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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Breast lumps in young women . 317:doi 10.1136/bmj.317.7152.209a

Editor - Dixon et al described a technique of excision of large volumes of breast tissue followed by early reconstruction with a latissimus dorsi muscle flap. 1 In their article they stated that the top figure showed no obvious resultant defect following removal of the latissimus dorsi muscle.

The latissimus dorsi muscle is one of the most frequently used flaps in reconstructive surgery. Harvest of the muscle with its overlying fat for breast reconstruction is not new.2 Russell et al have shown that all patients have obvious flattening of the soft tissue over the posteriolateral chestwall on the donor side.3 The posterior axillary fold is usually reduced or flattened.

Only an oblique view of the right side of the back is shown in their article. This illustration is not adequate to show a defect. The back of the patient should have been shown to allow comparison with the unoperated side. Care should be taken in using photographic evidence. The British Medical Journal should encourage authors to use appropriate views if any firm conclusions are to be drawn about results of treatment.

As the NHS moves into a new era of clinical excellence patients should not be given the impression of high expectation of surgery without stressing the drawbacks.

Kenneth E. Graham, Specialist Registrar.
Arthur M. Morris, Consultant Plastic Surgeon.

Department of Plastic Surgery, Dundee Royal Infirmary, Dundee DD1 9ND.


1 Dixon JM, Venizelos B, Matheson L. New technique has excellent cosmetic results. BMJ 1998; 317: 209-210. (18 July).

2 Germann G, Steinau H-U. Breast reconstruction with the extended latissimus dorsi flap. Plast. Reconstr. Surg. 1996; 97: 519-26.

3 Russell RC, Pribaz J, Zook EG, Leighton WD, Eriksson E, Smith CJ. Functional evaluation of latissimus dorsi donor site. Plast. Reconstr. Surg. 1986; 78: 336-344.

Competing interests: No competing interests

03 September 1998
Kenneth E Graham
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Re: Heroin use among young people is increasing in England and Wales Richard Harling. 317:doi 10.1136/bmj.317.7156.431

EDITOR - Reading your news item on the increasing heroin use among young people in England and Wales produces a deja
vu effect on those working in the field of drug de-addiction for more than a decade in India. This is a small note to share with you.

Heroin use (especially in the young) starts clandestinely, and spreads like a bonfire. From initial subcultural "pockets" of use, it quickly assumes an epidemic proportion spanning large sections of society even before health and surveillance authorities have started mounting counter measures. A position paper on the drug use scenario in India in 1980 noted that "the last point, and one which deserves careful consideration, is the absence of large-scale heroin or related substance abuse in India".2, p.46 Within the very next few years, however, the psychiatric and de-addiction clinics of India got flooded with cases of heroin addiction3, forcing the health authorities to finally take note of the "recent heroin epidemic"4 and then to set up ministry-funded drug de-addiction centers all over India in the 1990s. It was all somewhat late by then.

Secondly, heroin use ramifies into other and often more harmful substance use patterns amongst the youth. In the case of India, it was buprenorphine, a semisynthetic injectable opioid with supposedly minimal addictive properties, that was marketed in the late 1980s in India and often advocated for heroin detoxification. By the 1990s, injectable buprenorphine abuse became a popular substitute, or "add-on" to heroin 5,6, with its own substantial health risks associated with injectable drug use 7.
Finally, at least in the entire north India currently, codeine-containing cough syrups are holdings way amongst the young generation as a "recreational" drug 8. Carisoprodol is another 9.

As a final lesson from India, and in agreement with Prof. Parker's concern in the report about "overdependence on medical treatment" in this area1, it is to be noted that all the three drugs mentioned above were initially tried for detoxifying heroin addicts, producing ultimately what can be called an iatrogenic drug addiction due to a "prescription carry-over effect"9. Some of these lessons may be kept in mind while dealing with the situation in England and Wales.

Debasish Basu, Assistant professor
Surendra K. Mattoo, Associate Professor
Anil Malhotra, Additional Professor

Drug De-addiction & Treatment Centre
Department of Psychiatry
Postgraduate Institute of Medical Education & Research,
Chandigarh - 160 012, India.


