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 recentlv (within six weeks) in the BM7. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowvledgment. * Because we receive many more letters than zue can publish we may shorten those we do print, particularly when zve receive several on the same subject.
Prevention of coronary heart disease in Scotland SIR, -I would like to comment on recommendations concerning the management of hypercholesterolaemia contained in a recent publication ambitiously entitled The Prevention of Coronary Heart Disease in Scotland. ' This contains the report of a working group on prevention and health promotion and appears to have the blessing of the Scottish Health Service Advisory Council and the Scottish Home and Health Department. The advocated restriction of cholesterol screening to those with established vascular disease or a family history of premature coronary heart disease may be contested by advocates of opportunistic or systematic screening for cholesterol in the whole population. The remaining "lifestyle" strategies are unexceptional and in line with current opinion. The report's guidelines on the management of hypercholesterolaemia in individual patients are inadequate. The management of "high blood cholesterol" is dismissed in two paragraphs (118 and 119) of 128 words, and three times as much space is devoted to the role of exercise (paragraphs 95-98). The non-specialist reader, to whom the publication is presumably addressed, is not told that the hyperlipidaemias are a group of metabolic disorders which may be either primary or secondary to diabetes, hypothyroidism, renal disease, alcoholism, and a range of drugs and hormones. Hypertriglyceridaemia and the roles of age, sex, and other risk factors in determining the urgency with which cholesterol should be reduced are not discussed. Extraordinarily, it is stated that lipid lowering drugs "should not normally be prescribed for people with cholesterol levels below 10 mmol/l." The authors imply that this cut off point should operate even if "nutritional and life style advice has proved unsuccessful," provided that the total serum cholesterol concentration remains below 10 mmol/l. Lest the incredulous reader judge the choice of 10 mmol/l to be a misprint, this advice is repeated in a summary of recommendations on page 55 and in a summary of action to be taken about risk factors on page 69. The advice on risk factors suggests that "primary care assessment staff' without medical qualifications (who are they?) should use discretion in referring patients with total serum cholesterol concentrations of 6 5-10 mmol/l to general practitioners "if appropriate." The only criterion given for immediate referral to a general practitioner is a serum cholesterol concentration of greater than 10 mmol/l. The suggested cut off point of 10 mmol/l is considerably greater than that of 7-8 mmol/l, at which most physicians in the United Kingdom with an interest in lipid disorders would consider the use of a lipid lowering drug. A policy statement
BMJ
VOLUME
300
16
JUNE
1990
of the European Atherosclerosis Society is in agreement with this view.2 In the United States an expert panel of the National Institutes of Health has recommended that lipid lowering drugs should be considered in all adults with a low density lipoprotein cholesterol concentration that is equivalent to a total serum cholesterol concentration of 7 mmol/l. Many patients with serum cholesterol concentrations above 7 8 mmol/1 have familial hypercholesterolaemia, a dangerous inherited metabolic disorder with a high prevalence of premature myocardial infarction. Using a cut off point of 10 mmol/l will mean that many patients with severe polygenic and mendelian dominant familial hypercholesterolaemia will be deprived of effective treatment. The authors provide no epidemiological or therapeutic rationale for their choice of 10 mmol/l but a clue to their thinking is provided on page 47 of their report, in which the financial implications of each strategy are discussed. The authors estimate that restricting the use of drugs to patients with serum cholesterol concentrations of over 10 mmol/l will cost £3m a year. If drugs are provided for all patients with cholesterol concentrations over 8 mmol/l estimated costs rise to £40m a year. The unavoidable inference is that, with true Scottish parsimony, the authors chose the 10 mmol/l cut off point to save money. The report's advice on managing hypercholesterolaemia is brief, inadequate, and misleading. If implemented the guidelines will ensure that many patients with severe hypercholesterolaemia will be denied effective treatment in a country which has the second highest prevalence of ischaemic heart disease in the world after Northern Ireland. Without modification the authors' recommendations on the management of hyperlipidaemia should be prefaced by a government health warning: "implementation of these recommendations may damage your patients' health." M G DUJNNIGAN
Stobhill General Hospital, Glasgow G21 3UW I Working Group on Prevention and Health Promotion. The prevention of coronarv heart disease in Scotland. Edinburgh: HMiSO, 1990. 2 Study Group, European Atherosclerosis Society. Strategies for the prevention of coronary heart disease: a policy, statement of the European Atherosclerosis Society. Eur Heart 7 1987;8: 77-88. 3 National Cholesterol Education Program expert panel on detection, esaluation and treatmenit of high blood cholesterol in adults. Report. Arch Intern Med 1988;148:36-61.
