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502BRITISH MEDICAL JOURNAL 1 MARCH 1975 with the exception of case 7, were shown to have suffered from recent streptococcal infection by virtue of a raised titre of A.S.O. or anti-DNAase B or both, even though effective antibiotic therapy had been given before the sera were collected. The raised red lesions might have been confused with streptococcal cellulitis, especially in case 10, but cellulitis has a diffuse, spreading edge, is painful to touch, and often suppurates. The lesions described here had a raised and sharply circumscrilbed edge and were not noticeably tender-apart from complaints of burning and tightness of the skin. Direct isolation of streptococci from the skin lesion was not attempted before antibiotic treatment had been given. This is seldom successful in erysipelas unless fluid withdrawn from blisters or from subcutaneous tissue is cultured.8 In facial erysipelas swabs taken from the nose, throat, and ear are all more likely to yield positive results.Though these clinical and laboratory findings supported a diagnosis of idiopathic erysipelas it is curious that so uncom-mon a disease should have affected several patients simultaneously. The patients affected in this outbreak were of the sex and age group especially liable to develop erysipelas and the segregation of so many susceptible people in an abnormally secluded environment might be expected to encourage widespread and recurrent streptococcal infection once a virulent strain had been introduced. The initial treatment of the patients with ampicillin which failed to elminate the streptococcus may have influenced the spread of infection by delaying the subsequent successful treatment with penicillin G.The laboratory findings emphasize that even retrospective serological studies may supply useful evidence of streptococcal aetiology.

Compliance with most components of the nationally recommended ventilator care bundle is good. SSD has not been as widely implemented as the other components and patients are undergoing re-intubation to facilitate it.

Plasma diazepam and N-desmethyl diazepam concentrations were measured in patients receiving diazepam 5 mg or 10 mg i.v. at 4-h intervals for periods of 6-22 days. At both doses there was an accumulation of both diazepam and its metabolite, the latter reaching concentrations of up to two to three times that of the parent drug. Plasma diazepam concentrations reached a plateau after 8 days while the concentration of N-desmethyl metabolite continued to increase throughtout the period of drug administration. On discontinuation of diazepam therapy both diazepam and N-desmethyl diazepam concentrations decreased slowly, the former with a half-life of 2-4 days and the latter with a half-life of 4-8 days.