who will have a poor outcome remains problematic before discharge. For audit and training there is a strong point to be made in favour of follow up as transurethral resection of the prostate is not free from complications.4 Twenty three per cent of men visit their general practitioner for complications, 33% pass clots, 10% develop temporary clot retention, and 4% have defects in urinary continence where none was present before operation. It was perhaps telling that 54% of men in the study reported by Lynch and colleagues consulted their general practitioner-a rate double that usually recorded. Not all men who are unsatisfied are referred back to hospital, as shown by a rate of poor outcome in prospective studies of 20% to 25 %5-higher than in retrospective studies, in which the definition of poor outcome depends on rereferral. A routine follow up at six or eight weeks will allow most men to be discharged; the remainder with a poor outcome, prostatic cancer, or persistent impairment of bladder emptying may require further investigation and follow up. Follow up is not an unacceptable burden but an important part of training and audit. DAVID E NEAL
Department of Urology, Freeman Hospital, Newcastle upon Tyne NE7 7DN 1 Lynch TH, Waymont B, Beacock CJM, et al. Follow up after transurethral resection of prostate: Who needs it? BMJ 1991;302:27. (5 January.) 2 Neal DE, Styles RA, Powell PH, Ramsden PD. The relationship between detrusor function and residual urine in men undergoing prostatectomy. Brj Urol 1987;60:560-6. 3 Sacks SH, Aparicio SAJR, Bevan A, Oliver DO, Will EJ, Davison AM. Late renal failure due to prostatic obstruction: a preventable disease. BMJ 1989;298:156-9. 4 Fowler FJ, Wennberg JE, Timothy RP, Barry MJ, Mulley AG, Hanley D. Symptom status and quality of life after prostatectomy. JAMA 1988;259:3018-22. 5 Neal DE, Ramsden PD, Sharples L, et al. Outcome of elective prostatectomy. BMJ 1989;299:762-7.
collaboration between the respective audit groups in district health authorities and in family health services authorities. From April 1991 purchasers and providersincluding practice budget holders-are likely to focus greater attention on the appropriateness of follow up clinics. Clinical practice may be influenced by the type of contracts negotiated, but it is to be hoped that this will be in the interests of improved efficiency and not merely a cost cutting exercise. JEFFRIE R STRANG Department of Public Health Medicine, Darlington Health Authority, Darlington DL3 6HX
RODNEY COVE-SMITH South Cleveland Hospital, Middlesbrough TS4 3BW 1 Lynch TH, Waymount B, Beacock CJM, Dunn JA, Hughes MA, Wallace DMA. Follow up after transurethral resection of prostate: who needs it? BMJ 1991;302:27. (5 January.) 2 Strang JR, Cove-Smith JR. Outpatient follow up: why bother? Hospital Update 1989;15:321-2.
Resuscitating newborn babies SIR, -Dr Alison Walker quotes the recommendations by Dr Harold Gamsu and his working party that a more experienced member of staff, "usually a paediatrician," should be immediately available to perform advanced resuscitation when difficulties arise.' From the baby's point of view this certainly should happen. Unfortunately many sizable maternity hospitals in Britain are not staffed in such a way that this is possible. This particularly applies in districts where paediatric staffing consists of senior house officers, who are usually general practitioner trainees, and consultant paediatricians. In such hospitals consultant paediatricians may bear the brunt of resuscitating problem babies, but the nature of the consultant's contract, split sites, and other commitments mean that a consultant paediatrician is not always available around the clock at a moment's notice as would be required. General practitioner trainees come to special care baby units with no experience of resuscitation, and some of them never learn the task competently in the six months that they are on the unit. This is partly because of the shorter hours that junior doctors are now working and partly because of the smaller numbers of babies who require advanced resuscitation, as well as the need to train midwives and the requirement that the difficult cases are dealt with by an experienced person. Many health authorities seem unconcerned by this serious and potentially very expensive gap in the services that they are responsible for. Increasing the skill and competence of senior midwives to become "advanced resuscitators" may be a better solution to the problem.