Porton International and a herpes vaccine SIR,- I would like to express concern about the news article on Porton International.
Firstly, I question the appropriateness of much of the material for inclusion in (albeit) the news section of the journal. "Unorthodox" accounting procedures, a kind of upmarket shop floor insurrection at the Centre for Applied Microbiology and Research, and, most particularly, the personal finances of one person, or any person, may be heady stuff for the Financial Times, but it is surely of limited relevance to the journal's readership. We all like a bit of gossip, but not in one of our major professional journals. At a more serious level, the article does rather discredit Porton International without providing a clear picture of the company's activities and objectives. It was disappointing that the considerable contribution made by Porton to medicine and science was not recorded. Apart from giving major financial support to the follow up programme of vaccinated consorts at risk (the data on which will form an important component of the application to regulatory bodies for product registration within the next two years) the company has supported fundamental research into identification of the extent and nature of the humoral and cell mediated immunological response to virus infection and vaccination in humans, methods of vaccine preparation by gene cloning techniques, and development of vaccines against cytomegalovirus and chickenpox, which are now available for academic and commercial furtherance by the University of Birmingham. In addition, the company sponsored and organised a first class, well controlled, three centre trial in the United States, the results of which will be an important contribution to medical knowledge. It might have been more sensible to proceed ab initio with a trial of the vaccine as a preventive treatment, but, as we in clinical practice know only too well, the retrospectoscope is infallible. In summary, Porton has made a considerable body of creditworthy and non-self serving investment into medical research. The third matter concerns an increasing tendency in recent years for the definitive though unattributable word (and often the first word) on a medical issue to emanate from the media, and while there can be valid reason for urgent or early public disclosure this should at least be made under the authorship of the principal investigator, from whom further information can be sought and with whom proper scientific interchange can be established. Short circuits from the laboratory or clinical interface to the news columns of medical, paramedical, or even non-medical journals can have horrific possibilities; consideration should be given to establishing an independent scientific body to scrutinise data somewhere in the information chain before a newspaper on the breakfast table. Medicine and science must not become the playthings of lawyers, journalists, or commercial interests2; nor should undigested medical scientific 1583
Prevention of coronary heart disease in Scotland SIR, -I would like to comment on recommendations concerning the management of hypercholesterolaemia contained in a recent publication ambitiously entitled The Prevention of Coronary Heart Disease in Scotland. ' This contains the report of a working group on prevention and health promotion and appears to have the blessing of the Scottish Health Service Advisory Council and the Scottish Home and Health Department. The advocated restriction of cholesterol screening to those with established vascular disease or a family history of premature coronary heart disease may be contested by advocates of opportunistic or systematic screening for cholesterol in the whole population. The remaining "lifestyle" strategies are unexceptional and in line with current opinion. The report's guidelines on the management of hypercholesterolaemia in individual patients are inadequate. The management of "high blood cholesterol" is dismissed in two paragraphs (118 and 119) of 128 words, and three times as much space is devoted to the role of exercise (paragraphs 95-98). The non-specialist reader, to whom the publication is presumably addressed, is not told that the hyperlipidaemias are a group of metabolic disorders which may be either primary or secondary to diabetes, hypothyroidism, renal disease, alcoholism, and a range of drugs and hormones. Hypertriglyceridaemia and the roles of age, sex, and other risk factors in determining the urgency with which cholesterol should be reduced are not discussed. Extraordinarily, it is stated that lipid lowering drugs "should not normally be prescribed for people with cholesterol levels below 10 mmol/l." The authors imply that this cut off point should operate even if "nutritional and life style advice has proved unsuccessful," provided that the total serum cholesterol concentration remains below 10 mmol/l. Lest the incredulous reader judge the choice of 10 mmol/l to be a misprint, this advice is repeated in a summary of recommendations on page 55 and in a summary of action to be taken about risk factors on page 69. The advice on risk factors suggests that "primary care assessment staff' without medical qualifications (who are they?) should use discretion in referring patients with total serum cholesterol concentrations of 6 5-10 mmol/l to general practitioners "if appropriate." The only criterion given for immediate referral to a general practitioner is a serum cholesterol concentration of greater than 10 mmol/l. The suggested cut off point of 10 mmol/l is considerably greater than that of 7-8 mmol/l, at which most physicians in the United Kingdom with an interest in lipid disorders would consider the use of a lipid lowering drug. A policy statement
