Regional Catchment Area Research Articles

Drought forecasting model for future climate change effects in a regional catchment area in northern iraq

Drought forecasting model for future climate change effects in a regional catchment area in northern iraq

Accuracy of pelvic magnetic resonance imaging in local staging for rectal cancer: a single local health district, real world experience.

Neoadjuvant chemoradiotherapy plays a key role in reducing local recurrence rates for locally advanced rectal cancer. Pelvic magnetic resonance imaging (pMRI) is the gold standard for local clinical staging which allows clinicians to decide the treatment patients receive. A more advanced tumour or the presence of high-risk features on pMRI mean that neoadjuvant therapy will be offered to these patients. Understanding the accuracy of pMRI in local staging for rectal cancer is therefore crucial. A retrospective cohort analysis of the accuracy of pMRI staging in a subgroup of patients who had primary rectal cancer surgery without neoadjuvant therapy was performed. Specificity and sensitivity for T-staging, N-staging and presence of high-risk features (threatened circumferential resection margin and extramural venous invasion) were calculated. Patients who had previous pelvic surgery, previous pelvic radiotherapy and previous surgery for continence were excluded. A total of 114 patients were included in the analysis. MRI accurately predicts T-stage in 56.6% and N-stage in 55.8%. Prediction of extramural disease was accurate in 51%. A negative circumferential resection margin was accurately predicted in 98.6% of patients. Overall adherence to reporting proforma was 15.8%. Overall, this study provided valuable information about the clinical staging of patients with rectal cancer who are at an early stage within a large regional catchment area in Australia with pMRI. These results allow us to assess the accuracy of our local staging with ramifications to the clinical decisions being made in the context of the more recent trials which questioned the need for neoadjuvant chemo-radiotherapy in all node positive patients.

Predicting Thrombosis Recurrence in Children: The Role of Thrombophilia Testing

Background: The role of inherited thrombophilia testing in predicting a recurrence of deep vein thrombosis (DVT) after an incident of the first DVT in children remains unclear Objectives: To investigate the association between inherited thrombophilia and DVT recurrence. Design/Method: We conducted a retrospective regional study of all consecutive ICD10 codes of venous thromboembolism (VTE) in children over 15 years (January 1, 2000, to December 31, 2015) in a regional catchment area of southern Sweden using an electronic diagnosis registry. Eligible subjects were children aged 1-18 years presenting with DVT diagnosed with imaging and having undergone complete inherited thrombophilia workup after the first DVT event. Of the 174 patients diagnosed with DVTs, 139 were eligible for inclusion. Data regarding subject demographics and medical history, location of DVT and imaging method, coagulation studies at primary investigation including at least plasma concentrations of protein C, protein S, antithrombin, resistance to activated protein C, and the genotypes FVG1691A and FIIG20210A. Also, plasma values for coagulation factors, VIII and XI, D-dimer, INR, and cardiolipin antibodies, were analyzed. Results: A total of 139 patients had inherited thrombophilia workup after the incident of the first DVT. Inherited thrombophilia was found in 30 % of patients, the prevalence of minor thrombophilia among these 139 patients was 23 % (n = 32), whereas major thrombophilia accounted for 7 % (n = 10) of abnormal results. Anticoagulants as treatment were administered in 92 % of the first DVT. The majority of the cohort treated with anticoagulation therapy for 12 weeks. Patients with minor inherited thrombophilia treated for at least 24 weeks, whereas the patients with major inherited thrombophilia were continued on anticoagulation therapy for the long term. The incidence rate of recurrent thromboembolic events was 6.5 % (n = 9) of patients after their incident of the first thrombotic event. Recurrent thrombosis in patients with spontaneous DVT and proven inherited thrombophilia found in only 1 %. Conclusion: Inherited thrombophilia was not predictive of recurrent DVT among our cohort patients. Our findings suggest that Inherited thrombophilia testing may not predict risk for the recurrence of DVT, although it may help for adjustment of the duration of the anticoagulation therapy. Figure Disclosures No relevant conflicts of interest to declare.

