- Email: [email protected]
PERINATAL MORTALITY
1305 Rather than dabbling in social Darwinism and having us believe that trade unionism is a "collective bribery" which is the inheritance of a mammalian tendency toward plunder, preying, and violence, Passmore should leave the world of fresh fruit, early to bed, and outdoor exercise, which he says he learned as a child, and visit the coalmines and steelworks to meet some who had to resort to "collective bribery" to begin to secure those same amenities. A dilettante dissertation by a physiologist on primary care does not deserve to be in the pages of a journal such as The Lancet, which has in the past taken a serious view of the problems of getting care to people. If Passmore finds altruism, compassion, and dedication to meeting people’s needs, however and whenever those needs arise, too difficult to fit into his scheme of orderly, disease specific, practical primary care, then it would be well for him to stick to his experimental preparations, good eating habits, and jogging, and leave the problems of primary care to those of us who are trying to deliver it.
terfere with the natural course of gestation, perhaps prematurely ; this letter may reveal other areas with a similar experience. Exchange of ideas at this stage may help such investigations to be more effective in the endeavour to reduce intra-partum loss of life.
Glyncorrwg Health Centre, near Port Talbot, Glamorgan SA13
First, the consultative document containing the proposals, like all other consultative documents issued by the Commission, serves only to put forward proposals from the Commission on which the views of interested parties are sought. The objective is to see what others concerned think of the proposals, and the proposals made will be reconsidered in the light of the comments received. This leads me to the statement by Dr Freeman and Dr Ingham that the consultative document "does not seem to have been well publicised". The Commission put out a Press notice in the usual way when the document was published and sent out over 800 copies of the notice and the document to the national and regional Press and medical and scientific journals. In addition, the document was sent to some 50 of the professional and scientific bodies concerned, with a request for their comments. I am sorry that, at the time they wrote their letter, Dr Freeman and Dr Ingham had not received the copy of the document they had requested but demand for it has been
3BL
West Sussex Area Health
Authority, Goring-by-Sea, Worthing, West Sussex BN12 4NQ
DANGEROUS PATHOGENS
SIR,-Since my Division of the Health and Safety Executive had some involvement with the recent proposals for regulations to notify H.S.E. of work with dangerous pathogens I would like to comment on the letter from Dr Freeman and Dr
Ingham (Nov. 24, p. 1134).
J. J. FREY
PERINATAL MORTALITY
SIR,-Professor Rooth (Dec. 1, p. 1170) claims that high and maintained standards of obstetric care are responsible for the creditably low perinatal mortality rate (PMR) in Sweden. During the past twenty years we have been accustomed to finding the rate for West Sussex to be at least 10% lower than that for England and Wales. The standardised PMR of this area for the years 1974-78 was calculated by Mallett and Knox’ to be 88.6. This was eleventh in order from the lowest of the ninety health areas. Their thesis is that standardisation of the rate by birthweights eliminates, to an extent, the effects of social background. The performance of obstetricians in West Sussex was, on this measure, of high quality. In 1978, however, the PMR for this area was no better than the national figure of 15-5. It seems that this poor result was not just an occasional variation resulting from small numbers. The four-year moving average of the rate is rising, and the mean for the last four years is just about the present rate in England and Wales. There is a tendency for the rate to increase, contrary to its pattern before the last three years and contrary to the national trend. The stillbirth and early neonatal rates (the two components of the perinatal rate) have both reversed their previous steady improvement. When the rates in the three districts of the area are examined separately, no district is immune from an increase during the past three years. The lowest perinatal mortality and stillbirth rates are achieved in the district with the fewest births for each consultant obstetrician (i.e., the most generous consultant cover); the district with the largest number of all obstetric staff, proportional to the number of births, has the highest stillbirth rate. It may be that when junior staff are available, they take decisions beyond their competence. The evidence for the conclusions is inadequate; the association may occur purely by chance. We are in process of examining the multiple factors which can influence a PMR in order to determine whether the apparent increase truly represents a larger number of unsuccessful pregnancies. It is possible that changes in reporting methods are the only cause of alteration in the rates. We are analysing the characteristics of the mothers who lose babies and categorising the causes of early neonatal death. Our intention had been to present our findings to the obstetric and pxdiatric divisions concerned to open up a discussion on their validity and such changes in practice as might be indicated. Your series of articles on Better Perinatal Health, however, prompts us to in1. Mallett R, Knox EG. Standardized perinatal mortality ratios: utility and interpretation. Commun Med 1979; 1: 6-13.
