CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words.
* For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJr. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Availability of condoms in district general hospitals SIR, -Despite educational initiatives aimed at halting the spread of HIV infection self reported use of condoms in heterosexual young people remains low.'2 In our recent survey of college students the second commonest reason for not using condoms was their lack of availability. We studied their availability in hospitals, which employ large numbers of young people, many of whom are resident in the hospital. In April 1990 we sent a short questionnaire to the unit general managers of all 21 acute district general hospitals in the Northern region and 14 other randomly selected district general hospitals (one from each of the other English regions and one from the special teaching authorities). After one reminder 33 replies were received, a response rate of 94-3%. No hospital residency had a condom dispensing machine, but in six cases there was a machine in the hospital (in social clubs in two cases and in other places in four). Sixteen respondents believed that staff residences should have condom dispensing machines to help reduce the spread of AIDS, 10 were not in favour of the machines, and seven were undecided. The reasons against installing machines fitted within three broad categories: that protection against HIV infection was the individual's responsibility, that casual sex did not or should not take place within the residences in hospitals, and practical matters such as security of machines and income generation from the sale of condoms. We believe that there are two main reasons for providing machines. It is unrealistic to deny that casual sexual activity takes place in residences in hospitals. Sex is not always planned, and the absence of condoms is not necessarily an inhibitory influence. Furthermore, the unsocial hours of duty of residential hospital staff may limit their opportunity to obtain condoms elsewhere. Secondly, the attitudes and behaviour of health care professionals influence public opinion. Many NHS staff are advocating the easy availability of condoms to the rest of the population without ensuring similar provision within health service
premises. The cost of maintaining condom dispensing machines in hospitals needs to be studied, but the benefits of setting an example should not be forgotten. We recommend that the provision of condom dispensing machines in hospital premises be considered by all health authorities. R MADHOK R S BHOPAL
The Medical School, Newcastle upon Tyne NE2 4HH 1 Galt M, Gillies P, Wilson K. Surveying knowledge and attitudes
928
towards AIDS in young adults-just 19. Health Education Journal 1989;48:162-6. 2 Keegles SM, Adler NE, Irwin CE. Sexually active adolescents and condoms. Changes over one year in knowledge, attitudes and use. Am3 Public Health 1988;78:460-1.
Lipid screening SIR,-Dr H A W Neil and colleagues attempt to answer a question that is beyond the scope of the data they have collected.' Consequently, the conclusions reached depend almost entirely on their initial assumptions rather than on the results they present. The declared aim of the paper was "To determine the extent of the misclassification of the risk of coronary heart disease associated with a lipid screening protocol that measures only total cholesterol." No information was available, however, on the patients' risk of coronary heart disease, only on their lipid concentrations. The main conclusion- that high density lipoprotein cholesterol and triglyceride concentrations should be measured in all people with a total cholesterol concentration above 6 5 mmol/Il-rests on results from the Framingham study not on the results presented by Dr Neil and colleagues. ANDREW PHILLIPS A G SHAPER
Royal Free Hospital School of Medicine, London NW3 2PF 1 Neil HAW, Mant D, Jones L, Morgan B, Mann JI. Lipid screening: Is it enough to measure total cholesterol concentration? BMJ 1990;301:584-7. (22 September.)