SIR,-The paper by Dr Thomas H Lynch and colleagues showed that about 90% of patients did not require outpatient review in the short term, thereby releasing valuable clinic time to see new patients more speedily.' We have advocated that follow up clinics should be subjected to critical analysis in terms of the efficiency and the effectiveness of the care provided.2 Return visits to hospital after surgery should be no exception. The lack of concordance between general practitioners and patients about the desirability of follow up might have been reduced if, jointly, the urologists and referring family doctors had produced guidelines indicating the criteria for readmission or outpatient follow up. This information could have been conveyed to the patients in the leaflet given at the time of discharge, in the hope of minimising the differences in the expectations of those involved. Follow up attendances purely for the purpose of clinical audit should not be necessary. Early J M DAVIES postoperative problems requiring referral back S M HERBER to hospital will be documented in the medical B M REYNOLDS records, but it is important to remember that some Griansby Maternity Hospital, patients may be readmitted to a medical ward, Grimsby DN33 lNW perhaps with a pulmonary embolism, and may not be known to the urologists at that time. The long 1 Walker A. Resuscitating newborn babies. BM7 1991;302:69. term success of the operation is worthy of clinical (12 January.) audit by means of a questionnaire sent to the patient at an appropriate time after surgery. The high level of patient satisfaction would seem to be reflected in the response rate of 94% to the Chlamydia and cervical smear questionnaire after three months and might remain testing sufficiently high to measure the success of the treatment at a later date. SIR,-The lack of a sensitive test in diagnosing This study shows the need for closer cooperation chlamydial infection is of concern to clinicians as between general practitioners and consultants if most women are asymptomatic, as were those changes in the pattern of hospital follow up are studied by Dr J R Smith and colleagues.' to be introduced and monitored. The interface The laboratory diagnosis of urogenital between primary and secondary care is an im- chlamydial infection is based on isolation of portant topic for clinical audit but will require chlamydial trachomatis in cell culture; direct
BMJ
VOLUME
302
16
FEBRUARY
1991
detection of chlamydial antigen; and detection of specific antibody in the serum. The cell culture still remains the standard test, and all the other methods have been compared with cell culture, but the cell culture does not detect chlamydial infection in the lower genital tract in the presence of neutralising cervical antibody. Positive yield also depends on proper sample collection, transportation, storage of specimen, and technical factors. Direct detection of chlamydial antigen is more widely used now. It is easy to perform and results may be obtained within an hour of collecting the specimen so that treatment could be started immediately, but clinicians should be aware of false positive results. Serology for Chlamydia trachomatis specific IgG and IgM is of limited value. In chlamydial cervicitis the organism is confined to the endocervical cells and does not provoke a noticeable antibody response. IgM response is poor and does not necessarily indicate current infection. Chlamydia specific IgA antibody is detected in only a small proportion of apparently healthy adults but concentrations are raised in acute infection, which makes it an important marker of acute infection. As the sensitivity of the test is low this can assist but cannot replace either the direct detection of antigen in the specimen or the isolation of chlamydia. DNA hybridisation to detect chlamydial antigen has been studied and the results are promising, but more work is needed for further evaluation.2 Chlamydial infection of the urogenital tract is one of the most common sexually transmitted diseases and its implications -female infertility, ectopic pregnancy, recurrent infection, and dyspareunia -are serious. Improved sensitive and specific tests for diagnosis of the chlamydial genital tract infection is urgently needed, including microbiological criteria of "cure" after conventional treatment with antibiotics, particularly in women. V HARINDRA S SIVAPALAN R BASU ROY
Department of Genitourinary Medicine, Royal Victoria Hospital, Bournemouth BH7 6JF 1 Smith JR, Murdoch J, Carrington D, et al. Prevalence of Chlamydia trachomatis infection in women having cervical smear tests. WMJ 1991;302:82-4. (12 January.) 2 Oriel D, Ridgeway G, Schachter J, et al. Chlamydial infections. London: Cambridge University Press, 1986.
