levels for its achievement. While not reaching Swedish participation levels, our pilot study indicates that by virtually excluding older women from the programme we may be doing older women a disservice in relation to breast cancer control, because the means of access-self referral -is inappropriate for them.4 P HOBBS
Regional Oncology Support Service, Manchester M20 9QL 1 Forrest P. Breast cancer screening. Report to the health ministers of England, Wales, Scotland and Northern Ireland by a working group chaired by ProfessorSir Patrick Forrest. London: HMSO, 1986. 2 Verbeek ALM, Hendriks JHCL, Holland R, Mravunac M, Sturmans F, Day NE. Reduction in breast cancer mortality through mass screening with modem mammography. (First results of the Nijmegen project, 1975-1981.) Lancet 1984;i: 1222-4. 3 Tabar L, Fagerberg CJG, Gad A, et al. Reduction in mortality from breast cancer after mass screening with mammography. Lancet 1985;i:829-32. 4 Hobbs P, Smith A, George WD, Sellwood RA. Acceptors and rejectors of an invitation to undergo breast screening compared with those who referred themselves. J Epidemiol Community
Health 1980;34:19-22.
Diagnosis of Alzheimer's disease SIR,-Professor Nicholas Wald and his colleagues seem to take a very narrow view of the various purposes of making a clinical diagnosis of Alzheimer's disease.' Current reports on the subject are replete with clinical trials and neurobiological, neuropsychological, and other studies on patients with Alzheimer's disease. It is surely of some importance to know whether patients included in these studies during life do in fact suffer from the disease and that this can be confirmed at necropsy. We stated in our paper that we did not include patients in whom a diagnosis of Alzheimer's disease was not suspected,2 hence the calculations of specificity and sensitivity by Professor Wald and colleagues are inappropriate. We have shown that strict adherence to certain diagnostic criteria will ensure that a diagnosis will be right in most cases. The fact that in the process certain other cases may be excluded is not relevant to this purpose, although it would of course be highly important in an epidemiological study of prevalence or incidence of the condition. Our first paper made this clear,3 and the longer version that we submitted discussed the issues raised by your correspondents. The plain English word "accuracy" in the title may apply equally well to positive predictive value as to sensitivity and specificity. We hope that this clarifies the confusion over our original intention. ALISTAIR BURNS RAYMOND LEVY ROBIN JACOBY Institute of Psychiatry, London SE5 8AF 1 Wald N, Parkes C, Smith AD. Diagnosis of Alzheimer's disease. BMJ 1991;302:292. (2 February.) 2 Burns A, Levy R, Jacoby R. Diagnosis of Alzheimer's disease. BMJ 1991;302:48. (5 January.) 3 Bums A, Luthert P, Levy R, Jacoby R, Lantos P. Accuracy of clinical diagnosis of Alzheimer's disease. BMJ 1990;301:1026. (3 November.)
Medical atrocities SIR,-We were horrified to read about the medical atrocities in Kuwait.' Such events are not peculiar to dictatorships; parallel atrocities have been carried out by the Indian army in Kashmir. We are a group of Kashmiri doctors now settled in the United Kingdom, and Professor Yousof's accounts have a familiar ring for all of us. Each of us can give accounts of atrocities that have been carried out
412
among the people of the Kashmir valley since January 1990. Mr Max Madden, MP for Bradford, who visited Kashmir earlier this year, has reported personally seeing evidence of torture-a mother and child with burn marks on their bodies caused by the use of hot iron; young men with electrical burn marks on their faces, necks, and backs; young boys with crushed fingers and toes.2 He was shown photographs of dead bodies of young men whose faces had been so mutilated to make identification impossible. A systematic genocide of a people is being carried out by killing boys and men between the ages of 15 and 45. There has been a deliberate policy of not allowing medical supplies to be sent to Kashmir. Neither the International Red Cross nor Amnesty International has been allowed in, and little coverage has been given in the press. Professor Guru, professor of cardiothoracic surgery at the Sheri-Kashmir Institute in Srinagar, has been arrested and his whereabouts are unknown. Women of 85 and girls of 6 have been raped-this has been reported by a senior Kashmiri physician who has now fled Kashmir [name supplied]. Medical schools have been closed. The security forces have physically prevented hospital doctors from carrying out emergency treatment on patients. All this is corroborated by Indian human
