We performed a randomised controlled crossover trial of clinic letters. Structured letters were compared with conventional letters containing problem lists. There were 32 participants; 25 preferred the structured letter. Median rating and items identified were higher for the structured letter. Structured clinical correspondence with paragraph headings is strongly preferred and increases comprehension. E ffective correspondence is essential given the volume of mail reaching general practitioners (GPs) and the need for timely and accurate communication on complex cases. Past advice on clinical correspondence has been based on common sense, particularly "keep it short". 1 Previous studies have examined GPs' preference on letter structure. UK studies in paediatrics have established that GPs like problem lists 2 and some degree of structure. 3 Structure in letters was also preferred in other studies.4 5 The consistent overall message is: structure the letter, and tailor content to your audience.In a local questionnaire study of GPs we found they were action orientated, wanting rapid information on diagnosis, management, any actions for them, and patient/carer information. They were strategic readers, spending a median of 30 seconds on each correspondence item, concentrating on the first and last paragraphs. They expressed concern about "missing" important information hidden among a mass of irrelevant detail. Using these findings, we developed a proforma letter with problem list and subheadings. We hypothesised that this would improve letter comprehension compared with the traditional format. METHODSWe designed two letters of similar length by adapting the contents of anonymised clinic letters. Each contained all relevant information, and was in Times Roman 12 point with single line spacing. Each letter was prepared in two formats: unstructured with problem list (conventional) and structured. Participants were randomised by concealed number to read the structured letter either first or second.Participants read their first letter, noting the reading time in seconds. Next, we asked them to identify eight specific items of information using a checklist, as a measure of letter comprehension. They repeated the process for the second letter. They then rated each letter on a five point modified Likert scale (very poor, poor, average, good, excellent). Finally, they were asked which letter they preferred.The format was piloted using 10 participants (seven GPs and three paramedical specialists). Using these results we estimated that 22 participants would be required to achieve 80% power with a two sided significance level of 5%. Subsequently, with the agreement of local GP tutors, the study took place at the start of scheduled postgraduate GP education sessions. Non-GP principals were excluded from participation. Verbal consent was obtained from each participant.The main outcome measures were the number of items correctly identified, the letter rating, letter preference, and the reading time. We analysed results using SPSS 9.0...

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Background Over the past 25 years Sierra Leone has made progress in reducing maternal and child mortality, but the burden of preventable paediatric deaths remains high. Further progress towards achieving the Sustainable Development Goals will require greater strengthening of the health care system, including hospital care for perinatal and paediatric conditions. Emergency Triage Assessment and Treatment Plus (ETAT+) may offer a useful tool. Methods The five-day ETAT+ course was adapted as a six-month programme of in-situ training and mentoring integrated with patient flow and service delivery improvements in 14 regional and district government hospitals across the country. Nurses were trained to carry out the initial resuscitation and assessment of the sick paediatric patient, and to administer the first dose of medication per protocol. The course was for all clinical staff; most participants were nurses. Results The intervention was associated with an improvement in the quality of paediatric care and a reduction in mortality. In 2017 mortality decreased by 33.1%, from 14.5% at baseline to 9.7% after six months of the intervention. Mortality at the start of the 2018 intervention was 8.5% and reduced over six months to 6.5%. Care quality indicators showed improvement across the two intervention periods, with some evidence of sustained effect. Conclusions These results suggest that adapted ETAT+ training with in-situ mentoring alongside improved patient flow and service delivery supports improvements in the quality of paediatric care in Sierra Leonean hospitals. ETAT+ may provide an affordable framework for improving the quality of secondary paediatric care in Sierra Leone and a model of nurse-led resuscitation may allow for prompt and timely emergency paediatric care in Sierra Leonean hospitals where there are fewer physicians and other resources for care.

SUMMARY We describe a prospective study in which we investigated why children fail to get vaccinated against whooping cough, including an assessment of the attitudes of parents and professionals and the impact of different views of the contraindications. The Gloucestershire child health computer records for 1982 showed that for children born in 1979, although the average uptake for three courses of diphtheria, tetanus, pertussis (DTP) immunisations was 52%, in some general practices more than 60% were immunised against whooping cough ('high uptake'), whereas in others ('low uptake') the figure was less than 40%. Roughly half the general practices in Gloucestershire fell into these two categories. We followed up all babies born during a three month period (April, May, and June 1983) who were registered with these practices. After the first visit for immunisation the parent who brought the child (the mother in all cases) was asked to complete a structured questionnaire by the health visitor. The mother was asked about the reasons for the decision about whooping cough vaccination, who helped her make the decision, and what advice was given. At the same time, the mother's views on the risks of serious side effects of whooping cough vaccination, the effectiveness of the vaccine, the severity of whooping cough infection, and the risks of catching whooping cough if not vaccinated were assessed by graded questions (Fig. 1).Immediately after completion of the parents survey, questionnaires were sent to general practitioners, health visitors, and clinical medical officers involved in immunising children from these practices.The views of these health professionals on whooping cough vaccination and whooping cough infection were assessed with the same graded questions answered by the mothers (Fig. 1), and in addition their interpretation of contraindications was assessed by 44 short case histories in which the child was stated to be well except for the problem outlined and the parents willing to take the advice of the doctor or health visitor. Questions on related topics-for example, history of allergy in the child or members of the family-were distributed at random throughout the questionnaire. The x2 test and Student's t test were used for statistical comparison.

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