technique,
S. A. COOPER A. S. HARRIS B. S. HOLMES G. RICHARDS
heavy. .
There is not space to deal adequately with some of the other issues in their letter, or with those in your editorial of Nov. 10, and there seems little point in debating further at the moment when we are in fact at a consultative stage and can deal with all these matters as we receive comments on the document. Health & Safety Executive, 25 Chapel Street, London NW1 5DT
K. P.
DUNCAN,
Director of medical services
DELAYED HYPERSENSITIVITY TO CHLAMYDIA TRACHOMATIS: CAUSE OF CHRONIC PROSTATITIS? no specific microbial aetiology for chronic prosbe found treatment is notoriously unsuccessful.’I Mardh et al. suggested that chlamydiae might be a cause but their cultural and serological tests did not confirm this suggestion.3 Delayed hypersensitivity tests to chlamydial antigens are used in the diagnosis of lymphogranuloma venereum, and there is evidence that delayed hypersensitivity may play a role in the manifestations of trachoma.4 We have studied a case of chronic non-bacterial prostatitis which could be a manifestation of delayed hypersensitivity to Chlamydia trachomatis. C. trachomatis strain TE55 (serologically identical to LGVII),
SIR,-When
tatitis
can
kindly provided by
Prof. L. H. Collier (The London
Hospital),
was
1. Feit RM, Fair WR. Prostatitis. Sex Transm Dis 1978; 5: 78-80. P-A, Colleen S, Holmquist B. Chlamydia in chronic prostatitis. Br
2. Mardh
Med J 1972; 4: 361. 3. Mardh P-A, Ripa KT, Colleen S, Treharne JD, Darougar S. Role of Chlamydia trachomatis in non-acute prostatitis. Br J Vener Dis 1978; 54: 330-334. 4. Grayston JT, Wang S-P. New knowledge of chlamydiæ and the diseases they cause. J Infect Dis 1975; 132: 87-105.
terfere with the natural course of gestation, perhaps prematurely ; this letter may reveal other areas with a similar experience. Exchange of ideas at this stage may help such investigations to be more effective in the endeavour to reduce intra-partum loss of life.
Glyncorrwg Health Centre, near Port Talbot, Glamorgan SA13
First, the consultative document containing the proposals, like all other consultative documents issued by the Commission, serves only to put forward proposals from the Commission on which the views of interested parties are sought. The objective is to see what others concerned think of the proposals, and the proposals made will be reconsidered in the light of the comments received. This leads me to the statement by Dr Freeman and Dr Ingham that the consultative document "does not seem to have been well publicised". The Commission put out a Press notice in the usual way when the document was published and sent out over 800 copies of the notice and the document to the national and regional Press and medical and scientific journals. In addition, the document was sent to some 50 of the professional and scientific bodies concerned, with a request for their comments. I am sorry that, at the time they wrote their letter, Dr Freeman and Dr Ingham had not received the copy of the document they had requested but demand for it has been
3BL
West Sussex Area Health
Authority, Goring-by-Sea, Worthing, West Sussex BN12 4NQ
DANGEROUS PATHOGENS
SIR,-Since my Division of the Health and Safety Executive had some involvement with the recent proposals for regulations to notify H.S.E. of work with dangerous pathogens I would like to comment on the letter from Dr Freeman and Dr
Ingham (Nov. 24, p. 1134).
