1355
balance between what is ethically acceptable to us and what is most University of Rochester School of Medicine. Rochester, New York 14607, USA
Third, specialist member
important to our patients. AARON SPITAL
1. Elick BA, Sutherland DER, Gillingham K, Najarian JS. Use of distant relatives and living unrelated donors: a strategy to increase the application of kidney transplantation to treat chronic renal failure. Transplant Proc 1990; 22: 343-44. 2. Spital A. Unconventional living kidney donors: attitudes and use among transplant centers. Transplantation 1989; 48: 243-48. 3. Spiral A. The ethics of unconventional living organ donation. Clin Transplant 1991; 5: 322-26. 4. Simmons RG, Marine SK, Simmons RL. Living related donors: costs and gains. In: Gift of life. New Brunswick: Transaction Books, 1987: 153-97.
Specialist medical training and the European community SIR,-Ihave followed with interest the Chief Medical Officer’s’ (Dr Caiman) letter to all doctors in the UK and Brearley’s2 editorial on the European Commission’s challenge about the UK system of accreditation. Having graduated in France and successfully pursued postgraduate training in the UK, as well as having written an MD thesis on the free circulation of doctors within the European Community,3 I would like to comment. First, in continental Europe most specialists practise from their own premises, largely doing outpatient procedures that are funded by social insurances. A few of these specialists are hospital based and achieve promotion to the equivalent National Health Service (NHS) consultant grade according to poorly defined criteria, including several years of experience in hospital. Thus specialists are generally equivalent at most to experienced registrars in the UK and have not faced the competition for the senior registrar grade as is the norm for most specialist trainees in that country, with its subsequent corollaries: research publications, a second qualification, &c. Furthermore, hospital-training recognition visits are ahnost unheard of and the diversity of the provision of health care means that many patients are treated in the private sector, resulting in little exposure to specialist trainees in public hospitals. Specialists continue therefore to train on their own patients long after qualifying. Nowhere else on the European continent do trainees face such a wide clinical exposure as well as so many weekly hours of duty, as they do in the UK.4 On average, 1 year of training in the UK is equivalent to 3 years in continental Europe in terms of clinical experience, supervision, and medical education. This has long been recognised by the European Commission-both by its Consultative Committee for Medical Training5 and during correspondence with European members of parliament.6 The Commission’s position has been clear on the question of specialist training: the directives only define minimum criteria that member states must respect for the purposes of free circulation; however, member states are free to impose a higher level of specialist training for access to the specialty. Therefore the UK is not out of line with the European Community by using a consultant-led system mainly governed by accredited specialists. However, the question of the new General Medical Council register with the "T" suffix denoting accredited specialist training is more difficult to defend because it might discriminate against consultant grade specialists wishing to migrate to the UK from continental Europe. Second, the aim of the EC directives was to facilitate the free circulation of doctors within member states by defining minimum periods of specialist training (3, 4, or 5 years) as well as certificates of specialist training, to allow access to the legal privileges of a specialist in all member states (including access to social security systems). The word "completion" that is included in the title of the UK qualification does not mean the end of specialist training but a certain level of competence to allow access to the legal privileges of a specialist. European specialists can thus apply for senior registrar and consultant posts in this country in open competition with UK nationals, and thus the UK is not contravening the directives in any way. There is no specialist status per se in this country but the directives do not in any way oblige the UK to convert from a consultant-led to a specialist system. What is in question is the access to private practice in this country which is only accessible to the consultant grade.