SIR,-We offer our data in support of the conclusion drawn by Dr J R Smith and colleagues that chlamydial infection of the cervix is prevalent, irrespective of cytological state. ' We prospectively screened 67 women who routinely attended during 1990 for cervical smear tests in one rural Welsh general practice. We tested for the presence of cervical pathogens using culture, microscopy, and direct immunofluorescence (Microtrak, Syva) for Chlamydia trachomatis. The results (set against the cytological findings during the preceding two years) are summarised in the table. The important message is that silent chlamydial infection is common in rural seaside Wales just as in inner city Glasgow and may result in much Cervical pathogens present in smears Cytological results No (%) No (%) non-inflammatory inflammatory No pathogens or normal flora Gardnerella alone Gardnerella, bacteroides, and clue cells
28 (50) 5 (9)
12 (63) 0
8 (14)
Chlamydia Candida Coliforms
(9) 12 (21) 4 (7)
1 (5) 2 (10) 4 (20) 0
Total
57 (100)
19 (100)
5
413
Department of Urology, Freeman Hospital, Newcastle upon Tyne NE7 7DN 1 Lynch TH, Waymont B, Beacock CJM, et al. Follow up after transurethral resection of prostate: Who needs it? BMJ 1991;302:27. (5 January.) 2 Neal DE, Styles RA, Powell PH, Ramsden PD. The relationship between detrusor function and residual urine in men undergoing prostatectomy. Brj Urol 1987;60:560-6. 3 Sacks SH, Aparicio SAJR, Bevan A, Oliver DO, Will EJ, Davison AM. Late renal failure due to prostatic obstruction: a preventable disease. BMJ 1989;298:156-9. 4 Fowler FJ, Wennberg JE, Timothy RP, Barry MJ, Mulley AG, Hanley D. Symptom status and quality of life after prostatectomy. JAMA 1988;259:3018-22. 5 Neal DE, Ramsden PD, Sharples L, et al. Outcome of elective prostatectomy. BMJ 1989;299:762-7.
collaboration between the respective audit groups in district health authorities and in family health services authorities. From April 1991 purchasers and providersincluding practice budget holders-are likely to focus greater attention on the appropriateness of follow up clinics. Clinical practice may be influenced by the type of contracts negotiated, but it is to be hoped that this will be in the interests of improved efficiency and not merely a cost cutting exercise. JEFFRIE R STRANG Department of Public Health Medicine, Darlington Health Authority, Darlington DL3 6HX
RODNEY COVE-SMITH South Cleveland Hospital, Middlesbrough TS4 3BW 1 Lynch TH, Waymount B, Beacock CJM, Dunn JA, Hughes MA, Wallace DMA. Follow up after transurethral resection of prostate: who needs it? BMJ 1991;302:27. (5 January.) 2 Strang JR, Cove-Smith JR. Outpatient follow up: why bother? Hospital Update 1989;15:321-2.
Resuscitating newborn babies SIR, -Dr Alison Walker quotes the recommendations by Dr Harold Gamsu and his working party that a more experienced member of staff, "usually a paediatrician," should be immediately available to perform advanced resuscitation when difficulties arise.' From the baby's point of view this certainly should happen. Unfortunately many sizable maternity hospitals in Britain are not staffed in such a way that this is possible. This particularly applies in districts where paediatric staffing consists of senior house officers, who are usually general practitioner trainees, and consultant paediatricians. In such hospitals consultant paediatricians may bear the brunt of resuscitating problem babies, but the nature of the consultant's contract, split sites, and other commitments mean that a consultant paediatrician is not always available around the clock at a moment's notice as would be required. General practitioner trainees come to special care baby units with no experience of resuscitation, and some of them never learn the task competently in the six months that they are on the unit. This is partly because of the shorter hours that junior doctors are now working and partly because of the smaller numbers of babies who require advanced resuscitation, as well as the need to train midwives and the requirement that the difficult cases are dealt with by an experienced person. Many health authorities seem unconcerned by this serious and potentially very expensive gap in the services that they are responsible for. Increasing the skill and competence of senior midwives to become "advanced resuscitators" may be a better solution to the problem.
