use of targeted formulas in small for gestational age fetuses.

OBJECTIVE: To derive a formula for calculating fetal weight in small for gestational age (SGA) fetuses and to determine prospectively whether the use of such a targeted formula reduces birth weight prediction errors. METHODS: Standard ultrasonic measurements were made in 159 SGA fetuses within 7 days of delivery. Three classes of fetal weight formulas (linear, quadratic, and cubic) were fitted to the data using stepwise regression analysis. Birth weight predictions using these three formulas were then compared prospectively with five previously reported formulas in 187 SGA fetuses. RESULTS: R2 was 0.97 for each of the three derived formulas. The 95% prediction intervals were comparable for the three formulas (eg, cubic model -11.6, 17.8%), and none were statistically superior to previous formulas. Each of the formulas evaluated prospectively had a systematic error and, with the exception of the present study's linear formula, all had percentage errors that varied systematically over the range of actual birth weights. CONCLUSION: Clinically useful birth weight predictions can be made in SGA fetuses, although no particular formula estimates birth weight significantly more accurately than any other.

Liver biopsy in the diagnosis of malignancy.

In a National Audit of 1500 liver biopsies, 38% were for suspected malignancy. To measure their contribution to clinical decisions, the initial diagnoses, biopsy diagnoses, final diagnoses, and outcomes were coded by computer and compared. Most patients (92%) were investigated for advanced malignancy. The accuracy of clinical diagnosis was 78% against final diagnosis. Liver biopsy was seen as 'confirming' clinical diagnosis overall. This was achieved in 67% (75% with ultrasound guidance), and specificity was almost 100%. However, hepatocellular cancer was confirmed by biopsy in only 32% and haematological malignancy in 13% of suspected cases. Within 3 months, 44% of patients with histological malignancy had died. Histological tumour type was not used in 36% of final diagnoses. Of patients with a malignancy-negative liver biopsy--showing reactive hepatitis, normality, or cholangitis/cholestasis--25%, 47% and 60%, respectively, had final malignant diagnoses. In 6% of patients, biopsy showed chronic liver disease. Only 12% of deaths were autopsied. Liver biopsy contributes very high specificity to the diagnosis of malignancy, and detects non-malignant disease. Failure to use tumour type may result in sub-optimal therapy. Improving diagnostic practice requires more information on outcomes, including autopsies.

Assessment of mortality rates for congenital heart defects and surgeons' performance.

BACKGROUND: In the absence of reliable national data, we have collected results of all operations for congenital heart defects from five departments to assess mortality rates and compare them among surgeons and departments. METHODS: Data relating to all operations (2,718) carried out at the five centers during a period from April 1, 1997 through March 31, 1999. Clearly defined criteria were agreed for the classification of patients into various subgroups. RESULTS: The overall hospital mortality was 4.4% (95% confidence intervals 3.7%-5.3%). Mortality for open-operations was 12.6% in neonates, 5.1% in infants, and 3.5% in children. Mortality rates were 1.1% for coarctation, 0.4% ventricular septal defect, 4.1% atrioventricular septal defect, 2.9% Fallot, 0.9% switch, and 15.6% truncus arteriosus. Although individual surgeons' mortality rates ranged from 1.8% to 7.5%, none of the 12 surgeons' data were above 95% confidence intervals. For individual surgeons, the change in mortality rates between the 2 years ranged between -3.3% and +3.8%. CONCLUSIONS: With 2 years' data available, estimates of mortality rates are more precise as reflected by tighter confidence intervals. There were relatively small data sets for individual hospitals and surgeons, which made statistical evaluation difficult. For setting standards, data from more departments for a longer period will be required. Statistical methods alone cannot be used as a sole arbiter of what is considered acceptable performance.

A health impact assessment model for environmental changes attributable to development projects.