rights organisations. This is being carried out by the world's largest democracy, a country that has been reluctant in its condemnation of Iraq's occupation of Kuwait. We realise that as Kashmir does not have economic implications for the Western world international condemnation will not occur, but we hope that at least for the medical profession human lives, whether Kashmiri or Kuwaiti, have the same values. Y J DRABU North Middlesex Hospital, London N 18 lQX S A SADIQ Kingston Hospital, Kingston upon Thames KT2 7BG N BURZA Hindley, Lancashire M A MIR
University Hospital, Cardiff CF4 4XW N N SHAMEEM Birmingham South Health
Authority, Birmingham B29 6JF R A QAZI
Brierfield, Lancashire
N A KUCHAI Harold Hill,
Romford, Essex
Salford,
G J DRABU
Lancashire
Manchester Health Authority, personal communication). Taking an average figure of 85%, this leaves about 300 children aged 2 in 1990 who were incompletely immunised. Given that some children complete their basic immunisation course beyond the age of 2, but remembering that immunisation rates were well below 75% in the mid-1980s, the pool of incompletely immunised children up to 6 years of age (the upper age limit in this study) may number, in central Manchester, at least 1500. These calculations are rough and ready but suggest that over its first year a ward based opportunistic immunisation policy would reach at the most 5% of the target population. Is this approach cost effective? Unfortunately the authors do not consider this issue. Dr Riley and colleagues report that children were immunised "without change or inconvenience to the daily ward work." They noted, however, that "efficacy relies on adequate levels of enthusiastic staff." Even during the study period, when one would expect enthusiasm to be at its highest, the reasons for not immunising seven children (out of 16 not immunised) were logistic-staff difficulties or transfer of the patient to another ward. The authors briefly deal with this problem by suggesting training for nursing staff to allow them to administer immunisations. If this objective were achieved it begs the question why, in central Manchester, highly trained health visitors are not authorised to give immunisations. Progress on this latter deficiency could have potentially far greater benefits, particularly if health visitors were allowed to give immunisations in the child's home. Although we do not wish to decry the achievements reported in this paper, it continues to be our belief that community based initiatives2 are the most effective means of improving immunisation rates. For this reason we have recently overhauled our own system to improve vaccination uptake. We will be auditing our progress and hope to achieve a considerable improvement at little or no extra cost. HUGH REEVE CAROLYN CHEW INA WALLER-WILKINSON
G M GUNDRU James Paget Hospital, Great Yarmouth M F DAR Wakefield, West Yorkshire R K DRABU Eastleigh, Hampshire
Department of General Practice, University of Manchester, Rusholme Health Centre, Manchester M14 5NP
Redditch, Worcestershire
2 James J, Clark C, Rossdale M. Improving health care delivery in an inner city well baby clinic. Arch Dis Child 1986;61:630.
1 Riley DJ, Mughal MZ, Roland J. Immunisation state of young children admitted to hospital and effectiveness of a ward based
policy. BMJ 1991;302:31-3. (5 January.) S SHAH
Gravesend, Kent M S SARWAR
N A SHAMEEM
Halesowen,
Oldham,
West Midlands
Lancashire
I Smith R. Medical atrocities in Kuwait. BMJ 1990;301:1177-8.
(24 November.) 2 Madden M. India and Kashmir. House of Commons Official Report (Hansard). 1990 July 24;177:col 201-6. (No 149.)
