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Rationale Studies suggest that increased breastfeeding rates can provide substantial financial savings, but the scale of such savings in the UK is not known. Objective To calculate potential cost savings attributable to increases in breastfeeding rates from the National Health Service perspective. Design: and settings Cost savings focussed on where evidence of health benefit is strongest: reductions in gastrointestinal and lower respiratory tract infections, acute otitis media in infants, necrotising enterocolitis in preterm babies and breast cancer (BC) in women. Savings were estimated using a seven-step framework in which an incidence-based disease model determined the number of cases that could have been avoided if breastfeeding rates were increased. Point estimates of cost savings were subject to a deterministic sensitivity analysis. Results: Treating the four acute diseases in children costs the UK at least £89 million annually. The 2009- 2010 value of lifetime costs of treating maternal BC is estimated at £959 million. Supporting mothers who are exclusively breast feeding at 1 week to continue breast feeding until 4 months can be expected to reduce the incidence of three childhood infectious diseases and save at least £11 million annually. Doubling the proportion of mothers currently breast feeding for 7 - 1 8 months in their lifetime is likely to reduce the incidence of maternal BC and save at least £31 million at 2009-2010 value. Conclusions: The economic impact of low breastfeeding rates is substantial. Investing in services that support women who want to breast feed for longer is potentially cost saving. [ABSTRACT FROM AUTHOR]

Objective: This study assesses the evidence used for certification of the cause of death in an accident and emergency department.Methods: The subjects were all patients for whom a certificate of the cause of death was issued in the A&E department of a Scottish district general hospital over a period of two years from September 1998 to August 2000. The case notes and details of necropsies were examined for evidence of the cause of death. Patients were allocated to one of three descending categories according to the strength of the evidence available; (1) Evidence of the cause of death was available at the time of death or from postmortem examination. (2) There was a history (hospital notes/from relatives/from GP) of morbidity supporting the cause. (3) There was no recorded history of morbidity supporting the stated cause of death.Results: There were a total of 28 deaths in the A&E department over the study period. Two of the patients who died in A&E received postmortem examinations and had death certificates completed by pathologists. Death certificates were issued from A&E for a total of 24 cases. Of these 24, nine patients had strong evidence of the given cause of death and eight patients had a past history or other identifiable evidence that could support the cause of death. The cause of death in seven patients was not directly supported by available evidence.Conclusion: Death certificates issued in an A&E department were supported by strong evidence in one third of cases. Many certificates seem to be issued with slender evidence for the cause of death readily identifiable, and few patients are subjected to necropsy. [ABSTRACT FROM AUTHOR]

Objectives: A study of men with genital ulcer disease (GUD) in Durban, South Africa, at the start of the local HIV epidemic in 1988/1989 found that 36% of men with GUD continued with sexual intercourse despite symptoms. The aim of this study was to determine whether this high-risk behaviour was still prevalent and to enquire about similar risk behaviours with other sexually transmitted infection (STI)-related problems. Methods: 650 Men attending the main Durban STI clinic with a new complaint were enrolled. A standard questionnaire was administered. Polymerase chain reaction (PCR) tests were performed to diagnose genital herpes from ulcer specimens and gonorrhoea and chlamydia from those with urethral discharge and/or dysuria. Serology tests were performed for HIV, herpes simplex virus type 2 (HSV-2) and syphilis. Results: Sex since the start of symptoms was reported by between 33.3% and 43.9% of men with GUD, herpetic ulcers, gonorrhoea and/or chlamydia or dysuria. The incidence of condom use was very low in all groups having sex despite symptoms. In 87 men with genital ulcers confirmed positive for genital herpes by PCR testing, 30 (34.4%) had had sex since the start of symptoms, 28 (93.3%) of whom had had unprotected sex. Conclusions: There is a high level of risk behaviour in this group of men in whom genital herpes is the most common cause of GUD. This risky sexual behaviour could reflect disinhibition, possibly because so many have already been infected with HSV-2, lack of education or other unknown factors. Syndromic STI management should be strengthened with intensive health education to promote community awareness of both genital ulceration and genital herpes and their role in facilitating HIV transmission. The low level of condom use indicates that condom promotion programmes still have much to achieve. [ABSTRACT FROM AUTHOR]