STUDY OBJECTIVE: European Union legislation requires large industrial and civil development projects to undergo environmental impact assessment. The study objective was to identify environmental health risk estimates for these developments from the epidemiological literature and to develop, and apply these within, a mathematical health impact assessment model. DESIGN AND RESULTS: In the UK, good practice guidelines have set out environmental issues to be considered in development projects, but little attention is given to direct health effects. Broad quantifiable risks were identified for four-air, chemicals, noise, and road traffic-of 14 standard environmental effects. A mathematical model was constructed that is based on people moving between different health states over their lifetime. Age related hazard functions are applied to cause specific measures of mortality and morbidity. A hypothetical example for a development creating air and chemical pollutants is given. CONCLUSIONS: A mathematical model applying epidemiological risks to an exposed population can provide quantification of environmental health effects. The approach may in future find application during project development, and by public health regulatory authorities for environmental health impact assessment.

Computer modelling of a cataract waiting list.

AIM: To compare three different strategies for determining admission dates for patients awaiting cataract extraction after scoring for visual impairment. METHODS: 357 patients attending for assessment for cataract surgery were scored for visual impairment. These scores were used as a basis for ranking patients into three impairment strata. A computer simulation was used to compare 3 years' operation of different admission strategies-a first come first served booking system, a triage booking system, and a waiting list system in which admissions were strictly ordered according to priority stratum. Differences in priority weighted delays before treatment were analysed. RESULTS: Both the triage system and the priority based waiting list system gave considerable reduction in priority weighted delay compared with a first come first served admission policy. The percentage reduction achieved (30%-60%) is strongly influenced by the number of weeks fully booked when the booking systems are introduced. The priority weighted delay of the triage system, where booking decisions were made at the time of the outpatient assessment, was consistently and substantially outperformed by the priority based waiting list system where the decision to allocate an admission date was delayed as long as possible. CONCLUSIONS: There is considerable scope for reducing delays to high priority patients if simple rules are used to determine admission dates. Using these rules, booking patients at the time of the outpatient assessment gives substantially less benefit in terms of reducing delays to high priority patients than if the decision about the admission date is deferred.

Survival and quality of life in patients with protracted recovery from cardiac surgery. Can we predict poor outcome?

Of all the 2256 adult cardiac surgical patients operated upon during a 12-month period from 1st February 1992 in three units, only 162 (7.2%) spent more than 48 h in the intensive care unit (ICU) (median 6 days, range 3-90). There were 47 deaths in ICU, 7 more before hospital discharge, and a further 10 before the study end-point of one year after surgery. All 98 1-year survivors were at home with 86 of them reporting their quality of life, on formal evaluation, to be within the reference range which we have established for a less complicated cohort of cardiac surgical patients. Prospectively collected physiological measurements were used in a mathematical model to test how well we could predict which patients will die and which of the survivors have a poor quality of life. The algorithm performs well for cardiac surgery patients with a specificity of 98%. If treatment had been withdrawn when death or poor quality of life became predictable, the maximum number of ICU bed days that could be freed was of the order of 2%. The plight of these patients is distressing, but most survive and do well and they are infrequent compared with the large majority who survive to leave hospital after a short ICU stay.

Early identification of divergent performance in congenital cardiac surgery.

OBJECTIVES: Heterogeneous caseload and poorly quantified risk stratification make it difficult to monitor outcomes in congenital cardiac surgery. Reliance on formal statistical hypothesis testing may lead to substantial delays before a pattern of poor outcome can be established. Here, we report alternative methods for alerting surgeons to potential problems at an earlier stage. METHODS: Graphical methods developed for monitoring adult cardiac surgery have been adapted for use in congenital cardiac surgery. To illustrate their potential, we have retrospectively examined mortality data for a single surgeon involving 315 cases. Partial risk adjustment has been carried out according to patient's age and the open/closed categorization of the surgical procedure. Additional information has been derived by ranking procedures in order of their complexity and displaying the proportion of the surgeon's cases in each complexity stratum. RESULTS: The display of a surgeon's mortality data adjusted for age and open/closed category provides an easily understood chart of performance and allows one to identify periods when performance appears divergent, relative to the surgeon's own overall standards. Cases carried out during such periods can then be scrutinized by alternative methods. One such method is to examine caseload complexity during the periods of apparent divergent performance compared with other periods. CONCLUSIONS: These methods, while in no way representing formal statistical tests, provide a means that can alert surgeons to potential problems and help to identify sequences of cases that might benefit from further scrutiny.

