1214
BRITISH MEDICAL JOURNAL
5 NOVEMBER 1977
CORRES PONDENCE Special and intensive care of the newborn D E P Shapland, MRCOG; R R Gordon, FRCP ................................ 1214
Role of the hospital in primary paediatric care M J Robinson, MRCP, and others ........ 1215 ECT and the media K Sabbagh, MA ...................... 1215 Surgical emphysema during dental treatment M Segal, FRCP; C M Scully, MB, BDS; G H Forman, MB, FDSRCS ............. 1216 Evolution of poliovirus since introduction of attenuated vaccine Yvonne E Cossart, MRCPATH .1216 Polyunsaturated fatty acids in multiple sclerosis H M Sinclair, FRCP; D Bates, MRCP, and ....... 1217 others Preoperative anaesthetic visit D W Ryan, FFARCS; J J Slowe, FFARCS; A A Beaton, PHD .......................... 1217 Ipecacuanha as an emetic 1218 G R Brown ............... Post-marketing surveillance of new medicines R W Smithells, FRCP .................. 1218 Oestrogens for menopausal flushing S Campbell, FRCOG, and others .......... 1218 Campylobacter enteritis D Bruce, FIMLS, and others; L J Hayek, MRCPATH, and J G Cruickshank, FRCPATH. . 1219 SI units and acidity D Mainland, MB ...................... 1219
Surgical treatment of coronary disease C A Layton, MRCP ........ ............ Hyperglycaemia and complications of diabetes Ruth Rasch, MD, and H J G Gundersen, MD; C J V Fox, MRCP, and others ........ Control of hyperglycaemia in young diabetics D J Betteridge, MRCP .................. Another beta-blocker causing eye symptoms? D L Scott, MRCS ...................... Names of drugs E T Mathews, FFARCS; P de Haen; Annabel Peatman, MPS ...... .......... Screening children for visual defects Colonel R M Youngson, MB, DO ........ Hospital appointment procedure B Lee, MRCGP ........... ............. Obstetric audit in general practice J S K Stevenson, FRCGP; R M Darling, MRCP Oestrogen: creatinine ratio in all pregnancies? A T Howarth PHD, and others; L G S
Rao,
1220
1220
1220 1221
1221 1221
1222
1222
PHD ............................ 1222
The perilous skateboard S P Glascoe, MB ...................... 1222 Switching off A W Fowler, FRCS ........ ............ 1223 The neonatal electrocardiogram and unexpected death in infancy D P Southall, MRCP, and E A Shinebourne, MD ........... 1223 ....................... Oxytocin and neonatal jaundice Louise Friedman, BSC, and others ........ 1223
Correspondents are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors. Special and intensive care of the newborn
SIR,-The study on arrangements for special and intensive care of the newborn by Dr Eva Alberman and others (22 October, p 1045) must make alarming reading for all doctors involved in delivering babies and in neonatal care. The problem they highlighted-of nurseries in many district general hospitals virtually masquerading as "special care units" with no genuine specialist cover but characteristically controlled by an overworked designated consultant who can seldom be physically in his unit and actually run by inexperienced juniors or often by nurses only-is a very real one. From this rather long-distance viewpoint there seems to me to be a strong case for the following. (1) Establishing regional perinatology centres in certain major hospitals only and ensuring that these are properly staffed by real specialists (that is, not junior SHOs) who actually do the work and that they include genuine paediatric intensive care facilities. There should be enough through-put in these centres both to justify their level of staffing and equipment and to build up and maintain their expertise. (2) The conduct of
regular clinical audit of these and all other units providing obstetric and neonatal carebut on the basis of outcome criteria, please, not just on input as in the study by Dr Alberman and her colleagues. (3) The provision of an efficient (infrequently used, one hopes) neonatal emergency transport service essentially capable of taking a mobile, fully equipped special care unit to the neonate in trouble elsewhere, a system I was privileged to see recently in operation in Melboume, Australia. I would suggest that perinatology and neonatology are not suitable branches of medical practice for inexperienced junior doctors to be left virtually unsupervised in and that antenatal selection should permit the segregation of at-risk patients and their babies, who would and should benefit from the techniques now available if only these are properly applied by properly trained personnel. DAVID SHAPLAND Breconshire War Memorial Hospital, Brecon, Powys
Sealing of wounds with vacuum drainage C P Sames, FRCS ...................... 1223 Raised plasma urea concentration K Wiener, PHD ...................... Treatment of acute paracetamol poisoning G R Jones, MB, and T P L Thomas, MRCP Primary treatment of prostatic cancer P J Doyle, FRCSED .................... SI units J S Law, MD, and J M Stansfeld, FRCP .. Arthritis and primary biliary cirrhosis P R Mills, MRCP, and others ............ Sunlighting in medicine A E Carter, FRCS ...................... Shortage of radiologists J L G Thomson, FRCR ................ Revenue sources for community health services A P Tait, MB, and G I Benson, MRCS ...... Home Office v the NHS J P Driver-Jowitt, FRCSI ................ The Minister and the consultants J A K Davies, MRCOG .................. Payment for on-call duties of clinical assistants A P C Bacon, FRCP .................... General practitioners' pay M J Critchley, MRCGP .................. Use of deputising services D Lynch, MRCGP ...................... Work of community physicians G D Duncan, FFCM .................... Changing the FRCS exam R S Murley, PRCS ....... .............