manpower and quality of training within covered by these directives. Medical
states were not
unemployment has reached alarming proportions in some countries (France 6%, Germany 8%, Italy 173%), whereas it is almost unheard of in the UK (0.3%).4 Furthermore, medical schools in some countries (Germany, Netherlands, Spain) still have a student intake related to their educational capacities rather than to manpower needs.4 Continental Europe does not possess Royal Colleges responsible for the standards and structure of training as in the UK. There is consequently a wide variation in the quality of specialists, dependent on the university and the hospital from which they qualify. Again the European Commission has replied to European MPs who have raised this issue by saying that this is not covered by the directives and that they were not aware of any complaints by individual member states.6 I do not believe that most specialist trainees in the UK wish to exchange the consultant-led system for one with senior and junior specialists. The solution lies with the expansion of the consultant grade in the UK, an idea that has been exposed by the document "Achieving a Balance" and reiterated by Baigrie and Reed.’ Of course, a properly organised, continually assessed, and audited specialist training programme could be considerably shorter and could result in better trained specialists in the UK and would be welcomed by all. Birmingham Maternity Hospital, Birmingham B15 2TG, UK
LAWRENCE MASCARENHAS
1. Calman KC. Specialist medical training in the UK. London: Department of Health, 1992 (PL/CMO(92)13). 2. Brearley S. Specialist medical training and the European Community. BMJ 1992; 305: 661-62. 3. Mascarenhas LJ. Consequences de la libre circulation des médecins dans la CEE. Tours Medical Faculty 1986, Dec 15, no 175. 4. Brearley S. Medical manpower. BMJ 1991; 303: 1534-36. 5. Comite Consultatif Pour La Formation Des Medecins. Rapports, avis et Recommendations Adoptes par le Comite du 6 Avril 1979 au 31 Decembre 1984. Brussels: Commision Des Communautes Euorpeennes 1985, (III/D/1003/85-
FR). 6. Cresson E. Question Ecrite No 816/79 a la Commission des Communautes Europeennes.J Officiel Commun Eur 1978; no C 107/9. 7. Baigrie RJ, Reed MWR. Specialist training. BMJ 1992; 305: 1021.
Drug safety monitoring
in
Europe
made on SIR,-Your report (Oct 24, p 1028) refers the performance of the WHO programme on drug monitoring, and particularly that "the WHO centre rarely produces an ADR [adverse drug reaction] signal on which regulatory action could be taken". The WHO programme was set up to create signals from internationally pooled data from spontaneous ADR reporting, from 36 countries. The centre regularly produces such signals, which are circulated to programme members, and many are evaluated by experts designated by the national centres themselves. Each national centre can also request database searches or initiate them via an on-line connection that is free of charge. In addition there is the quarterly mailing of output documents that are designed to allow for each checking that signals are not missed. More recently, the centre has published some of the signals, in an endeavour to alert the medical profession to those that seem to have strong causal relations and do not appear in most drug compendia. WHO signals cannot be used directly for regulatory action. They are merely suspicions of problems with drugs. Moreover, they need to be evaluated against drug use to determine incidence. Thus, unless a causal relation in individual cases is certain, only the most serious reports of previously unknown reactions can lead to immediate regulatory action. Thankfully these are rare, and their rarity should not be used as a criticism of the WHO programme. Efficient signal generation has technical difficulties. Data received and transmitted by national centres are often incomplete or even inaccurate because of poor original reporting and transcription errors, for example. These cause delay while they are followed up. Some national centres take some time to provide data on new drug products and transmit their ADR data. Few such centres have taken advantage of on-line data input and advice on error checks. All these difficulties would apply to any type of international database. Years to comments
1356
of work have gone into solutions to these technical difficulties in the WHO programme so that now only occasional human errors or failure to use available technology cause such delays. The comment was also made that the "scheme was not under EC control". This programme like any other WHO activity is subject to scrutiny and control by any member state at each annual World Health Assembly. The EC countries (apart from Luxembourg) are programme members and can also make their claims on its operation at annual meetings of the 36 countries belonging to the programme. As far as we are aware the EC does not wish to emulate existing international systems, but if the WHO ADR database were to be replicated for the EC countries, the confusions created by tracking report duplications internationally would be exacerbated and inevitably a further delay in gathering international ADR data would occur. Finally, a little discussed way to make major progress in drug safety is facilities for rapid pharmacoepidemiological studies. The developments of databases such as VAMP in England and MEMO in Scotland should be encouraged elsewhere in Europe. Such databases can only operate properly if the current proposals by the Council of Europe and the EC on data protection are reconsidered with this in mind. Then perhaps our many signals could be analysed further and rapidly with respect to their importance for regulatory action. WHO Collaborating Centre for International Drug Monitoring, Box 26, S-751 03 Uppsala, Sweden
