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OXYTOCIN CHALLENGE TEST AND NEONATAL HYPERBILIRUBINÆMIA
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hypo-restrinism, in 3 the picture was normal, and in 2 oestrogen production, though estimated, could not be evaluated. The following risk factors were found: positive family history in 8, hypertension in 8, more than 15% above ideal weight in 5, hypercholesterolaemia (more than 260 mg/dl) in 5, smoking (more than 10 cigarettes daily) in 2, abnormal glucose-tolerance test in 1. 2 females without risk factors had low production of cestrogens. Thus in males hyper-restrinism was found while in females, on the contrary, we found hypo-oestrinism. Both these factors could be considered as risk factors for ischaemic heart-disease in young people. Hypo-oestrinism in young females is not physiological and may be one of the causes of infertility. Hyper-oestrinism is physiological in pregnancy, whereas in males it seems to be a
certainly difficult in practice to persuade them to dnnk ar pint of fresh milk daily. As mentioned by Dr Bntt and Dr Harper (Oct. 9, p. 799) the occasional patient with megaloblastic anxmia due to vitamin-B12 dietary deficiency will, a5 one would expect, respond to one pint of fresh milk daily. As Dr Britt and Dr Harper emphasise, pernicious anæmia is not uncommon in Asian patients in whom it may present particularly early in adult life. Some of these patients with pernicious anxmia are also lacto-vegetarians, and they need full investigations when they present with megaloblastic ansmia It is
extra
West Middlesex
Hospital,
Isleworth,
P. D. ROBERTS
Middlesex TW7 6AF
pathological finding. 4th Medical Department and 1st Gynæcological Department, University Hospital, Charles University, Prague 2, Czechoslovakia
KVĚTA SOUKUPOVÁ JITKA KOBILKOVÁ
CARDIOPULMONARY RESUSCITATION BY LAY PEOPLE
SIR,-With the study by Dr Lund and Dr Skulberg (Oct. 2, p. 702) we have at last got an indication that the teaching of cardiac resuscitation to laymen is not a waste of time. However, the fact that 20% of the survivors had some degree of cerebral damage, described as severe in 8 cases, makes one wonder whether we are really benefiting the patients or their families who must look after them. In 20 out of 75 (35%) resuscitations the technique was apparently unsatisfactory, and nearly all died. The hope is that better training will mean better resuscitation, but will more training merely result in more resuscitation of the same rather low standard? Certainly leaflets, posters, and paragraphs in the backs of diaries or motoring handbooks are unlikely to improve the standard. They never stress the importance of accurate diagnosis or the necessity of simultaneous pulmonary ventilation. In any case the technique is unlikely to be remembered if not practised in some way. Dr Clark’s suggestion (Oct. 23, p. 904) of television instruction is interesting but suffers from the same flaw. There is really no substitute for personal instruction and
practice. Is a little (too little) knowledge dangerous? Are of sacrificing quality of life for quantity. Vauxhall Motors Luton LU2 0SY
we
in
danger
Ltd,
J.
D. BARRETT
VITAMIN-B12 DEFICIENCY IN ASIAN IMMIGRANTS SIR,—Dr Rose (Sept. 25, p. 681) has drawn attention to the problem of dietary vitamin-B12 deficiency in Asian immigrants in Britain, in whom serum-vitamin-B12 levels below our accepted normal range are common; overt megaloblastic anaemia from this cause may develop,2 but is relatively uncommon. These subjects seldom show morphological changes of vitamin-B12 deficiency in either peripheral blood or bone-marrow. Inamdar-Deshmukh and his colleagues3 described a similar situation in the Bombay area of India but found that although the serum-vitamin-B121evels were low in the lactovegetarians, erythrocyte-vitamin-B12 levels were normal. It may be that supplements should be given to raise the serumvitamin-B12 levels in these people, but we are still short of evidence that this is necessary for normal health in the majority.