Stillbirth and fetal anomalies: secondary analysis of a case-control study.

Approximately 10% of stillbirths are attributed to fetal anomalies, but anomalies are also common in live births. We aimed to assess the relationship between anomalies, by system and stillbirth. Secondary analysis of a prospective, case-control study. Multicentre, 59 hospitals in five regional catchment areas in the USA. All stillbirths and representative live birth controls. Standardised postmortem examinations performed in stillbirths, medical record abstraction for stillbirths and live births. Incidence of major anomalies, by type, compared between stillbirths and live births with univariable and multivariable analyses using weighted analysis to account for study design and differential consent. Of 465 singleton stillbirths included, 23.4% had one or more major anomalies compared with 4.3% of 1871 live births. Having an anomaly increased the odds of stillbirth; an increasing number of anomalies was more highly associated with stillbirth. Regardless of organ system affected, the presence of an anomaly increased the odds of stillbirth. These relationships remained significant if stillbirths with known genetic abnormalities were excluded. After multivariable analyses, the adjusted odds ratio (aOR) of stillbirth for any anomaly was 4.33 (95% CI 2.80-6.70) and the systems most strongly associated with stillbirth were cystic hygroma (aOR 29.97, 95% CI 5.85-153.57), and thoracic (aOR16.18, 95% CI 4.30-60.94) and craniofacial (aOR 35.25, 95% CI 9.22-134.68) systems. In pregnancies affected by anomalies, the odds of stillbirth are higher with increasing numbers of anomalies. Anomalies of nearly any organ system increased the odds of stillbirth even when adjusting for gestational age and maternal race. Stillbirth risk increases with anomalies of nearly any organ system and with number of anomalies seen.

Incidence of Mild Traumatic Brain Injury: A Prospective Hospital, Emergency Room and General Practitioner-Based Study.

Background: There are no recent estimates of incidence rates of mild traumatic brain injury (MTBI) from Norway. Moreover, reported incidence rates rarely comprise cases of MTBI evaluated in the primary care setting. In this study, we utilized existing data collected as part of the recruitment to a large, follow-up study of patients with MTBI. We estimated the incidence rate of MTBI, including patients who visited outpatient clinics, in the age group 16–59 years in a Norwegian region.Methods: During 81 weeks in 2014 and 2015, all persons aged 16–59 years, presenting with possible MTBI to the emergency department (ED) at St. Olavs Hospital, Trondheim University Hospital or to the general practitioner (GP)-run Trondheim municipal outpatient ED, were evaluated for a diagnosis of MTBI. Patients were identified by computerized tomography (CT) referrals and patient lists. Patients referred to acute CT from their primary GP with suspicion of MTBI were also recorded. This approach identified 732 patients with MTBI. Age- and sex-specific incidence rates of MTBI were calculated using population figures from the regional catchment area.Results: Overall incidence of MTBI in people between 16 and 59 years was 302 per 100,000 person-years (95% confidence interval 281–324). The incidence rate was highest in the age group 16–20 years, where rates were 835 per 100,000 person-years in males and 726 in females.Conclusion: The overall incidence rate of MTBI was lower than expected from existing estimates. Like other reports, the incidence was highest in the late teens.

Venous Thromboembolism in Children 0-18 Years — a Regional Population-Based Study from Sweden

