On the basis of historical studies, hepatitis delta virus (HDV) infection is considered uncommon in the United Kingdom (UK) and mainly confined to intravenous drug users. In order to assess the current prevalence of HDV co-infection in patients with chronic hepatitis B (HBV), a retrospective analysis was performed of 962 consecutive HBV-infected adult patients referred to King's College Hospital between January 1st 2000 and March 31st 2006. The 82 subjects positive for HDV antibody (8.5%) had a similar age to those without HDV (median 36 years, interquartile range 30-47, vs. 35 years, 29-43). Excluding non-UK residents, the prevalence of HDV Antibody was 7.1%. Most HDV-infected subjects were born in regions where HDV is endemic, for example, Southern or Eastern Europe (28.1%), Africa (26.8%) or Middle-East (7.3%). Forty one (50%) were considered to have acquired HDV infection via intra-familial transmission but intravenous drug use was still a common route of transmission (24.4%). Comparing HBV/HDV co-infected to HBV mono-infected patients, a higher proportion were hepatitis C antibody positive (25.6% versus 3.8%; odds ratio 8.89, 95% confidence interval 4.4-17.9; P < 0.00001) and more had cirrhosis (26.8% vs. 12.9%; odds ratio 2.64, 95% confidence interval 1.55-4.49; P < 0.0001) but, despite this, the risk of hepatocellular carcinoma was similar (odds ratio 1.34, 95% confidence interval 0.62-2.91). Although HDV infection is reportedly declining in some endemic regions, our data demonstrate a high prevalence in South London. HDV co-infection is associated with increased morbidity and patients with HBV should be tested for HDV infection.

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senior consultant, Anita Jolly consultant in public health medicine, On behalf of Prederi Prederi, Oxted RH8 9EE, UKAs authors of the Department of Health commissioned report on the cost of visitors and short term migrants to the NHS in England, 1 we offer a counter interpretation to that of Schulkind and colleagues. 2 Far from being "absurd," it was a credible attempt to quantify use of NHS services by overseas visitors in the absence of any statistics directly measuring this. Peer review of our work supported our findings.The report is a top down estimate based on the best publicly available population data at the time of analysis. We derived a daily equivalent UK population of overseas visitors and calculated associated NHS costs on the basis of age and sex adjusted estimates of use. The costs of regular migrant use of NHS services were estimated at £1.4bn (€1.94bn; $2.2bn). Our report was underpinned by empirical evidence, which shows that migrants are generally less likely to use NHS services than people born in the UK.We estimated the cost of irregular migrant NHS use as about £330m. We also distinguished between "normal" use and "health tourism," which we estimated costs the NHS £70m-300m. Although far less than the £2bn misquoted by Nigel Farage, 3 this is a substantial amount. The uncertainty surrounding all estimates was fully acknowledged. Schulkind states that "Evidence of health tourism from the front line is equally lacking." We would like to point out that qualitative research commissioned concurrently by the Department of Health provides evidence that it does happen. 4 We drew no inferences about how much it costs to treat non-UK

Background. Mental well-being is an essential concept in research and public health as it is recognised as an indicator of population mental health and quality of life. Previous studies have provided evidence that general self-efficacy is positively related to mental well-being. The aim of this study is to examine whether higher help-seeking self-efficacy and higher psychological well-being self-efficacy respectively, are associated with increased mental well-being.Methods. In this cross-sectional study 1795 adults from the general English population were recruited from a market research panel to fill out an online questionnaire between 24th September 2018 and 05th October 2018. Two simple linear regression analyses were used to investigate the relationship between each of help-seeking self-efficacy and psychological well-being self- efficacy as exposure variables and mental well-being as the outcome. Multiple imputation by chained equations was used to handle missing data.Results. No evidence was found for an association between either help-seeking self-efficacy or psychological well-being self-efficacy and mental well-being.Conclusions. These findings do not provide evidence that improving help-seeking or psychological well-being self-efficacy could lead to improving well-being. Methodological limitations, such as unmeasured confounders might be responsible for the lack of evidence in this study. Having a mental health condition is a potential negative confounder that might not have been measured adequately.