**Professor Guru is reported to have been released at the end of December. -ED, BM7.
Effectiveness of ward based opportunistic immunisation policy SIR,-In the study by Drs D J Riley, M Z Mughal, and J Roland 40 children were immunised over a six month period, extrapolating to a figure of 80 in a full year.' Central Manchester had about 2000 children reaching the age of 2 years in 1990. In August 1990 the district's immunisation rates for completed courses (at age 2 years) of diphtheria, measles, and pertussis were 85%, 87%, and 78% respectively (Department of Public Health, Central
Follow up after transurethral resection of prostate SIR,-The article by Mr Thomas H Lynch and colleagues' seemed to consider only the preferences of patients rather than their needs, but of course routine practices that are expensive of scarce resources should be questioned. Nevertheless, follow up of certain patients is not an option to be discarded lightly, particularly in a training setting. As pointed out by the authors, about 15% of men have unsuspected prostatic cancer and need follow up. As well, 10% to 15% have chronic retention and about 5% to 10% have upper tract dilatation.2 Such men also need follow up as a third of men with chronic retention remain with a large residual amount of urine and may be at risk of renal impairment in the future.3 Fifteen per cent of men develop infection requiring antibiotics and 2% develop epididymitis.4 These men need follow up to check that infection has settled and that there are no underlying causes such as persistent outflow obstruction or impaired bladder emptying. Identifying men with prostatic cancer, infective complications, or impaired bladder emptying or those
BMJ
VOLUME
302
16 FEBRUARY 1991
who will have a poor outcome remains problematic before discharge. For audit and training there is a strong point to be made in favour of follow up as transurethral resection of the prostate is not free from complications.4 Twenty three per cent of men visit their general practitioner for complications, 33% pass clots, 10% develop temporary clot retention, and 4% have defects in urinary continence where none was present before operation. It was perhaps telling that 54% of men in the study reported by Lynch and colleagues consulted their general practitioner-a rate double that usually recorded. Not all men who are unsatisfied are referred back to hospital, as shown by a rate of poor outcome in prospective studies of 20% to 25 %5-higher than in retrospective studies, in which the definition of poor outcome depends on rereferral. A routine follow up at six or eight weeks will allow most men to be discharged; the remainder with a poor outcome, prostatic cancer, or persistent impairment of bladder emptying may require further investigation and follow up. Follow up is not an unacceptable burden but an important part of training and audit. DAVID E NEAL
Department of Urology, Freeman Hospital, Newcastle upon Tyne NE7 7DN 1 Lynch TH, Waymont B, Beacock CJM, et al. Follow up after transurethral resection of prostate: Who needs it? BMJ 1991;302:27. (5 January.) 2 Neal DE, Styles RA, Powell PH, Ramsden PD. The relationship between detrusor function and residual urine in men undergoing prostatectomy. Brj Urol 1987;60:560-6. 3 Sacks SH, Aparicio SAJR, Bevan A, Oliver DO, Will EJ, Davison AM. Late renal failure due to prostatic obstruction: a preventable disease. BMJ 1989;298:156-9. 4 Fowler FJ, Wennberg JE, Timothy RP, Barry MJ, Mulley AG, Hanley D. Symptom status and quality of life after prostatectomy. JAMA 1988;259:3018-22. 5 Neal DE, Ramsden PD, Sharples L, et al. Outcome of elective prostatectomy. BMJ 1989;299:762-7.
collaboration between the respective audit groups in district health authorities and in family health services authorities. From April 1991 purchasers and providersincluding practice budget holders-are likely to focus greater attention on the appropriateness of follow up clinics. Clinical practice may be influenced by the type of contracts negotiated, but it is to be hoped that this will be in the interests of improved efficiency and not merely a cost cutting exercise. JEFFRIE R STRANG Department of Public Health Medicine, Darlington Health Authority, Darlington DL3 6HX
RODNEY COVE-SMITH South Cleveland Hospital, Middlesbrough TS4 3BW 1 Lynch TH, Waymount B, Beacock CJM, Dunn JA, Hughes MA, Wallace DMA. Follow up after transurethral resection of prostate: who needs it? BMJ 1991;302:27. (5 January.) 2 Strang JR, Cove-Smith JR. Outpatient follow up: why bother? Hospital Update 1989;15:321-2.
Resuscitating newborn babies SIR, -Dr Alison Walker quotes the recommendations by Dr Harold Gamsu and his working party that a more experienced member of staff, "usually a paediatrician," should be immediately available to perform advanced resuscitation when difficulties arise.' From the baby's point of view this certainly should happen. Unfortunately many sizable maternity hospitals in Britain are not staffed in such a way that this is possible. This particularly applies in districts where paediatric staffing consists of senior house officers, who are usually general practitioner trainees, and consultant paediatricians. In such hospitals consultant paediatricians may bear the brunt of resuscitating problem babies, but the nature of the consultant's contract, split sites, and other commitments mean that a consultant paediatrician is not always available around the clock at a moment's notice as would be required. General practitioner trainees come to special care baby units with no experience of resuscitation, and some of them never learn the task competently in the six months that they are on the unit. This is partly because of the shorter hours that junior doctors are now working and partly because of the smaller numbers of babies who require advanced resuscitation, as well as the need to train midwives and the requirement that the difficult cases are dealt with by an experienced person. Many health authorities seem unconcerned by this serious and potentially very expensive gap in the services that they are responsible for. Increasing the skill and competence of senior midwives to become "advanced resuscitators" may be a better solution to the problem.
