Design: Two necropsy series completed in 1981 and in 1991.

Setting: Department of Forensic Medicine, University of Helsinki, Finland.

Subjects: 528 men, aged 35 to 69 years, subjected to medicolegal necropsy.

Main outcome measures: Scoring of spermatogenesis and morphometric analysis of testicular tissue components. Individual risk factors for testicular disorders obtained by postmortem blind interviews with acquaintances.

Results: Normal spermatogenesis was found in 41.7% of the men (mean age 53.1 years). Between 1981 and 1991, the ratio of normal spermatogenesis decreased significantly (odds ratio 3.5; 95% confidence interval 2.5 to 5.1) from 56.4% to 26.9%, with a parallel increase in the incidence of partial and complete spermatogenic arrest (2.1; 1.4 to 2.9 and 2.9; 1.7 to 5.0, respectively). During this period, the size of seminiferous tubules decreased, the amount of fibrotic tissue increased, and the weight of testicles decreased significantly. Alterations in testicular characteristics over time could not be explained by changes in body mass index, smoking, alcohol drinking, or exposure to drugs.

Conclusions: The incidence of normal spermatogenesis decreased among middle aged Finnish men from 1981 to 1991, and the incidence of disorders of spermatogenesis and pathological alterations in testicles increased. Deteriorating spermatogenesis may thus be one important factor in the explanation of declining sperm counts observed worldwide.

Department of Forensic Medicine,
University of Helsinki,
PO Box 40,
00014,
Finland

Jarkko Pajarinen, doctor
Antti Penttila, professor

Department of Biometrics,
University of Tampere,
Finland

Pekka Laippala, professor

School of Medicine,
University of Tampere,
Finland

Pekka J Karhunen, professor

Correspondence to: Dr Pajarinen.

Design: Prospective study of mortality in relation to alcohol consumption at recruitment, with active annual follow up.

Setting: Four small, geographically defined communities in Shanghai, China.

Subjects: 18244 men aged 45-64 years enrolled in a prospective study of diet and cancer during January 1986 to September 1989.

Main outcome measure: All cause mortality.

Results: By 28 February 1995, 1198 deaths (including 498 from cancer, 269 from stroke, and 104 from ischaemic heart disease) had been identified. Compared with lifelong non-drinkers, those who consumed 1-14 drinks a week had a 19% reduction in overall mortality (relative risk 0.81; 95% confidence interval 0.70 to 0.94) after age, level of education, and cigarette smoking were adjusted for. This protective effect was not restricted to any specific type of alcoholic drink. Although light to moderate drinking (28 or fewer drinks per week) was associated with a 36% reduction in death from ischaemic heart disease (0.64; 0.41 to 0.998), it had no effect on death from stroke, which is the leading cause of death in this population. As expected, heavy drinking (29 or more drinks per week) was significantly associated with increased risks of death from cancer of the upper aerodigestive tract, hepatic cirrhosis, and stroke.

Conclusions: Regular consumption of small amounts of alcohol is associated with lower overall mortality including death from ischaemic heart disease in middle aged Chinese men. The type of alcoholic drink does not affect this association.

Department of Preventive Medicine,
USC/Norris Comprehensive Cancer Center,
University of Southern California School of Medicine,
Los Angeles,
California 90033,
USA

Jian-Min Yuan, research fellow
Ronald K Ross, professor
Mimi C Yu, professor
Brian E Henderson, professor

Department of Epidemiology,
Shanghai Cancer Institute,
Shanghai 200032,
People's Republic of China

Yu-Tang Gao, professor

Correspondence to: Dr Yuan.

Design: Multicentre cross sectional survey.

Settings: 34 HIV treatment facilities, including inpatient hospital wards, day hospitals, and ambulatory care clinics, in 13 cities throughout France.

Subjects: 315 HIV patients at different stages of the disease.

Main outcome measures : Patients: recorded presence and severity of pain and rated quality of life. Doctors: reported disease status, estimate of pain severity, and analgesic treatment ordered.

Results: From 30% (17/56) of outpatients to 62% (73/118) of inpatients reported pain due to HIV disease. Pain severity significantly decreased patients' quality of life. Doctors underestimated pain severity in 52% (70/135) of HIV patients reporting pain. Underestimation of pain severity was more likely for patients who reported moderate (odds ratio 24) or severe pain (165) and less likely for patients whose pain source was identified or who were perceived as more depressed. Of the patients reporting moderate or severe pain, 57% (61/107) did not receive any analgesic treatment; only 22% (23/107) received at least weak opioids. Likelihood of analgesic prescription increased when doctors estimated pain to be more severe and regarded patients as sicker.