BMJ
VOLUME
300
16
JUNE
1990
of the European Atherosclerosis Society is in agreement with this view.2 In the United States an expert panel of the National Institutes of Health has recommended that lipid lowering drugs should be considered in all adults with a low density lipoprotein cholesterol concentration that is equivalent to a total serum cholesterol concentration of 7 mmol/l. Many patients with serum cholesterol concentrations above 7 8 mmol/1 have familial hypercholesterolaemia, a dangerous inherited metabolic disorder with a high prevalence of premature myocardial infarction. Using a cut off point of 10 mmol/l will mean that many patients with severe polygenic and mendelian dominant familial hypercholesterolaemia will be deprived of effective treatment. The authors provide no epidemiological or therapeutic rationale for their choice of 10 mmol/l but a clue to their thinking is provided on page 47 of their report, in which the financial implications of each strategy are discussed. The authors estimate that restricting the use of drugs to patients with serum cholesterol concentrations of over 10 mmol/l will cost £3m a year. If drugs are provided for all patients with cholesterol concentrations over 8 mmol/l estimated costs rise to £40m a year. The unavoidable inference is that, with true Scottish parsimony, the authors chose the 10 mmol/l cut off point to save money. The report's advice on managing hypercholesterolaemia is brief, inadequate, and misleading. If implemented the guidelines will ensure that many patients with severe hypercholesterolaemia will be denied effective treatment in a country which has the second highest prevalence of ischaemic heart disease in the world after Northern Ireland. Without modification the authors' recommendations on the management of hyperlipidaemia should be prefaced by a government health warning: "implementation of these recommendations may damage your patients' health." M G DUJNNIGAN
Stobhill General Hospital, Glasgow G21 3UW I Working Group on Prevention and Health Promotion. The prevention of coronarv heart disease in Scotland. Edinburgh: HMiSO, 1990. 2 Study Group, European Atherosclerosis Society. Strategies for the prevention of coronary heart disease: a policy, statement of the European Atherosclerosis Society. Eur Heart 7 1987;8: 77-88. 3 National Cholesterol Education Program expert panel on detection, esaluation and treatmenit of high blood cholesterol in adults. Report. Arch Intern Med 1988;148:36-61.
Porton International and a herpes vaccine SIR,- I would like to express concern about the news article on Porton International.
Firstly, I question the appropriateness of much of the material for inclusion in (albeit) the news section of the journal. "Unorthodox" accounting procedures, a kind of upmarket shop floor insurrection at the Centre for Applied Microbiology and Research, and, most particularly, the personal finances of one person, or any person, may be heady stuff for the Financial Times, but it is surely of limited relevance to the journal's readership. We all like a bit of gossip, but not in one of our major professional journals. At a more serious level, the article does rather discredit Porton International without providing a clear picture of the company's activities and objectives. It was disappointing that the considerable contribution made by Porton to medicine and science was not recorded. Apart from giving major financial support to the follow up programme of vaccinated consorts at risk (the data on which will form an important component of the application to regulatory bodies for product registration within the next two years) the company has supported fundamental research into identification of the extent and nature of the humoral and cell mediated immunological response to virus infection and vaccination in humans, methods of vaccine preparation by gene cloning techniques, and development of vaccines against cytomegalovirus and chickenpox, which are now available for academic and commercial furtherance by the University of Birmingham. In addition, the company sponsored and organised a first class, well controlled, three centre trial in the United States, the results of which will be an important contribution to medical knowledge. It might have been more sensible to proceed ab initio with a trial of the vaccine as a preventive treatment, but, as we in clinical practice know only too well, the retrospectoscope is infallible. In summary, Porton has made a considerable body of creditworthy and non-self serving investment into medical research. The third matter concerns an increasing tendency in recent years for the definitive though unattributable word (and often the first word) on a medical issue to emanate from the media, and while there can be valid reason for urgent or early public disclosure this should at least be made under the authorship of the principal investigator, from whom further information can be sought and with whom proper scientific interchange can be established. Short circuits from the laboratory or clinical interface to the news columns of medical, paramedical, or even non-medical journals can have horrific possibilities; consideration should be given to establishing an independent scientific body to scrutinise data somewhere in the information chain before a newspaper on the breakfast table. Medicine and science must not become the playthings of lawyers, journalists, or commercial interests2; nor should undigested medical scientific 1583