Introduction: Venous thromboembolism (VTE) is a rare complication in childhood. Pediatric VTE is an important and increasingly frequent clinical challenge likely due to increased detection and advanced medical interventions leading to improved survival of previously fatal conditions.Objective: The principal aim of this population based study was to describe the incidence, age distribution, type/location of VTE, and acquired and genetic pro-thrombotic risk factors of VTE and recurrence of VTE in children 0-18 years.Material and Methods: The Regional Ethical Review Board in Lund approved the study. We conducted a retrospective regional study of all consecutive ICD-10 codes of VTE in children 0-18 years over a 15-year period (January 1, 2000, to December 31, 2015) in a regional catchment area of southern Sweden using an electronic diagnosis registry. Eligible subjects were defined as children under the age of 18 who presented with VTE and had imaging evidence of thrombosis. Of the 174 patients diagnosed with VTEs, 164 fulfilled the study group criteria. Data regarding subject demographics and medical history (central venous catheter, cancer, congenital heart disease, history of VTE, current infection, etc.), location of VTE and imaging method (upper, lower extremities, pulmonary embolism, renal, cardiac, cerebral sinus venous thrombosis (CSVT), etc.), coagulation studies at primary investigation which included in all cases evaluation of at least plasma concentrations of protein C, protein S, antithrombin, resistance to activated protein C and the genotypes FV-G1691A and FII-G20210A. In addition, plasma values for coagulation factors VIII and XI, D-dimer, PK-INR, and cardiolipin antibodies were analyzed.Results: The incidence of VTE in children in the investigated region of Sweden was found to be 0.8 per 10,000 children. Of the study group with confirmed VTE (n=164), 73/164 (45%) were males and 91/164(55%) females, with bimodal age distribution at diagnosis, 25 (15%) < 1 month, 139 (85%) >1 month-18 years. Of the children, 143/164 (87%) had DVT (deep venous thrombosis), 21/164 (13%) had PE (pulmonary embolism) and 5/164 (3%) had both DVT and PE. Of 143 patients with DVT, 50 (30%) had lower extremity DVT, 46 (28%) had upper extremity DVT and 34 (20.7%) CSVT and the remaining 13 various locations. 79/164 (59%) had acquired potential risk factors, 11/164 (11%) had genetic risk factors, 34/164 (21%) had both genetic and acquired risk factors, and 22/164 (13%) had no identified risk factors. The most frequent acquired risk factors in the cohort were the use of hormonal therapy (34%), concomitant malignancy (21%), infection at the time of thrombosis (19%) or a CVL (central venous line) (15%). Genetic thrombophilia risk factors were found in 45/164 (27.5%), the most common were Factor V Leiden (FVL) in heterozygous form in 35 (21%), FII mutation (heterozygous) in 4 (2%) and double heterozygosity for FVL and FII mutation found in 2 (1%). Plasma deficiency of Protein S was found in 5, Protein C deficiency in 6 and Antithrombin deficiency in 1 patient (who had 3 episodes of VTE). Recurrent VTE was documented in 9 (5%), of which 5 had a congenital pro-thrombotic disorder (i.e. FVL mutation (n=3), antithrombin deficiency (n=1) and a protein S deficiency (n=1). Two out of the nine with recurrent VTE had neither a genetic nor an acquired identified risk factor. Six out of a total of 45 (13.3%) with genetic risk factors had a recurrent VTE. No common acquired pro-thrombotic risk factor was found in the group with recurrent VTE.Conclusion: The incidence, age-distribution, locations and underlying disorders agree with published findings in pediatric populations. In our study, 87% of the children with VTE had either an identifiable acquired or genetic risk factor or a combination of both. Of those with a genetic risk factor, 13% had a recurrent VTE during the study period which indicates an even higher cumulative risk during childhood which emphasizes the need to consider prophylaxis in situations with increased risk of VTE. However, of those with recurrent VTE, no frequent acquired risk factor was identified. DisclosuresNo relevant conflicts of interest to declare.

Can mental health related hospital visits be relied upon for suicide prevention?

IntroductionEven among people with mental disorders, relatively few die of suicide. However, a large proportion of people dying from suicide have seen a physician in the year before death. This raises the question whether focusing on hospital visits for suicide-related outcomes is a viable suicide prevention strategy.&#x0D; Objectives and ApproachOur objective was to examine whether a hospital visit for a mental disorder or prior suicide attempt preceded suicide death. We requested Saskatchewan’s provincial coroner for records of people dying of suicide in the Saskatoon Health Region catchment area for the years 2012 to 2016. The coroner’s list was linked with hospital and community mental health databases. Patient charts and medical abstracts in both settings were reviewed for risk factors.&#x0D; ResultsThere were 143 suicide deaths in the time period and the yearly incidence was higher in Saskatoon as compared with the national average. Only 38 percent were seen previously in any Saskatoon hospital for a mental disorder (11 percent for a self-harm diagnosis). The chart review confirmed several known psychological and social risk factors. Having a history of depression or psychosis and alcohol and/or drug use were common. Many decedents also had disadvantaged socio-economic backgrounds characterized by vulnerable housing and being on social assistance.&#x0D; Conclusion/ImplicationsWith only 38 percent of decedents being seen in hospital, community-based mental health care and data are important for suicide prevention. Suicide prevention efforts can be aided by facilitating the linkage of community and medical records to better track patients as they move between care settings.