J. J. FREY
PERINATAL MORTALITY
SIR,-Professor Rooth (Dec. 1, p. 1170) claims that high and maintained standards of obstetric care are responsible for the creditably low perinatal mortality rate (PMR) in Sweden. During the past twenty years we have been accustomed to finding the rate for West Sussex to be at least 10% lower than that for England and Wales. The standardised PMR of this area for the years 1974-78 was calculated by Mallett and Knox’ to be 88.6. This was eleventh in order from the lowest of the ninety health areas. Their thesis is that standardisation of the rate by birthweights eliminates, to an extent, the effects of social background. The performance of obstetricians in West Sussex was, on this measure, of high quality. In 1978, however, the PMR for this area was no better than the national figure of 15-5. It seems that this poor result was not just an occasional variation resulting from small numbers. The four-year moving average of the rate is rising, and the mean for the last four years is just about the present rate in England and Wales. There is a tendency for the rate to increase, contrary to its pattern before the last three years and contrary to the national trend. The stillbirth and early neonatal rates (the two components of the perinatal rate) have both reversed their previous steady improvement. When the rates in the three districts of the area are examined separately, no district is immune from an increase during the past three years. The lowest perinatal mortality and stillbirth rates are achieved in the district with the fewest births for each consultant obstetrician (i.e., the most generous consultant cover); the district with the largest number of all obstetric staff, proportional to the number of births, has the highest stillbirth rate. It may be that when junior staff are available, they take decisions beyond their competence. The evidence for the conclusions is inadequate; the association may occur purely by chance. We are in process of examining the multiple factors which can influence a PMR in order to determine whether the apparent increase truly represents a larger number of unsuccessful pregnancies. It is possible that changes in reporting methods are the only cause of alteration in the rates. We are analysing the characteristics of the mothers who lose babies and categorising the causes of early neonatal death. Our intention had been to present our findings to the obstetric and pxdiatric divisions concerned to open up a discussion on their validity and such changes in practice as might be indicated. Your series of articles on Better Perinatal Health, however, prompts us to in1. Mallett R, Knox EG. Standardized perinatal mortality ratios: utility and interpretation. Commun Med 1979; 1: 6-13.
technique,
S. A. COOPER A. S. HARRIS B. S. HOLMES G. RICHARDS
heavy. .
There is not space to deal adequately with some of the other issues in their letter, or with those in your editorial of Nov. 10, and there seems little point in debating further at the moment when we are in fact at a consultative stage and can deal with all these matters as we receive comments on the document. Health & Safety Executive, 25 Chapel Street, London NW1 5DT
K. P.
DUNCAN,
Director of medical services
DELAYED HYPERSENSITIVITY TO CHLAMYDIA TRACHOMATIS: CAUSE OF CHRONIC PROSTATITIS? no specific microbial aetiology for chronic prosbe found treatment is notoriously unsuccessful.’I Mardh et al. suggested that chlamydiae might be a cause but their cultural and serological tests did not confirm this suggestion.3 Delayed hypersensitivity tests to chlamydial antigens are used in the diagnosis of lymphogranuloma venereum, and there is evidence that delayed hypersensitivity may play a role in the manifestations of trachoma.4 We have studied a case of chronic non-bacterial prostatitis which could be a manifestation of delayed hypersensitivity to Chlamydia trachomatis. C. trachomatis strain TE55 (serologically identical to LGVII),
SIR,-When
tatitis
can
kindly provided by
Prof. L. H. Collier (The London
Hospital),
was
1. Feit RM, Fair WR. Prostatitis. Sex Transm Dis 1978; 5: 78-80. P-A, Colleen S, Holmquist B. Chlamydia in chronic prostatitis. Br
2. Mardh
Med J 1972; 4: 361. 3. Mardh P-A, Ripa KT, Colleen S, Treharne JD, Darougar S. Role of Chlamydia trachomatis in non-acute prostatitis. Br J Vener Dis 1978; 54: 330-334. 4. Grayston JT, Wang S-P. New knowledge of chlamydiæ and the diseases they cause. J Infect Dis 1975; 132: 87-105.