1. Harling R. Heroin use among young people is increasing in England and Wales (news). BMJ 1998; 317 : 431.

2. Mohan D. India : Socioenconomic development and changes in drug use. In : Edwards G, Arif A, eds. Drug

problems in the sociocultural context : a basis for policies and programme planning. Public Health Papers, No.73.

Geneva : World Health Organization, 1980 : 42-8.

3. Saxena S, Mohan D. Rapid increase of heroin dependence in Delhi : some initial observations. Indian J

Psychiatry 1984, 26 : 41-5.

4. Varma VK, Malhotra A. Recent heroin epidemic. In : Proceedings of the 40th Annual Conference, Indian

Psychiatric Society, 1988 : 29-31.

5. Chowdhury AN, Chowdhury S. Buprenorphine abuse : report from India. Br J Addict 1990; 85 : 1349-50.

6. Singh RA, Mattoo SK, Malhotra A, Varma VK. Cases of buprenorphine dependence from India. Acta

Psychiatr Scand 1992; 86 : 46-8.

7. Basu D, Mattoo SK, Arora A, Malhotra A, Varma VK. Pseudoaneurysm in injecting drug abusers : cases

from India. Addiction 1994; 89-1697-9.

8. Mattoo SK, Basu D, Sharma A, Balaji M, Malhotra A. Abuse of codeine containing cough syrups : a report

from India. Addiction 1997 ; 92 : 1783-7.

9, Sikdar S, Basu D, Malhotra A, Varma VK, Mattoo SK. Carisoprodol abuse : report from India. Acta

Psychiatr Scand 1993; 88 : 302-3.

Competing interests: No competing interests

03 September 1998
Debasish Basu
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Re: Cholesterol: how low is low enough? A Rosengren. 317:doi 10.1136/bmj.317.7156.425

EDITOR, - In his stimulating editorial, Professor A Rosengren (August 15, p.425)1 considers that reaching target levels may be better than relative reductions. He stated that 'in observational studies a prolonged difference in usual serum cholesterol value of 0.6mmol/l is associated with an almost 30% reduction in risk of coronary disease.'

None would question the need for the reduction of serum cholesterol level in large proportions of adults in Western populations. However, the whole field of cholesterol level and its pathological significance is one of complexities. Firstly, known risk factors for coronary heart disease (CHD) of which serum cholesterol is one, explain only one half of the variance in the occurrence of the disease.2 Next, there are numerous contextual problems. For example, in the Sheffield risk table, in the high risk moiety cholesterol reduction may be called for at 5.5mmol/l; whereas for those at low risk, intervention may not be needed until 9.0mmol/l level.3 There is also the dichotomy of experience of CHD in Belfast and Toulouse. While mean cholesterol levels in the two cities are similar, 6.19 and 5.94 mmol/l, CHD mortality rate is 3-4 times higher in the former compared with the latter city.4

Perplexities are also common in developing populations, as in South Africa.5 In early studies on African men, mean cholesterol level of the middle aged was about 4.0 mmol/l. At that time, observations at necropsy revealed a very low level of atherosclerotic lesions of the aorta, and negligible deaths from the disease. Currently, in Soweto (3-4 million inhabitants), mean cholesterol level is about 5mmol/l. Yet CHD remains very uncommon, being responsible for less than 0.5% of total deaths. Like reports of its relative rarity have emanated from big cities in other countries in Africa. As a comparison, in the Seven Countries Study, it was reported that the same mean level of serum cholesterol, about 5.15mmol/l, prevails in Mediterranean countries, but where CHD is responsible for 4.7% of total deaths.

An additional complicating factor is the wide range of cholesterol levels in a community. In African village schoolchildren, almost all of the same poor socio-economic state and accustomed to the same low atherogenic diet, cholesterol level was found to vary from 2.5 to 4.2 mmol/l.

