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BACKGROUND: Training in patient safety is an important element of medical education. Most educational interventions on patient safety training adopt a 'health-professional lens' with limited consideration on the impact of safety lapses on the patient and their families and little or no involvement of patients in the design or delivery of the training. AIMS: This paper describes a pilot study to test the feasibility and acceptability of implementing a patient-led educational intervention to facilitate safety training amongst newly qualified doctors. METHOD: Patients and/or carers who had experienced harm during their care shared narratives of their stories with trainees; this was followed by a focused discussion on patient safety issues exploring the causes and consequences of safety incidents and lessons to be learned from these. RESULTS: The intervention, which will be further tested in an NIHR-funded randomised controlled trial (RCT), was successfully implemented into an existing training programme and found acceptance amongst the patients and trainees. CONCLUSION: The pilot study proved to be a useful step in refining the intervention for the RCT including identifying appropriate outcome measures and highlighting organisational issues.

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Clinical governance is an essential part of quality assurance for everyday clinical practice. It is part of the generic curriculum for all specialist registrars (SpRs) training in medical specialities. The authors of this update undertook a survey of SpRs training in geriatric medicine to determine their perceived knowledge of clinical governance and whether they had received training in this area.

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Hospital-at-home schemes are becoming an increasingly popular way of delivering health care world-wide. Schemes differ in the type of patients they cater for and in the intensity and complexity of treatment they provide. Although they have been in existence since 1961, there have been few randomized controlled studies to determine their effectiveness as an alternative to standard hospital care. Furthermore, some studies have produced conflicting results. Although there is accumulating evidence that they produce satisfactory patient outcomes and are acceptable to patients and carers, their cost-effectiveness is still uncertain. Further randomized controlled studies incorporating prospective cost analyses are needed. This paper discusses the evidence to support hospital-at-home as an alternative and complementary model of health care particularly for older people.

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BACKGROUND: Rates of Clostridium difficile diarrhoea have recently been rising, with the elderly being at highest risk. AIM: To compare the incidence of C. difficile colonization and diarrhoea in elderly patients treated for presumed infection with either empirical cefotaxime (CTX) or piperacillin-tazobactam (PT). METHODS: A prospective, ward-based, crossover study was carried out on two well-matched care of the elderly wards at a UK tertiary care hospital, in patients requiring empirical broad-spectrum antibiotic treatment. RESULTS: There was a highly significant increased incidence of C. difficile colonization (26/34 vs. 3/14, P=0.001) and diarrhoea (18/34 vs. 1/14, P=0.006) in patients who received CTX as opposed to PT. DNA fingerprinting suggested that most infections arose from strains acquired from the hospital environment. CONCLUSIONS: Elderly patients are significantly less likely to develop C. difficile diarrhoea after treatment with PT than after CTX. The source of C. difficile appears to be predominantly from the ward environment.

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In a randomised, double-blind, controlled trial, a comparison was made of the relative efficacy of using streptokinase/streptodornase (Varidase) in a hydrogel (KY Jelly) or the hydrogel alone in the debridement of Grade IV pressure sores. Seventeen subjects aged 57-94 years (mean age 81) took part; 21 sores were studied, 11 of which were randomised to the enzyme treatment regime. Both treatments led to eschar removal; fewer days were needed in the hydrogel-only group (mean 8.1 days, sd 1.8) compared to the enzyme/hydrogel group (mean 11.8 days, sd 2.9), but this was not statistically significant. The results suggest that the use of hydrogel alone may be a cost-effective alternative to the use of streptokinase/streptodornase and hydrogel in the treatment of these wounds.

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We studied the prevalence of Clostridium difficile over a period of 2 months on a mixed-function geriatric ward. Seven (14%) of the 49 patients were long-stay but the remainder were in hospital for acute illness or required a short period of active rehabilitation. Although 69% patients had recently received antibiotics, from only two (4%) was C. difficile isolated from their faeces. Our results show that C. difficile is not endemic in patients on all geriatric wards as has been previously suggested.

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In a 2-year double-blind placebo controlled study an immunological evaluation was carried out on 33 patients (15 males, 18 females, mean age 29.2 years) with mite-induced perennial rhinitis who were submitted to specific immunotherapy (IT) with an alginate-conjugated extract of D. pteronyssinus. The behaviour of IgE, IgG, IgG1 and IgG4 antibodies specific to D. pteronyssinus and its major allergen Der p1 was characterized by assessment of their changes in serum, and changes in IgG in nasal secretions during the treatment. The placebo-treated patients did not show any significant variation in the levels of specific antibodies, while in the actively treated patients we found: a statistically significant decrease (P less than 0.005) of specific IgE, a statistically significant increase of specific IgG (P less than 0.005), IgG1 (P less than 0.005) and IgG4 (P less than 0.005) in serum and a statistically significant increase (P less than 0.001) of specific IgG in nasal secretions. The IgG response showed an early relative predominance of the IgG1 subclass and a late absolute predominance of IgG4 subclass, that confirmed the model of IgG4 restriction in prolonged allergen stimulation. No correlation was found between immunological and clinical data.

