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Near-death experiencesSIR,-Dr Owens and colleagues (Nov 10, p 1175) report aninvestigation of near-death experiences (NDE). I am a physician ina busy district hospital where patients are treated everyday for life-threatening conditions. I have been aware of published reports ofNDE for about eight years. I agree that doctors are very reluctant todiscuss NDE and that most reports are outside mainstream medical

journals. One of the reasons for scepticism is the consistentreference to NDE during cardiac arrest. Sabom’ and Morse andcolleagues2 have compared data from case notes with patients’autoscopic experiences while apparently dead or near death.

Although there are some striking correlations there are manydiscrepancies. Because of accurate portrayal of hospital life ontelevision many people admitted to hospital might have seen a veryaccurate representation of a cardiac arrest, and retrospective studiesmight recruit patients whose memories could have been influencedby such programmes. I have come across only one case during aninvestigation that included a patient who had had hypothermiccoronary artery bypass surgery.

I have often asked patients with life-threatening hypoglycaemia(unrecognised and deep unconsciousness) about their memoriesduring coma since this is as near to death as many of the recordedinstances of NDE. I have not come across any who has had an NDEor indeed remembers anything, although NDE has been reportedwith ketoacidosis.2 I undertook a small survey in my diabetic clinicto identify patients who had had severe hypoglycaemia during thepast two years. Six patients had been admitted to hospital and noneof these had any recall of that time. Of the remaining thirteenpatients, two thought they had improved cognitive function withclarity of colours and thought, although they were unable torecognise their hypoglycaemia. The main thrust of Owens andcolleagues’ argument is that there can be improved cognitivefunction near death, although the reverse would be expected.Clearly the perceived improvement of cognitive function could befalse, as it was in the hypoglycaemic patients. If, as Owens et alconclude, their data might lead to a transcendental interpretation ofNDE I feel I should have identified at least one patient who had anNDE during severe hypoglycaemic coma.

I suspect that any life-threatening metabolic abnormality mightlead a patient to believe that they have heightened cognitivefunction, and hypoglycaemia is but one example. I also believe thatNDE is brain based and that it does not occur in hypoglycaemiabecause the brain and mental processes do not function at that time.If further research is planned, out-of-the-body experience (OOBE)is probably a better model for the investigation of cognitivefunction. I suspect many of the experiences described as NDE areOOBE. OOBE is much more common than NDE, is associatedwith improved cognitive function, and lacks the life review andbeing of light aspects. It can apparently sometimes be induced atwill and is more appropriate for psychological testing.3Mount Vernon Hospital,Northwood, Middlesex HA6 2RN, UK D. J. B. THOMAS

1. Sabom M. Recollections of death: a medical investigation. New York: Harper Row,1982.

2. Morse M, Castillo P, Venecia D, et al. Childhood near death experiences. Am J DisChild 1986; 140: 1110-13.

3. Blackmore SJ. Beyond the body. an investigation of out of the body experiences.London: Granada, 1983.

SIR,-Dr Owens and his colleagues describe seven commonlyreported features of the near death experience (NDE). One of these,the belief that one had left one’s body (also known as the "out of thebody experience" [OBE]), was a consistent finding in 68% of cases.I report a patient undergoing respiratory psychophysiologicalinvestigation in our department, who voluntarily had an OBE. Themechanism demonstrated might further elucidate some or all of theother features of the NDE.A 53-year-old woman was referred by her general practitioner for

chronic fatigue syndrome. She described 5 years of severeexhaustion after a viral illness. She also had difficulty in focusing,sudden wakening in the middle of the night, paraesthesiae of thefinger tips, gasping and difficulty in taking a deep breath, sharp

pains in the left chest, and palpitations. Further questioningrevealed that the patient had not been well before she had the viralillness. She had had a very disturbed childhood-she had witnessedher father’s suicide when she was 6 and the death of her motherthree weeks later. After a difficult marriage to a man who proved tobe bisexual, she pursued a very busy career in the film industry. Shelived in the "fast lane" for several years, smoking 20 cigarettes a day,drinking a bottle of wine a day, and having many lovers. She felt thatthis life-style contributed to the exhaustion that preceded her viralillness. She had brisk reflexes but nothing else of note. A workingdiagnosis of effort syndrome (exhaustion and hyperventilationsecondary to effort and distress beyond physiological tolerance) wasmade. 1

Clinical capnography was done and showed a low normal restingend-tidal partial pressure of carbon dioxide (PeCO,) at 33 mm Hgand normal recovery after a 3 minute forced hyperventilationprovocation test (FHPT), the recovered value being 25 mm Hg.However, recollection of personal stressors—in this patientthinking about her dying brother-produced a fall in P ’CO, to 25mm Hg, clearly corroborative of the clinical diagnosis. The patientthen had an OBE. She felt that she left her body and saw it below heras she struggled to travel to France to visit her brother. She primedherself for the OBE by having a 20 second breath hold, followed byprofound hyperventilation, with Pe COZ falling to 20 mm Hg.