To re-iterate, while there is no intention of belittling the role of cholesterol level in CHD, it is important to recognize that a given level of the parameter has widely different connotations for ill, as affected by familiality, ethnicity, gender, and environmental factors.

Head: Human Biochemistry Research Unit, Department of Tropical Diseases,
School of Pathology of the University of the Witwatersrand, and the South African Institute for Medical Research, Johannesburg

1. Rosengren A. Cholesterol: how low is low enough? BMJ 1998; 317: 425-6.
2. Leeder S, Gliksman M. Prospects for preventing heart disease. Br Med J 1990; 301: 1004-5.
3. Haq IU, Jackson PR, Yeo WW, Ramsay LE. Sheffield risk and treatment table for cholesterol lowering for primary prevention of coronary heart disease. Lancet 1995; 346: 1467-71.
4. Evans AE, Ruidavets J-B, McCrum EE, et al. Autres pays, autres coeurs? Dietary patterns, risk factors and ischaemic heart disease in Belfast and Toulouse. Q J Med 1995; 88: 469-77.
5. Walker ARP, Sareli P. Coronary heart disease: outlook for Africa. J Roy Soc Med 1997; 90: 937-8.

Competing interests: No competing interests

03 September 1998
A R P Walker
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Re: Cochrane Injuries Group Albumin ReviewersWhy albumin may not work Abi Berger. 317:doi 10.1136/bmj.317.7153.235

We read with interest the recent article by Cochrane Injuries Group Albumin reviewers on the Human Albumin administration in critically ill patients (BMJ No. 7153, 25 July 1998) together with the accompanying editorial in the same journal 1, 2

The Authors in the above article concluded that human albumin should not be given anymore outside the context of rigorously conducted randomised controlled trials. They have shown that albumin administration in critically ill patients with hypovolaemia, burns or hypoalbuminaemia may increase mortality.

In the early part of 1997 we carried out an audit on the use of human albumin solution (HAS 4.5% and 20%), following a dramatic increase in usage in our Trust. Our audit showed 4.5% HAS was used non-specifically in patients with low serum albumin levels in a variety of clinical conditions (including an occasional request for 500 ml only) and 20% HAS was used mainly in patients with chronic liver disease.

During this audit we did a literature search on the indication for the use of human albumin solution including the product data from Zenalb (BPL) 3 - 7. We found little conformity and often conflicting advice given on clinical indications in all the literature reviewed. Comparison between four European Countries which had agreed National indications for use of HAS also showed considerable variation with two indications only in Country A ranging to 12 clinical indications given in Country D. The amount of albumin used per 1000 population also varied widely (from 109 - 810 gms/year)5.

Our Literature search has shown ineffective use of HAS in the following clinical situations:
As nutritional supplementation,volume replacement if blood loss is less than 30% of total blood volume, early treatment (less than 24 to 48 hours) of burns and thermal injuries, albumin replacement in chronic protein loss due to enteropathy, cirrhosis and nephrosis,and in low volume paracentesis. We have established local clinical indications for the use of HAS both for 4.5% and 20% taking into the considerations of non-indications given above. However, in the light of the Cochrane paper we may now need to review the clinical indications on the use of HAS.

The inappropriate use of this product may thus be due to lack of universal and specific clinical indications. Although albumin administration may be harmful in certain categories of patients, favourable effects of albumin administration in some patients may have been obscured in the Cochrane analysis and the use of albumin solution should not be stopped. It is important instead that a concerted effort is made to identify those patients who may benefit from albumin administration.


1 Martin Offringa. Excess Mortality after human albumin administration in critically ill patients. BMJ 1998; 317:223-224.

2 Cochrane Injuries Group Albumin Reviewers. Human albumin administration in critically ill patients: systemic review of randomised controlled trials. BMJ 1998; 317:235-240.

3 ABC of Transfusion, Second Edition, BMJ Publishing Group 1992.

4 Handbookd of transfusion medicine, United Kingdom Blood Transfusion Services (1996).

5 Therapy with plasma and albumin production and clinical use. Proceedings of the third SIITC-AICT symposium for European co-operation-Rome 6th June 1992.