SIR,-The paper by Dr Thomas H Lynch and colleagues showed that about 90% of patients did not require outpatient review in the short term, thereby releasing valuable clinic time to see new patients more speedily.' We have advocated that follow up clinics should be subjected to critical analysis in terms of the efficiency and the effectiveness of the care provided.2 Return visits to hospital after surgery should be no exception. The lack of concordance between general practitioners and patients about the desirability of follow up might have been reduced if, jointly, the urologists and referring family doctors had produced guidelines indicating the criteria for readmission or outpatient follow up. This information could have been conveyed to the patients in the leaflet given at the time of discharge, in the hope of minimising the differences in the expectations of those involved. Follow up attendances purely for the purpose of clinical audit should not be necessary. Early J M DAVIES postoperative problems requiring referral back S M HERBER to hospital will be documented in the medical B M REYNOLDS records, but it is important to remember that some Griansby Maternity Hospital, patients may be readmitted to a medical ward, Grimsby DN33 lNW perhaps with a pulmonary embolism, and may not be known to the urologists at that time. The long 1 Walker A. Resuscitating newborn babies. BM7 1991;302:69. term success of the operation is worthy of clinical (12 January.) audit by means of a questionnaire sent to the patient at an appropriate time after surgery. The high level of patient satisfaction would seem to be reflected in the response rate of 94% to the Chlamydia and cervical smear questionnaire after three months and might remain testing sufficiently high to measure the success of the treatment at a later date. SIR,-The lack of a sensitive test in diagnosing This study shows the need for closer cooperation chlamydial infection is of concern to clinicians as between general practitioners and consultants if most women are asymptomatic, as were those changes in the pattern of hospital follow up are studied by Dr J R Smith and colleagues.' to be introduced and monitored. The interface The laboratory diagnosis of urogenital between primary and secondary care is an im- chlamydial infection is based on isolation of portant topic for clinical audit but will require chlamydial trachomatis in cell culture; direct
BMJ
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FEBRUARY
1991
detection of chlamydial antigen; and detection of specific antibody in the serum. The cell culture still remains the standard test, and all the other methods have been compared with cell culture, but the cell culture does not detect chlamydial infection in the lower genital tract in the presence of neutralising cervical antibody. Positive yield also depends on proper sample collection, transportation, storage of specimen, and technical factors. Direct detection of chlamydial antigen is more widely used now. It is easy to perform and results may be obtained within an hour of collecting the specimen so that treatment could be started immediately, but clinicians should be aware of false positive results. Serology for Chlamydia trachomatis specific IgG and IgM is of limited value. In chlamydial cervicitis the organism is confined to the endocervical cells and does not provoke a noticeable antibody response. IgM response is poor and does not necessarily indicate current infection. Chlamydia specific IgA antibody is detected in only a small proportion of apparently healthy adults but concentrations are raised in acute infection, which makes it an important marker of acute infection. As the sensitivity of the test is low this can assist but cannot replace either the direct detection of antigen in the specimen or the isolation of chlamydia. DNA hybridisation to detect chlamydial antigen has been studied and the results are promising, but more work is needed for further evaluation.2 Chlamydial infection of the urogenital tract is one of the most common sexually transmitted diseases and its implications -female infertility, ectopic pregnancy, recurrent infection, and dyspareunia -are serious. Improved sensitive and specific tests for diagnosis of the chlamydial genital tract infection is urgently needed, including microbiological criteria of "cure" after conventional treatment with antibiotics, particularly in women. V HARINDRA S SIVAPALAN R BASU ROY
Department of Genitourinary Medicine, Royal Victoria Hospital, Bournemouth BH7 6JF 1 Smith JR, Murdoch J, Carrington D, et al. Prevalence of Chlamydia trachomatis infection in women having cervical smear tests. WMJ 1991;302:82-4. (12 January.) 2 Oriel D, Ridgeway G, Schachter J, et al. Chlamydial infections. London: Cambridge University Press, 1986.
