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Rib fractures are associated with significant morbidity and mortality. Ultrasound-guided thoracic paravertebral catheter insertion has been described for the management of pain secondary to rib fractures. We conducted a retrospective observational study of all patients with rib fractures who had a paravertebral catheter inserted for analgesia provision over a 4-year period. Data from the Trauma Audit and Research Network were used to compare patients with rib fractures who were managed with paravertebral catheters to those managed with systemic analgesia. A total of 314 consecutive paravertebral catheters were inserted in 290 patients. Five (1.9%) catheters were removed due to ineffective analgesia. Other minor complications occurred in three cases (0.96%). The proportion of rib fracture patients managed with paravertebral catheters increased from 31/200 (15.5%) in the first year of study to 81/168 (48.2%) in the fourth; over this time-period the observed:predicted mortality ratio fell from 1.04 to 0.66. Proportional hazard regression with and without propensity score matching demonstrated a reduction in mortality associated with paravertebral catheter use, but this became statistically non-significant when time-dependent analysis was used. Paravertebral catheters are a safe and effective technique for rib fracture analgesia; however, our data were insufficient to demonstrate any improvement in mortality. [ABSTRACT FROM AUTHOR]

A controlled comparison study was completed using interview data from 80 women each experiencing their first pregnancy whilst single. Half of the women continued their pregnancy, in some cases marrying the father. The other half obtained an abortion. Two interviewers, one male and the other female, each completed an equal number of interviews with both groups of women.The women selected for the study had the following traits: (1) never married before this, their first conception; (2) aged 17–30 years; (3) white ethnic status; (4) had not delivered or terminated the pregnancy at the time of the interview. The sample consisted of volunteers from the ante-natal and gynaecology clinics at St Mary's Hospital Medical School and Samaritan Hospital for Women, London, W.2, and Kingston and Richmond Hospitals, Surrey.Almost all topics examined in the pre-conception period turned out to be characteristic of women experiencing their first illegitimate conception, whether or not they continued the pregnancy. A detailed examination of contraceptive background revealed no significant differences between the two groups of women, with two exceptions. Women having abortions were more likely, at the time before they conceived, to have accepted the idea of using contraception. A small number of these women were also more likely to have made an effort to obtain a clinical contraceptive device.The only other pre-conception factor found to be associated with abortion involved the relationship with the father up to the time of conception. If that relationship was uncertain, less meaningful than previous ones, or a social rather than a romantic one, the woman was more likely to terminate the pregnancy.In contrast to the pre-conception period, almost all analyses of events subsequent to conception revealed differences between the two groups of women. Both concern over being discredited by other people and concealing information about the pregnancy were traits associated with having an abortion, but in a qualitative rather than an absolute sense. These aspects of social stigma were common to all women before the first pregnancy test, but became more evident amongst women having abortions once the pregnancy had been clinically confirmed. Both concern over being discredited and concealing the pregnancy were experienced in relation to particular persons. For women terminating their pregnancies these were usually their parents.The degree of acceptability of abortion and unmarried motherhood differed between the groups, but they were similar in their views on the acceptability of marriage with pregnancy and adoption. These four alternatives were further examined in terms of the women's preferences and here the two groups differed.Finally, there were differences between the groups in the effect of the pregnancy on the relationship with the putative father. Women having abortions were more likely to find themselves in a relationship that had either finished or was likely to finish after the father knew of the pregnancy. Some were pregnant by a social acquaintance which precluded either marriage or joint parenthood.The findings are discussed in terms of the relationship between contraception and abortion for the single woman and consideration is given to the implications for fertility research and contraceptive and pregnancy services. [ABSTRACT FROM PUBLISHER]

