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STAPHYLOCOCCAL PNEUMONIA IN INFANTS
268
resulting from the decision to divert funds from them to long-stay hospitals.
now
Whilst there is a clear need for much more money to be spent on long-stay hospitals, my colleagues and I view with apprehension the Secretary of State’s decision to transfer funds for this purpose from those already allocated to shortstay and acute hospitals. We are concerned at the adverse effect this will have on an already strained hospital service and urge that the additional revenue should be obtained from other sources. We feel that these views, which must be shared by hospital medical staff generally, should be brought to the notice of the Secretary of State for Social Services. EDWARD LYONS Abergele, Chairman, Clwyd and Deeside Group Medical Advisory Committee. Denbighshire.
STAPHYLOCOCCAL PNEUMONIA IN INFANTS here our experience with 136 infants SIR,-We report and toddlers admitted to our unit between October, 1961, and December, 1968, with staphylococcal pneumonia. 67-5% of them were less than one year old. The admission diagnosis was correct in only 70%; and the other 30% were believed in the outpatient department to have conditions including septicaemia, meningitis, virus infections, and acute gastroenteritis. The symptoms at the time of admission were as follows, in descending order of frequency: fever, respiratory distress, cough, restlessness and grunting, abdominal distension, vomiting, anorexia, cyanosis, diarrhoea, spasms, and jaundice. Only 12% had a history of previous staphylococcal infection of the skin. All but 10 of the patients had increased leucocyte counts -in 20%, over 20,000 per c.mm. Blood-cultures were positive for Staph. aureus in only 10%, probably because antibiotics had often been given before admission. Staph. aureus was found in the nasopharynges of 57% of the children, and in 14 out of 28 cultured specimens of pleuritic fluid. The X-ray picture was typical of staphylococcal pneumonia in 30% of the patients on admission. Pulmonary cavitation was observed in 70% of the patients, pleural effusion in 41 %, pneumothorax in 15%, and mediastinal emphysema in 3%. The mean length of hospital stay for the patients who survived was 27 days (range 15-140) as against 18 (range 1-62) for those who died. Between 1961 and 1963 the antibiotics most used were erythromycin and chloramphenicol. But for the other 5 years nearly all patients received methicillin, alone or in combination with penicillin or ampicillin. During the first 2 weeks methicillin was given by intravenous drip. The treatment, which subsequently was administered by intramuscular injections, and then by mouth (oxacillin or cloxacillin) lasted 5-6 weeks. The total mortality-rate was 17-6%. When the 7 infants who died within 24 hours of admission are subtracted, the mortality-rate drops to 12-5%. As expected, the highest mortality-rate was in the youngest infants: for babies in the first month of life the rate was 28%, and for babies under 6 months old the rate was 25%. The use of semisynthetic penicillins from 1964 onwards did not significantly reduce The
mortality. importance of the earliest possible diagnosis of staphylococcal pneumonia cannot be stressed too strongly.
Pædiatric Clinic of Athens University, Athens (608), Greece.
F. D. P. S.
MAOUNIS NICOLOPOULOS PAPASIDERI BENETOS.
THE DURATION OF PREGNANCY SiR,łThe discussion in your columns 1-4 of the problem of the duration of pregnancy prompts us to write about our own investigations. Most of the confusion arises, we think, from failure to recognise that the duration of pregnancy is affected by two main variables: one is the moment of ovulation (i.e., conception), and the other is the length of gestation itself. An additional source of error is produced by using weeks, instead of days, as units of measurement. We have analysed pregnancy records from family-planning and sterility clinics, collected by one of us (R. G.) at Harvard University. To get an idea of the day of ovulation we coded all temperature charts for the day of the thermal shift in the basal body temperature (B.B.T.), which is the day of the beginning of the hyperthermic plateau (similar criteria have been used by Bartzen 6 and by Marshall’). Generally this day is located 1 day after the low-point in the B.B.T., on which most people think ovulation takes place. Is Fig. 1 shows the distribution of the day of the temperature shift in 1408 conception cycles. Women who had menstrual
Fig. I-Distribution of day of thermal shift in the B.B.T. chart in 1408 conception cycles. Mean= 16-515
days;
s.D.=3-77.
