ASTHMA IN PREGNANCY letter

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lettersWe select the letters for these pages from the rapidresponses posted on bmj.com favouring those receivedwithin five days of publication of the article to which theyrefer. Letters are thus an early selection of rapid responseson a particular topic. Readers should consult the websitefor the full list of responses and any authors replies, whichusually arrive after our selection.

Caring for the oldest old

Odst od ar not jst passivrcipints of car

Although Robine et al raise serious pointsabout future trends in ageing, dependency,and care provision in later life,1 it is alsoworth noting that older people are not justpassive recipients of care. Of particularimportance is the contribution that theythemselves bring to their own care. Alongitudinal study of ageing in Ireland founda marked increase in the amount that olderpeople spend on provision of health andsocial care2 over a four year sampling period,

despite increases in access to services suchas free general practitioner care. Over 8% ofolder people in this study were themselvesthe primary carer for another familymember.Therefore, even in advanced old age, a

sense of partnership between services andall older people needs to be developed.Enabling this partnership, and responding tothe changing demands of health and socialcare services, will require increased emphasison effective care for older people, whetherthrough acute geriatric medicine (which canreduce death and disability by 25%)3 or by

improved chronic disease management.4 Itwill also require some thought to ensuringthat the societal structures, such as housingand transport,5 do not hinder participation ofthe oldest old in sharing in their own care.Dsmond ONi associate professor, Department of

Medical Gerontology, Adelaide and Meath Hospital, Dublin

24, Republic of Ireland [email protected]

Hannah McG professor, Department of Health Services

Research, Royal College of Surgeons in Ireland, Dublin 2

Compting intrsts: None declared.

1 RobineJM,MichelJP,HerrmannFR.Whowillcarefortheoldestpeopleinourageingsociety?BMJ2007;334:570-1.(17March.)

2 OHanlonA,McGeeA,BarkerM,GaravanR,HickeyA,ConroyR,etal.Health and social services for olderpeople II (HeSSOP II): changing profiles from 2000 to

BMJ| 31 MARCH 2007 | VOluMe 334 651

2004.Dublin:NationalCouncilonAgeingandOlderPeople,2005.

3 EllisG,LanghorneP.Comprehensivegeriatricassessmentforolderhospitalpatients. Br Med Bull2005;71:45-59.

4 LorigKR,RitterPL,LaurentDD,PlantK.Internet-basedchronicdiseaseself-management:arandomizedtrial.Med Care2006;44:964-71.

5 ONeillD,DobbsB.Age-relateddisease,mobilityanddriving.In:Transportationinanagingsociety,adecadeofexperience.Washington,DC: Transportation Research

Board,2004:56-68.

Cord Clamping

NICe is ncoraging artificiaintrvntionAs well as seeming to discourage the detectionof postpartum depression,1 the NationalInstitute for Health and Clinical Excellence(NICE) is also encouraging the artificialintervention of immediate cord clamping.2

The NICE guideline for caesarean sectionincludes a section on cord clamping. It statesa number of suggested benefits and anumber of possible harms. The referenceis a review paper in a midwifery journal.3This review clearly provides evidence for

the benefits, not simply a suggestion,and clearly disputes any evidence of harmfrom polycythemia, hyperviscosity, orhyperbilirubinaemia.The NICE draft guideline on intrapartum

care never mentions cord clamping (www.nice.org.uk/page.aspx?o=334322). Theauthors recognise that the major rapidphysiological changes that take place enablethe baby to adapt to life outside the womb.How rapidly should we expect these changesto take place? Is it reasonable to expect thesephysiological changes to occur within a fewseconds and at the whim of a bystander?Active management of the third stage isconsidered to be an established part of goodintrapartum care, and early cord clamping anintegral part of it.4

How precise does the practice need tobe? The timing of the oxytocic agent variesamong the studies and in different parts of theworld. There is no real logic for incorporatingearly cord clamping in a strategy to reducepostpartum haemorrhage. Removing theclamp and draining the residual placentalblood seems to shorten the third stage.3 Thisis recommended practice in rhesus negative

women, in an effort to reduce the risk offetomaternal haemorrhage.5 It is therefore

totally illogical to recommend immediatecord clamping and cutting, followed bydrainage of the residual placental blood.This is blood that is physiologically requiredby the newborn baby. It would be better todrain the placenta into the newborn babyor at least provide the baby with the amountof blood that it requires. Any residual bloodat that stage can be allowed to drain away.David J R Hutchon consultant, Darlington Memorial Hospital,

Darlington DL3 6HX obstetrician

[email protected]


1 CoyneJC,MitchellAJ.NICEmaybediscouragingdetectionofpostpartumdepression. BMJ2007;334:550-a.(17March.)doi:10.1136/bmj.39150.424896.BE.