I. R. EDWARDS, Medical Director
Antismoking adverts and sports sponsorship SIR,- Your report (Oct 24, p 1027) about the Australian Cricket (ACB) fining a test cricketer 25% of his contract fee for
Board
participating in a public service antismoking advertisement reflects the anger raised worldwide by such action. The ACB deserves criticism, especially in view of its stated defence that it needed to protect the interests of its sponsors. A major issue is the role of the ACB not only in sports but also in society. In the USA, most professional athletes recognise that they wield powerful influence over an adulating population of young people. Some athletes have far exceeded expectations; quarterback Warren Moon, for example, formed the now very successful Crescent Moon Foundation. By contrast, the sence of social responsibility has only partly carried over to the governing organisations. Televised games of the National Football League are liberally sprinkled with players requesting support for the United Way, an umbrella group that distributes funds to non-profit groups. On the other hand, broadcasts of major league baseball games are punctuated with shots of players catapulting spitballs produced from great wads of chewing tobacco wedged into their mouths. The effect of such behaviour is that youngsters now believe that the act of chewing tobacco is synonymous with future careers in the major leagues. The actions of the ACB clearly demonstrate that this organisation senses no pangs of social irresponsibility. If the ACB is to side with a financial bedfellow rather than take an ethical highground, then the Australian public can certainly apply the same rules to cricket. Smoking-related disease incurs a huge cost to society and to government. The taxpayer, then, has every right to demand full withdrawal of any and all governmental support of cricket, including discontinuation of broadcasts on the Australian Broadcasting Commission, discontinuation of unreimbursed police presence at major matches, and the charging of appropriate ground maintenance fees at municipal ovals. Department of Pediatrics, Baylor College of Medicine,
STEPHEN J. ELLIOTT
Houston, Texas 77030, USA
Methods for increased SIR,—Professor John
and
poliovirus diagnosis
colleagues (Oct 17, p 975) report a antibody-bound poliovirus in stool specimens. They investigated 16 children with acute flaccid paralysis and exposed samples to the acid glycine buffer, pH 2-4, at room temperature for 3 h. Antibody-bound poliovirus type 1 was method
to
detect
dissociated in 6 samples. The enhanced sensitivity of the dissociation procedure would be proven by demonstration of poliovirus antibody as well as viral RNA genomes. IgM or IgA class antibodies should also be searched for in these 6 samples. This could be done by affniity immunoblotting or agarose electrophoresis, as was attempted in cerebrospinal fluid from 36 patients with post-poliomyelitis syndrome.’ Oligoclonal IgM bands specific to poliovirus were detected in 21 of these patients but in none of the controls. Furthermore, abnormally high values of IgM were detectable in 17 patients.’ To demonstrate poliovirus RNA, stool samples could be examined by polymerase chain reaction with poliovirus-specific primers,2 or by an in-situ transcription with pan-enteroviral and individual poliovirus-specific primer to capture poliovirus RNA.3 An appropriate modification of the easy-to-use 96-well, microtitreplate protocol that involves immobilisation of oligonucleotides for mRNA4 is essential for the development of a much needed practical procedure for the detection of poliovirus in areas without facilities for tissue culture. Developing countries would need simplified, one or two step procedures that did not depend on tissue culture for screening polioviruses in stool or other clinical specimens and to measure antibody concentrations. Immobilised oligonucleotide technology requires active support and innovative action. Centre for Logistical Research and Innovation, M-122 (part Greater Kailash-II, New Delhi 110048, India
2),
SUBHASH C. ARYA
1. Sharief MK,
Hentges R, Ciardi M. Intrathecal immune response in patients with the post-polio syndrome. N Engl J Med 1991; 325: 749-55. 2. Yang C-F de L, Holloway BP, Pallansch MA, Kew OM. Detection and identification of vaccine-related polioviruses by the polymerase chain reaction. Virus Res 1991; 20: 159-79. 3. Carstens JM, Tracy S, Chapman NM, Gauntt CJ. Detection of enteroviruses in cell cultures using in situ transcription. J Clin Microbiol 1992; 30: 25-35. 4. Mitsuhashi M, Keller C, Akitaya T. Gene manipulation in plastic plates. Nature 1992; 357: 519-20.