OBJECTIVES: To investigate the changing nature of the benign screen detected breast abnormalities removed at open biopsy over a seven year period and to compare this with the improving cancer detection rate and non-operative diagnosis rate. SETTING: The Bolton, Bury, and Rochdale Breast Screening Programme. METHODS: The histopathology reports of the benign lesions removed from patients undergoing open biopsy for screen detected abnormalities between 1 April 1994 and 31 March 2001 were reviewed and the lesions classified on the B1 to B5 scale. Cancer detection rates and non-operative cancer diagnosis rates were ascertained from the breast screening computer system. RESULTS: 148 benign surgical biopsies were performed in the seven year period. There was a moderate increase in the overall benign biopsy rate over the period (from 1.26 open biopsies per 1000 women screened for the three years 1994–97 to 1.63 open biopsies per 1000 women screened for the three years 1998–2001). The biopsy rate for B2 (benign) lesions decreased slightly over the study period but the biopsy rate for B3 lesions (that is, of uncertain malignant potential) more than doubled. The majority (84%) of the B3 lesions were radial scars. There was a steady improvement in the cancer detection rate and the non-operative cancer diagnosis rate over the period, similar to that seen nationally. CONCLUSIONS: Improvements in screening technique and detection ability result in an increase in the number of subtle radiologically indeterminate or suspicious lesions detected. Many of these are radial scars, which require excision. Crude benign open biopsy rates for screening programmes are no longer meaningful, and should now be refined with separate rates for B2 lesions and B3 lesions. High quality programmes can expect to have low B2 open biopsy rates and high B3 open biopsy rates. It is inappropriate to have an upper limit for the B3 open biopsy rate. [ABSTRACT FROM AUTHOR]

Background: The coronavirus (COVID-19) pandemic resulted in the rapid implementation of remote consultations to maintain musculoskeletal physiotherapy services. However, little is known about UK musculoskeletal physiotherapists' experiences of providing services during the COVID-19 pandemic., Objectives: To explore musculoskeletal physiotherapists' experiences of using remote consultations in one area of England during the COVID-19 pandemic., Design: Qualitative study using hermeneutic phenomenology based on the approach of Gadamer., Methods: Semi-structured interviews with twelve musculoskeletal physiotherapists were conducted online using Microsoft Teams. Data were analysed using frameworks based on the philosophical concepts of Gadamer's hermeneutics., Findings: Musculoskeletal physiotherapists' experience of using remote consultations during the COVID-19 pandemic was framed by three concepts: therapeutic relationship, transformational change, and uncertainty. These concepts are underpinned by four main themes capturing their experiences: (1) Disconnection: Difficulties building a rapport and reduced non-verbal communication affected building an effective therapeutic relationship, (2) Necessity: Transformation of services to remote consultations was positive, although technology and connectivity issues had a negative impact, (3) Loss of control: Diagnostic uncertainty, being unprepared, and experience affected physiotherapists' clinical practice, (4) Protection: Peer support and the use of technology facilitated a feeling of protection for physiotherapists., Conclusion: The findings of this study contribute to a better understanding of musculoskeletal physiotherapists' experience of using remote consultations during the COVID-19 pandemic. Implications for practice include the need to provide training for all musculoskeletal physiotherapists and undergraduates to enable the effective delivery of remote physiotherapy. Furthermore, digital infrastructure should be optimised to support future delivery of remote musculoskeletal physiotherapy services., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Complex Regional Pain Syndrome (CRPS) is a disabling and distressing chronic pain condition characterised by a range of sensory, motor, autonomic and trophic symptoms. Guidelines recommend early referral for therapies that promote movement of the painful limb. However, evidence suggests a lack of defined therapy pathways for CRPS., Aims: The current study aims to explore CRPS therapy management in centres of excellence in England, and outside of these settings, to understand what facilitates and hinders best practice. The overall aim is to develop a draft stratified package of care to expedite patient access to optimal CRPS therapy across the management pathway., Methods and Analysis: Semi-structured interviews will be conducted with therapists working in CRPS centres of excellence and with therapists in other settings. Observations of therapy interventions in CRPS centres of excellence and interviews with patients who have received this care, will also help to identify potential key care package components. Interview data will be analysed using thematic analysis, mapped to the Theoretical Domains Framework (TDF), and Intervention Mapping Adapt (IMA) framework. Observations will be described and documented using the TDF headings., Conclusion: A triangulation protocol for qualitative health research will be used to integrate all data. Online stakeholder events will be held using consensus methods to agree a draft package of care for future implementation following further refinement, testing and evaluation., Clinical Trial Registration: The trial was registered with ISRCTN registry on 24 February 2022 (ISRCTN16917807)., (© 2023 The Authors. Musculoskeletal Care published by John Wiley & Sons Ltd.)