SIR,-We offer our data in support of the conclusion drawn by Dr J R Smith and colleagues that chlamydial infection of the cervix is prevalent, irrespective of cytological state. ' We prospectively screened 67 women who routinely attended during 1990 for cervical smear tests in one rural Welsh general practice. We tested for the presence of cervical pathogens using culture, microscopy, and direct immunofluorescence (Microtrak, Syva) for Chlamydia trachomatis. The results (set against the cytological findings during the preceding two years) are summarised in the table. The important message is that silent chlamydial infection is common in rural seaside Wales just as in inner city Glasgow and may result in much Cervical pathogens present in smears Cytological results No (%) No (%) non-inflammatory inflammatory No pathogens or normal flora Gardnerella alone Gardnerella, bacteroides, and clue cells
28 (50) 5 (9)
12 (63) 0
8 (14)
Chlamydia Candida Coliforms
(9) 12 (21) 4 (7)
1 (5) 2 (10) 4 (20) 0
Total
57 (100)
19 (100)
5
413
Regional Oncology Support Service, Manchester M20 9QL 1 Forrest P. Breast cancer screening. Report to the health ministers of England, Wales, Scotland and Northern Ireland by a working group chaired by ProfessorSir Patrick Forrest. London: HMSO, 1986. 2 Verbeek ALM, Hendriks JHCL, Holland R, Mravunac M, Sturmans F, Day NE. Reduction in breast cancer mortality through mass screening with modem mammography. (First results of the Nijmegen project, 1975-1981.) Lancet 1984;i: 1222-4. 3 Tabar L, Fagerberg CJG, Gad A, et al. Reduction in mortality from breast cancer after mass screening with mammography. Lancet 1985;i:829-32. 4 Hobbs P, Smith A, George WD, Sellwood RA. Acceptors and rejectors of an invitation to undergo breast screening compared with those who referred themselves. J Epidemiol Community
Health 1980;34:19-22.
Diagnosis of Alzheimer's disease SIR,-Professor Nicholas Wald and his colleagues seem to take a very narrow view of the various purposes of making a clinical diagnosis of Alzheimer's disease.' Current reports on the subject are replete with clinical trials and neurobiological, neuropsychological, and other studies on patients with Alzheimer's disease. It is surely of some importance to know whether patients included in these studies during life do in fact suffer from the disease and that this can be confirmed at necropsy. We stated in our paper that we did not include patients in whom a diagnosis of Alzheimer's disease was not suspected,2 hence the calculations of specificity and sensitivity by Professor Wald and colleagues are inappropriate. We have shown that strict adherence to certain diagnostic criteria will ensure that a diagnosis will be right in most cases. The fact that in the process certain other cases may be excluded is not relevant to this purpose, although it would of course be highly important in an epidemiological study of prevalence or incidence of the condition. Our first paper made this clear,3 and the longer version that we submitted discussed the issues raised by your correspondents. The plain English word "accuracy" in the title may apply equally well to positive predictive value as to sensitivity and specificity. We hope that this clarifies the confusion over our original intention. ALISTAIR BURNS RAYMOND LEVY ROBIN JACOBY Institute of Psychiatry, London SE5 8AF 1 Wald N, Parkes C, Smith AD. Diagnosis of Alzheimer's disease. BMJ 1991;302:292. (2 February.) 2 Burns A, Levy R, Jacoby R. Diagnosis of Alzheimer's disease. BMJ 1991;302:48. (5 January.) 3 Bums A, Luthert P, Levy R, Jacoby R, Lantos P. Accuracy of clinical diagnosis of Alzheimer's disease. BMJ 1990;301:1026. (3 November.)
Medical atrocities SIR,-We were horrified to read about the medical atrocities in Kuwait.' Such events are not peculiar to dictatorships; parallel atrocities have been carried out by the Indian army in Kashmir. We are a group of Kashmiri doctors now settled in the United Kingdom, and Professor Yousof's accounts have a familiar ring for all of us. Each of us can give accounts of atrocities that have been carried out
412
among the people of the Kashmir valley since January 1990. Mr Max Madden, MP for Bradford, who visited Kashmir earlier this year, has reported personally seeing evidence of torture-a mother and child with burn marks on their bodies caused by the use of hot iron; young men with electrical burn marks on their faces, necks, and backs; young boys with crushed fingers and toes.2 He was shown photographs of dead bodies of young men whose faces had been so mutilated to make identification impossible. A systematic genocide of a people is being carried out by killing boys and men between the ages of 15 and 45. There has been a deliberate policy of not allowing medical supplies to be sent to Kashmir. Neither the International Red Cross nor Amnesty International has been allowed in, and little coverage has been given in the press. Professor Guru, professor of cardiothoracic surgery at the Sheri-Kashmir Institute in Srinagar, has been arrested and his whereabouts are unknown. Women of 85 and girls of 6 have been raped-this has been reported by a senior Kashmiri physician who has now fled Kashmir [name supplied]. Medical schools have been closed. The security forces have physically prevented hospital doctors from carrying out emergency treatment on patients. All this is corroborated by Indian human