1223 1224 1224
1224 1224
1224
1225 1225
1225
1225 1225
1226
1226 1226 1226
SIR,-We must thank Dr Eva Alberman and her colleagues (22 October, p 1045) for their very interesting paper. As they say, the ability quickly to resuscitate asphyxiated newborn infants is the essence of their special care and this facility should now be the right of them all whatever the birth weight. It should therefore be available in every maternity unit. Those in which it cannot be provided should close. It would be equally absurd to deliver a woman in a maternity unit without the capacity for forceps delivery. The facilities in staff and equipment required for asphyxiated newboms of all birth weights are the same as those required for apnoeic attacks in preterm infants, so if they are available to the former they are available to the latter. The discussion at the moment hinges around the provision of assisted respiration for those small infants who have recurrent apnoeic attacks or other respiratory difficulties. It is assumed that continuous positive airways pressure and respirator care have a marked effect in reducing mortality rates in such pre-term infants, but there is as yet no evidence that this is so in unselected groups of patients. Dr Alberman and her colleagues mention that "national" figures for 1974 show a neonatal mortality rate of 99/1000 live births in the 2-5-kg-or-less group. The 1976 figure for the same group in England and Wales is 86/1000
BRITISH MEDICAL JOURNAL
5 NOVEMBER 1977
CORRES PONDENCE Special and intensive care of the newborn D E P Shapland, MRCOG; R R Gordon, FRCP ................................ 1214
Role of the hospital in primary paediatric care M J Robinson, MRCP, and others ........ 1215 ECT and the media K Sabbagh, MA ...................... 1215 Surgical emphysema during dental treatment M Segal, FRCP; C M Scully, MB, BDS; G H Forman, MB, FDSRCS ............. 1216 Evolution of poliovirus since introduction of attenuated vaccine Yvonne E Cossart, MRCPATH .1216 Polyunsaturated fatty acids in multiple sclerosis H M Sinclair, FRCP; D Bates, MRCP, and ....... 1217 others Preoperative anaesthetic visit D W Ryan, FFARCS; J J Slowe, FFARCS; A A Beaton, PHD .......................... 1217 Ipecacuanha as an emetic 1218 G R Brown ............... Post-marketing surveillance of new medicines R W Smithells, FRCP .................. 1218 Oestrogens for menopausal flushing S Campbell, FRCOG, and others .......... 1218 Campylobacter enteritis D Bruce, FIMLS, and others; L J Hayek, MRCPATH, and J G Cruickshank, FRCPATH. . 1219 SI units and acidity D Mainland, MB ...................... 1219
Surgical treatment of coronary disease C A Layton, MRCP ........ ............ Hyperglycaemia and complications of diabetes Ruth Rasch, MD, and H J G Gundersen, MD; C J V Fox, MRCP, and others ........ Control of hyperglycaemia in young diabetics D J Betteridge, MRCP .................. Another beta-blocker causing eye symptoms? D L Scott, MRCS ...................... Names of drugs E T Mathews, FFARCS; P de Haen; Annabel Peatman, MPS ...... .......... Screening children for visual defects Colonel R M Youngson, MB, DO ........ Hospital appointment procedure B Lee, MRCGP ........... ............. Obstetric audit in general practice J S K Stevenson, FRCGP; R M Darling, MRCP Oestrogen: creatinine ratio in all pregnancies? A T Howarth PHD, and others; L G S
Rao,
1220
1220
1220 1221
1221 1221
1222
1222
PHD ............................ 1222
The perilous skateboard S P Glascoe, MB ...................... 1222 Switching off A W Fowler, FRCS ........ ............ 1223 The neonatal electrocardiogram and unexpected death in infancy D P Southall, MRCP, and E A Shinebourne, MD ........... 1223 ....................... Oxytocin and neonatal jaundice Louise Friedman, BSC, and others ........ 1223
Correspondents are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors. Special and intensive care of the newborn
