Erythrodermic Skin Diseases-Fox et al. MEDIBALJOURNAL has shown that this can stimulate non-shivering thermogenesis in man. Cold-adapted subjects also showed an increased calorigenic action of noradrenaline (Joy, 1962 ;Davis, 1963), so that the slightly raised V.M.A. excretions found in this study may be important. Shivering tends to disappear in the cold-adapted subject, and this may explain why all except one of our patients with a relative hypothermia failed to shiver.These observations emphasize certain aspects of the managements of these patients. Because of the reduced capacity to thermoregulate, with its attendant dangers of hypothermia or hyperthermia, body temperature must be accurately observed, using a low-temperature thermometer when indicated. Patients usually require more clothes and a warmer room than the average person, and the risk of hypothermia is obviously greatest during winter months and when they are treated at home, but even in hospital care is needed during treatment periods. If the patient develops a high body temperature steps should be taken to reduce it in order to avoid an excessive increase in the cardiac load. The aim should be to steer a course between the two extremes and keep body temperature close to normal. If the patient is seen to be shivering, complains of the cold, or has a subnormal temperature, the room temperature or his clothing should be promptly increased. The temperature at which he becomes comfortable and shivering ceases should be recorded and used as a guide to adjust his environment. Prompt treatment of the skin condition, usually with corticosteroids, is the best way of avoiding heart failure. The unexplained high mortality of patients with erythrodermic skin diseases may in large part be due to the haemodynamic and thermoregulatory problems we have discussed. SummaryHaemodynamic studies on six patients with widespread erythrodermic skin conditions have shown marked increases in skin blood-flow equivalent to up to two-thirds of that seen in normal subjects when fully vasodilated by heat ; there was a considerable further increase in skin blood-flow when the body temperature was raised. All had a raised venous pressure with hypervolaemia, and in two patients the cardiac output was moderately increased.Body-temperature regulation was grossly disturbed. Four out of five patients had either a fever or an elevation of the set point for temperature regulation with body temperatures below the fever level. The capacity to thermoregulate is greatly diminished in these patients, and hypothermia, which is an important risk, is related to the high skin blood-flow and inability of the skin blood-vessels to constrict fully.The basal metabolic rate was raised considerably in 9 out of 11 patients. Radioactive iodine studies showed no evidence of hyperthyroidism, but there was a slight increase in vanillyl mandelic acid excretion. The hypermetabolism is probably mainly due to the abnormal skin metabolism, but the development of non-shivering thermogenesis may also play a p...

Death rates for cerebrovascular disease (stroke) in New Zealand are declining. To investigate the reasons for this decline and to measure the impact of stroke on a defined population, a register of new episodes of stroke was kept in the Auckland region for the year ending March 1982. All cases were followed for one year, with in-depth interviews at onset, one month and six months and a telephone follow-up at one year to establish dead or alive status. A total of 703 episodes were registered for 680 patients, 331 men and 349 women. The crude event rate for all those over 15 years was 228 and 220 per 100,000 for men and women, respectively. Age-adjusted event rates for all strokes were 28% higher for men than women and the age-adjusted event rates for Maoris were 44% higher than for non-Maoris. The case fatality rates were 23.1% at one week, 33.5% at one month, 43.5% at six months and 48.5% at one year. In comparison with other studies, case fatality rates are similar but the incidence rates appear to be lower.

SUMMARY To examine long-term trends in subarachnoid hemorrhage (SAH) mortality and morbidity, an analysis of routinely available information is presented for the 20 year period from 1959. To document the current incidence and case fatality of SAH, the results of a large scale community-based study in the Auckland region are presented. SAH mortality rates for both men and women, especially women, have declined since the mid-1970's. The decline appears to be real, and is most striking in the 45-64 year age groups. A corresponding decline in discharge rates from hospital has also occurred in these age groups. In contrast, cases fatality rates have remained stable at about 42% for the 20 year period under review. The community-based study identified 92 cases in a total population of 829,464 in a twelve month period. The age standardised incidence rates were 13.4 and 15.8 per 100,000 for men and women respectively. In the age group 25-35 years, the incidence rate was particularly high at 8.5/100,000. Case fatality at 28 days was 52%. A decline in incidence appears the most likely explanation for the overall decline in national mortality.Stroke, Vol 14, No. 3, 1983 SUBARACHNOID HEMORRHAGE (SAH) is an important sub-category of cerebrovascular disease (CVD) because of its high mortality and its relatively frequent occurrence in young people. It is usually caused by rupture of an aneurysm, and unlike other types of stroke, diagnostic procedures more frequently confirm the clinical diagnosis. Death rates for all categories of CVD in New Zealand are declining, particularly among women, 1 and in this paper data on SAH mortality and morbidity in New Zealand for the past 20 years are examined to determine if the SAH trends follow a similar pattern. Baseline data on the incidence and case fatality at one month of SAH from a large community-based study of cerebrovascular disease in Auckland, New Zealand, are also presented. Methods (a) National Mortality and Morbidity DataBetween 1959 and 1968 SAH was classified under rubric 330 of the seventh revision of the International Classification of Diseases (ICD) and since then under rubric 430 in the eighth and ninth revisions. This change has had no effect on classification rules. Data on mortality and morbidity from SAH by age and sex, together with corresponding population figures, for the 20 year period from 1959, were provided by the National Health Statistics Centre.2 These cases were grouped into triennial periods and the age specific rates were calculated using the population for the mid-year of the period as the denominator. Mortality and hospital morbidity rates were then age standardised by the direct method to the total 1951 New Zealand population and expressed as average annual rates per 100,000 population. To identify false positives in national mortality data, all deaths certified as due to SAH in Auckland during the year beginning 1st March 1981 were identified. Information from the medical records

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