Aims: To assess the effect of several measures of infant feeding on diarrhoeal disease, and whether these effects vary according to markers of social deprivation. Methods: Case-control study of diarrhoeal disease cases presenting to 34 general practices in England. Controls were stratified on age group, area deprivation index for the practice, and whether or not the practice was in London. Data were available on 304 infants (167 cases and 137 controls). Results: After adjustment for confounders, breast feeding was associated with significantly less diarrhoeal disease. Associations were striking even in infants aged ⩾ 6 months. They did not vary by social class, but were greater in those living in rented council accommodation and in more crowded households. The effect of receiving no breast milk was stronger in more deprived areas than in less deprived areas. The effect of not receiving exclusive breast milk was stronger in more deprived areas than in less deprived areas. In formula fed infants, there was significantly more diarrhoeal disease in those not sterilising bottles/teats with steam or chemicals. The protective effect of breast feeding did not persist beyond two months after breast feeding had stopped. Conclusions: Breast feeding protects against diarrhoeal disease in infants in England although the degree of protection may vary across infants and wear off after breast feeding cessation. Education about the benefits of breast feeding and the risks of inadequate sterilisation should be targeted at carers in deprived areas or households. [ABSTRACT FROM AUTHOR]

Background: Lateral ligament ankle sprains are the single most common sports injury. Objective: To determine the functional outcome of the ankle joint after a moderate or severe inversion injury, comparing standard treatment with an elastic support bandage against an Aircast ankle brace. Design: Prospective, randomised controlled trial. Selling: Two accident and emergency departments. Method: Fifty patients presenting consecutively were randomised into two equal groups: one group was treated with an elastic support bandage and the other with an Aircast ankle brace. All patients were given a standardised advice sheet referring to rest, ice, compression, and elevation. Patients were reviewed after 48-72 hours, 10 days, and one month. Primary outcome measure: Ankle joint function assessed at 10 days and one month using the modified Karlsson scoring method (maximum score 90). Secondary outcome measure: The difference in ankle girth (swelling) and pain score at 10 days. Results: Seventeen patients in the elastic support bandage group (six defaulted, two excluded) and 18 patients in the Aircast ankle brace group (six defaulted, one excluded) completed the study. There were no significant differences between the two groups at presentation in terms of age (mean 35.3 and 32.6 years respectively), sex, dominant leg, left or right ankle injured, previous injury, time to presentation (median three and four hours respectively), difference in ankle girth (mean 14.5 and 14.3 mm respectively), and pain scores (mean 6.2 and 5.8 respectively). The Karlsson score was significantly higher in the Aircast ankle cast group than in the elastic bandage group at 10 days (mean 50 v 35, p = 0.028, 95% confidence interval (CI) 1.7 to 27.7) and one month (mean 68 v 55, p = 0.029, 95% CI 1.4 to 24.8) (Student's t test). There was no difference between the groups in the secondary outcome measures (swelling, p = 0.09; pain, p = 0.07). When hierarchical multiple regression analysis was used to correct for possible baseline confounding factors, the Aircast ankle brace group was significantly associated with higher Karlsson scores at 10 days (p = 0.009) and one month (p = 0.024). Conclusion: The use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function at both 10 days and one month compared with standard management with an elastic support bandage. [ABSTRACT FROM AUTHOR]