Minimizing inequality in access to precision medicine in breast cancer by real-time population-based molecular analysis in the SCAN-B initiative.

BackgroundSelection of systemic therapy for primary breast cancer is currently based on clinical biomarkers along with stage. Novel genomic tests are continuously being introduced as more precise tools for guidance of therapy, although they are often developed for specific patient subgroups. The Sweden Cancerome Analysis Network – Breast (SCAN‐B) initiative aims to include all patients with breast cancer for tumour genomic analysis, and to deliver molecular subtype and mutational data back to the treating physician.MethodsAn infrastructure for collection of blood and fresh tumour tissue from all patients newly diagnosed with breast cancer was set up in 2010, initially including seven hospitals within the southern Sweden regional catchment area, which has 1.8 million inhabitants. Inclusion of patients was implemented into routine clinical care, with collection of tumour tissue at local pathology departments for transport to the central laboratory, where routines for rapid sample processing, RNA sequencing and biomarker reporting were developed.ResultsMore than 10 000 patients from nine hospitals have currently consented to inclusion in SCAN‐B with high (90 per cent) inclusion rates from both university and secondary hospitals. Tumour samples and successful RNA sequencing are being obtained from more than 70 per cent of patients, showing excellent representation compared with the national quality registry as a truly population‐based cohort. Molecular biomarker reports can be delivered to multidisciplinary conferences within 1 week.ConclusionPopulation‐based collection of fresh tumour tissue is feasible given a decisive joint effort between academia and collaborative healthcare groups, and with governmental support. An infrastructure for genomic analysis and prompt data output paves the way for novel systemic therapy for patients from all hospitals, irrespective of size and location.

MA 14.14 The First 100 Days: Early findings from the Lung Cancer Screening Pilot for People at High Risk in Ontario, Canada

An estimated 330,000 people in the province of Ontario are at high risk of developing lung cancer and eligible for screening with low-dose computed tomography (LDCT). On June 1 2017 Cancer Care Ontario launched the Lung Cancer Screening Pilot for People at High Risk with the purpose of informing the design and implementation of a province-wide organized screening program. Organized screening is available at 3 hospitals, and provider and public recruitment strategies are being implemented to engage the target population in regional catchment areas.

The association of alcohol consumption patterns with self-rated physical health and psychiatric distress among Afghanistan- and Iraq-era U.S. veterans

Alcohol misuse is associated with negative mental and physical health outcomes, which presents a public health concern in veterans. However, less is known regarding outcomes among veterans with low to moderate alcohol consumption. This study included veterans with military service in Iraq and/or Afghanistan (N = 1083) who resided in the VA Mid-Atlantic region catchment area (North Carolina, Virginia, and parts of West Virginia). Participants completed a mailed survey that inquired about demographics, past-year alcohol consumption, self-rated physical health, and psychiatric symptoms. Logistic regression was used to evaluate associations between alcohol consumption and posttraumatic stress disorder (PTSD), depression, and self-rated physical health. In both bivariate results and adjusted models, non-drinkers and hazardous drinkers were more likely to endorse clinically significant PTSD and depression symptoms than moderate drinkers. Moderate drinkers were also less likely to report fair/poor health, after adjusting for demographics and psychiatric symptoms. Results overall showed a U-shaped curve, such that moderate alcohol use was associated with lower rates of mental health problems and fair/poor health. While the VA routinely screens for alcohol misuse, current results suggest that non-drinkers are also at risk for poor mental and physical health.