6 Hastings GE, Wolf PG. The Therapeutic use of Albumin. Arch fam Med 1992; 1(2), 281 - 287.

7 Zenalb Human Albumin Solution 4.5% Naturally, Beyond Simple Volume EXPANSION Bio Products Laboratory, Dagger Lane, Elstree, Herts, U.K. (August 1996).

Consultant Haematologist.
Consultant Haematologist.

Competing interests: No competing interests

03 September 1998
M Bhavnani
consultant haematologist
wigan infirmary
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Re: Objective measures and the diagnosis of asthma John Britton, Sarah Lewis. 317:doi 10.1136/bmj.317.7153.227

We read with interest the editorial by Britton and Lewis about objective measures and the diagnosis of asthma.1 The editorial nicely illustrates the essential lack of one single parameter to diagnose asthma. However, most of the statements in their paper are based upon and refer to epidemiological research. The authors state that the value of measuring the degree of airways responsiveness and peak expiratory flow variability in assessing a diagnosis of asthma must be questionned, since these objective markers are also found in other diseases and even healthy people. Although we agree with the statement that measuring diurnal peakflow variability is not sensitive in primary care patients, evidence remains that almost all asthmatics show airways hyperresponsiveness especially when they present with symptoms. 2 For general practitioners diagnosing asthma is important to avoid overuse of antibiotics and underuse of adequate anti inflammatory treatment in order to improve the clinical state in an early phase. In many cases identifying (or excluding)asthma is possible by symptoms and physical examination only.3 Furthermore, GPs should perform spirometry (including bronchodilator response) and/or a provocation test in case of doubt, sometimes followed by a course of steroids. 3 Britton and Lewis state that longterm risk of airway hyperresponsiveness is unknown, although several papers have unambigeously shown its prognostic significance both in epidemiological and clinical setting.4,5 We would like to stress that this nihilistic attitude towards diagnosing asthma should not be advocated as a guideline for practical doctors treating patients presenting with respiratory symptoms, which are often non-specific.

Henk Thiadens, general practitioner Plompstraat 3, 3815MV,Amersfoort.
Dirkje Postma, professor, department of pulmonology, University of Groningen, the Netherlands

1. Britton J, Lewis S. Objective measures and the diagnosis of asthma BMJ 1998;317:227-228
2. Cockcroft DW, Hargreave FE. Airway hyperresponsiveness. Relevance of random population data to clinical usefulness. Am Rev Respir Dis 1990;142:497-500
3. Thiadens HA, De Bock GH, Dekker FW, Huysman JAN, Van Houwelingen JC, Springer MP, Postma DS. Identifying asthma and chronic obstructive pulmonary disease in patients with persistent cough presenting to general practitioners: descriptive study. BMJ 1998;316:1286-1290
4. Xu X, Rijcken B, Schouten JP, Weiss ST. Airway responsiveness and development and remission of chronic respiratory symptoms in adults. Lancet 1997;350:1431-34
5. O Connor GT, Sparrow D, Weiss ST. A prospective longitudinal study of methacholine airway responsiveness as a predictor of pulmonary function decline: the normative aging study. Am J Respir Crit Care Med 152:1377-82

Competing interests: No competing interests

03 September 1998
Henk Thiadens
general practitioner
Amersfoort The Netherlands
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Re: Confidential inquiry into quality of care before admission to intensive care Alasdair Short, Giles Morgan, Mick Nielsen, David Barrett, et al. 316:doi 10.1136/bmj.316.7148.1853

McQuillan's paper was of huge interest to us as Emergency Physicians at the West Middlesex University Hospital. It highlights a widely held belief that care of patients prior to their admission to intensive care units can be sub-optimal.

We were interested to note however that the role of the Accident & Emergency Department was not mentioned in the paper. Of particular relevance to Emergency Physicians would be how many patients originated from the Emergency Department and of these how many were directly transferred to the Intensive Care Unit and how many went via the wards. We believe this information will be of interest to a wide audience and that it would help emphasise the importance of the critical care axis between the Emergency Department and the Intensive Care Unit.