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Serological tests for syphilis were performed on 659 elderly patients admitted to hospital medical and psychiatric departments. Positive tests were found in 23 patients (3.5% of the sample), 17 women and 6 men. Six were subsequently discovered to have been treated previously for syphilis, and one other had radiological evidence to suggest that she had been treated with bismuth in the pre-penicillin era. Difficulties were encountered in classifying the stage of infection in some patients, particularly those with significant intellectual impairment. Eleven were diagnosed as late latent syphilis, seven as probable late latent syphilis, one as tabes dorsalis, one as possible cardiovascular syphilis, one as possible meningovascular syphilis, and one as late congenital syphilis.

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The efficacy of hyposensitization with a standardised extract of Dermatophagoides pteronyssinus (D. pteronyssinus) conjugated to alginate and containing known amounts of antigen P1 (Conjuvac) was tested in a double blind, placebo controlled, multi-centre study in 66 adult patients with perennial rhinitis. Patients received 11 weekly injections of increasing concentrations of Conjuvac containing from 56 x 10(1) to 448 10(3) IU D. pteronyssinus or placebo injections of the alginate diluent to some of which 5 micrograms of histamine has been randomly added. This was followed by 15 monthly injections of Conjuvac or placebo. The severity of nasal blockage, sneezing and rhinorrhoea was recorded twice daily in a diary and visual analogue assessments (VAS) made at each clinic visit. Nasal provocation testing (NPT) was performed with increasing concentrations of the same extract of D. pteronyssinus as used in the hyposensitization injections, and changes in nasal airways resistance measured by passive anterior rhinomanometry. VAS was recorded and NPT was performed on entry to the study and after the fifth, ninth and final monthly injection. Conjuvac injections were well tolerated. Large local reactions (greater than 5 cm) occurred within 30 min in only 1% of patients but later in 23%. No systemic reactions or anaphylaxis occurred within 30 min of injections, but urticaria or worsening of asthma and rhinitis was reported later in 3% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

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Blood alcohol levels were estimated in 141 patients admitted acutely over a one month period to a geriatric unit. Only four (2.8%) had alcohol detectable in their blood. The levels were low, suggesting that alcohol intoxication is not a major factor in the admission of the elderly to hospital.

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We have studied the outcome of geriatric patients with lengths of stay exceeding 180 days. In 1985 there were 77 of these patients (37 discharges and 40 deaths) representing 2.8% of all discharges and deaths in that year. Female long stay patients survived longer than their male counterparts. Forty six per cent of patients were discharged to their own homes or local authority residential homes and 46% to private care. Elderly patients may be successfully discharged from hospital despite a protracted hospital stay.

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It is unusual for disorders of sexual differentiation to be first diagnosed in old age. We describe a case of 46XY pure gonadal dysgenesis, aged 93 years at the time of diagnosis, the oldest patient with this disorder ever reported.

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We describe a patient who developed rectal ulceration after an apparently minor injury caused during the administration of a 130 ml 'disposable' phosphates enema. Treatment included parenteral antibiotics and a colostomy. Minor degrees of injury by rectal procedures are common. Rectal necrosis is a complication of injury during the administration of phosphates enemata which, although rare, deserves greater awareness. Painless rectal bleeding may be the only sign of injury and is an indication for thorough and repeated rectal examinations and early intervention.

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1. Changes in nasal airways resistance (NAR) following the topical application of histamine and allergen solutions were measured by passive anterior rhinomanometry. 2. The repeatability of five consecutive measurements of resting NAR prior to provocation with histamine or allergen (expressed as the coefficient of variation) was 32.8% and following instillation of saline control solution 37.2%. 3. The repeatability of five consecutive measurements of NAR during the nasal obstruction produced by histamine and allergen was similar to that recorded prior to provocation; the coefficients of variation (median values) being 39.6% and 33.1% respectively. The degree of variability was not related to the dose of agonist or the degree of nasal obstruction. 4. The reproducibility of histamine or allergen induced changes in NAR on four separate weekly occasions showed no significant intra-subject differences. 5. The effects of sodium cromoglycate (SCG), clemastine and ketotifen administered to the nasal mucosa 30 min before provocation with histamine and allergen were compared in a random order, double-blind, placebo controlled study. 6. Clemastine and SCG, but not ketotifen, significantly inhibited the nasal response to increasing concentrations of histamine. None of the drugs administered in the concentrations used in this study significantly inhibited the nasal response to allergen.

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We have investigated the effect of nedocromil sodium in preventing the symptoms of rhinitis occurring immediately after allergen provocation in 10 patients with allergic rhinitis. The study had a double-blind, placebo-controlled, crossover design. Nedocromil sodium (1% w/v) and placebo were administered intranasally from identical metered-dose inhalers 20 minutes before allergen provocation. Three variables were measured: nasal airway resistance, the production of secretion, and the number of sneezes. Nedocromil sodium was significantly more effective than placebo in preventing nasal obstruction (p less than 0.01), rhinorrhea (p less than 0.01), and sneezing (p less than 0.05), suggesting that this drug may be useful in the treatment of allergic rhinitis.

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Systemic amyloid (AL) was diagnosed by abdominal wall fat biopsy in an 81 year old woman presenting with severe postural hypotension. The advantages of this little-used diagnostic method are discussed.

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