rights organisations. This is being carried out by the world's largest democracy, a country that has been reluctant in its condemnation of Iraq's occupation of Kuwait. We realise that as Kashmir does not have economic implications for the Western world international condemnation will not occur, but we hope that at least for the medical profession human lives, whether Kashmiri or Kuwaiti, have the same values. Y J DRABU North Middlesex Hospital, London N 18 lQX S A SADIQ Kingston Hospital, Kingston upon Thames KT2 7BG N BURZA Hindley, Lancashire M A MIR
University Hospital, Cardiff CF4 4XW N N SHAMEEM Birmingham South Health
Authority, Birmingham B29 6JF R A QAZI
Brierfield, Lancashire
N A KUCHAI Harold Hill,
Romford, Essex
Salford,
G J DRABU
Lancashire
Manchester Health Authority, personal communication). Taking an average figure of 85%, this leaves about 300 children aged 2 in 1990 who were incompletely immunised. Given that some children complete their basic immunisation course beyond the age of 2, but remembering that immunisation rates were well below 75% in the mid-1980s, the pool of incompletely immunised children up to 6 years of age (the upper age limit in this study) may number, in central Manchester, at least 1500. These calculations are rough and ready but suggest that over its first year a ward based opportunistic immunisation policy would reach at the most 5% of the target population. Is this approach cost effective? Unfortunately the authors do not consider this issue. Dr Riley and colleagues report that children were immunised "without change or inconvenience to the daily ward work." They noted, however, that "efficacy relies on adequate levels of enthusiastic staff." Even during the study period, when one would expect enthusiasm to be at its highest, the reasons for not immunising seven children (out of 16 not immunised) were logistic-staff difficulties or transfer of the patient to another ward. The authors briefly deal with this problem by suggesting training for nursing staff to allow them to administer immunisations. If this objective were achieved it begs the question why, in central Manchester, highly trained health visitors are not authorised to give immunisations. Progress on this latter deficiency could have potentially far greater benefits, particularly if health visitors were allowed to give immunisations in the child's home. Although we do not wish to decry the achievements reported in this paper, it continues to be our belief that community based initiatives2 are the most effective means of improving immunisation rates. For this reason we have recently overhauled our own system to improve vaccination uptake. We will be auditing our progress and hope to achieve a considerable improvement at little or no extra cost. HUGH REEVE CAROLYN CHEW INA WALLER-WILKINSON
G M GUNDRU James Paget Hospital, Great Yarmouth M F DAR Wakefield, West Yorkshire R K DRABU Eastleigh, Hampshire
Department of General Practice, University of Manchester, Rusholme Health Centre, Manchester M14 5NP
Redditch, Worcestershire
2 James J, Clark C, Rossdale M. Improving health care delivery in an inner city well baby clinic. Arch Dis Child 1986;61:630.
1 Riley DJ, Mughal MZ, Roland J. Immunisation state of young children admitted to hospital and effectiveness of a ward based
policy. BMJ 1991;302:31-3. (5 January.) S SHAH
Gravesend, Kent M S SARWAR
N A SHAMEEM
Halesowen,
Oldham,
West Midlands
Lancashire
I Smith R. Medical atrocities in Kuwait. BMJ 1990;301:1177-8.
(24 November.) 2 Madden M. India and Kashmir. House of Commons Official Report (Hansard). 1990 July 24;177:col 201-6. (No 149.)
**Professor Guru is reported to have been released at the end of December. -ED, BM7.
Effectiveness of ward based opportunistic immunisation policy SIR,-In the study by Drs D J Riley, M Z Mughal, and J Roland 40 children were immunised over a six month period, extrapolating to a figure of 80 in a full year.' Central Manchester had about 2000 children reaching the age of 2 years in 1990. In August 1990 the district's immunisation rates for completed courses (at age 2 years) of diphtheria, measles, and pertussis were 85%, 87%, and 78% respectively (Department of Public Health, Central
Follow up after transurethral resection of prostate SIR,-The article by Mr Thomas H Lynch and colleagues' seemed to consider only the preferences of patients rather than their needs, but of course routine practices that are expensive of scarce resources should be questioned. Nevertheless, follow up of certain patients is not an option to be discarded lightly, particularly in a training setting. As pointed out by the authors, about 15% of men have unsuspected prostatic cancer and need follow up. As well, 10% to 15% have chronic retention and about 5% to 10% have upper tract dilatation.2 Such men also need follow up as a third of men with chronic retention remain with a large residual amount of urine and may be at risk of renal impairment in the future.3 Fifteen per cent of men develop infection requiring antibiotics and 2% develop epididymitis.4 These men need follow up to check that infection has settled and that there are no underlying causes such as persistent outflow obstruction or impaired bladder emptying. Identifying men with prostatic cancer, infective complications, or impaired bladder emptying or those