2 KentA.Whatsnewintheotherjournals?BJOG2007114:379-80.

3 MercerJS.Currentbestevidence:areviewoftheliteratureonumbilicalcordclamping. J MidwiferyWomens Health2001;46:40214.

4 SoltaniH,DickinsonF,SymondsI.Placentalcorddrainageafterspontaneousvaginaldeliveryaspartofthemanagementofthethirdstageoflabour.CochraneDatabase Syst Rev2005(4):CD004665.

5 PrendivilleW,ElbourneD.Careduringthethirdstageoflabour.In:ChalmersI,EnkinM,KeirseMJNC,eds.Effective care in pregnancy and childbirth.Oxford:OxfordUniversityPress,1989:1145-69.

perinatal death in twins

Absot risk: bttr basis fordcision makingSmith et als conclusion of threefold tofourfold increased mortality in a second twinwhen born vaginally at term is a relativerather than an absolute risk.1 There wasan excess second twin all cause mortalityof 73 infants, and an excess second twinanoxic mortality of 60 infants. Altogetherthere were nearly 100 000 births, but thepreterm rate (higher in twin births) was notstated, so there might have been 90 000 fullterm confinements. This gives an increasedmortality for the second twin of 0.8 per 1000births, and an increased anoxic mortalityfor the second twin of 0.67 per 1000 births.If caesarean section successfully avoided allthe second twin mortality, 1250 caesareansections would be needed to save one infant.If caesarean section were only successful inpreventing anoxic deaths, 1500 caesareansections would be needed to save one infant.Although this large number of extra sectionsmight be justifiable, the low possible statistical

benefit might persuade some mothers ortheir obstetricians that a vaginal delivery is a

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reasonable option for full term confinements.The absolute rather than the relative risk isthe correct guide to decision making.The figures do not prove that caesarean

sections would prevent deaths in the secondtwin.2 Fetal behaviour may affect birth orderin twin deliveries, and the more vulnerableinfant may be delivered second in vaginalbut not in caesarean deliveries. The benefitof caesarean section can be proved only by acomparison of total fetal mortality in vaginaland caesarean deliveries.Christophr Chtham consultant paediatrician (retired),

High Wycombe HP13 6QW

[email protected]


1 SmithGCS,FlemingKM,WhiteIR.BirthorderoftwinsandriskofperinataldeathrelatedtodeliveryinEngland,NorthernIreland,andWales,1994-2003:retrospectivecohortstudy.BMJ2007;334:576-8.(17March.)

2 SteerP.Perinataldeathintwins.BMJ2007;334;545-6.

(17March.)

asthma in pregnanCy

Attacks sm rar in aborI was concerned to read that 10-20% ofwomen experience an exacerbation ofasthma during labour.1 In 40 years practiceas an obstetric physician, I never saw anattack of asthma in labour; and nor haveother obstetricians and respiratory physiciansthat I have questioned at conferences. Iwonder if any of the BMJsreaders havepersonal experience of managing asthmaattacks in labour? This is important becausewomen with asthma are very frightenedof not being able to cope with asthma atdelivery. Up to now I have reassured patientsthat this is very unlikely to be a problem.Micha d Swit emeritus professor of obstetric medicine,

London N6 5LU [email protected]