Linked statistics from hospital records and death certificates were used to study the incidence of and mortality from motor neuron disease in a defined English population. The incidence of motor neuron disease, measured as first-admission rates for the disease, was studied from 1963 to 1985 and death certificates for the patients admitted to hospital were obtained to the end of 1990. The average annual first-admission rate for motor neuron disease was 2.1/100,000 men (95% confidence interval (CI) 1.9 to 2.4) and 1.7/100,000 women (95% CI 1.5 to 1.9). First-admission rates increased with age and peaked in the age range 65-84 years. Motor neuron disease was recorded on the death certificate for 86% of patients who died while they had the disease and there was no appreciable change over time in the recording of motor neuron disease as the underlying cause of death. The admission and mortality data derive from different sources, hospital statistical abstracts and death certificates respectively, but trends over time in the two data sets were similar. There was an increase in mortality during the period covered by the study, as there has been in mortality from motor neuron disease nationally, and the increase in mortality in the Oxford region was accompanied by an increase in first-admission rates. It is concluded that the increase in mortality from motor neuron disease probably occurred as a result of an increase in the diagnosed incidence of the disease rather than changes in death certification practice. [ABSTRACT FROM AUTHOR]

Most infants in the UK start solids before the recommended age of 6 months. We assessed the independent effects of solids and breast feeding on the risk of hospitalisation for infection in term, singleton infants in the Millennium Cohort Study (n = 15,980). For both diarrhoea and lower respiratory tract infection (LRTI), the monthly risk of hospitalisation was significantly lower in those receiving breast milk compared with those receiving formula. The monthly risk of hospitalisation was not significantly higher in those who had received solids compared with those not on solids (for diarrhoea, adjusted odds ratio 1.39, 95% CI 0.75 to 2.59; for LRTI, adjusted odds ratio 1.14, 95% CI 0.76 to 1.70), and the risk did not vary significantly according to the age of starting solids. [ABSTRACT FROM AUTHOR]

Naltrexone is a long acting opioid antagonist that is used in rehabilitation programmes to maintain heroin abstinence. It is a relatively new drug prescribed by specialists in substance misuse. Its actions and effects may not be familiar to many accident and emergency doctors or even to the people who take it. A case report is described where accidental ingestion of naltrexone results in a medical emergency by precipitating acute withdrawal in a heroin addict. [ABSTRACT FROM AUTHOR]

An abstract of the article "Effect of pregnancy planning and fertility treatment on cognitive outcomes in children at ages 3 and 5: longitudinal cohort study," by C. Carson, Y. Kelly, J. J. Kurinczuk, A. Sacker, M. Redshaw, and M. A. Quigley is presented.

Objective To examine the effects of pregnancy planning, time to conception and assisted reproductive treatment on expressive language ability at 3 years. Design Population-based cohort (Sweeps 1 and 2 of the UK Millennium Cohort Study). Setting UK. Participants 11 790 English-speaking singletons born 2000–2001. Exposure measure Mothers reported whether the pregnancy was planned, and their feelings when first pregnant. Women who planned their pregnancy provided time to conception (TTC) and details of any assisted reproductive treatment (ART). The population was divided into “unintended” pregnancies (unplanned and unhappy about pregnancy), “unplanned” pregnancies (unplanned but happy), “planned” (planned and TTC≤12 months), “subfertile” (planned and TTC>12 months), “ovulation stimulated (OS)” (received clomiphene citrate) and “ART” (in vitro fertilisation or intracytoplasmic sperm injection). Outcome measure Expressive language ability was assessed using the Naming Vocabulary component of the British Ability Scale. There is evidence that expressive language skills predict cognitive ability. Results 15% of pregnancies were unintended and a further 26% were unplanned. 53% were planned; 4% subfertile; 2% used OS and 1% ART to help them conceive. The mean BAS naming vocabulary score was 76.5 in the planned group and was not significantly different in the OS or subfertile groups. In the unadjusted analysis the mean score was lower among the unintended and unplanned groups (difference in mean score was −4.8 (95% CI −6.0 to 3.7) and −2.8 (95% CI −3.4 to −1.51) respectively) and higher in the ART group (3.8 (95% CI −0.2 to 7.85)). This equates to a 3.8 month cognitive delay in the unintended group, and to a 3.0 month advantage in the ART group, compared to the planned group. These effects almost entirely disappear once the models are adjusted for sociodemographic factors (parent's income, qualifications, mother's age, whether the baby is her first child and alcohol in pregnancy). Compared to the fertile group, the difference in means becomes −0.9 (95% CI −1.9 to 0.2) in the unintended group, −0.4 (95% CI −1.2 to 0.4) in the planned group and 1.2 (95% CI −2.0 to 4.4) in the ART group. Further adjustment for lifecourse mediating factors (birthweight, parent-child relationship, and parental involvement) makes little difference to the final results. Conclusions We find no evidence that pregnancy planning, subfertility or ART adversely affects children's expressive language ability at 3 years of age. The effects observed in the crude analyses are almost entirely explained by confounding by socio-economic factors, indicating that maternal education and poverty are strong influences on children's cognitive tests in early childhood. [ABSTRACT FROM AUTHOR]