Computer tools to assist the monitoring of outcomes in surgery.

OBJECTIVE: In recent years, there has been increasing use of analytical and graphical methods to assist the monitoring of outcomes in adult cardiac surgery. In this paper, we present extensions to the basic VLAD methodology that add flexibility and assist in its interpretation. METHODS: Using techniques from probability theory, we have devised graphical tools whereby deviations from expected outcomes can be monitored to see how likely they are to have occurred by chance. The methods are based upon pre-operative assessments of risk and use exact analytical techniques. RESULTS: These tools allow deviations from expected outcomes to be readily assessed and compared with the distribution of chance outcomes. Appropriate colour coding allows interpretation in terms of a temperature gradient. CONCLUSIONS: Exact analysis methods based on the use of pre-operative risk assessment provide a useful means for assisting the interpretation of VLAD charts. Such analysis has the advantage that it is applicable even for relatively short series of operations. Also, it takes specific account of the heterogeneity of case mix when quantifying the variability that is expected. By displaying the overall history of outcomes in a visually intuitive manner, it complements the more formal tools for detecting isolated good and bad runs that are available.

Disability and distress following cardiac surgery in patients over 70 years of age.

We have reviewed the outcome in a consecutive series of 254 patients over the age of 70 undergoing cardiac surgery between 1987-89. Of the patients, 62% were male and the median age was 73 years. Operations included: coronary bypass 57%, valve replacement 26%, combinations 14% and other procedures 3%. The hospital mortality was 7.5% and late mortality was 13.8%. Complications included: intraaortic balloon 6%, resternotomy for bleeding 4%, permanent pacing 3%, chest infection 14%, tracheostomy 5%, major cerebrovascular events 3% and minor 4%. Eighty-two percent left the intensive care unit within 24 h and 89% left hospital within 8 days. Two questionnaires (York University) were sent to 207 patients believed to be alive in order to evaluate the change in their quality of life following surgery. Of the 207 questionnaires 197 (95%) were returned, 7 of which were from relatives of patients who had died and 7 were incomplete. The responses of 183 assessable patients (at a mean follow-up of 36 months) were converted into Rosser disability (I-VIII) and distress (A-D) groups. There was a decrease in disability and distress in 60% and 67%, respectively, no change in 34% and 30% and deterioration in 6% and 3%. Cardiac surgery can be carried out in elderly patients with an acceptable early morbidity and mortality, and although many patients show sustained improvement in their quality of life, this was not demonstrated in about a third of patients. As the emphasis in the elderly should be on quality of life we ought to continue to concentrate on careful selection in this age group.

Assessment of elderly people in general practice. 3. Confiding relationships.

Little is known about the importance of confiding relationships in elderly people. Associations between lack of confiding relationships and depression, lifestyle characteristics, medication use, and contacts with doctors were studied by interviewing a random sample of 235 elderly people aged 75 years and over registered with nine general practices in inner London. It was found that men were not significantly more likely than women to report lack of confiding relationships. Married people of both sexes were more likely to have confiding relationships than those who were single, separated, divorced or widowed. Depression was not associated with lack of a confiding relationship, but those lacking such relationships were significantly more likely to smoke, and were prescribed significantly more medicines than those with confiding relationships. Individuals without a confiding relationship were significantly less likely to admit to any alcohol consumption in the previous three months, suggesting that alcohol consumption in this age group is largely a social phenomenon. Confiding relationships do not appear to confer strong protection against depression and a question on confiding relationships should not therefore be routinely incorporated into surveillance programmes for elderly people in the community.

Screening for cognitive impairment in the elderly using the mini-mental state examination.