Brain atrophy is a frequent finding in elderly patients with first episode psychosis

To characterize the yearly incidence, diagnostic distribution, and neuro-radiologic findings in patients aged over 60 years, referred to psychiatric treatment with first episode psychosis (FEP). A computerized search, including all patients referred to psychiatric treatment during 12 consecutive months with a de novo diagnosis of psychosis was performed in the Helsinki region catchment area with 1.2 million inhabitants. Diagnoses based on hospital records were made by a group of one neurologist and three psychiatrists. MRI- or CT scans performed as a part of routine clinical management were used when available. 107 patients (27 males and 80 females) with FEP were identified and categorized into four diagnostic groups: schizophrenia, delusional disorder, psychotic depression, and psychosis due to another medical condition. No patients with de novo onset mania were found. Psychosis due to another medical condition was the most common diagnosis. A high frequency of signs of cortical brain atrophy was seen in all diagnostic groups, while central atrophy was more frequent in patients with psychosis due to another medical condition than in the other groups. Organic brain changes related to ageing or degenerative illnesses may be an etiologic factor in elderly patients with FEP.

Audit of Pulse Oximetry Screening for Critical Congenital Heart Disease (Cchd) in Newborns

Abstract BACKGROUND: UK data suggests that 25% of infants with CCHD are not diagnosed with heart disease until after discharge from the nursery (0.6 per 1000). In general SpO2 ≤ to 95% or a difference of upper and lower SpO2 of more than 3% in a newborn greater than 24 hours of age is considered significant. In March 2014 the Maternal Child Newborn Screening Committee of the Provincial Council for Maternal Child Health (PCMCH) recommended screening for critical congenital heart disease in Ontario. OBJECTIVES: To assess the efficacy and cost related parameters of a new screening protocol for CCHD. DESIGN/METHODS: An audit of consecutive healthy normal newborn patients over a one-year period was undertaken. RESULTS: The cost of screening estimated for our center was approximately $7.20 per patient. The median age of screening was 25 hours (6-80 hours). Four patients were screened positive and were seen by a paediatrician in consultation. No Echocardiograms were ordered. No child in this screening survey had CCHD (specificity 99.4%). The screening compliance was 94.7%. One patient from our regional catchment area was delivered at an alternate secondary level center where there is no CCHD protocol in effect. The infant was discharged home and returned to the primary level center two days later in shock. The ultimate diagnosis was Hypoplastic Left Heart Syndrome. The estimated cost of the resuscitation was $1000. The emergency transport (direct) cost for this unstable newborn by helicopter is estimated to be $5000.00. Conclusion: Cost analysis: The total direct costs of the CCHD screening program for a year is approximately $5200. The costs for the four patients who were falsely identified as having CCHD is estimated at $200. The total direct cost to the system of the one patient in our region who was not screened and was subsequently identified as having CCHD was estimated to be $6000. Assessment issues: In contrast to the US references, none of the false positive cases had an echocardiogram ordered. The cases were dealt with by utilizing a consultation with a paediatrician. Compliance with routine newborn orders: The screening compliance rate of 94.7%. CONCLUSIONS: A simple screening test for Critical Congenital Heart Disease was successfully undertaken in a secondary level center over a one-year period. The test was cost effective, with high specificity (99.4%) and good compliance (94.7%).

Patient satisfaction survey of the same day assessment for adult cochlear implant candidates

Introduction At the Emmeline Centre (EC) we have used the Same Day Assessment (SDA) process for assessing cochlear implant (CI) candidates since 2011. This process was established as it became clear the traditional method, where the patient would be seen on separate days for audiology, rehabilitation, medical assessment, scans, and balance testing culminating in an appointment with the ENT Consultant after several days – possibly weeks – for a final decision, was not working. In 2009, John Briggs, Head of The EC at that time, presented the results from a survey with patients who had been through the traditional CI assessment process (Briggs et al., 2010). On the whole, good feedback about the quality of the service was received, but one of the findings was from the patients who had been discharged. They were disappointed with the process as they were told they were unsuitable for a CI often after a lengthy assessment. In addition, 2009 saw the introduction of the NICE Guidelines for cochlear implantation (NICE, 2009) as well as the NHS 18 week referral to treatment target (RTT). This led to an increase in referrals of adults in our regional catchment area and to a new approach the SDA being introduced (Harris, 2013). The SDA process is based on a triage system, where after their first visit candidates are divided three groups: • Clearly outside NICE guidelines for CI leading to same day discharge • Clearly within criteria, and without additional clinical complexity; and • Needing more in-depth assessment.