With our best wishes

Yours faithfully

Mr S Ahmad FRCS (Ed) Miss D Hulbert FRCS FFAEM
Specialist Registrar Consultant
Accident & Emergency Accident & Emergency

Accident & Emergency Department, West Middlesex University Hospital

1. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential Inquiry into quality of care before admission to intensive care. BMJ1998: 316:1853-8

We the undersigned authors of the enclosed letter declare that there is no conflict of interest involved in this matter

Competing interests: No competing interests

03 September 1998
S Ahmad
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Re: Cochrane Injuries Group Albumin ReviewersWhy albumin may not work Abi Berger. 317:doi 10.1136/bmj.317.7153.235

Roberts (1) reports a meta-analysis of 30 studies on albumin administration in critically ill patients. Their conclusions suggest that this fluid may be associated with an increased risk of death. However,in none of the studies was mortality a pre-specified end-point and, probably for this reason, the causes of mortality are generally unspecified in the original papers. Indeed, all-cause mortality has been challenged as a suitable end-point for studies in seriously ill patients (2).

Moreover, the studies form a very heterogeneous group, ranging between premature newborns, elective operations, emergency surgery after trauma and patients with shock. As might be expected from such a mixture of clinical indications, the overall mortality rates in individual studies varied from 0% (6 studies) to 70.6%.

The majority (21) of of the studies included less than 30 patients in each arm. These numbers of patients are quite small when studying a clinical situation with many confounding factors. The total number of patients in the review was only 1,419 and the duration of follow-up varied widely between the studies (from hours to weeks).. As with many other meta-analyses the study design leaves much to be discussed (3). The heterogeneity of the reviewed studies is further highlighted by the range of concentrations of albumin infused (from 2.5% to 25.0%) and in the salt concentrations of the albumin solutions.

We would like to draw attention to other major limitations of the study i.e. the lack of information about the albumin preparations which were used in the different studies and the period over which they were published (from 1976, with the publication date of some 60% before 1991). Although the generic name albumin suggests uniformity of all albumin products, differences occur. During the period in which the trials were reported, there have been many technological changes in the manufacture of albumin. During the fractionation of plasma, vaso-active agents like prekallikrein activator (PKA) and bradykinin may be generated which can be detected in albumin. Several studies have demonstrated that albumin solutions containing PKA or bradykinin may induce severe hypotension such as in patients undergoing coronary bypass surgery (4). Investigations in animal models have confirmed these observations.The European Pharmacopoeia Commission defined an upper limit of PKA in albumin solutions in 1996(5).

The studies selected by Roberts (1) were performed before testing on PKA in albumin became routine. So if the results of this meta-analysis truly represent an effect of albumin, they may only be relevant for the older products.

Finally, most of the studies (20) were conducted in the USA.

Yours sincerely

PFW Strengers
Head of Medical Department, CLB
Central Laboratory of the Netherlands
Red Cross Blood Transfusion Service
Plesmanlaan 125
P O Box 9190
1006 AD Amsterdam

CH Dash
Medical Director, BPL
Bio Products Laboratory
Dagger Lane
Herts WD6 3BX


1. Roberts I. Albumin administration in critically ill patients Brit Med J 1998;317:335-40.
2. Petros AJ, Marshall JC, van Saene HKF. Should morbidity replace mortality as an endpoint for clinical trials in intensive care? Lancet 1995;345:369-71.
3. Bailar JC. The promise and problems with meta-analysis. N Engl J Med 1997; 337: 559-61.
4. Alving BM, Hojima Y, Pisano JJ et al. Hypotension associated with prekallikrein activator (Hageman factor fragments) in plasma protein fraction N Engl J Med 1978; 299: 66.
5. European Pharmacopoeia, third edition. Albumin solution, human 1997;0255:351-3.