OXYTOCIN CHALLENGE TEST AND NEONATAL HYPERBILIRUBINÆMIA
SIR Mast et al.’ first suggested a relationship between oxytocin and neonatal hyperbilirubinæmia. While some reports-’ confirmed these findings, others5-7 did not. Beazley et al. found that oxytocin seemed to affect neonatal hyperbilirubinxmia in a way which was dose-dependent when the drug was used for the induction of labour, while acceleration of spontaneous labour with oxytocin had no significant dosedependent relationship. Nevertheless, no attempt has so far been made to relate neonatal hyperbilirubinsemia to a previous oxytocin challenge test. In our series (unpublished) the incidence of neonatal hyperbilirubinæmia was higher in the offspring of women who underwent an oxytocin challenge test before labour. Excluded from the study were infants born after induction or acceleration of labour with oxytocin, infants of Rh-negative mothers, preterm and small-for-dates (low birthweight) neonates, as well as breast-fed newborns. The incidence and severity of jaundice seems to be high in those neonates whose mothers underwent repeated oxytocin challenge tests. No convincing explanation has been offered for the relationship between the use of oxytocin and the development of hyperbilirubinæmia; and the mechanism involved is unknown, We therefore recommend that the oxytocin challenge test should be used very cautiously in women whose babies are at risk of developing hyperbilirubinaemia, especially in conditions such as ABO or rhesus isoimmunisation or immaturity. Department of Obstetrics and Gynæcology, Hasharon Hospital, Petah-Tikva, and Tel-Aviv University Medical School, Israel
DAN PELEG
JACK A. GOLDMAN
RATIONAL CHOICE OF ANTIBIOTIC to his critics (Oct. 23, p. 901) Dr Selwvn in support of his case for bacteriocidal rather than bacteriostatic antibiotics. Our view is that, except in patient with significantly impaired bacterial clearance mechanisms. the difference may be more impressive in the laboratory than it is in the patient. For a bacteriostatic agent to be effective, inhibitory lo-els must be held in contact with the bacteria long enough for mtrinsic defence mechanisms to control the infection. Such agents consequently require relatively long half-lives, and this
SIR,-In his reply
names us
1.
Mast, H., Quackernack, K., Lenfers, M. Geburtsh. Frauenheilk. 1971, 31, 443.
2. Ghosh,
1. Roberts,
P. D., James, H., Petrie, A., Morgan, J. O., Hoffbrand, A. V. Br.
med. J. 1973, iii, 67. 2. Stewart, J. S., Roberts, P. D., Hoffbrand, A. V. Lancet, 1970, ii, 542. 3. Inamdar-Deshmukh, A. B., Jathar, V. S., Joseph, D. A., Satoskar, R. S. Br. J. Hæmat. 1976, 32, 395.
A., Hudson, F. P. Lancet, 1972, ii, 823. 3. Ghosh, A., Hudson, F. P. Br. med J. 1973, iii, 636. 4. Roberts, G., Weaver, A. Lancet, 1974, i, 935. 5. Friedman E. A., Sachtleben, M. R. ibid. 1974, ii, 600. 6. Gray, H. G., Mitchell, R. ibid. p. 1144. 7. Thiery, M., Hemptinne, D., 8. Beazley, J M., Alderman, B
Schuddinck, L., Martens, G. ibid. 1975, i,161. Br. J. Obstet. Gynæc. 1975, 82, 265.
hypo-restrinism, in 3 the picture was normal, and in 2 oestrogen production, though estimated, could not be evaluated. The following risk factors were found: positive family history in 8, hypertension in 8, more than 15% above ideal weight in 5, hypercholesterolaemia (more than 260 mg/dl) in 5, smoking (more than 10 cigarettes daily) in 2, abnormal glucose-tolerance test in 1. 2 females without risk factors had low production of cestrogens. Thus in males hyper-restrinism was found while in females, on the contrary, we found hypo-oestrinism. Both these factors could be considered as risk factors for ischaemic heart-disease in young people. Hypo-oestrinism in young females is not physiological and may be one of the causes of infertility. Hyper-oestrinism is physiological in pregnancy, whereas in males it seems to be a
certainly difficult in practice to persuade them to dnnk ar pint of fresh milk daily. As mentioned by Dr Bntt and Dr Harper (Oct. 9, p. 799) the occasional patient with megaloblastic anxmia due to vitamin-B12 dietary deficiency will, a5 one would expect, respond to one pint of fresh milk daily. As Dr Britt and Dr Harper emphasise, pernicious anæmia is not uncommon in Asian patients in whom it may present particularly early in adult life. Some of these patients with pernicious anxmia are also lacto-vegetarians, and they need full investigations when they present with megaloblastic ansmia It is
extra
West Middlesex
Hospital,
Isleworth,
P. D. ROBERTS
Middlesex TW7 6AF
pathological finding. 4th Medical Department and 1st Gynæcological Department, University Hospital, Charles University, Prague 2, Czechoslovakia
KVĚTA SOUKUPOVÁ JITKA KOBILKOVÁ
CARDIOPULMONARY RESUSCITATION BY LAY PEOPLE
SIR,-With the study by Dr Lund and Dr Skulberg (Oct. 2, p. 702) we have at last got an indication that the teaching of cardiac resuscitation to laymen is not a waste of time. However, the fact that 20% of the survivors had some degree of cerebral damage, described as severe in 8 cases, makes one wonder whether we are really benefiting the patients or their families who must look after them. In 20 out of 75 (35%) resuscitations the technique was apparently unsatisfactory, and nearly all died. The hope is that better training will mean better resuscitation, but will more training merely result in more resuscitation of the same rather low standard? Certainly leaflets, posters, and paragraphs in the backs of diaries or motoring handbooks are unlikely to improve the standard. They never stress the importance of accurate diagnosis or the necessity of simultaneous pulmonary ventilation. In any case the technique is unlikely to be remembered if not practised in some way. Dr Clark’s suggestion (Oct. 23, p. 904) of television instruction is interesting but suffers from the same flaw. There is really no substitute for personal instruction and
practice. Is a little (too little) knowledge dangerous? Are of sacrificing quality of life for quantity. Vauxhall Motors Luton LU2 0SY
we
in
danger
Ltd,
J.