Background: As a result of long delays for physiotherapy for musculoskeletal problems, several areas in the UK have introduced PhysioDirect services in which patients telephone a physiotherapist for initial assessment and treatment advice. However, there is no robust evidence about the effectiveness, cost-effectiveness or acceptability to patients of PhysioDirect., Objective: To investigate whether or not PhysioDirect is equally as clinically effective as and more cost-effective than usual care for patients with musculoskeletal (MSK) problems in primary care., Design: Pragmatic randomised controlled trial to assess equivalence, incorporating economic evaluation and nested qualitative research. Patients were randomised in 2 : 1 ratio to PhysioDirect or usual care using a remote automated allocation system at the level of the individual, stratifying by physiotherapy site and minimising by sex, age group and site of MSK problem. For the economic analysis, cost consequences included NHS and patient costs, and the cost of lost production. Cost-effectiveness analysis was carried out from the perspective of the NHS. Interviews were conducted with patients, physiotherapists and their managers., Setting: Four community physiotherapy services in England., Participants: Adults referred by general practitioners or self-referred for physiotherapy for a MSK problem., Interventions: Patients allocated to PhysioDirect were invited to telephone a senior physiotherapist for initial assessment and advice using a computerised template, followed by face-to-face care when necessary. Patients allocated to usual care were put on to a waiting list for face-to-face care., Main Outcome Measures: Primary outcome was the Short Form questionnaire-36 items, version 2 (SF-36v2) Physical Component Score (PCS) at 6 months after randomisation. Secondary outcomes included other measures of health outcome [Measure Yourself Medical Outcomes Profile, European Quality of Life-5 Dimensions (EuroQol health utility measure, EQ-5D), global improvement, response to treatment], wait for treatment, time lost from work and usual activities, patient satisfaction. Data were collected by postal questionnaires at baseline, 6 weeks and 6 months, and from routine records by researchers blind to allocation., Results: A total of 1506 patients were allocated to PhysioDirect and 743 to usual care. Patients allocated to PhysioDirect had a shorter wait for treatment than those allocated to usual care [median 7 days vs 34 days; arm-time ratio 0.32, 95% confidence interval (CI) 0.29 to 0.35] and had fewer non-attended face-to-face appointments [incidence rate ratio 0.55 (95% CI 0.41 to 0.73)]. The primary outcome at 6 months' follow-up was equivalent between PhysioDirect and usual care [mean PCS 43.50 vs 44.18, adjusted difference in means -0.01 (95% CI -0.80 to 0.79)]. The secondary measures of health outcome all demonstrated equivalence at 6 months, with slightly greater improvement in the PhysioDirect arm at 6 weeks' follow-up. Patients were equally satisfied with access to care but slightly less satisfied overall with PhysioDirect compared with usual care. NHS costs (physiotherapy plus other relevant NHS costs) per patient were similar in the two arms [PhysioDirect £ 198.98 vs usual care £ 179.68, difference in means £ 19.30 (95% CI -£ 37.60 to £ 76.19)], while QALYs gained were also similar [difference in means 0.007 (95% CI -0.003 to 0.016)]. Incremental cost per QALY gained was £ 2889. The probability that PhysioDirect was cost-effective at a £ 20,000 willingness-to-pay threshold was 88%. These conclusions about cost-effectiveness were robust to sensitivity analyses. There was no evidence of difference between trial arms in cost to patients or value of lost production. No adverse events were detected., Conclusions: Providing physiotherapy via PhysioDirect is equally clinically effective compared with usual waiting list-based care, provides faster access to treatment, appears to be safe, and is broadly acceptable to patients. PhysioDirect is probably cost-effective compared with usual care.