This report shows that, in this patient, hyperventilation probablymediated her OBE. It is well known that hyperventilation (the effectof which can be accentuated by a preliminary breath hold) canproduce a wide range of neurological and psychological effects byalkalosis-induced cerebral vasoconstriction and the Bohr effect .3,4In addition, these same mechanisms could readily explain enhancedperception of light, sense of being in a tunnel, and altered cognitionand emotions. Further, the sense of impending death is a frequentfeature of hyperventilation-induced panic attacks. Finally, it isworth remembering that NDEs often occur in patients successfullyresuscitated after cardiac arrest, an event often contributed to byhyperventilation-induced coronary vasoconstriction and

arrhythmia.s 5

Cardiac Department,Charing Cross Hospital,London W6 8RF, UK STUART D. ROSEN

1. Rosen SD, King JC, Nixon PGF. Is chronic fatigue syndrome synonymous with effortsyndrome? J R Soc Med 1990; 83: 761-65.

2. Nixon PGF, Freeman LJ. The ’think test’: a further technique to elicit

hyperventilation. J R Soc Med 1988; 81: 277-79.3. Lum LC. The syndrome of chronic habitual hyperventilation. In: Hill OW, ed.

Modem trends in psychosomatic medicine, 3. London Butterworth, 19764. Wyke B. Brain function and metabolic disorders. London: Butterworth, 1963.5. Lum LC, Nixon PGF. Endorphms, I presume, or hyperventilation? Lancet 1981; r

160.

Disaster epidemiologySiR,—Your Oct 6 editorial (p 845) states that "while severe

malnutrition is a major risk factor for death, communicable diseasesrather than starvation cause most morbidity and death amongrefugee communities". You do not, however, consider the

significance of high prevalence rates of moderate malnutrition indrought-affected communities,1,2 or the interactions betweenmalnutrition and communicable diseases .3We studied the association between light, moderate, and severe

wasting and the incidence of death during the southern Ethiopianfamine of 1985-86. 24 communities from Arero and Borana

Provinces, containing about 10 000 children, were observedmonthly for prevalence of malnutrition and incidence of death.Severe wasting was defmed as weight/height less than 70% ofreference median, moderate as 70-80%, and light as 80-85%.Incidence of death was measured in the same communities.

Multiple linear regression was done of incidence of death one monthafter registration of degrees of wasting on prevalence of severe,moderate, and light malnutrition. The results confirm that factorsassociated with famine-relief shelters represent the main risk fordeath among children. However, they also show that moderatewasting may be a stronger predictor of death than severe wasting.Life in famine-relief shelters plus a high prevalence of moderate and

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severe wasting produced the most severe consequences of drought-induced famine The fact that nutritional rehabilitation wasassociated with a decrease in crude childhood mortality and adecrease in the incidence of severe diarrhoeal diseases demonstratedthe importance of malnutrition as a risk factor.The epidemiology of drought disasters is more complex than

indicated in the editorial. A lesson of the past decade is that more

emphasis should be given to the control of communicable diseasesin famine-relief shelters. However, if the frequency and impact ofdisasters is to be reduced, appropriate early interventions areneeded to prevent the social collapse that occurs when copingmechanisms break down.

Centre for International Health,University of Bergen,5021 Bergen, Norway BERNT LINDTJØRN

1 Lindtjørn B. Famine m Ethiopia 1983-85: kwashiorkor and marasmus in four regions.Ann Trop Paediatr 1987, 7: 1-5.

2. Hogan RC, Broske SP, Davis JP, et al. Sahel nutrition surveys, 1974 and 1975.Disasters 1977; 1: 117-24.

3. Toinkins AM Protein-energy malnutrition and nsk of infection Proc Nutr Soc 1986;45: 289-304.

4 Lindtjørn B Famine in southern Ethiopia 1985-86: population structure, nutritionalstatus and death among children. Br Med J 1990; 301: 1123-27.

5 Lindtørn B. Famine in southern Ethiopia 1985-86: malnutrition, diarrhoea anddeath. Trop Geogr Med (in press).

Day-case surgerySIR,-Professor Opit and Mr Collins (Dec 15, p 1512) correctly

highlight difficulties in comparisons of interdistrict day-casestatistics while definitions of what constitutes a day-case remainimprecise. However, to develop from this an argument againstincreasing general surgical day-care is unconvincing.

In Maidstone, where we have been campaigning to increase ourday-case resources, our figures are amongst the highest of thoseOpit and Collins quote. Our high figures partly result from veryefficient data collection, partly because some outpatient procedureswere included, but mainly because we already do much of oursurgery on a day-care basis.With the help of funds from the waiting-list initiative we have

confirmed the feasibility of doing hernia repairs, varicose veinsurgery, breast lumpectomy, and similar procedures on a day-carebasis-with the emphasis on care. Our own audit has re-affirmedthe findings of others1 that patient acceptability is excellent.

