532 MEDICAL SCREENING OF OLD PEOPLE
SIR,-Dr Wright (Aug: 5. p. 323) seems to have misunderstood a number of aspects of the screening programme described in our paper of July 15. The disorders that we enumerated were those which constituted new findings, and established diseases (stroke, parkinsonism, and so on already known to the general practitioner, investigated, and treated) were not described in our paper. This examination was entirely additional to whatever medical arrangements were deemed necessary by the general practitioner and thus in no way delayed treatment of intercurrent infections and so on. The procedure was not regarded as a method of dealing with acute breakdown, either medical or social, and immediate hospital admission and domiciliary advice continued to be given in the normal way without being affected by the screening examination. There was no delay in securing the outpatient appointment, and the time required for the whole examination and additional investigations never exceeded two hours. This is certainly less than spending a whole day at a day hospital, as Wright suggests.
J.C.BROCKLEHURST J.J. T. L.EEMING
C. BROCKLEHURST
Department of Geriatric Medicine, University of ofManchester, Manchester, University Hospital of South Manchester,
"
,-.
M. w H. CARTY J. M. ROBINSON
Manchester M20 8LR
SIR,-Ifound some of Dr Wright’s suggestions regarding the investigation of old people confusing. An elderly person who has taken to his bed surely warrants more energetic intervention than that described, at least to exclude acute arthropathies, skeletal disorders, electrolyte disturbances, neuromuscular diseases, diabetes mellitus, anaemia, infections, myxoedema, and cardiac disease by a few simple blood-tests and X-rays. Since loss of both mobility and independence can result from even minor disorders of this nature in the elderly, active investigation and treatment are entirely
_
laxis in at-risk infants who have had asphyxiating episodes have centred on prevention of bacterial colonisation. Approaches have included withholding of all oral feeds, use of fresh breast milk (for which there is experimental support), oral antibiotics.67 Trials of kanamycin and gentamicin67 seemed hopeful in that the results were statistically significant, albeit with very small numbers of patients. To test the hypothesis that oral gentamicin prevents N.E.C. in at-risk infants we have done a double-blind trial. Infants were admitted to the trial if they fulfilled any one of the following criteria: (1) under 1500 g birth-weight, (2) requiring umbilical external or venous catheters, and (3) prematurity with a history of fetal distress, postnatal episodes of severe hypoxia or hypotension, or Apgar score of less than 7 at 5 min in infants under 2000 g. On arrival in the nursery, infants were randomly assigned to one of two groups by the chief pharmacist. The medical and nursing staff were blind to the allocation. One group received oral gentamicin in a dose of 2-55 mg/kg 6-hourly for one week and the other infants were given a placebo solution of purified sterile water from identically labelled bottles, 6-hourly for one week. 50 patients were allocated to active treatment and 50 to placebo. There were 9 cases of N.E.C., proved by X-ray evidence by intraluminal gas-6 in the active group and 3 in the placebo group. This result is not statistically significant. This study does not support the contention that prophylactic oral gentamicin is of value in N.E.c. This may be because of the ubiquitous nature of potential infecting organisms and their various antibiotic resistance patterns-a possibility because the organism may have no role in the initiation process.
Queen Victoria Hospital, Rose Park, South Australia 5067
MARTIN P. ROWLEY
Department of Pædiatrics, University of Adelaide (at Queen Victoria Hospital)
GEOFFREY W. DAHLENBURG
appropriate. Mental disturbances likewise
warrant more
intensive inves-
tigation, albeit to a limited extent in long-standing dementia. Again, a few simple tests such as hemoglobin, blood film, treponemal serology, blood-sugar, thyroid function, and serum calcium, urea, and electrolytes hardly inconvenience even the demented cripple. Apart from their value in epidemiological studies of this common problem, even a low response rate invites investigation and treatment for the sake of the individual concerned, regardless of whether or not he or she is valued by or an added burden upon the relatives. Surely the rights of any individual to both a mobile existence and optimal intellectual functioning should not be compromised by social or pecuniary considerations. Recent reports have confirmed the high incidence of treatable conditions in medically screened elderly people, reminding us that active investigation and treatment of old people will indeed improve the quality of their twilight years. Department of Geriatrics and General Medicine; Guy’s Hospital, London SE1 9RT
BRUCE W. S. ROBINSON
GENTAMICIN IN PROPHYLAXIS OF NEONATAL NECROTISING ENTEROCOLITIS
SIR,-There has been a worldwide upsurge in the incidence of neonatal necrotising enterocolitis (N.E.c.).’ The most prevalent theory is that, consequent upon hypoxic damage to the gut wall, gas-forming organisms colonise the necrotic tissue when feeding begins.2-4 In view of this theory, attempts at prophy1. Bunton, G. L., and others. Archs Dis. Childh. 1977, 52, 772. 2. British Medical Journal, 1978, i, 132. 3. Cummins, G. E. Med. J. Aust. 1977, i, 376. 4. Proceedings of Australian Pædiatric Association, May, 1977.