Aim Our aim was to examine whether breast feeding is associated with behavioural development in children aged 5 years. Methods We used data from a large, prospective, nationally representative UK cohort, the Millennium Cohort Study. Breast feeding was ascertained from parent-interviews at baseline and child behaviour from parent-rated outcome, the Strengths and Difficulties Questionnaire (SDQ). Our analyses included 10 037 mother-child pairs with data on breast feeding, SDQ and potential confounders. 9525 of the children were born at term and 512 were preterm. We used logistic regression models to investigate the associations of breast feeding duration with abnormal parent-rated SDQ total and sub-scores at age five in term and preterm children separately. Results Overall, abnormal SDQ scores were less common in breast fed than formula-fed children. Term children breast fed for four months or longer had lower odds of an abnormal total SDQ score (multivariable-adjusted OR compared to never breast fed children: 0.65, 95% CI 0.52 to 0.82). This effect was similar for all the SDQ sub-scores. In preterm children prolonged breast feeding was generally associated with lower odds of abnormal SDQ total and sub-scores but the effect estimates were imprecise. The associations between exclusive breast feeding and abnormal SDQ scores were similar to those of any breast feeding and abnormal SDQ scores. Conclusions Our findings suggest that, at least in term children, prolonged breast feeding is associated with having fewer parent-rated behavioural problems at the age of 5 years. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about sports medicine clinics in Great Britain.

Petersen and Lippert-Rasmussen argue that, while a tax credit scheme to encourage organ donation would be costly, the increased number of organs for transplantation would lead to other savings in the healthcare system. In the present work some calculations are provided and it is suggested that, even given optimistic assumptions, the cost to the state of implementing the system as proposed would be high and unlikely to garner the support of politicians and policymakers.

Following the publication of the Weatherall report on the use of non-human primates in research, this paper reflects on how to provide appropriate and ethical models for research beneficial to humankind. Two of the main justifications for the use of non-human primates in biomedical research are analysed. These are the "least-harm/greatest-good" argument and the "capacity" argument. This paper argues that these are equally applicable when considering whether humans are appropriate subjects of biomedical research.

This paper argues that the new commercial and quasi-commercial activities of medicine, scientists, pharmaceutical companies and industry with regard to human tissue has given rise to a whole new way of valuing our bodies. It is argued that a property framework may be an effective and constructive method of exploring issues arising from this. The paper refers to A M Honoré's theory of ownership and aims to show that we have full liberal ownership of our own bodies and as such can be considered to be self-owners.

A response is given to the claim by Claxton and Culyer, who stated that the policies of the National Institute for Health and Clinical Excellence (NICE) do not evaluate patients rather than treatments. The argument is made that the use of values such as quality of life and life-years is ethically dubious when used to choose which patients ought to receive treatments in the National Health Service (NHS).