Objective: To assess direct and indirect evidence of active infection which may benefit from further antibiotics in adults who reconsult within 4 weeks of initial antibiotic management of acute lower respiratory tract infection in primary care. Design: Observational study with a nested case-control group. Setting: Two suburban general practices in Arnold, Nottingham, over 7 winter months. Subjects: 367 adults aged 16 years and over fulfilling a definition of lower respiratory tract infection and treated with antibiotics. 74 (20%) patients who reconsulted within 4 weeks for the same symptoms and 82 "control" patients who did not were investigated in detail at follow up. Main outcome measures: Direct and indirect evidence of active infection at the time of the reconsultation or the follow up visit with the research nurse for the controls. Investigations performed included sputum culture, pneumococcal antigen detection, serial serology for viral and atypical pathogens and C reactive protein, throat swabs for detecting viral and atypical pathogens by culture and polymerase chain reaction, and chest radiographs.

Background-Acute lower respiratory tract illness in previously well adults is usually labelled as acute bronchitis and treated with antibiotics without establishing the aetiology. Viral infection is thought to be the cause in most cases. We have investigated the incidence, aetiology, and outcome of this condition. Methods-Previously

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Objective To assess whether sharing the uncertainty of the value of antibiotics for acute bronchitis in the form of written and verbal advice affects the likelihood of patients taking antibiotics.

These data demonstrate that simple clinical methods can be used to categorize features of individual ulcers, and that area, depth and arteriopathy contribute independently to a model to predict outcome. A system of classification such as this is an essential requirement for the categorization of populations with similar features and similar prognosis, which may then be used as the basis for prospective research into optimal wound management.

A century of aryne chemistry has not dampened the interest in this class of reactive intermediates. The cover picture shows the structure of a calicheamicin–DNA complex, the “warhead” of which is a cyclic enediyne unit (highlighted). The biological activity of the enediyne cytostatics is based on the depicted Bergman cyclization of the enediyne to a didehydrobenzene biradical. More about these short‐lived species is given by Sander et al. on pp. 502 ff.

Respiratory symptoms are the most common cause of general practitioner (GP) consultation, and hospital-based specialists are often called on to provide management guidelines, particularly in the area of antibiotic prescribing. The present authors have assessed factors associated with antibiotic use by 115 GPs when managing 1089 adults with an acute lower respiratory tract illness, including cough. They prescribed antibiotics to three-quarters of patients, but felt antibiotics to be definitely indicated in less than one-third of these cases and not needed in one-fifth. Univariate analysis revealed that antibiotics were prescribed more frequently by older GPs for older patients in the presence of underlying disease, discoloured sputum, shortness of breath, wheeze, fever, signs on chest examination, and 'other factors'. Multivariate logistic regression confirmed an independent effect for all these findings except for the presence of underlying disease, shortness of breath and wheeze. 'Other factors' included patient 'pressure' and social factors, and GP work pressure or prior experience with the patient. These factors were an important influence on prescribing, especially if the GP felt an antibiotic was not indicated. Amoxycillin was the first choice (58% of total) except where the patient had recently received antibiotics for the same illness. Broader spectrum antibiotics were used more commonly in patients with chronic lung disease, discoloured sputum, chest signs on examination and where the GP felt antibiotics were indicated. However, these antibiotics were also prescribed to 14% of previously well patients. General practitioners used a wide variety of terms to describe the illness with little consistency or structure. The decision concerning the use and choice of antibiotics and the confidence with which the GP makes that decision is a complex interaction between patient, doctor and disease, being affected not only by clinical features but also by the social and psychological elements of the presenting problem. Such issues need to be appreciated by hospital specialists when called on to advise on developing relevant guidelines for primary care.

Diabetic foot ulcers are of many types and different ulcers require management in different ways. Their optimal management is currently hindered by lack of a useful working classification. Such a classification must be flexible enough to be applied to all lesions likely to be encountered but specific enough to enable clear definition of an individual lesion. It must also be simple enough to ensure that it is understood by all categories of health care workers, whether specialist or not. An attempt has been made to devise a classification--based on the key elements used in describing foot lesions--and it is put forward to act as stimulus for debate. It is based on the clinical definition of infection, ischaemia, and neuropathy. Although two of these, or even all three, may be found in the same foot, they should be considered in the order given because this reflects the sequence of clinical decisions which should be made. The adoption of a classification such as this would aid education, communication, research and audit, and would lead to better management of ulcers.