Increase in
birthweight in undernourished women
SIR,-Dr Garner and colleagues (Oct 24, p 1021) consider in communities in which there is chronic malnutrition. High-energy (1950 kj per day) supplementation of mothers’ diet in the last trimester of pregnancy produces babies that remain significantly heavier until 24 months of age and taller until 60 months of age compared with the children of mothers who receive a supplementation of only 218 kj per day.’ Significant weight gain is, however, only seen during the first six months of postnatal life and height gain only in the third postnatal month. Mortality rate is not affected by supplementation, so would the effort of implementing this on a wide scale be worth while? Without there being radical changes in the way societies assess priorities in maternal health and nutrition, such a programme is not sustainable. Gamer et al examine the increased risk of obstructed labour in small women having bigger babies, but this risk is unlikely to contribute significantly to mortality and morbidity rates with the small increases in birthweight recorded in another study.’ Prevention of maternal anaemia, malaria, and malnutrition will inevitably result in increased birthweight, and the beneficial effect on maternal morbidity and mortality of preventing these problems will far outweigh the increased risk of obstructed labour with bigger babies. Babies who are symmetrically growth retarded for gestational age perform poorly in developmental tests, and intellectual ability at school is impaired, compared with normal-birthweight babies or those with low birthweight but normal length and head circumference.2,3 They tend to show poor somatic growth, particularly in head circumference. This group of babies have had chronic intrauterine insults—eg, maternal malnutrition, maternal malaria, maternal smoking, maternal alcohol. 67% of lowbirthweight babies were in this group of symmetrical growth retardation in rural South Africa,4compared with 20% in the UK.3 .3 The impaired development that these children face is analogous to
increasing birthweight
maternal
balance between what is ethically acceptable to us and what is most University of Rochester School of Medicine. Rochester, New York 14607, USA
Third, specialist member
important to our patients. AARON SPITAL
1. Elick BA, Sutherland DER, Gillingham K, Najarian JS. Use of distant relatives and living unrelated donors: a strategy to increase the application of kidney transplantation to treat chronic renal failure. Transplant Proc 1990; 22: 343-44. 2. Spital A. Unconventional living kidney donors: attitudes and use among transplant centers. Transplantation 1989; 48: 243-48. 3. Spiral A. The ethics of unconventional living organ donation. Clin Transplant 1991; 5: 322-26. 4. Simmons RG, Marine SK, Simmons RL. Living related donors: costs and gains. In: Gift of life. New Brunswick: Transaction Books, 1987: 153-97.