Competing interests: No competing interests

03 September 1998
C H Dash
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Re: NPD blues James Owen Drife. 317:doi 10.1136/bmj.317.7157.546

Drife (1) is rightly sceptical of the views of non-practising doctors and questions whether he could teach or pass comment on colleagues if he was not clinically active. However doctors are less guilty of teaching what they do not practise than are other health care professionals. It is quite rare to find nurses, midwives, radiographers, and physiotherapists, in higher education, who carry a significant clinical workload. There are exceptions to this, such a lecturer practitioners, but generally teaching loads are very much higher than those of medical academics in order to keep costs down and ensure that institutions are financially competitive. The very real challenge for higher education and the NHS in the delivery of non-medical education and training is how academic staff will retain clinical credibility. Unless this is achieved, there is a very real danger that the courses offered will become less relevant to the needs
of those aspiring to a clinical career. Research success will bring academic credibility but, unless it is clinically relevant, it will do little to reassure those at the sharp end that those who teach them really know what life on the shop floor is like.

Robert Michael Pittilo Dean
Faculty of Healthcare Sciences
Kingston University and St George's Hospital Medical School (University
of London)
Cranmer Terrace, London SW17 0RE

1 Drife JO. Soundings NPD blues. BMJ 1998, 317:546 (22 August).

Competing interests: No competing interests

03 September 1998
Robert Michael Pittilo
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Re: All this sewering and watering . 317:doi 10.1136/bmj.317.7158.0a

I felt somehow threatened by this article. That one of the best and most reliable sources of information about public health, accessible by all, is to some extent being pressured to "correct" supposed imbalances in terms of the contents that it publishes is disturbing.

To reinforce my point: the BMJ is not filling only local, UK demands for accurate and up to date scientific information. It is also a beacon of light for those who work and struggle elsewhere for a decent practice and comprehensive policymaking approach in public health.

As you may suspect, the conditions in Brazil are rather harsh. We have to be extremely practical to deal with the bureaucratic establishment and sectorial agendas; this is not wrong, it is just part of the game. Then, very often, we need the robust support provided by the e-BMJ to enrich the debate and bring a little bit of evidence based knowledge.

Tight schedules, the need for rapid decisions, and increasing demands leave us very little time for to keep up to date.

Receive this as an acknowledgement and incentive to keep playing better than your counterparts, providing a global resource of holistic and scientific public health. We all--the rest of the world--thank you for this.

Dr. Rojas-Hinojosa
Programme Offcial

Competing interests: No competing interests

02 September 1998
Jaime Rojas-Hinojosa
Programme Official
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Re: Under half of psychiatrists tell patients their diagnosis of Alzheimer's disease R A Clafferty, K W Brown, E McCabe. 317:doi 10.1136/bmj.317.7158.603b

Recently we published a study (1) in which 372 questionnaires were sent to GPs asking about their practice in disclosing the diagnosis of dementia to their patients. We received 281 fully completed replies (76%). Only 5% of GPs always told patients of their diagnosis of dementia, with a further 34% often doing so.

Interestingly when GPs were asked what they told patients with terminal cancer 27% alway told their patients the diagnosis and a further 67% often did so, reflecting the change in attitude to physicians talking about cancers with their patients.

Because of the large numbers of sufferers from dementia in the population only a small proportion will end up seeing a psychiatrist. GPs are in the front line as far as making a diagnosis is concerned and they need to be involved in the debate about informing patients with Alzheimer’s disease of their diagnosis. Clearly practice has changed with respect to disclosure of the diagnosis of cancer we believe that it will do so with the dementias but how this ought to be done is a topic that warrants further debate in itself.

1. Vassilas CA, Donaldson J.Telling the truth: what do general practitioners say to patients with dementia or terminal cancer? B. J. Gen. Pract. 1998; 48: 1081-1082.

CA Vassilas, Consultant psychiatrist
West Suffolk Hospital, Bury St Edmunds, IP33 2QZ.

J Donaldson, medical student
St Bartholomew’s school of medicine and dentistry
London E1 2AD.

Competing interests: No competing interests

02 September 1998
C A Vassilas
consultant psychiatrist
west suffolk hospital
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