SIR,-Dr H A W Neil and colleagues concluded that measurifig fasting triglyceride and high density lipoprotein cholesterol concentrations identifies few patients at risk of coronary artery disease if the total cholesterol concentration is less than 6 5 mmol/l.' We believe that this approach is too simplistic and may fail to identify many subjects at increased risk of coronary artery disease. In the Framingham study the average cholesterol concentration in men with coronary artery disease under the age of 65 was 5-9mmol/1-well below both the concentration quoted by Dr Neil and colleagues and the threshold for intervention in many guidelines.3 In these subjects a better discrimination of risk of disease was provided by the ratio of total to high density lipoprotein cholesterol concentrations, particularly in the presence ofadditional risk factors such as smoking. Furthermore, in the multiple risk factor intervention trial it was found that mortality from coronary artery disease increased progressively above a plasma cholesterol concentration of 47 mmol/l (20th centile), although the relative risk was greatest (3-8) above 6-5 mmol/l (85th centile).4
Expression of coronary artery disease varies considerably among patients with familial hypercholesterolaemia who are normally considered to be at increased risk of premature coronary artery disease. Other poorly defined genetic factors may determine susceptibility, and a possible candidate is the concentration of apolipoprotein A. Serum concentrations of apolipoprotein A were found to be higher in patients with familial hypercholesterolaemia who had coronary artery disease than in those who did not have the disease, and this was the most significant variable distinguishing between the two groups.5 The full assignment of cardiovascular risk state is therefore a matter of detailed individual assessment, and present screening programmes and arbitrary guidelines may be inadequate. It may thus be necessary to measure concentrations of other lipids (and possibly that of apolipoprotein A) even if total plasma cholesterol concentration is less than 6- 5 mmol/l, particularly in the presence of other risk factors. C M FLORKOWSKI R CRAMB
Queen Elizabeth Medical Centre, Birmingham B 15 2TH 1 Neil HAW, Mant D, Jones L, Morgan B, Mann JI. Lipid screening: Is it enough to measure total cholesterol concentration? BMJ 1990;301:584-7. (22 September.) 2 Kannel WB, Castelli WP, Gordon T. Cholesterol in the prediction of atherosclerotic disease: the development of coronary heart disease-six-year follow-up experience: the Framingham study. Ann Intern Med 1979;55:33-50. 3 European Atherosclerosis Society Study Group. The recognition and management of hyperlipidaemia in adults: a policy statement ofthe European Atherosclerosis Society. EurHeart3' 1988;9:571-600. 4 Martin MJ, Hulley SB, Browner WS, Kuller LH, Wentworth D. Serum cholesterol, blood pressure and mortality: implications from a cohort of 361662 men. Lancet 1986;ii:933-6. S Wiklund 0, Angelin B, Olofsson S-0, et al. Apolipoprotein (a) and ischaemic heart disease in familial hypercholesterolaemia. Lancet 1990;335:1360-3.
AUTHORS' REPLY,-Dr Phillips and Professor Shaper correctly recognise that we did not undertake an epidemiological cohort study and that our assumptions on cardiovascular risk are based on studies such as the Framingham and British regional heart studies, rather than on our own data. They have, however, mistaken our intention. Doctors are faced with the practical question of whether it is sufficient to measure total cholesterol concentration or if a full fasting lipid profile is necessary. We were able to answer this question because we obtained fasting (rather than random) blood samples from a population screened in general practice in Oxfordshire. This allowed us to relate total cholesterol concentration to high density lipoprotein cholesterol and triglyceride concentrations in individual patients and determine whether total cholesterol concentration can predict the other concentrations. Our interest is in
BMJ
VOLUME 301
20 OCTOBER 1990
* For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJr. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Availability of condoms in district general hospitals SIR, -Despite educational initiatives aimed at halting the spread of HIV infection self reported use of condoms in heterosexual young people remains low.'2 In our recent survey of college students the second commonest reason for not using condoms was their lack of availability. We studied their availability in hospitals, which employ large numbers of young people, many of whom are resident in the hospital. In April 1990 we sent a short questionnaire to the unit general managers of all 21 acute district general hospitals in the Northern region and 14 other randomly selected district general hospitals (one from each of the other English regions and one from the special teaching authorities). After one reminder 33 replies were received, a response rate of 94-3%. No hospital residency had a condom dispensing machine, but in six cases there was a machine in the hospital (in social clubs in two cases and in other places in four). Sixteen respondents believed that staff residences should have condom dispensing machines to help reduce the spread of AIDS, 10 were not in favour of the machines, and seven were undecided. The reasons against installing machines fitted within three broad categories: that protection against HIV infection was the individual's responsibility, that casual sex did not or should not take place within the residences in hospitals, and practical matters such as security of machines and income generation from the sale of condoms. We believe that there are two main reasons for providing machines. It is unrealistic to deny that casual sexual activity takes place in residences in hospitals. Sex is not always planned, and the absence of condoms is not necessarily an inhibitory influence. Furthermore, the unsocial hours of duty of residential hospital staff may limit their opportunity to obtain condoms elsewhere. Secondly, the attitudes and behaviour of health care professionals influence public opinion. Many NHS staff are advocating the easy availability of condoms to the rest of the population without ensuring similar provision within health service
premises. The cost of maintaining condom dispensing machines in hospitals needs to be studied, but the benefits of setting an example should not be forgotten. We recommend that the provision of condom dispensing machines in hospital premises be considered by all health authorities. R MADHOK R S BHOPAL
The Medical School, Newcastle upon Tyne NE2 4HH 1 Galt M, Gillies P, Wilson K. Surveying knowledge and attitudes
928
towards AIDS in young adults-just 19. Health Education Journal 1989;48:162-6. 2 Keegles SM, Adler NE, Irwin CE. Sexually active adolescents and condoms. Changes over one year in knowledge, attitudes and use. Am3 Public Health 1988;78:460-1.