Specialist medical training and the European community SIR,-Ihave followed with interest the Chief Medical Officer’s’ (Dr Caiman) letter to all doctors in the UK and Brearley’s2 editorial on the European Commission’s challenge about the UK system of accreditation. Having graduated in France and successfully pursued postgraduate training in the UK, as well as having written an MD thesis on the free circulation of doctors within the European Community,3 I would like to comment. First, in continental Europe most specialists practise from their own premises, largely doing outpatient procedures that are funded by social insurances. A few of these specialists are hospital based and achieve promotion to the equivalent National Health Service (NHS) consultant grade according to poorly defined criteria, including several years of experience in hospital. Thus specialists are generally equivalent at most to experienced registrars in the UK and have not faced the competition for the senior registrar grade as is the norm for most specialist trainees in that country, with its subsequent corollaries: research publications, a second qualification, &c. Furthermore, hospital-training recognition visits are ahnost unheard of and the diversity of the provision of health care means that many patients are treated in the private sector, resulting in little exposure to specialist trainees in public hospitals. Specialists continue therefore to train on their own patients long after qualifying. Nowhere else on the European continent do trainees face such a wide clinical exposure as well as so many weekly hours of duty, as they do in the UK.4 On average, 1 year of training in the UK is equivalent to 3 years in continental Europe in terms of clinical experience, supervision, and medical education. This has long been recognised by the European Commission-both by its Consultative Committee for Medical Training5 and during correspondence with European members of parliament.6 The Commission’s position has been clear on the question of specialist training: the directives only define minimum criteria that member states must respect for the purposes of free circulation; however, member states are free to impose a higher level of specialist training for access to the specialty. Therefore the UK is not out of line with the European Community by using a consultant-led system mainly governed by accredited specialists. However, the question of the new General Medical Council register with the "T" suffix denoting accredited specialist training is more difficult to defend because it might discriminate against consultant grade specialists wishing to migrate to the UK from continental Europe. Second, the aim of the EC directives was to facilitate the free circulation of doctors within member states by defining minimum periods of specialist training (3, 4, or 5 years) as well as certificates of specialist training, to allow access to the legal privileges of a specialist in all member states (including access to social security systems). The word "completion" that is included in the title of the UK qualification does not mean the end of specialist training but a certain level of competence to allow access to the legal privileges of a specialist. European specialists can thus apply for senior registrar and consultant posts in this country in open competition with UK nationals, and thus the UK is not contravening the directives in any way. There is no specialist status per se in this country but the directives do not in any way oblige the UK to convert from a consultant-led to a specialist system. What is in question is the access to private practice in this country which is only accessible to the consultant grade.
manpower and quality of training within covered by these directives. Medical
states were not
unemployment has reached alarming proportions in some countries (France 6%, Germany 8%, Italy 173%), whereas it is almost unheard of in the UK (0.3%).4 Furthermore, medical schools in some countries (Germany, Netherlands, Spain) still have a student intake related to their educational capacities rather than to manpower needs.4 Continental Europe does not possess Royal Colleges responsible for the standards and structure of training as in the UK. There is consequently a wide variation in the quality of specialists, dependent on the university and the hospital from which they qualify. Again the European Commission has replied to European MPs who have raised this issue by saying that this is not covered by the directives and that they were not aware of any complaints by individual member states.6 I do not believe that most specialist trainees in the UK wish to exchange the consultant-led system for one with senior and junior specialists. The solution lies with the expansion of the consultant grade in the UK, an idea that has been exposed by the document "Achieving a Balance" and reiterated by Baigrie and Reed.’ Of course, a properly organised, continually assessed, and audited specialist training programme could be considerably shorter and could result in better trained specialists in the UK and would be welcomed by all. Birmingham Maternity Hospital, Birmingham B15 2TG, UK
LAWRENCE MASCARENHAS
1. Calman KC. Specialist medical training in the UK. London: Department of Health, 1992 (PL/CMO(92)13). 2. Brearley S. Specialist medical training and the European Community. BMJ 1992; 305: 661-62. 3. Mascarenhas LJ. Consequences de la libre circulation des médecins dans la CEE. Tours Medical Faculty 1986, Dec 15, no 175. 4. Brearley S. Medical manpower. BMJ 1991; 303: 1534-36. 5. Comite Consultatif Pour La Formation Des Medecins. Rapports, avis et Recommendations Adoptes par le Comite du 6 Avril 1979 au 31 Decembre 1984. Brussels: Commision Des Communautes Euorpeennes 1985, (III/D/1003/85-
FR). 6. Cresson E. Question Ecrite No 816/79 a la Commission des Communautes Europeennes.J Officiel Commun Eur 1978; no C 107/9. 7. Baigrie RJ, Reed MWR. Specialist training. BMJ 1992; 305: 1021.