Background: Microaspiration is often considered a potential cause of cough. The aim of this study was to investigate the relationship between microaspiration, the degree and type of gastroesophageal reflux, and the frequency of coughing in patients with chronic cough., Methods: One hundred patients with chronic cough (mean [± SD] age, 55.8 years [± 11.0 years]; 65 women) and 32 healthy volunteers (median age, 43.5 years [interquartile range (IQR), 30-50.8 years]; 16 women) were recruited. Patients with chronic cough performed 24-h objective cough frequency with simultaneous esophageal impedance/pH monitoring and measurement of pepsin concentrations in sputum and BAL. Twelve healthy volunteers underwent bronchoscopy/BAL, and 20 underwent impedance/pH monitoring., Results: Patients with chronic cough had significantly more reflux episodes than healthy volunteers (median, 63.5 reflux episodes [IQR, 52.5-80.0] vs 59.0 [IQR, 41.8-66.0]; P = .03), although the absolute difference was small, and there was no difference in numbers of events extending into the proximal esophagus (median, 17.2% [IQR, 8.0%-26.0%] vs 20.3% [IQR, 5.1%-32.1%]; P = .36). BAL pepsin levels were also similar in chronic cough to control subjects (median, 18.2 ng/mL [range, 0-56.4 ng/mL] vs 9.25 ng/mL [range, 0-46.9 ng/mL]; P = .27). Sputum but not BAL pepsin weakly correlated with the number of proximally occurring reflux events (r = 0.33, P = .045) but was inversely related to cough frequency (r = −0.52, P = .04). Sputum pepsin was, therefore, best predicted by combining the opposing influences of cough and proximal reflux (r = 0.50, P = .004)., Conclusions: Proximal gastroesophageal reflux and microaspiration into the airways have limited roles in provoking chronic cough. Indeed, coughing appears to be protective, reducing pepsin concentration in the larger airways of patients with chronic cough.

Background: In view of public concern about standards of emergency care in independent hospitals and the impact of transferred patients on NHS facilities we aimed to estimate the number and risk of emergency transfers from independent hospitals to NHS hospitals; to describe the circumstances; and estimate costs to the NHS., Methods: Patients transferred in three months from 137 independent hospitals were identified from central records systems and local hospital enquiries. Circumstances were described by Directors of Nursing in telephone interviews. Numbers were weighted for whole year activity and non-participating hospitals to estimate total transfers in 1999. Medical Directors of NHS Trusts receiving the patients supplied durations of stay in critical care and other facilities. NHS Reference Costs were applied., Results: There were 158 emergency transfers (plus 105 planned transfers, and 18 as a result of funding problems). Proportionately more emergency transfers were from hospitals lacking intensive care facilities. Patients over 65 years old constituted 61 per cent of transfers but only 25 per cent of all cases. Transfer followed major abdominal surgery in 42 (26 per cent) cases and major orthopaedic surgery in 31 (20 per cent), although these treatments constituted only 2 per cent and 3 per cent of the caseloads. There were an estimated 749 emergency transfers in 1999 (95 per cent confidence interval 640-875), a risk of 1 in 956 (all ages) and 1 in 392 (aged over 65); 729 had been funded privately, of whom two-thirds became NHS patients after transfer, costing Pound Sterling 2.61 million., Conclusions: The scale of emergency transfer (two per day) and resulting cost to the NHS is small. The risk is reducible if patients and interventions are matched to hospitals' critical care capabilities. Common clinical service guidelines should apply to NHS and independent hospitals.