cycles of 35 days or more were excluded from the series, and only term deliveries were included. The mean is 16’515, which gives an approximate mean day of ovulation around day 15. Note that the distribution is slightly skewed, with a tail to the right. When only the period between ovulation and birth is considered, a closely normal distribution is seen (fig. 2). The mean length of gestation from the temperature shift is 264.8 days, and the time from ovulation to delivery should be 1 day more. When making predictions one has to rely on averages; and if this is done in the case of the duration of pregnancy we have to say that the expected day of delivery (E.D.D.) is 16-5152+64-790, or around 281 days from the last menstrual period-i.e., the 2nd day of the 41st week. Other estimates give 280-5 days 10 and 280-8 days "-i.e., the 1st day of the 41st week. A deviation of 1 day or less from these averages would place them within the 40th week. This may be part of the explanation why some series indicate the 40th week, and others the 41st as the most likely week for delivery. Undoubtedly more accurate prediction is possible if the day of ovulation is known, or at least the probable day of 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Pack, G. L. Lancet, 1968, ii, 1388. White, J. ibid. 1969, i, 201. Oliver, M. Y. ibid. p. 307. Rawlings, E. E. ibid. p. 419. Guerrero, R. PH.D. thesis submitted to the Harvard School of Public Health, Boston, June, 1968. Bartzen, P. Fert. Steril. 1968, 18, 694. Marshall, J. Int. J. Fert. 1968, 13, 110. Buxton, C. L., Engle, E. T. Am. J. Obstet. Gynec. 1950, 60, 539. Siegler, S. L., Siegler, A. M. Fert. Steril. 1951, 2, 287. Gibson, J. R., Dougray, T. Br. J. prev. soc. Med. 1953, 7, 160. Eastman, N. J., Hellman, T. M. (editors) ’Williams’ Obstetrics; p. 219. New York, 1966.
resulting from the decision to divert funds from them to long-stay hospitals.
now
Whilst there is a clear need for much more money to be spent on long-stay hospitals, my colleagues and I view with apprehension the Secretary of State’s decision to transfer funds for this purpose from those already allocated to shortstay and acute hospitals. We are concerned at the adverse effect this will have on an already strained hospital service and urge that the additional revenue should be obtained from other sources. We feel that these views, which must be shared by hospital medical staff generally, should be brought to the notice of the Secretary of State for Social Services. EDWARD LYONS Abergele, Chairman, Clwyd and Deeside Group Medical Advisory Committee. Denbighshire.
STAPHYLOCOCCAL PNEUMONIA IN INFANTS here our experience with 136 infants SIR,-We report and toddlers admitted to our unit between October, 1961, and December, 1968, with staphylococcal pneumonia. 67-5% of them were less than one year old. The admission diagnosis was correct in only 70%; and the other 30% were believed in the outpatient department to have conditions including septicaemia, meningitis, virus infections, and acute gastroenteritis. The symptoms at the time of admission were as follows, in descending order of frequency: fever, respiratory distress, cough, restlessness and grunting, abdominal distension, vomiting, anorexia, cyanosis, diarrhoea, spasms, and jaundice. Only 12% had a history of previous staphylococcal infection of the skin. All but 10 of the patients had increased leucocyte counts -in 20%, over 20,000 per c.mm. Blood-cultures were positive for Staph. aureus in only 10%, probably because antibiotics had often been given before admission. Staph. aureus was found in the nasopharynges of 57% of the children, and in 14 out of 28 cultured specimens of pleuritic fluid. The X-ray picture was typical of staphylococcal pneumonia in 30% of the patients on admission. Pulmonary cavitation was observed in 70% of the patients, pleural effusion in 41 %, pneumothorax in 15%, and mediastinal emphysema in 3%. The mean length of hospital stay for the patients who survived was 27 days (range 15-140) as against 18 (range 1-62) for those who died. Between 1961 and 1963 the antibiotics most used were erythromycin and chloramphenicol. But for the other 5 years nearly all patients received methicillin, alone or in combination with penicillin or ampicillin. During the first 2 weeks methicillin was given by intravenous drip. The treatment, which subsequently was administered by intramuscular injections, and then by mouth (oxacillin or cloxacillin) lasted 5-6 weeks. The total mortality-rate was 17-6%. When the 7 infants who died within 24 hours of admission are subtracted, the mortality-rate drops to 12-5%. As expected, the highest mortality-rate was in the youngest infants: for babies in the first month of life the rate was 28%, and for babies under 6 months old the rate was 25%. The use of semisynthetic penicillins from 1964 onwards did not significantly reduce The
mortality. importance of the earliest possible diagnosis of staphylococcal pneumonia cannot be stressed too strongly.