Drug safety monitoring
in
Europe
made on SIR,-Your report (Oct 24, p 1028) refers the performance of the WHO programme on drug monitoring, and particularly that "the WHO centre rarely produces an ADR [adverse drug reaction] signal on which regulatory action could be taken". The WHO programme was set up to create signals from internationally pooled data from spontaneous ADR reporting, from 36 countries. The centre regularly produces such signals, which are circulated to programme members, and many are evaluated by experts designated by the national centres themselves. Each national centre can also request database searches or initiate them via an on-line connection that is free of charge. In addition there is the quarterly mailing of output documents that are designed to allow for each checking that signals are not missed. More recently, the centre has published some of the signals, in an endeavour to alert the medical profession to those that seem to have strong causal relations and do not appear in most drug compendia. WHO signals cannot be used directly for regulatory action. They are merely suspicions of problems with drugs. Moreover, they need to be evaluated against drug use to determine incidence. Thus, unless a causal relation in individual cases is certain, only the most serious reports of previously unknown reactions can lead to immediate regulatory action. Thankfully these are rare, and their rarity should not be used as a criticism of the WHO programme. Efficient signal generation has technical difficulties. Data received and transmitted by national centres are often incomplete or even inaccurate because of poor original reporting and transcription errors, for example. These cause delay while they are followed up. Some national centres take some time to provide data on new drug products and transmit their ADR data. Few such centres have taken advantage of on-line data input and advice on error checks. All these difficulties would apply to any type of international database. Years to comments
1356
of work have gone into solutions to these technical difficulties in the WHO programme so that now only occasional human errors or failure to use available technology cause such delays. The comment was also made that the "scheme was not under EC control". This programme like any other WHO activity is subject to scrutiny and control by any member state at each annual World Health Assembly. The EC countries (apart from Luxembourg) are programme members and can also make their claims on its operation at annual meetings of the 36 countries belonging to the programme. As far as we are aware the EC does not wish to emulate existing international systems, but if the WHO ADR database were to be replicated for the EC countries, the confusions created by tracking report duplications internationally would be exacerbated and inevitably a further delay in gathering international ADR data would occur. Finally, a little discussed way to make major progress in drug safety is facilities for rapid pharmacoepidemiological studies. The developments of databases such as VAMP in England and MEMO in Scotland should be encouraged elsewhere in Europe. Such databases can only operate properly if the current proposals by the Council of Europe and the EC on data protection are reconsidered with this in mind. Then perhaps our many signals could be analysed further and rapidly with respect to their importance for regulatory action. WHO Collaborating Centre for International Drug Monitoring, Box 26, S-751 03 Uppsala, Sweden
I. R. EDWARDS, Medical Director
Antismoking adverts and sports sponsorship SIR,- Your report (Oct 24, p 1027) about the Australian Cricket (ACB) fining a test cricketer 25% of his contract fee for
Board
participating in a public service antismoking advertisement reflects the anger raised worldwide by such action. The ACB deserves criticism, especially in view of its stated defence that it needed to protect the interests of its sponsors. A major issue is the role of the ACB not only in sports but also in society. In the USA, most professional athletes recognise that they wield powerful influence over an adulating population of young people. Some athletes have far exceeded expectations; quarterback Warren Moon, for example, formed the now very successful Crescent Moon Foundation. By contrast, the sence of social responsibility has only partly carried over to the governing organisations. Televised games of the National Football League are liberally sprinkled with players requesting support for the United Way, an umbrella group that distributes funds to non-profit groups. On the other hand, broadcasts of major league baseball games are punctuated with shots of players catapulting spitballs produced from great wads of chewing tobacco wedged into their mouths. The effect of such behaviour is that youngsters now believe that the act of chewing tobacco is synonymous with future careers in the major leagues. The actions of the ACB clearly demonstrate that this organisation senses no pangs of social irresponsibility. If the ACB is to side with a financial bedfellow rather than take an ethical highground, then the Australian public can certainly apply the same rules to cricket. Smoking-related disease incurs a huge cost to society and to government. The taxpayer, then, has every right to demand full withdrawal of any and all governmental support of cricket, including discontinuation of broadcasts on the Australian Broadcasting Commission, discontinuation of unreimbursed police presence at major matches, and the charging of appropriate ground maintenance fees at municipal ovals. Department of Pediatrics, Baylor College of Medicine,