Lipid screening SIR,-Dr H A W Neil and colleagues attempt to answer a question that is beyond the scope of the data they have collected.' Consequently, the conclusions reached depend almost entirely on their initial assumptions rather than on the results they present. The declared aim of the paper was "To determine the extent of the misclassification of the risk of coronary heart disease associated with a lipid screening protocol that measures only total cholesterol." No information was available, however, on the patients' risk of coronary heart disease, only on their lipid concentrations. The main conclusion- that high density lipoprotein cholesterol and triglyceride concentrations should be measured in all people with a total cholesterol concentration above 6 5 mmol/Il-rests on results from the Framingham study not on the results presented by Dr Neil and colleagues. ANDREW PHILLIPS A G SHAPER
Royal Free Hospital School of Medicine, London NW3 2PF 1 Neil HAW, Mant D, Jones L, Morgan B, Mann JI. Lipid screening: Is it enough to measure total cholesterol concentration? BMJ 1990;301:584-7. (22 September.)
SIR,-Dr H A W Neil and colleagues concluded that measurifig fasting triglyceride and high density lipoprotein cholesterol concentrations identifies few patients at risk of coronary artery disease if the total cholesterol concentration is less than 6 5 mmol/l.' We believe that this approach is too simplistic and may fail to identify many subjects at increased risk of coronary artery disease. In the Framingham study the average cholesterol concentration in men with coronary artery disease under the age of 65 was 5-9mmol/1-well below both the concentration quoted by Dr Neil and colleagues and the threshold for intervention in many guidelines.3 In these subjects a better discrimination of risk of disease was provided by the ratio of total to high density lipoprotein cholesterol concentrations, particularly in the presence ofadditional risk factors such as smoking. Furthermore, in the multiple risk factor intervention trial it was found that mortality from coronary artery disease increased progressively above a plasma cholesterol concentration of 47 mmol/l (20th centile), although the relative risk was greatest (3-8) above 6-5 mmol/l (85th centile).4
Expression of coronary artery disease varies considerably among patients with familial hypercholesterolaemia who are normally considered to be at increased risk of premature coronary artery disease. Other poorly defined genetic factors may determine susceptibility, and a possible candidate is the concentration of apolipoprotein A. Serum concentrations of apolipoprotein A were found to be higher in patients with familial hypercholesterolaemia who had coronary artery disease than in those who did not have the disease, and this was the most significant variable distinguishing between the two groups.5 The full assignment of cardiovascular risk state is therefore a matter of detailed individual assessment, and present screening programmes and arbitrary guidelines may be inadequate. It may thus be necessary to measure concentrations of other lipids (and possibly that of apolipoprotein A) even if total plasma cholesterol concentration is less than 6- 5 mmol/l, particularly in the presence of other risk factors. C M FLORKOWSKI R CRAMB
Queen Elizabeth Medical Centre, Birmingham B 15 2TH 1 Neil HAW, Mant D, Jones L, Morgan B, Mann JI. Lipid screening: Is it enough to measure total cholesterol concentration? BMJ 1990;301:584-7. (22 September.) 2 Kannel WB, Castelli WP, Gordon T. Cholesterol in the prediction of atherosclerotic disease: the development of coronary heart disease-six-year follow-up experience: the Framingham study. Ann Intern Med 1979;55:33-50. 3 European Atherosclerosis Society Study Group. The recognition and management of hyperlipidaemia in adults: a policy statement ofthe European Atherosclerosis Society. EurHeart3' 1988;9:571-600. 4 Martin MJ, Hulley SB, Browner WS, Kuller LH, Wentworth D. Serum cholesterol, blood pressure and mortality: implications from a cohort of 361662 men. Lancet 1986;ii:933-6. S Wiklund 0, Angelin B, Olofsson S-0, et al. Apolipoprotein (a) and ischaemic heart disease in familial hypercholesterolaemia. Lancet 1990;335:1360-3.
AUTHORS' REPLY,-Dr Phillips and Professor Shaper correctly recognise that we did not undertake an epidemiological cohort study and that our assumptions on cardiovascular risk are based on studies such as the Framingham and British regional heart studies, rather than on our own data. They have, however, mistaken our intention. Doctors are faced with the practical question of whether it is sufficient to measure total cholesterol concentration or if a full fasting lipid profile is necessary. We were able to answer this question because we obtained fasting (rather than random) blood samples from a population screened in general practice in Oxfordshire. This allowed us to relate total cholesterol concentration to high density lipoprotein cholesterol and triglyceride concentrations in individual patients and determine whether total cholesterol concentration can predict the other concentrations. Our interest is in
BMJ
VOLUME 301
20 OCTOBER 1990