Objectives: To study the association between community influenza activity and acute hospital admissions for pneumonia and influenza among elderly persons., Design: Multiple regression analysis of acute hospital admissions against community influenza activity, air temperature and seasonal and long-term trends., Setting: Three English health districts: 1987-95., Subjects: Persons aged > or = 65 years., Outcome Measures: Acute hospital admissions for pneumonia and influenza (ICD9: 480-487); excess hospital admissions during epidemic periods., Results: The final regression model explained 70% of the total variation in hospital admissions for pneumonia and influenza, including 14% due to community influenza activity. However, most variation was explained by long-term and seasonal changes unrelated to influenza. In the large influenza epidemic of 1989/90 a typical health district (500,000 total population) experienced 56 excess admissions for pneumonia and influenza attributable to epidemic influenza among persons aged > or = 65 years, requiring 672 additional bed-days. However the figure varied widely between seasons and over the whole study period, the average winter excess was 17.5 admissions per health district, requiring an additional 210 bed-days., Conclusions: Influenza epidemics exert a variable impact on acute hospital admissions for pneumonia and influenza among elderly persons, which in the past have been poorly quantified. Although the absolute numbers of excess admissions is modest, their impact on bed availability may be considerable because of the duration of hospital stay in elderly persons.

Influenza vaccination for healthcare workers is not recommended in Britain, but some hospitals offer vaccine to reduce sickness absence. However, in Nottingham, the influenza epidemics of 1993-94 and 1996-97 made no impact on staff absence. Annual vaccination of healthcare workers against influenza is unlikely to reduce absence most winters, but there may be gains in terms of preventing nosocomial infection.

Objective: To use information collected by the Confidential Enquiry into Stillbirths and Deaths in Infancy to help obstetric, midwifery and paediatric practice in the management of shoulder dystocia., Design: Review of casenotes by a multidisciplinary focus group., Sample: All 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy from England, Wales and Northern Ireland in 1994 and 1995, where stillbirth or neonatal death was attributed to shoulder dystocia., Main Outcome Measures: Case notes were reviewed with respect to a range of perinatal variables. Comparisons were made with normative data from other studies when appropriate., Results: Maternal obesity and big babies were over-represented in pregnancies complicated by fatal shoulder dystocia. Fetal compromise was recorded in 26% of labours. The median time interval between delivery of the head and the rest of the body was only five minutes. The lead professional at the time the head was delivered was a midwife in 65% of cases. Middle grade or senior obstetric staff were supervising 47% of cases by the time the body was delivered., Conclusions: Antenatal prediction of shoulder dystocia is imprecise, and the majority of deliveries are attended by midwives. A relatively brief delay in delivery of the shoulders may be associated with a fatal outcome.

The effectiveness of influenza vaccine in reducing hospital admissions for pneumonia, influenza, bronchitis, or emphysema was assessed by a case-control study of people aged 16 years and older who were admitted to 10 Leicestershire hospitals between 1 December 1989 and 31 January 1990. Hospital and general practitioners' records for 156 admissions (the cases) and 289 controls matched for age and sex were reviewed. Information was collected on demography, the usual place of residence (institutional or non-institutional), the existence of chronic illness, and vaccination during the 5 years before admission. The odds ratio for hospital admission among vaccinees was 0.67 (95% CI 0.39-1.12) giving an estimate of vaccine effectiveness in this setting of 33% (95% CI 0-61). However, multivariate logistic regression, adjusting for the effects of institutional care and chronic illness, revealed that influenza vaccination reduced hospital admissions by 63% (95% CI 17-84%). There was a strong trend towards improved vaccine effectiveness when used in institutional settings. Influenza vaccine is effective in reducing hospital admissions for influenza, pneumonia, bronchitis and emphysema, and effectiveness is comparable to that observed for influenza and pneumonia admissions in North America.

Objective: To examine the quality of social support among unemployed residents in Trent, England., Design: Secondary analysis of data generated by those of working age drawn from a postal lifestyle survey of the adult population of Trent region., Subjects and Setting: Subjects were 6987 individuals (males 16-64 years and females 16-59 years of age), of whom 9.9% (689/6987) were unemployed., Main Outcome Measures: Responses about the quality of social support obtained from three key questions., Results: Generally, the unemployed reported poorer quality of social support than employed persons (p < 0.0001) on all three key elements examined: 31% v 17% respectively had no practical support; 19% v 10% had no help with solving problems, and 21% v 10% had no emotional support. Only 57% of the unemployed had all three of these elements compared with 75% of the employed. Unemployment and lack of social support had independent and deleterious effects on perceptions of general health and mental health. Relationships remained after allowing for the possible confounding effects of age, gender, and household composition., Conclusions: There is a relationship between unemployment and poorer quality of social support which may help to explain some of the increased morbidity and mortality experienced by this group, especially that related to mental health.

