It is estimated that 10% of patients attending accident and emergency (A&E) departments are elderly and that in some cases the department is used as an extension of a primary care facility.1 In a recent report we showed that even 'minor fractures' significantly impaired elderly patients' ability to live independently and that more than 50% of such patients discharged from A&E had functional scores compatible with moderate to severe functional impairement.2 While many of the patients acquired help from family, friends and neighbours, a proportion required additional help or were totally dependent on statutory help. This 'at risk' group needs to be identified before discharge from A&E.In a survey to establish the extent of social screening in A&E; 105 patients aged 70 years or over, who had sustained minor fractures, had not been admitted to hospital, but were attending a fracture clinic were interviewed by the author during their first fracture clinic visit. The interviews occurred mostly within 7 days of sustaining a fracture -84% were interviewed within 5 days of their injury. The patients were asked whether enquiries had been made concerning their social needs, who made such enquiries, and if they knew how to request statutory social services in the community.We found that in this cohort of 105 patients 71 (68%) had not been asked whether they could cope with activities of daily living once discharged. Of the remaining 34 (32%) who remembered being asked: 22 had been asked by a nurse in A&E; 17 by an A&E doctor; nine by a general practitioner; and three had been asked by other persons, e.g. physiotherapist.Two patients had been interviewed by a medical social worker before leaving the A&E department. Of patients, 42 (40%) did not know how they would go about requesting statutory help in the community and 61 (58%) were knowledgeable about community services.These results mirror the findings of Currie et al.3 who found scanty documentation of social and functional screening after scrutiny of A&E records. The problem is further amplified by the fact that 40% of the elderly patients in this study were not aware of how to acquire statutory help in the community. While the A&E doctor may be well-placed to assess the social and functional needs of the patients, in a busy A&E department, time is at a premium. Additionally, functional assessment requires special knowledge and skills which are not taught routinely to doctors. The importance of social management in elderly people cannot be over-emphasized and it is imperative that all who treat them be made aware of this.To alleviate this problem, some A&E departments have adjacent short-stay wards and cover from a social worker. Others have an

Summary A case is reported of implantation metastases occurring at pleural aspiration sites in a 70‐year‐old man with pulmonary adenocarcinoma.

The carpal tunnel syndrome is five times more common in women than in men'; it is found most often in women aged over 40 and is therefore common postmenopausally. The ultimate form of treatment is surgical relief of nerve entrapment.2 There is, however, general agreement that conservative measures should be tried first. These include mainly splinting, injection of steroids into the carpal tunnel, and nonsteroidal anti-inflammatory agents.2 3 Treatment with vitamin B-6 has also been advocated, but the therapeutic effect was not corroborated by controlled studies.3 4 We describe two women with severe carpal tunnel syndrome unresponsive to medical treatment, whose symptoms resolved unexpectedly soon after starting hormone replacement therapy for their menopausal symptoms. Case reportsCase 1-A 52 year old healthy woman had a six month history of numbness and pain in both hands. Examination showed paresthesia in the distribution area ofthe median nerve. Electromyography confirmed the severity of the disease. Non-steroidal antiinflammatory agents gave no relief, and she was referred for surgical release of the entrapped nerve. While waiting for surgery and independently of the carpal tunnel syndrome, cyclic hormone replacement therapy (conjugated oestrogen 0-625 mg/day for 25 consecutive days and medroxyprogesterone acetate 5 mg/day for the last 13 days) was started for her climacteric symptoms. A gradual alleviation of her carpal tunnel symptoms followed, and the pain and numbness resolved completely about three weeks subsequently. Surgery was withheld; she was subsequently followed up for 20 months and remained asymptomatic. An interruption of oestrogen treatment for three months did not exacerbate her symptoms.Case 2-A 54 year old healthy housewife was examined because of typical complaints of the carpal tunnel syndrome in both hands. At the age of 47 she had had a panhysterectomy because ofuterine bleeding due to a submucosal myoma. Pain and numbness began in both hands at the age of48. Electromyography disclosed findings typical of the syndrome, and after failure of conservative measures division of the left transverse carpal ligament was performed. The outcome of surgery was poor, and she did not submit for surgery of the other hand. At the age of 50 substitution hormone therapy was started. The pain in her hands regressed gradually over several weeks subsequently until both hands became free of pain. During the subsequent three years hormone therapy was interrupted on several occasions for three to four months. Consistently, pain and numbness recurred shortly after cessation of the hormone therapy, only to resolve once the treatment was renewed. CommentAlthough a temporal relation between the onset of the menopause and the carpal tunnel syndrome has been reported,' the effect of hormone replacement on the syndrome has not been referred to. In these two patients the beneficial effect of combined oestrogen and progesterone therapy on the symptoms of the carpal tunnel syndrome was unequivocal. In the second pati...

Older people with acute UGIH have advanced upper gut pathology with preponderance of esophageal lesions. Classical symptoms seem lacking, but mortality can be decreased despite adverse comorbid factors. Lower thresholds for endoscopy are advocated in older adults, and comparative studies of UGIH symptoms with younger patients are required.

Many patients have diabetes‐related complications at diagnosis. This study assessed the awareness of chiropody provision among patients with diabetes mellitus and evaluated whether age, gender, duration of diabetes or treatment type influenced exposure to a chiropodist. One hundred and twenty eight patients participated in the study. Mean duration of diabetes was 9.3 years. Duration of diabetes, gender, or treatment type per se did not influence exposure to a chiropodist; only age did (p=0.017). Forty‐one (32%) patients had no contact with a chiropodist since diagnosis, and 35 (27%) were not sure how to request this service. Fortynine patients were unsure whether chiropody was free to those with diabetes. This project highlights the need to increase patients' awareness and access to proper chiropodial treatment in our quest to reduce discomfort and leg amputation rates.