STEPHEN J. ELLIOTT
Houston, Texas 77030, USA
Methods for increased SIR,—Professor John
and
poliovirus diagnosis
colleagues (Oct 17, p 975) report a antibody-bound poliovirus in stool specimens. They investigated 16 children with acute flaccid paralysis and exposed samples to the acid glycine buffer, pH 2-4, at room temperature for 3 h. Antibody-bound poliovirus type 1 was method
to
detect
dissociated in 6 samples. The enhanced sensitivity of the dissociation procedure would be proven by demonstration of poliovirus antibody as well as viral RNA genomes. IgM or IgA class antibodies should also be searched for in these 6 samples. This could be done by affniity immunoblotting or agarose electrophoresis, as was attempted in cerebrospinal fluid from 36 patients with post-poliomyelitis syndrome.’ Oligoclonal IgM bands specific to poliovirus were detected in 21 of these patients but in none of the controls. Furthermore, abnormally high values of IgM were detectable in 17 patients.’ To demonstrate poliovirus RNA, stool samples could be examined by polymerase chain reaction with poliovirus-specific primers,2 or by an in-situ transcription with pan-enteroviral and individual poliovirus-specific primer to capture poliovirus RNA.3 An appropriate modification of the easy-to-use 96-well, microtitreplate protocol that involves immobilisation of oligonucleotides for mRNA4 is essential for the development of a much needed practical procedure for the detection of poliovirus in areas without facilities for tissue culture. Developing countries would need simplified, one or two step procedures that did not depend on tissue culture for screening polioviruses in stool or other clinical specimens and to measure antibody concentrations. Immobilised oligonucleotide technology requires active support and innovative action. Centre for Logistical Research and Innovation, M-122 (part Greater Kailash-II, New Delhi 110048, India
2),
SUBHASH C. ARYA
1. Sharief MK,
Hentges R, Ciardi M. Intrathecal immune response in patients with the post-polio syndrome. N Engl J Med 1991; 325: 749-55. 2. Yang C-F de L, Holloway BP, Pallansch MA, Kew OM. Detection and identification of vaccine-related polioviruses by the polymerase chain reaction. Virus Res 1991; 20: 159-79. 3. Carstens JM, Tracy S, Chapman NM, Gauntt CJ. Detection of enteroviruses in cell cultures using in situ transcription. J Clin Microbiol 1992; 30: 25-35. 4. Mitsuhashi M, Keller C, Akitaya T. Gene manipulation in plastic plates. Nature 1992; 357: 519-20.
Increase in
birthweight in undernourished women
SIR,-Dr Garner and colleagues (Oct 24, p 1021) consider in communities in which there is chronic malnutrition. High-energy (1950 kj per day) supplementation of mothers’ diet in the last trimester of pregnancy produces babies that remain significantly heavier until 24 months of age and taller until 60 months of age compared with the children of mothers who receive a supplementation of only 218 kj per day.’ Significant weight gain is, however, only seen during the first six months of postnatal life and height gain only in the third postnatal month. Mortality rate is not affected by supplementation, so would the effort of implementing this on a wide scale be worth while? Without there being radical changes in the way societies assess priorities in maternal health and nutrition, such a programme is not sustainable. Gamer et al examine the increased risk of obstructed labour in small women having bigger babies, but this risk is unlikely to contribute significantly to mortality and morbidity rates with the small increases in birthweight recorded in another study.’ Prevention of maternal anaemia, malaria, and malnutrition will inevitably result in increased birthweight, and the beneficial effect on maternal morbidity and mortality of preventing these problems will far outweigh the increased risk of obstructed labour with bigger babies. Babies who are symmetrically growth retarded for gestational age perform poorly in developmental tests, and intellectual ability at school is impaired, compared with normal-birthweight babies or those with low birthweight but normal length and head circumference.2,3 They tend to show poor somatic growth, particularly in head circumference. This group of babies have had chronic intrauterine insults—eg, maternal malnutrition, maternal malaria, maternal smoking, maternal alcohol. 67% of lowbirthweight babies were in this group of symmetrical growth retardation in rural South Africa,4compared with 20% in the UK.3 .3 The impaired development that these children face is analogous to
increasing birthweight
maternal