LEAD AND MORBIDITY
SIR,-The paper on lead and morbidity by Dr Irwig and colleagues (July 1, p. 4) raises many questions which cast doubt on the conclusions. The authors emphasise that occupational and environmental standards should whenever possible be based directly on mortality and morbidity. Therefore, one has to observe excess mortality and morbidity before being able to set a standard. The W.H.O., however, stated quite rightly that "one has to measwe those parameters that can serve as a warning signal for impending risks, i.e., one has to rely, whenever possible, on early reversible changes in biological parameters before health impairment has become manifest".2 More recently the W.H.O. concluded3that "the basic objectives in establishing permissible levels are now very similar in both countries" (U.S.A., U.S.S.R.). Moreover, the authors should at least have discussed the recommended permissible levels for occupational exposure recommended by an international group of experts4 which to a large extent were based upon early biochemical (increase of zinc protoporphyrin) and functional (decreased motor-nerve conduction velocity) effects. The paper was cited but these effects were not examined. The group of experts recommended a maximal individual blood-lead of 60 fLg/dl for male workers. More than half the 489 workers examined by Irwig et al. had a much higher level. An increased prevalence of abdominal ache was found at a 5. Pitt, J., and others. Pediat. Res. 1977, 11, 906. 6. Egan, E. A., and others. J. Pediat. 1976, 89, 466. 7. Grylack, L., Scanlon, J. W. Lancet, 1977, ii, 506. 1. Irwig, L. M., Harrison, W. O., Rocks, P., Webster, I. Lancet, 2. W.H.O. techn. Rep. Ser. 1975, no. 571. 3. ibid. no. 601, 1977. 4. Zielhuis, R. L. Int. Archs. occup. envir. Hlth, 1977, 39, 59.
1978, i, 4.
SIR,-Dr Wright (Aug: 5. p. 323) seems to have misunderstood a number of aspects of the screening programme described in our paper of July 15. The disorders that we enumerated were those which constituted new findings, and established diseases (stroke, parkinsonism, and so on already known to the general practitioner, investigated, and treated) were not described in our paper. This examination was entirely additional to whatever medical arrangements were deemed necessary by the general practitioner and thus in no way delayed treatment of intercurrent infections and so on. The procedure was not regarded as a method of dealing with acute breakdown, either medical or social, and immediate hospital admission and domiciliary advice continued to be given in the normal way without being affected by the screening examination. There was no delay in securing the outpatient appointment, and the time required for the whole examination and additional investigations never exceeded two hours. This is certainly less than spending a whole day at a day hospital, as Wright suggests.
J.C.BROCKLEHURST J.J. T. L.EEMING
C. BROCKLEHURST
Department of Geriatric Medicine, University of ofManchester, Manchester, University Hospital of South Manchester,
"
,-.
M. w H. CARTY J. M. ROBINSON
Manchester M20 8LR
SIR,-Ifound some of Dr Wright’s suggestions regarding the investigation of old people confusing. An elderly person who has taken to his bed surely warrants more energetic intervention than that described, at least to exclude acute arthropathies, skeletal disorders, electrolyte disturbances, neuromuscular diseases, diabetes mellitus, anaemia, infections, myxoedema, and cardiac disease by a few simple blood-tests and X-rays. Since loss of both mobility and independence can result from even minor disorders of this nature in the elderly, active investigation and treatment are entirely
_
laxis in at-risk infants who have had asphyxiating episodes have centred on prevention of bacterial colonisation. Approaches have included withholding of all oral feeds, use of fresh breast milk (for which there is experimental support), oral antibiotics.67 Trials of kanamycin and gentamicin67 seemed hopeful in that the results were statistically significant, albeit with very small numbers of patients. To test the hypothesis that oral gentamicin prevents N.E.C. in at-risk infants we have done a double-blind trial. Infants were admitted to the trial if they fulfilled any one of the following criteria: (1) under 1500 g birth-weight, (2) requiring umbilical external or venous catheters, and (3) prematurity with a history of fetal distress, postnatal episodes of severe hypoxia or hypotension, or Apgar score of less than 7 at 5 min in infants under 2000 g. On arrival in the nursery, infants were randomly assigned to one of two groups by the chief pharmacist. The medical and nursing staff were blind to the allocation. One group received oral gentamicin in a dose of 2-55 mg/kg 6-hourly for one week and the other infants were given a placebo solution of purified sterile water from identically labelled bottles, 6-hourly for one week. 50 patients were allocated to active treatment and 50 to placebo. There were 9 cases of N.E.C., proved by X-ray evidence by intraluminal gas-6 in the active group and 3 in the placebo group. This result is not statistically significant. This study does not support the contention that prophylactic oral gentamicin is of value in N.E.c. This may be because of the ubiquitous nature of potential infecting organisms and their various antibiotic resistance patterns-a possibility because the organism may have no role in the initiation process.