BMJ
VOLUME
302
16 FEBRUARY 1991
who will have a poor outcome remains problematic before discharge. For audit and training there is a strong point to be made in favour of follow up as transurethral resection of the prostate is not free from complications.4 Twenty three per cent of men visit their general practitioner for complications, 33% pass clots, 10% develop temporary clot retention, and 4% have defects in urinary continence where none was present before operation. It was perhaps telling that 54% of men in the study reported by Lynch and colleagues consulted their general practitioner-a rate double that usually recorded. Not all men who are unsatisfied are referred back to hospital, as shown by a rate of poor outcome in prospective studies of 20% to 25 %5-higher than in retrospective studies, in which the definition of poor outcome depends on rereferral. A routine follow up at six or eight weeks will allow most men to be discharged; the remainder with a poor outcome, prostatic cancer, or persistent impairment of bladder emptying may require further investigation and follow up. Follow up is not an unacceptable burden but an important part of training and audit. DAVID E NEAL
Department of Urology, Freeman Hospital, Newcastle upon Tyne NE7 7DN 1 Lynch TH, Waymont B, Beacock CJM, et al. Follow up after transurethral resection of prostate: Who needs it? BMJ 1991;302:27. (5 January.) 2 Neal DE, Styles RA, Powell PH, Ramsden PD. The relationship between detrusor function and residual urine in men undergoing prostatectomy. Brj Urol 1987;60:560-6. 3 Sacks SH, Aparicio SAJR, Bevan A, Oliver DO, Will EJ, Davison AM. Late renal failure due to prostatic obstruction: a preventable disease. BMJ 1989;298:156-9. 4 Fowler FJ, Wennberg JE, Timothy RP, Barry MJ, Mulley AG, Hanley D. Symptom status and quality of life after prostatectomy. JAMA 1988;259:3018-22. 5 Neal DE, Ramsden PD, Sharples L, et al. Outcome of elective prostatectomy. BMJ 1989;299:762-7.
collaboration between the respective audit groups in district health authorities and in family health services authorities. From April 1991 purchasers and providersincluding practice budget holders-are likely to focus greater attention on the appropriateness of follow up clinics. Clinical practice may be influenced by the type of contracts negotiated, but it is to be hoped that this will be in the interests of improved efficiency and not merely a cost cutting exercise. JEFFRIE R STRANG Department of Public Health Medicine, Darlington Health Authority, Darlington DL3 6HX
RODNEY COVE-SMITH South Cleveland Hospital, Middlesbrough TS4 3BW 1 Lynch TH, Waymount B, Beacock CJM, Dunn JA, Hughes MA, Wallace DMA. Follow up after transurethral resection of prostate: who needs it? BMJ 1991;302:27. (5 January.) 2 Strang JR, Cove-Smith JR. Outpatient follow up: why bother? Hospital Update 1989;15:321-2.
Resuscitating newborn babies SIR, -Dr Alison Walker quotes the recommendations by Dr Harold Gamsu and his working party that a more experienced member of staff, "usually a paediatrician," should be immediately available to perform advanced resuscitation when difficulties arise.' From the baby's point of view this certainly should happen. Unfortunately many sizable maternity hospitals in Britain are not staffed in such a way that this is possible. This particularly applies in districts where paediatric staffing consists of senior house officers, who are usually general practitioner trainees, and consultant paediatricians. In such hospitals consultant paediatricians may bear the brunt of resuscitating problem babies, but the nature of the consultant's contract, split sites, and other commitments mean that a consultant paediatrician is not always available around the clock at a moment's notice as would be required. General practitioner trainees come to special care baby units with no experience of resuscitation, and some of them never learn the task competently in the six months that they are on the unit. This is partly because of the shorter hours that junior doctors are now working and partly because of the smaller numbers of babies who require advanced resuscitation, as well as the need to train midwives and the requirement that the difficult cases are dealt with by an experienced person. Many health authorities seem unconcerned by this serious and potentially very expensive gap in the services that they are responsible for. Increasing the skill and competence of senior midwives to become "advanced resuscitators" may be a better solution to the problem.