150 questionnaires were sent to patients who had undergonevarious day-care procedures and 113 replied. When asked "wouldyou be happy to attend as a day-case again?" 86% of respondentsanswered yes, and to the question "would you prefer to have thesame operation again as a day-case?" 69% replied yes. For herniarepairs 79% and 53%, respectively, answered yes to these

questions.We would like day-care general surgery to be a subspecialty, and

believe that the results of these procedures, so often delegated tosurgeons in training (not always with the best supervision), wouldbe greatly improved if done by experienced day-care surgeons. Awell performed Shouldice repair, for example, has a less than 1 %recurrence risk,2 whereas rates as high as 20%3 have been reportedin England. Ideally such specialists would have consultant

appointments to provide clinical autonomy, but a staff gradeappointment, with a clinical director of day-care services appointedfrom the existing establishment, is a workable alternative. By theappointment of additional specialist day-care staff in separate suitesOpit and Collins’ anxieties about possible subversion of clinicalpriorities would not arise.The lowering of "target efficiency" is another fear that can be

dispelled. Although no-one can seriously deny that day-casesurgery has convincing economic advantages, we wholeheartedlyendorse the Royal College of Surgeons’ view4 that day-care surgeryexpansion will require extra resources. Clearly in districts that are asfinancially constrained as Maidstone these resources must be

provided centrally. We strongly believe that day-care generalsurgery is the only realistic approach to tackling ever increasingwaiting lists while inpatient bed numbers continue to fall-not as

second best, but as a method whose safety and acceptability is wellestablished.5 There is no evidence of any increased morbidity insuch procedures done on a day-care basis. Mrs Wengraf (Dec 15,p 1513) who as a surgeon presumably elected to be a day-caseprovides no evidence to support her claim of "a striking increase inmorbidity and a lengthening of recovery time".Most patients prefer to have operations as day-cases where

possible. Add to this the reliability of forward planning with no lastminute bed cancellations, and the compelling need to urgentlyexpand day-care facilities becomes unassailable.

We thank Sister K. Wretton, SRN, adult day care, Maidstone Hospital, fororganising this study and collecting the results.

General Wing,Maidstone Hospital,Maistone, Kent ME16 9QQ, UK

PETER A. JONESSUSAN E. JONES

1 Goulbourne IA, Ruckley CV. Operations for hernia and varicose veins in a day-bedunit Br Med J 1979; ii. 712-14.

2 Devlin HB. Management of abdominal hernias Ch II. London: Butterworths, 1988:101-05, 116.

3. Shuttleworth KED, Davies WH. Treatment of inguinal herniae. Lancet 1960; i.

126-27.4. Commission on the provision of surgical services. Guidelines for day case surgery.

London: Royal College of Surgeons of England, July, 1985.5. Ruckley CV, Cuthbertson C, Fenwick N, Prescott RJ, Garraway AM. Day care after

operations for hernia or varicose veins: a controlled trial. Br J Surg 1978; 65:456-59.

Registration of stillbirths and neonataldeaths of very low birthweight babies

SIR,-We read with interest the European Communitycollaborative study of outcome of pregnancy between 22 and 28weeks’ gestation (Sept 29, p 782) and the subsequentcorrespondence (Nov 10, p 1192 and Nov 24, p 1317). Thesereports highlight the difficulty of the different definitions used forstillbirth and neonatal death in various countries.

In Australia, the legal definition for the registration of births is 20weeks or more gestational age or a birthweight of 400 g or more if theperiod of gestation is not known. A stillbirth is defined as any fetusof 20 or more weeks’ gestation or weighing 400 g or more at deliverywhich did not show any evidence of life after delivery. A neonataldeath is defined as an infant who is born alive, irrespective ofgestational age or birthweight, who dies within 28 days of birth.These legal definitions are different from those used for statistical

purposes. The figures collected and published by the AustraliaBureau of Statistics1 are extracted from these births after exclusionof infants weighing less than 500 g or of less than 22 weeks’gestation. This is in accordance with the World Health

Organisation definitions which take a cut-off point of 500 g or 22weeks’ gestation in both stillbirths and neonatal deaths.The WHO criteria for stillbirth, neonatal death, and perinatal

mortality should be adopted world wide. They obviously precluderegistering abortuses weighing less than 500 g, which would havebeen recorded as neonatal deaths if the fetus had shown any signs oflife after expulsion. We feel that birthweight is a more reliablevariable than gestational age.2 The latter is certainly a better indexonly if it is accurate.From our experience a cut-off point as low as 20 weeks’ gestation

puts a lot of pressure on obstetric, paediatric, and midwifery staff inthe decision making necessary for management of such verypremature births. This is in addition to the unrealistic hopes thatmay be held by families and the long-term sequelae of aggressivemanagement of very low birthweight infants. We feel that a cut-offpoint for perinatal deaths at 22 weeks’ gestation (500 g) or preferablyat 24 weeks (650 g) is a practical and realistic approach.

Department of Obstetrics and Gynaecology,Royal Darwin Hospital,PO Box 41326,Casuarina NT 0811, Australia

G. S. H. MATTHIASG. MORGAN

1 Perinatal deaths Australia Australian Bureau of Statistics, 1988, catalogue no 3304 0.2 Fenton AC, Fields DV, Mason E, Clarke M. Attitudes to viability of preterm infants

and their effect on figures for perinatal mortality. Br Med J 1990; 300: 434-36.