Queen Victoria Hospital, Rose Park, South Australia 5067
MARTIN P. ROWLEY
Department of Pædiatrics, University of Adelaide (at Queen Victoria Hospital)
GEOFFREY W. DAHLENBURG
appropriate. Mental disturbances likewise
warrant more
intensive inves-
tigation, albeit to a limited extent in long-standing dementia. Again, a few simple tests such as hemoglobin, blood film, treponemal serology, blood-sugar, thyroid function, and serum calcium, urea, and electrolytes hardly inconvenience even the demented cripple. Apart from their value in epidemiological studies of this common problem, even a low response rate invites investigation and treatment for the sake of the individual concerned, regardless of whether or not he or she is valued by or an added burden upon the relatives. Surely the rights of any individual to both a mobile existence and optimal intellectual functioning should not be compromised by social or pecuniary considerations. Recent reports have confirmed the high incidence of treatable conditions in medically screened elderly people, reminding us that active investigation and treatment of old people will indeed improve the quality of their twilight years. Department of Geriatrics and General Medicine; Guy’s Hospital, London SE1 9RT
BRUCE W. S. ROBINSON
GENTAMICIN IN PROPHYLAXIS OF NEONATAL NECROTISING ENTEROCOLITIS
SIR,-There has been a worldwide upsurge in the incidence of neonatal necrotising enterocolitis (N.E.c.).’ The most prevalent theory is that, consequent upon hypoxic damage to the gut wall, gas-forming organisms colonise the necrotic tissue when feeding begins.2-4 In view of this theory, attempts at prophy1. Bunton, G. L., and others. Archs Dis. Childh. 1977, 52, 772. 2. British Medical Journal, 1978, i, 132. 3. Cummins, G. E. Med. J. Aust. 1977, i, 376. 4. Proceedings of Australian Pædiatric Association, May, 1977.
LEAD AND MORBIDITY
SIR,-The paper on lead and morbidity by Dr Irwig and colleagues (July 1, p. 4) raises many questions which cast doubt on the conclusions. The authors emphasise that occupational and environmental standards should whenever possible be based directly on mortality and morbidity. Therefore, one has to observe excess mortality and morbidity before being able to set a standard. The W.H.O., however, stated quite rightly that "one has to measwe those parameters that can serve as a warning signal for impending risks, i.e., one has to rely, whenever possible, on early reversible changes in biological parameters before health impairment has become manifest".2 More recently the W.H.O. concluded3that "the basic objectives in establishing permissible levels are now very similar in both countries" (U.S.A., U.S.S.R.). Moreover, the authors should at least have discussed the recommended permissible levels for occupational exposure recommended by an international group of experts4 which to a large extent were based upon early biochemical (increase of zinc protoporphyrin) and functional (decreased motor-nerve conduction velocity) effects. The paper was cited but these effects were not examined. The group of experts recommended a maximal individual blood-lead of 60 fLg/dl for male workers. More than half the 489 workers examined by Irwig et al. had a much higher level. An increased prevalence of abdominal ache was found at a 5. Pitt, J., and others. Pediat. Res. 1977, 11, 906. 6. Egan, E. A., and others. J. Pediat. 1976, 89, 466. 7. Grylack, L., Scanlon, J. W. Lancet, 1977, ii, 506. 1. Irwig, L. M., Harrison, W. O., Rocks, P., Webster, I. Lancet, 2. W.H.O. techn. Rep. Ser. 1975, no. 571. 3. ibid. no. 601, 1977. 4. Zielhuis, R. L. Int. Archs. occup. envir. Hlth, 1977, 39, 59.
1978, i, 4.