Background: The elderly residents of nursing and old people's homes are at substantially increased risk from influenza and its complications. Annual vaccination is therefore strongly recommended by the UK Departments of Health. However, few data exist on the uptake of influenza vaccine in this setting; this was last estimated to be 45 percent in 1988-1989. A major epidemic of influenza A occurred in 1989-1990 which may have changed vaccination behaviours., Methods: A structured interview survey was conducted in 49 old people's homes in Nottingham to determine practices and policies for influenza vaccine. The medical records of 151 randomly selected elderly residents were examined to determine vaccine uptake in the 1992-1993 season., Results: Twenty-five homes (52.1 percent) claimed to operate a policy for influenza immunization but only 3 (12.0 percent) were written down and none set targets. Methods of vaccine promotion were generally weak. Accordingly, vaccine uptake was only 39.6% percent (95 percent confidence interval 33.2-46.0)., Conclusions: In contrast to other high-risk groups living in the open community, no improvement in influenza vaccine uptake has occurred in nursing and old people's homes since the late 1980s. Future attempts to increase vaccine uptake in this setting should focus on developing joint policies between general practitioners and home staff to facilitate better co-ordinated programmes of vaccine promotion and administration.

Objective: Assessment of outcome after varicose vein surgery., Design: Prospective study using the Health Assessment Questionnaire (SF36) which considers different aspects of overall health., Setting: University Hospital and Community., Materials: 150 patients undergoing varicose vein surgery., Chief Outcome Measures: SF36 questionnaires were sent pre-operatively and at 1 and 6 months post surgery., Main Results: Eighty-nine (59%) patients answered all three questionnaires. Pre-operatively their overall health was similar to that of the general population. The "cost" to the patient of the operation was demonstrated by an increased pain and reduced role function at 1 month post-operation (p < 0.01). By 6 months post-operation, when compared with preoperative values, all dimensions except social function and health perception were improved (p < 0.01). Overall symptoms improved (p < 0.01) by 1 month and were further improved at 6 months., Conclusions: The general good health of varicose vein patients may justify the low priority given to their treatment, but the improvement in symptoms and general health that relatively simple surgery provides should ensure its continued provision as a health care service.

Objective: To find out whether women with bacterial vaginosis detected early in pregnancy are at increased risk of preterm delivery., Design: Prospective description cohort study., Setting: Antenatal clinic in a district general hospital., Subjects: 783 women examined during their first antenatal clinic visit and screened for recognised risk factors for preterm delivery and the presence of bacterial vaginosis or intermediate abnormal flora detected by examination of a vaginal smear stained by Gram's method., Main Outcome Measures: Gestational age at delivery classified as late miscarriage (16-24 weeks' gestation), preterm delivery (24-37 weeks' gestation), term delivery (> or = 37 weeks' gestation)., Results: Multiple logistic analysis showed that there was an increased incidence of preterm delivery in women with a previous preterm delivery (9/24; odds ratio 25; 95% confidence interval 9 to 70; P < 0.001) and bacterial vaginosis (9/115; 2.8; 1.1 to 7.4; P = 0.04). A further logistic analysis of data from women recruited before 16 weeks' gestation showed that preterm deliveries or late miscarriages occurred more often in women with bacterial vaginosis (12/77; 5.5; 2.3 to 13.3; P < 0.001)., Conclusions: Late miscarriage and preterm delivery are associated with the presence of bacterial vaginosis in early pregnancy. This is independent of recognised risk factors such as previous preterm delivery.