SIR,-The study on arrangements for special and intensive care of the newborn by Dr Eva Alberman and others (22 October, p 1045) must make alarming reading for all doctors involved in delivering babies and in neonatal care. The problem they highlighted-of nurseries in many district general hospitals virtually masquerading as "special care units" with no genuine specialist cover but characteristically controlled by an overworked designated consultant who can seldom be physically in his unit and actually run by inexperienced juniors or often by nurses only-is a very real one. From this rather long-distance viewpoint there seems to me to be a strong case for the following. (1) Establishing regional perinatology centres in certain major hospitals only and ensuring that these are properly staffed by real specialists (that is, not junior SHOs) who actually do the work and that they include genuine paediatric intensive care facilities. There should be enough through-put in these centres both to justify their level of staffing and equipment and to build up and maintain their expertise. (2) The conduct of
regular clinical audit of these and all other units providing obstetric and neonatal carebut on the basis of outcome criteria, please, not just on input as in the study by Dr Alberman and her colleagues. (3) The provision of an efficient (infrequently used, one hopes) neonatal emergency transport service essentially capable of taking a mobile, fully equipped special care unit to the neonate in trouble elsewhere, a system I was privileged to see recently in operation in Melboume, Australia. I would suggest that perinatology and neonatology are not suitable branches of medical practice for inexperienced junior doctors to be left virtually unsupervised in and that antenatal selection should permit the segregation of at-risk patients and their babies, who would and should benefit from the techniques now available if only these are properly applied by properly trained personnel. DAVID SHAPLAND Breconshire War Memorial Hospital, Brecon, Powys
Sealing of wounds with vacuum drainage C P Sames, FRCS ...................... 1223 Raised plasma urea concentration K Wiener, PHD ...................... Treatment of acute paracetamol poisoning G R Jones, MB, and T P L Thomas, MRCP Primary treatment of prostatic cancer P J Doyle, FRCSED .................... SI units J S Law, MD, and J M Stansfeld, FRCP .. Arthritis and primary biliary cirrhosis P R Mills, MRCP, and others ............ Sunlighting in medicine A E Carter, FRCS ...................... Shortage of radiologists J L G Thomson, FRCR ................ Revenue sources for community health services A P Tait, MB, and G I Benson, MRCS ...... Home Office v the NHS J P Driver-Jowitt, FRCSI ................ The Minister and the consultants J A K Davies, MRCOG .................. Payment for on-call duties of clinical assistants A P C Bacon, FRCP .................... General practitioners' pay M J Critchley, MRCGP .................. Use of deputising services D Lynch, MRCGP ...................... Work of community physicians G D Duncan, FFCM .................... Changing the FRCS exam R S Murley, PRCS ....... .............
1223 1224 1224
1224 1224
1224
1225 1225
1225
1225 1225
1226
1226 1226 1226
SIR,-We must thank Dr Eva Alberman and her colleagues (22 October, p 1045) for their very interesting paper. As they say, the ability quickly to resuscitate asphyxiated newborn infants is the essence of their special care and this facility should now be the right of them all whatever the birth weight. It should therefore be available in every maternity unit. Those in which it cannot be provided should close. It would be equally absurd to deliver a woman in a maternity unit without the capacity for forceps delivery. The facilities in staff and equipment required for asphyxiated newboms of all birth weights are the same as those required for apnoeic attacks in preterm infants, so if they are available to the former they are available to the latter. The discussion at the moment hinges around the provision of assisted respiration for those small infants who have recurrent apnoeic attacks or other respiratory difficulties. It is assumed that continuous positive airways pressure and respirator care have a marked effect in reducing mortality rates in such pre-term infants, but there is as yet no evidence that this is so in unselected groups of patients. Dr Alberman and her colleagues mention that "national" figures for 1974 show a neonatal mortality rate of 99/1000 live births in the 2-5-kg-or-less group. The 1976 figure for the same group in England and Wales is 86/1000