1 ReyE,BouletL-P.Asthmainpregnancy.BMJ2007;334:582-5.(17March.)

a good death

Dying on th act tak can bimprovdNumerous patients with chronic illnesses inwhom death may be expected or patientswith severe and significant comorbidites willbe admitted to acute medicine.1 We recentlyperformed a retrospective audit of patientsadmitted through the medical admissionsunit who subsequently died. Death did notcome as a surprise in 21/23 patients; sevenof the 21 patients had terminal cancer,and nine had severe infection with severecomorbidities. An average delay of 11 hours

occurred from recognition that the patientwas dying to institution of any palliative

measures. Of the terminally ill patients, sixwere judged to have had adequate palliation,10 received no palliative drugs, and fivereceived minimal palliation. The commonestreason for withholding palliative drugsseemed to be a trial of active treatment in thefirst instance.Care of dying patients in acute medicine

may not always be seen as a priority.However, these patients should be recognisedearlyso that symptomatic treatment canbe used to ensure a comfortable death andenable the patient and family to prepare fordeath.2 These measures can be institutedalongside active management in thesepatients who are sick enough to die.Suzi Gion senior house officer, general medicine,

Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP

[email protected]

Kathryn Mannix consultant in palliative care

David A Pric consultant in acute medicine (and infectiousdiseases)


1 DyS,LynnJ.Gettingservicesrightforthosesickenoughtodie.BMJ2007;334:511-3.(10March.)

2 EllershawJ,WardC.Careofthedyingpatient:thelasthoursordaysoflife.BMJ2003;326:30-4.

mtas

Nw systm thratns uKcinica rsarchWe are committed to the development ofa professional medical workforce, able to

contribute to national health, wealth, andknowledge creation. To achieve this wemust identify and nurture a strong cadre ofclinical academics for the future, buildingon the opportunities afforded by the recentUK funding schemes. It has therefore beenparticularly disappointing that the newsystem of application to specialist medicaltraining (MTAS) has paid scant regard to thedeterminants of academic potential.1

Academic traineesthose doctors wishingto pursue careers that encompass research aswell as patient carehave been particularly

badly affected by the decision to anonymiseapplications and deprive the assessors ofdetails of previous clinical and researchexperience. These trainees, who are amongthe brightest of their generation, are aprecious commodity.Without a scientifically informed and

research oriented medical workforcethroughout the country, the governmentsvision of the UK as a world class centre forbiomedical research and health care, cannotbe realised.J B president, Academy of Medical Sciences, London

SW1Y 5AH [email protected]

John Took chair, Council of Heads of Medical Schools,London WC1H 9HD


1 BrownMJ,etal.RagingagainstMTAS.BMJ2007Mar7.www.bmj.com/cgi/eletters/333/7579/0-f#161670.

publisher boyCott

editoria misss th pointClearly there is an unsavoury and unethicalaspect to the sale of weapons,1 but thereis a legitimate trade as well. Few woulddoubt that there are benefits from variouspeacekeeping forces in the world, thoughobviously there are controversial invasions.Only the most naive would argue that ourown democracy was not protected during thecold war by our weaponry. We can pretendit is not happening and let other countriesdominate the arms trade, but we will still buyweapons for our armies. If my son is to besent to an area of conflict, I dont want him

being armed with inferior weaponry becausea non-combatant thought it unethical to seekthe best technology.Unpalatable as it is, there will always be

an arms trade and dissociating ourselvesfrom it will merely remove any possibility ofinfluencing control. Landmines would notdisappear if Reed Elsevier stopped organisingexhibitions.lauri R Davis general practitioner, South Hermitage

Surgery, Shrewsbury SY3 7JS [email protected]

Compting intrsts: LRD owns shares in Qinetic, a Britishdefence company.

1 YoungC,GodleeF.ReedElseviersarmstrade.BMJ2007;334:547-8.(17March.)

Its a hatcht jobYoung and Godlee write: The BMJhas nowish to see the Lancetdiminished.1 Well,you could have fooled me. Calling forcontributors to boycott the Lancetwill leadto its closure, which would almost certainlybenefit the BMJ. Is there a hint of self interestdressed up as moral outrage in this article?Does anyone believe that boycotting Reed

Elsevier will make the slightest difference to

the international arms trade? It is a sad factof human existence that the sophistication ofa society is often measured in its weaponry.The arms trade is loathsome but at least ReedElsevier is conducting its business in plainview. Its when it goes underground that youneed to worry. I think it would be betterif they werent involved, and Im sure theboard of the Lancetdoes too. But boycotting ajournal that has no control over another partof its parent company is not the way to go.Christophr e Nancoas general practitioner, Newnham

GL14 1BE [email protected]


1 YoungC,GodleeF.ReedElseviersarmstrade.BMJ2007;334:547-8.(17March.)

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