Empty shops in Australian regional towns as an index of rural wellbeing

The regional catchment area of an Australian regional university city provided the basis for an exploratory research project generating an index of wellbeing of rural towns. The project used the residential locations of first-year sociology students to investigate several dozen rural town communities each year in three successive years. This empirically established the number and proportion of empty shops across a sweep of rural towns. Common patterns and differences between towns in the proportion of empty shops provided points of reflection and analysis. Because the research had a pedagogical as well as an investigative purpose, a space was opened up to debate the adequacy of the index to measure the complex realities of rural wellbeing, balancing the project’s limitations with it value as a ‘proof of concept’. Other issues concerning the validity of empty shops as a measure of rural social health were examined.

Flying blind, or going with the flow?: Using constructivist evaluation to manage the unexpected in the GraniteNet project

The GraniteNet Project is a research and development collaboration between the University of Southern Queensland, Australia, and the community of Stanthorpe – a rural community of just over 10,000 people located within the university’s regional catchment area. The vision of this Community Informatics project, which commenced in 2007 and is now in its third phase, is the development of a sustainable community designed, owned and managed web portal that will support Stanthorpe’s development as a ‘learning community’. With funding from the State Government, the GraniteNet Board commissioned an evaluation of the second phase of the project which focussed on the design, development and trial of an incubator community portal environment, a portal governance framework and community engagement strategy. Participatory Action Research (PAR) and constructivist (or “Fourth Generation”) evaluation methodologies were adopted to guide the evaluation with the aims of documenting the project, establishing an evidence base to inform future decision-making, identifying and exploring significant contextual factors impacting on the project, evaluating the effectiveness of the models and processes used to guide the project, and building a culture of evaluation that would help to ensure ongoing review and critical reflection on progress. The evaluation design encompassed formative, summative and research evaluation. This paper reports the evaluation processes and outcomes, with a focus on exploring the ways in which these methodologies can be used to help Community Informatics researchers and practitioners learn from and about the unexpected and unanticipated in a field where learning through experimentation is the name of the game, imagination, creativity and collaborative design the keys to innovation and transformation, and where more traditional evaluation methodologies are becoming increasingly irrelevant.

Late Pleistocene genesis of the middle Yarlung Zhangbo Valley, southern Tibet (China), as deduced by sedimentological and luminescence data

Knowledge on valley formation and palaeohydrology of the Yarlung Zhangbo (named Brahmaputra south of the Himalayas) is still in an early stage. Research was conducted in the middle valley reach around Gonggar in order to investigate the sediment properties, age and palaeoenvironmental implication of a widespread aggradational valley terrace. This heavily dissected terrace, lying c. 25 m above the present floodplain, consists of topping aeolian and colluvial deposits, intermediate lacustrine fines and basal fluvial sands. Sedimentological properties of the lacustrine layers suggest a cold-climate depositional environment. Geochemical data refer to a common provenance of all sediments investigated from a regional catchment area, implying a local provenance of topping loesses and sands by aeolian sorting of nearby fluvial deposits. OSL dates, representing the first luminescence dating effort partly applied to non-aeolian sediments in this valley, cluster closely in the interval 11.7 ± 0.8–17.4 ± 1.4 ka. During the Late Pleistocene (until c. 16 ka) the investigated middle valley reach around Gonggar was occupied by a lake attaining an extension of at least 100 km.