Pædiatric Clinic of Athens University, Athens (608), Greece.
F. D. P. S.
MAOUNIS NICOLOPOULOS PAPASIDERI BENETOS.
THE DURATION OF PREGNANCY SiR,łThe discussion in your columns 1-4 of the problem of the duration of pregnancy prompts us to write about our own investigations. Most of the confusion arises, we think, from failure to recognise that the duration of pregnancy is affected by two main variables: one is the moment of ovulation (i.e., conception), and the other is the length of gestation itself. An additional source of error is produced by using weeks, instead of days, as units of measurement. We have analysed pregnancy records from family-planning and sterility clinics, collected by one of us (R. G.) at Harvard University. To get an idea of the day of ovulation we coded all temperature charts for the day of the thermal shift in the basal body temperature (B.B.T.), which is the day of the beginning of the hyperthermic plateau (similar criteria have been used by Bartzen 6 and by Marshall’). Generally this day is located 1 day after the low-point in the B.B.T., on which most people think ovulation takes place. Is Fig. 1 shows the distribution of the day of the temperature shift in 1408 conception cycles. Women who had menstrual
Fig. I-Distribution of day of thermal shift in the B.B.T. chart in 1408 conception cycles. Mean= 16-515
days;
s.D.=3-77.
cycles of 35 days or more were excluded from the series, and only term deliveries were included. The mean is 16’515, which gives an approximate mean day of ovulation around day 15. Note that the distribution is slightly skewed, with a tail to the right. When only the period between ovulation and birth is considered, a closely normal distribution is seen (fig. 2). The mean length of gestation from the temperature shift is 264.8 days, and the time from ovulation to delivery should be 1 day more. When making predictions one has to rely on averages; and if this is done in the case of the duration of pregnancy we have to say that the expected day of delivery (E.D.D.) is 16-5152+64-790, or around 281 days from the last menstrual period-i.e., the 2nd day of the 41st week. Other estimates give 280-5 days 10 and 280-8 days "-i.e., the 1st day of the 41st week. A deviation of 1 day or less from these averages would place them within the 40th week. This may be part of the explanation why some series indicate the 40th week, and others the 41st as the most likely week for delivery. Undoubtedly more accurate prediction is possible if the day of ovulation is known, or at least the probable day of 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Pack, G. L. Lancet, 1968, ii, 1388. White, J. ibid. 1969, i, 201. Oliver, M. Y. ibid. p. 307. Rawlings, E. E. ibid. p. 419. Guerrero, R. PH.D. thesis submitted to the Harvard School of Public Health, Boston, June, 1968. Bartzen, P. Fert. Steril. 1968, 18, 694. Marshall, J. Int. J. Fert. 1968, 13, 110. Buxton, C. L., Engle, E. T. Am. J. Obstet. Gynec. 1950, 60, 539. Siegler, S. L., Siegler, A. M. Fert. Steril. 1951, 2, 287. Gibson, J. R., Dougray, T. Br. J. prev. soc. Med. 1953, 7, 160. Eastman, N. J., Hellman, T. M. (editors) ’Williams’ Obstetrics; p. 219. New York, 1966.