SIR,-The paper by Dr Thomas H Lynch and colleagues showed that about 90% of patients did not require outpatient review in the short term, thereby releasing valuable clinic time to see new patients more speedily.' We have advocated that follow up clinics should be subjected to critical analysis in terms of the efficiency and the effectiveness of the care provided.2 Return visits to hospital after surgery should be no exception. The lack of concordance between general practitioners and patients about the desirability of follow up might have been reduced if, jointly, the urologists and referring family doctors had produced guidelines indicating the criteria for readmission or outpatient follow up. This information could have been conveyed to the patients in the leaflet given at the time of discharge, in the hope of minimising the differences in the expectations of those involved. Follow up attendances purely for the purpose of clinical audit should not be necessary. Early J M DAVIES postoperative problems requiring referral back S M HERBER to hospital will be documented in the medical B M REYNOLDS records, but it is important to remember that some Griansby Maternity Hospital, patients may be readmitted to a medical ward, Grimsby DN33 lNW perhaps with a pulmonary embolism, and may not be known to the urologists at that time. The long 1 Walker A. Resuscitating newborn babies. BM7 1991;302:69. term success of the operation is worthy of clinical (12 January.) audit by means of a questionnaire sent to the patient at an appropriate time after surgery. The high level of patient satisfaction would seem to be reflected in the response rate of 94% to the Chlamydia and cervical smear questionnaire after three months and might remain testing sufficiently high to measure the success of the treatment at a later date. SIR,-The lack of a sensitive test in diagnosing This study shows the need for closer cooperation chlamydial infection is of concern to clinicians as between general practitioners and consultants if most women are asymptomatic, as were those changes in the pattern of hospital follow up are studied by Dr J R Smith and colleagues.' to be introduced and monitored. The interface The laboratory diagnosis of urogenital between primary and secondary care is an im- chlamydial infection is based on isolation of portant topic for clinical audit but will require chlamydial trachomatis in cell culture; direct
BMJ
VOLUME
302
16
FEBRUARY
1991
detection of chlamydial antigen; and detection of specific antibody in the serum. The cell culture still remains the standard test, and all the other methods have been compared with cell culture, but the cell culture does not detect chlamydial infection in the lower genital tract in the presence of neutralising cervical antibody. Positive yield also depends on proper sample collection, transportation, storage of specimen, and technical factors. Direct detection of chlamydial antigen is more widely used now. It is easy to perform and results may be obtained within an hour of collecting the specimen so that treatment could be started immediately, but clinicians should be aware of false positive results. Serology for Chlamydia trachomatis specific IgG and IgM is of limited value. In chlamydial cervicitis the organism is confined to the endocervical cells and does not provoke a noticeable antibody response. IgM response is poor and does not necessarily indicate current infection. Chlamydia specific IgA antibody is detected in only a small proportion of apparently healthy adults but concentrations are raised in acute infection, which makes it an important marker of acute infection. As the sensitivity of the test is low this can assist but cannot replace either the direct detection of antigen in the specimen or the isolation of chlamydia. DNA hybridisation to detect chlamydial antigen has been studied and the results are promising, but more work is needed for further evaluation.2 Chlamydial infection of the urogenital tract is one of the most common sexually transmitted diseases and its implications -female infertility, ectopic pregnancy, recurrent infection, and dyspareunia -are serious. Improved sensitive and specific tests for diagnosis of the chlamydial genital tract infection is urgently needed, including microbiological criteria of "cure" after conventional treatment with antibiotics, particularly in women. V HARINDRA S SIVAPALAN R BASU ROY
Department of Genitourinary Medicine, Royal Victoria Hospital, Bournemouth BH7 6JF 1 Smith JR, Murdoch J, Carrington D, et al. Prevalence of Chlamydia trachomatis infection in women having cervical smear tests. WMJ 1991;302:82-4. (12 January.) 2 Oriel D, Ridgeway G, Schachter J, et al. Chlamydial infections. London: Cambridge University Press, 1986.
SIR,-We offer our data in support of the conclusion drawn by Dr J R Smith and colleagues that chlamydial infection of the cervix is prevalent, irrespective of cytological state. ' We prospectively screened 67 women who routinely attended during 1990 for cervical smear tests in one rural Welsh general practice. We tested for the presence of cervical pathogens using culture, microscopy, and direct immunofluorescence (Microtrak, Syva) for Chlamydia trachomatis. The results (set against the cytological findings during the preceding two years) are summarised in the table. The important message is that silent chlamydial infection is common in rural seaside Wales just as in inner city Glasgow and may result in much Cervical pathogens present in smears Cytological results No (%) No (%) non-inflammatory inflammatory No pathogens or normal flora Gardnerella alone Gardnerella, bacteroides, and clue cells
28 (50) 5 (9)
12 (63) 0
8 (14)
Chlamydia Candida Coliforms
(9) 12 (21) 4 (7)
1 (5) 2 (10) 4 (20) 0
Total
57 (100)
19 (100)
5
413