Conclusions: Pain is a common and debilitating symptom of HIV disease which is gravely underestimated and undertreated.

Consultation de Traitement de la Douleur,
Institut Mutualiste Montsouris,
42 Boulevard Jourdan,
75014 Paris,
France

Francois Larue, pain consultant

Departement de Sante Publique,
Faculte Bichat,
Universite Paris VII,
75018 Paris,
France

Alain Fontaine, health services research staff physician

WHO Collaborating Center for Symptom Evaluation in Cancer Care,
University of Wisconsin Medical School,
Madison,
WI 53705,
USA

Sophie M Colleau, assistant director for communication

Correspondence to: Dr Larue.

Design: Subjects were randomised to either rapid or slow initial weight loss. Completing patients were re-randomised to one year weight maintenance programme of ad lib diet or fixed energy intake diet. Patients were followed up one year later.

Setting: University research department in Copenhagen, Denmark.

Subjects: 43 (41 women) obese adults (body mass index 27-40) who were otherwise healthy living in or around Copenhagen.

Interventions: 8 weeks of low energy diet (2 MJ/day) or 17 weeks of conventional diet (5 MJ/day), both supported by an anorectic compound (ephedrine 20 mg and caffeine 200 mg thrice daily); one year weight maintenance programme of ad lib, low fat, high carbohydrate diet or fixed energy intake diet (7.8 MJ/day or less), both with reinforcement sessions 2-3 times monthly.

Main outcome measures: Mean initial weight loss and proportion of patients maintaining a weight loss of >5 kg at follow up.

Results: Mean initial weight loss was 12.6 kg (95% confidence interval 10.9 to 14.3 kg) in rapid weight loss group and 12.6 (9.9 to 15.3) kg in conventional diet group. Rate of initial weight loss had no effect on weight maintenance after 6 or 12 months of weight maintenance or at follow up. After weight maintenance programme, the ad lib group had maintained 13.2 (8.1 to 18.3) kg of the initial weight loss of 13.5 (11.4 to 15.5) kg, and the fixed energy intake group had maintained 9.7 (6.1 to 13.3) kg of the initial 13.8 (11.8 to 15.7) kg weight loss (group difference 3.5 (-2.4 to 9.3) kg). Regained weight at follow up was greater in fixed energy intake group than in ad lib group (11.3 (7.1 to 15.5) kg v 5.4 (2.3 to 8.6) kg, group difference 5.9 ( 0.7 to 11. 1) kg, P<0.03). At follow up, 65% of ad lib group and 40% of fixed energy intake group had maintained a weight loss of >5 kg (P<0.07).

Conclusion: Ad lib, low fat, high carbohydrate diet was superior to fixed energy intake for maintaining weight after a major weight loss. The rate of the initial weight loss did not influence long term outcome.

Research Department of Human Nutrition,
Royal Veterinary and Agricultural University,
Rolighedsvej 30,
1958 Frederiksberg,
Copenhagen,
Denmark

Søren Toubro, associate professor
Arne Astrup, head of department

Correspondence and reprint requests to: Professor Toubro.

Design: Retrospective data on primary care were collected over a 4.5 year period from both computerised and manually filed records. Standardised data on socioeconomic status were obtained by postal questionnaire.

Setting: Inner city group practice with a socioeconomically diverse population.

Subjects: 382 male and female subjects of all ages, with a total of 1296 person years of observation.

Main outcome measures: Primary care costs resulting from consultations with a general practitioner or a practice nurse and both new and repeat prescriptions.

Results: Morbidity, workload, and costs of drug treatment increased with decreasing socioeconomic status. The difference in cost for patients in social classes IV and V combined compared with those in I and II combined was about £150 per person year at risk (£47 for workload and £103 for drugs). Deprivation payments met only half the extra workload cost for patients from qualifying wards.

Conclusions: The greater workload caused by social disadvantage has been previously underestimated by simple consultation rates. The absolute difference in costs for socially disadvantaged patients increases as more detailed measures of workload and drug treatment are included. Current deprivation payments only partially offset the increased expenditure on workload. This shortfall will have to be addressed to attract general practitioners to, or retain them in, deprived areas.

Kentish Town Health Centre,
London NW5 2AJ

Adrian Worrall, research officer
J Nicolas Rea, general practitioner

Department of Social Medicine,
Bristol University,
Bristol BS8 2PR

Yoav Ben-Shlomo, senior lecturer in clinical epidemiology

Correspondence to: Dr Rea.