D. BARRETT
VITAMIN-B12 DEFICIENCY IN ASIAN IMMIGRANTS SIR,—Dr Rose (Sept. 25, p. 681) has drawn attention to the problem of dietary vitamin-B12 deficiency in Asian immigrants in Britain, in whom serum-vitamin-B12 levels below our accepted normal range are common; overt megaloblastic anaemia from this cause may develop,2 but is relatively uncommon. These subjects seldom show morphological changes of vitamin-B12 deficiency in either peripheral blood or bone-marrow. Inamdar-Deshmukh and his colleagues3 described a similar situation in the Bombay area of India but found that although the serum-vitamin-B121evels were low in the lactovegetarians, erythrocyte-vitamin-B12 levels were normal. It may be that supplements should be given to raise the serumvitamin-B12 levels in these people, but we are still short of evidence that this is necessary for normal health in the majority.
OXYTOCIN CHALLENGE TEST AND NEONATAL HYPERBILIRUBINÆMIA
SIR Mast et al.’ first suggested a relationship between oxytocin and neonatal hyperbilirubinæmia. While some reports-’ confirmed these findings, others5-7 did not. Beazley et al. found that oxytocin seemed to affect neonatal hyperbilirubinxmia in a way which was dose-dependent when the drug was used for the induction of labour, while acceleration of spontaneous labour with oxytocin had no significant dosedependent relationship. Nevertheless, no attempt has so far been made to relate neonatal hyperbilirubinsemia to a previous oxytocin challenge test. In our series (unpublished) the incidence of neonatal hyperbilirubinæmia was higher in the offspring of women who underwent an oxytocin challenge test before labour. Excluded from the study were infants born after induction or acceleration of labour with oxytocin, infants of Rh-negative mothers, preterm and small-for-dates (low birthweight) neonates, as well as breast-fed newborns. The incidence and severity of jaundice seems to be high in those neonates whose mothers underwent repeated oxytocin challenge tests. No convincing explanation has been offered for the relationship between the use of oxytocin and the development of hyperbilirubinæmia; and the mechanism involved is unknown, We therefore recommend that the oxytocin challenge test should be used very cautiously in women whose babies are at risk of developing hyperbilirubinaemia, especially in conditions such as ABO or rhesus isoimmunisation or immaturity. Department of Obstetrics and Gynæcology, Hasharon Hospital, Petah-Tikva, and Tel-Aviv University Medical School, Israel
DAN PELEG
JACK A. GOLDMAN
RATIONAL CHOICE OF ANTIBIOTIC to his critics (Oct. 23, p. 901) Dr Selwvn in support of his case for bacteriocidal rather than bacteriostatic antibiotics. Our view is that, except in patient with significantly impaired bacterial clearance mechanisms. the difference may be more impressive in the laboratory than it is in the patient. For a bacteriostatic agent to be effective, inhibitory lo-els must be held in contact with the bacteria long enough for mtrinsic defence mechanisms to control the infection. Such agents consequently require relatively long half-lives, and this
SIR,-In his reply
names us
1.
Mast, H., Quackernack, K., Lenfers, M. Geburtsh. Frauenheilk. 1971, 31, 443.
2. Ghosh,
1. Roberts,
P. D., James, H., Petrie, A., Morgan, J. O., Hoffbrand, A. V. Br.
med. J. 1973, iii, 67. 2. Stewart, J. S., Roberts, P. D., Hoffbrand, A. V. Lancet, 1970, ii, 542. 3. Inamdar-Deshmukh, A. B., Jathar, V. S., Joseph, D. A., Satoskar, R. S. Br. J. Hæmat. 1976, 32, 395.
A., Hudson, F. P. Lancet, 1972, ii, 823. 3. Ghosh, A., Hudson, F. P. Br. med J. 1973, iii, 636. 4. Roberts, G., Weaver, A. Lancet, 1974, i, 935. 5. Friedman E. A., Sachtleben, M. R. ibid. 1974, ii, 600. 6. Gray, H. G., Mitchell, R. ibid. p. 1144. 7. Thiery, M., Hemptinne, D., 8. Beazley, J M., Alderman, B
Schuddinck, L., Martens, G. ibid. 1975, i,161. Br. J. Obstet. Gynæc. 1975, 82, 265.