The use by non-medical staff of a brief screening instrument (the mini-mental state examination) to detect cognitive impairment among the elderly in primary care is described. Patients aged 75 years and over registered with nine general practices in north and north west London were invited by their general practitioners to take part in the study and 1170 patients participated, a response rate of 90%. The prevalence of possible or probable cognitive impairment (score below 25 on the mini-mental state examination) was 12.8%. Six per cent of patients scored below 19, at which score a high probability of dementia exists, although less than a third of this group had a diagnosis of dementia in their medical records. There was no significant difference between men and women or by social class in the proportion of patients with low scores, but the proportion with dementia rose from 2.5% in those aged 75-79 years to 29.0% among those aged 90 years and over. Under the new general practitioner contract there is a requirement to provide annual services to the elderly, including a 'mental assessment'. In a practice with a list size of 2000 around 130 patients are likely to be aged 75 years and over. Of these around 17 would require further assessment for possible dementia on the basis of results obtained using the mini-mental state examination.

Assessment of elderly people in general practice. 1. Social circumstances and mental state.

A survey of patients aged 75 years and over registered with general practitioners in north and north west London was carried out by trained interviewers to investigate cognitive impairment. A random sample of 239 patients was selected for the more detailed home assessment. General practitioners had seen nearly two thirds (65.3%) of their patients aged 75 years and over in the three months prior to the study, the majority of these consultations (82.1%) being initiated by the patient and occurring at the surgery. Half of the patients lived alone (50.2%), nearly one in three had no living siblings (31.9%), a similar proportion had no living children (29.5%), and contact with neighbours and relatives was relatively infrequent. One in five elderly patients had evidence of depression (22.0%) although this appeared to be severe in only two cases, and 36 participants (15.1%) had scores on the mini-mental state examination suggesting cognitive impairment. General practitioners underdiagnosed both dementia and depression. The population contained a small group of people who consumed alcohol on a daily basis (10.5%). This study showed that an annual assessment of elderly people as required by the new general practitioners' contract would yield much new evidence of depression and dementia and assist in the identification of heavy drinkers. Up to 30% of patients aged 75 years and over are likely to require further assessment on the basis of screening tests for depression and cognitive impairment, although it remains unclear to what extent identification of these patients will lead to improvements in outcome for them or their carers.

Assessment of elderly people in general practice. 2. Functional abilities and medical problems.

A random sample of 239 patients aged 75 years and over registered with general practitioners in north and north west London was selected for home assessment to determine the functional abilities and medical problems of this group of patients. Nearly one in five of the patients were incontinent of urine (18.4%), although this was on a daily basis for only 4.1%. Around one in 20 patients were incontinent of faeces (5.9%), yet only one patient had laundry service support. Unassisted mobility outdoors was reported as possible by 81.2% of the patients. Fourteen different types of aids were present in the participants' homes, the commonest being walking sticks, bath aids and stair rails. Only a small proportion of aids seemed to be currently unused. The major functional problems were bathing, housework, shopping, washing and ironing, and cooking main meals, but the level of demand for extra help was low. One in five patients had a hearing aid (19.8%) but for only 30% of these patients was it in continuous use. Polypharmacy was common, with 29.7% of patients taking three or more prescribed medicines. The workload implications of this approach to anticipatory care of elderly people are considerable. In an average practice of 2000 patients with 130 patients aged 75 years and over the primary care team would need over 150 hours of face-to-face contact per year with these patients to fulfil the new contractual obligation and the yield of new information leading to effective medical or social intervention is limited.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of elderly people in general practice. 4. Depression, functional ability and contact with services.

The aim of this study was to look at the interrelationship between depression, physical disability and contact with services. In a random sample of 239 people aged 75 years and over from nine general practices in north London, depression (as measured by a shortened version of the comprehensive assessment and referral evaluation schedule) was found to be significantly associated with being a woman, and inability to perform a number of activities of daily living. Consumption of three or more prescribed medicines, a home visit by the general practitioner in the previous three months and contact with health visitors and home helps were all significantly more likely among depressed patients. There were also significant associations between loss of functional abilities, measured using items from an activities of daily living scale, and use of certain services: general practitioner home visits and reduced mobility indoors and both home help and district nurse visits to those with difficulty in bathing. Multiple logistic regression analysis suggested that contact with services was principally associated with loss of mobility, although contact with home helps was independently associated with depression, when adjustment was made for functional impairment.