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Digoxin did not reduce overall mortality, but it reduced the rate of hospitalization both overall and for worsening heart failure. These findings define more precisely the role of digoxin in the management of chronic heart failure.

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The ethical issues surrounding orders not to resuscitate are complex and increasingly a matter for legislative acts and judicial decisions."I 13 Furthermore, decisions on resuscitation have implications for resource management. Despite these issues "Do not resuscitate" orders in many British hospitals are used without guidelines and without assessment of their effectiveness in preventing futile cardiopulmonary resuscitation.This survey indicates that in the absence of local guidelines about decisions on resuscitation many crash calls may be inappropriate. We advocate more discussion of patients' suitability for resuscitation between doctors, nurses, patients, and patients' relatives. We suggest that the most senior available doctor of the admitting team should be responsible for making initial resuscitation decisions, writing these in the medical notes, and communicating them to the ward nurses. Such decisions should follow locally agreed criteria based on knowledge of pre-arrest characteristics in relation to outcome. Patients' suitability for resuscitation should be reviewed on every consultant ward round, taking into account the views of all the staff caring for the patient and, when appropriate, the views of the patient or the patient's relatives, or both.We thank the nurses and junior doctors at Fazakerley Hospital for filling in the questionnaires, and Dr F J Nye for his comments on the manuscript.

An I I-year retrospective review of women with breast abscesses presenting to a district general hospital was performed.The incidence of lactational breast abscesses is declining but non-lactational breast abscesses are seen more frequently','. Non-lactational breast abscesses often recur and may be associated with mammillary fistulae or mammary duct ectasia ',3.4. This study examined the factors which might predispose women with non-lactational breast abscesses to develop further sepsis. Patients and methodsThe case records of all women presenting with a diagnosis of a breast abscess over an 11-year period were reviewed ( 1 January 1980-31 December 1990). Breast abscess was defined as an acute inflammatory lump which yielded pus on incision. Details were recorded of the clinical features, smoking habits, surgical treatment and eventual outcome in all women.From 1980 the Nursing Kardex and Selly Oak Hospital Medical Admissions Chart required the patient's smoking habits to be recorded. A patient was recorded as smoking currently and the number of cigarettes smoked per day noted. Light smokers were defined as women smoking 1 ~ 10 cigarettes/day and heavy smokers as women smoking 11 or more cigarettes per day. Women were recorded as 'never smoked' if at admission they did not smoke unless the case notes recorded that they had previously done so. When a breast biopsy had been taken histological details were recorded. Bacteriological details were noted for all patients. Histological specimens were reviewed to confirm the presence of dilated ducts and for acute/chronic inflammation surrounding the ducts5.Nineteen women were non-smokers, eight women previously smoked and ten were currently cigarette smokers. Staphylococcus auveus was isolated from 27 patients, anaerobic bacteria from four, coliform bacteria from one woman and no growth was obtained from five women.Six women developed recurrence of their abscess, four who had never smoked, one who was a previous smoker and one who was currently smoking 20 cigarettes per day. Biopsy of the cavity wall from ten women (including all six with recurrent abscesses) failed to show any evidence of mammary duct ectasia. Non-lactational bveust ubscessesEighty-five women (70 per cent j (mean age 35.8 (range 11 -69) years ) had non-lactational breast abscesses incised and drained. Twenty-eight (33 per cent) had never smoked, eight had previously smoked and 49 (58 per cent) were currently doing so regularly (Table 1 ). Smoking habits were not age-related (Table 2).Women with non-lactational breast abscesses were more likely to be current smokers (x' = 9.6, P < 0.005) and more likely to have ever smoked (relative risk 2.15, 95 per cent confidence interval 2.04-2.26 ) than women with lactational breast abscesses. The bacteria isolated from the initial abscess are listed in Tuble 3. Fifteen of 18 women who developed anaerobic breast A total of 122 women presented with a breast abscess over the 11-year period. Several patients had experienced more than one episode of abscess formation...