Effects of a drought period on physico-chemical surface water quality in a regional catchment area

Hydrological drought periods are expected to become more severe in North-Western Europe as a result of climate change. This may have implications for water quality, as demonstrated by declining water quality of large rivers (e.g. Rhine, Meuse) during droughts. However, similar investigations in regional catchment areas are lacking to date. In the present study, we investigated the effects of a drought period on the water quality of the Dommel River, a tributary of the Meuse river in the Netherlands. Water quality during the drought of 2003 was compared to that in reference years (2004-2006) for 18 physical/chemical parameters using ANOVA analysis. It was demonstrated that the drought period of 2003 did not significantly affect water quality, although the origin of river flow during the drought shifted from mainly overland flow to deep groundwater flow and (treated) communal effluents. Significant differences in water quality were noted for some monitoring stations during the study period, which could be related to operational water management such as cleaning of sediment traps in the river and improvements in communal effluent treatment. The results of this study are interesting to water managers in Western Europe as they contribute to understanding the potential impact of climate change on water quality/quantity patterns in regional water systems.

Terminal Moraines, Outwash Plains, and Lake Terraces in the Vicinity of Lago Cardiel (49°S; Patagonia, Argentina)—Evidence for Miocene Andean Foreland Glaciations

Nine late Miocene glacier advances are identified in the Lago Cardiel region (49°S, 72°15′W in southern South America), a region that until now has been assumed to be unglaciated. Several dating results indicate a minimum age of 6.4 Ma for four advances of the Monte San Lorenzo lobe terminating east of Lago Cardiel and 6.6 Ma for the three oldest glaciations of the San Martín lobe terminating south of this lake. Two further advances have a minimum age of 5.4 Ma. Eleven to 14 m.y. old basaltic lava, which partly covers Patagonian Gravel, indicates the maximum age of these advances. The two oldest terminal moraines of the San Martín glacier are only modestly incised into the Patagonian Gravel suggesting an age of 9 to 10.5 Ma. These age estimates are especially accurate for both meseta glaciations of the San Lorenzo lobe. These glaciers were about 240 km long during their Miocene maximum, which is four times their length during the Last Glacial Maximum. Hence, the late Miocene glacier advances require colder and/or more humid conditions that were considerably longer lasting than the Pleistocene glaciations. Due to glacial meltwater, Lago Cardiel was significantly larger and served as a regional catchment area during these early glaciations in southern South America. The erratic boulders of the southeastern lake terraces at more than 350 m above modern lake level may be attributed to the oldest late Miocene moraine or outwash plain.

Twenty years’ experience of a telehealth service in the UK

Since 1996 a small call centre has been operated to provide instant self-help, non-medical advice to members. Non-clinical advisers work under a medical director. The scheme grew to 1,200 member-families from a regional catchment area, peaking at 2,500 across the country. About 30-50 telephone calls are received each day and up to 1,000 Web visits per day; about 20-50 postal items are sent out daily to members. In a telephone poll during 2001, half of our current members said that they used the National Health Service about 70% less than before they joined, but a third said that they used complementary and alternative medicines 80% more. Half had gained in confidence by about 50% in managing their own health. Members most often join for alternative medical help with a specific problem, but stay if they begin to appreciate the help we can give them in regaining and keeping health in the round. Our retention of new members for a second year is only 10-20%. The 'barefoot' profession of telehealth adviser appears to meet a community need.

Are Special Hospitals needed?

It has been recommended that the Special Hospitals should be replaced by high-security services at a regional level. This study examines the implications of such a change in policy and demonstrates that local facilities would have to contain a significant proportion of patients whose violent and criminal behaviour cannot be managed in medium security and where in some cases all previous therapeutic interventions have failed to prevent a progression through successively higher levels of hospital security over time. Admissions to Special Hospitals followed more serious behavioural disturbance in other psychiatric services and more serious offences; the patients had more extensive previous criminal histories and were more likely to have primary and comorbid diagnoses of personality disorder and paraphilias. Almost a quarter of all admissions to the Special Hospitals in 1988–94 were transfers from medium security. This study provides little evidence that medium-security services reduced the demand for beds in Special Hospitals over the study period. The transfer of high-security beds to local services would have to take into account the threefold difference in levels of demand across regional catchment areas.