SIR,-The paper by Dr Thomas H Lynch and colleagues showed that about 90% of patients did not require outpatient review in the short term, thereby releasing valuable clinic time to see new patients more speedily.' We have advocated that follow up clinics should be subjected to critical analysis in terms of the efficiency and the effectiveness of the care provided.2 Return visits to hospital after surgery should be no exception. The lack of concordance between general practitioners and patients about the desirability of follow up might have been reduced if, jointly, the urologists and referring family doctors had produced guidelines indicating the criteria for readmission or outpatient follow up. This information could have been conveyed to the patients in the leaflet given at the time of discharge, in the hope of minimising the differences in the expectations of those involved. Follow up attendances purely for the purpose of clinical audit should not be necessary. Early J M DAVIES postoperative problems requiring referral back S M HERBER to hospital will be documented in the medical B M REYNOLDS records, but it is important to remember that some Griansby Maternity Hospital, patients may be readmitted to a medical ward, Grimsby DN33 lNW perhaps with a pulmonary embolism, and may not be known to the urologists at that time. The long 1 Walker A. Resuscitating newborn babies. BM7 1991;302:69. term success of the operation is worthy of clinical (12 January.) audit by means of a questionnaire sent to the patient at an appropriate time after surgery. The high level of patient satisfaction would seem to be reflected in the response rate of 94% to the Chlamydia and cervical smear questionnaire after three months and might remain testing sufficiently high to measure the success of the treatment at a later date. SIR,-The lack of a sensitive test in diagnosing This study shows the need for closer cooperation chlamydial infection is of concern to clinicians as between general practitioners and consultants if most women are asymptomatic, as were those changes in the pattern of hospital follow up are studied by Dr J R Smith and colleagues.' to be introduced and monitored. The interface The laboratory diagnosis of urogenital between primary and secondary care is an im- chlamydial infection is based on isolation of portant topic for clinical audit but will require chlamydial trachomatis in cell culture; direct
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detection of chlamydial antigen; and detection of specific antibody in the serum. The cell culture still remains the standard test, and all the other methods have been compared with cell culture, but the cell culture does not detect chlamydial infection in the lower genital tract in the presence of neutralising cervical antibody. Positive yield also depends on proper sample collection, transportation, storage of specimen, and technical factors. Direct detection of chlamydial antigen is more widely used now. It is easy to perform and results may be obtained within an hour of collecting the specimen so that treatment could be started immediately, but clinicians should be aware of false positive results. Serology for Chlamydia trachomatis specific IgG and IgM is of limited value. In chlamydial cervicitis the organism is confined to the endocervical cells and does not provoke a noticeable antibody response. IgM response is poor and does not necessarily indicate current infection. Chlamydia specific IgA antibody is detected in only a small proportion of apparently healthy adults but concentrations are raised in acute infection, which makes it an important marker of acute infection. As the sensitivity of the test is low this can assist but cannot replace either the direct detection of antigen in the specimen or the isolation of chlamydia. DNA hybridisation to detect chlamydial antigen has been studied and the results are promising, but more work is needed for further evaluation.2 Chlamydial infection of the urogenital tract is one of the most common sexually transmitted diseases and its implications -female infertility, ectopic pregnancy, recurrent infection, and dyspareunia -are serious. Improved sensitive and specific tests for diagnosis of the chlamydial genital tract infection is urgently needed, including microbiological criteria of "cure" after conventional treatment with antibiotics, particularly in women. V HARINDRA S SIVAPALAN R BASU ROY
Department of Genitourinary Medicine, Royal Victoria Hospital, Bournemouth BH7 6JF 1 Smith JR, Murdoch J, Carrington D, et al. Prevalence of Chlamydia trachomatis infection in women having cervical smear tests. WMJ 1991;302:82-4. (12 January.) 2 Oriel D, Ridgeway G, Schachter J, et al. Chlamydial infections. London: Cambridge University Press, 1986.
SIR,-We offer our data in support of the conclusion drawn by Dr J R Smith and colleagues that chlamydial infection of the cervix is prevalent, irrespective of cytological state. ' We prospectively screened 67 women who routinely attended during 1990 for cervical smear tests in one rural Welsh general practice. We tested for the presence of cervical pathogens using culture, microscopy, and direct immunofluorescence (Microtrak, Syva) for Chlamydia trachomatis. The results (set against the cytological findings during the preceding two years) are summarised in the table. The important message is that silent chlamydial infection is common in rural seaside Wales just as in inner city Glasgow and may result in much Cervical pathogens present in smears Cytological results No (%) No (%) non-inflammatory inflammatory No pathogens or normal flora Gardnerella alone Gardnerella, bacteroides, and clue cells
28 (50) 5 (9)
12 (63) 0
8 (14)
Chlamydia Candida Coliforms
(9) 12 (21) 4 (7)
1 (5) 2 (10) 4 (20) 0
Total
57 (100)
19 (100)
5
413