Study Objective: The study aimed to consider the impact of two different types of reminder on response rates and costs in a postal survey., Design: The study was a cross sectional survey. A self-completion lifestyle questionnaire was used. Those who did not respond after the initial mailing were randomly allocated to receive either a postcard or questionnaire as a first reminder. All outstanding non-responders received a questionnaire as a second reminder., Subjects: A representative sample of 698 adults aged 16-70 was used, drawn from a family health services authority register., Main Results: Postcard reminders were as effective as questionnaire reminders in increasing response whether one or two reminders are sent. The costs per response were calculated. Two questionnaires as reminders were found to be 1.7 times more expensive than a postcard plus questionnaire. Including the initial mailing, the cost per response using all questionnaires was 1.3 times the cost when a postcard was used for the first reminder., Conclusions: To increase the response to a postal survey effectively and economically, two reminders should be sent--first a postcard and then a questionnaire.

To assess problems of care in a private nursing home an observational study was carried out over two months, during which a research nurse worked as a member of the staff in a home caring for 25 patients aged 62-90. During the second month a consultant physician visited the home weekly to hold case conferences and assess each patient's functional ability and drug regimen. Various problems in medical, nursing, and bureaucratic matters were identified--for example, staff failed to understand the appropriate response to various medical symptoms; no clear policy existed for managing pressure sores; and one patient's anticoagulant state could not be assessed when industrial action meant that transport to take him to hospital was not available--and several changes in drug treatments were recommended. The problems that were identified were mainly due to poor communication between the home and general practitioners and hospitals and to the lack of guidance policy on common issues that arise in long term care. Such a policy could be produced by health authority staff, general practitioners, and representatives of nursing homes.

Medical students in Nottingham all complete an honours Bachelor of Medical Sciences course in one department including a research project. The honours programme in community health is described, with results from a survey of the 122 graduates since the medical school started. The 98 (80%) responses showed high levels of satisfaction and gain from the programme, the great majority regarding the course as valuable, enjoyable, and giving both research skills and skills in interpersonal relationships.

An Asian patient with undiagnosed typhoid fever was admitted to a maternity hospital and delivered within 10 min. Salmonella typhi (phage type D5) was isolated from her blood and from the faeces of her baby. Another women in a different room of the labour suite at the same time acquired the same organism in her faeces; her brother was admitted to the Infectious Diseases Unit 5 weeks later with typhoid fever. Two babies, born over 60 h after the index case was delivered, became faecal excreters of the same strain and one of them also developed S. typhi osteitis of the hip. These two babies and their mothers were in the same ward as each other, but not that occupied by the infected mother and her baby. Nine other excreters in two of the families involved were identified. The index case and her baby were isolated immediately after delivery, and the relevant rooms in the labour suite were adequately disinfected. No evidence of undisinfected equipment used by the index case and the other infected patients was found, and no spread to staff was detected. The mode of spread remains unknown.

A method of improving information about injuries sustained in road traffic accidents is described. It was achieved by combining data from the police with that from the accident and emergency department in such a way that patient confidentiality was preserved. This improved data base shows that present estimates of the number of injuries sustained on the road are too low and that assessments of their severity are probably inaccurate.

Studies carried out in 1978 and 1981 found postneonatal mortality to be associated with poor environmental conditions. Since then, many changes have occurred to the environment. This study was designed to discover which factors are now associated with a higher risk of postneonatal death. A retrospective case-control study was carried out using 107 cases and 422 controls matched only for date of birth, to look at the effect of area of residence, social class, mother's age, and sex, birthweight, legitimacy and number of siblings. Fifty-eight per cent of the deaths were due to the sudden infant death syndrome, making this the leading cause of death. Causes previously absent from the death certificates are now appearing, particularly prematurity related deaths which now account for almost 6 per cent. The deaths were found to occur more frequently at home, in the winter, and at a peak age of 2 to 4 months. As shown previously in Nottingham, the deaths were more likely to have been male (relative risk 2.03), illegitimate (2.91), and of low birthweight (28.8). Total mortality was significantly higher in babies of mothers aged 19 or less and in babies of manual workers. Surprisingly, babies born to unemployed parents were found to have a very low relative risk of death (0.26). Mortality is still higher in the city than the suburbs and in areas of deprivation. Although still a risk factor for SIDS, high parity of the mother was found to be non-significant for postneonatal mortality in total.(ABSTRACT TRUNCATED AT 250 WORDS)