beverages and found that the tyramine contents in red wines, white wines, and beers were similar.' B3ut they also found large variations (up to 50-fold) within each category of wine, even those from the same grape stock. Therefore it seems that the tyramine content of at least alcoholic beverages is not reliably predictable. Murray et al reported a case of non-fatal acute cerebral haemorrhage in a patient who was taking tranylcypromine and who drank 250 ml of alcohol free beer. As there is no difference between the tyramine content of low alcohol or alcohol free beers and alcoholic beers (Brewing Research Foundation, personal communication) we would urge caution and not recommend that these beverages are safe for patients taking monoamine oxidase inhibitors. D T BESWICK
South Western Regional Drug Information Centre, Bristol Royal Infirmary, Bristol BS2 8HW M L ROGERS North East Thames Regional Drug Information Centre, The London Hospital, London E I I BB
1 Tyrer P. Any questions. BrMedj 1990;300:1328. (19 May.) 2 Correspondence. Monoamine oxidase inhibitors and low alcohol or alcohol free drinks. BrMedj 1990;300:1527. (9 June.) 3 Hannah P, Glover V, Sandler M. Tyramine in wine and beer. Lancet 1988;i:879. 4 Murray JA, Walker JF, Doyle JS. Tyramine in alcohol-free beer. Lancet 1988;i:1167-8.
Vitamin B-12 and folate deficiency presenting as leukaemia SIR,-The letter of mine that was published in the issue of 7 July' is not that read and replied to in that issue by Dr J S Dokal and colleagues. In my unedited letter I suggested that a trephine roll would give adequate cellular morphology in cases in which an aspirate was unobtainable, and not that a good trephine biopsy sample would achieve this. Dr Dokal and colleagues "are not convinced that examination of a trephine roll would have given the correct diagnosis." They may well be right, and in this case we shall never know. The crucial issue here is that every effort should be made to obtain cytological preparations before a diagnosis of acute leukaemia is made and, more importantly, before cytotoxic chemotherapy is administered; and a trephine biopsy sample alone can never do this. There were other editorial alterations, which had a more subtle influence on my argument; but I am less concerned with these. For the sake of the readership, however, I think it is important for this mistake to be corrected and for the different diagnostic parts played by these two basic haematological techniques to be clarified. ANNE LENNARD
Department of Haematology, Royal Victoria Infirmary, Newcastle upon Tyne NE 1 4LP I Lennard A. Vitamin B-12 and folate deficiency presenting as
leukaemia. BrMedJ 1990;301:42. (7 July.)
Prevention of coronary heart disease in Scotland SIR,-In his comments on the report on prevention of coronary heart disease in Scotland' Dr M G Dunnigan mistakenly infers that the view expressed by the working group on the use of lipid lowering drugs resulted from Scottish parsimony,2 although it would clearly have been irresponsible of the group to ignore completely the resource implications of its recommendations. The report does not seek to deny treatment with
180
lipid lowering drugs to people with high enough serum cholesterol concentrations to require it but seeks to promote the adoption of a nutritional and general lifestyle approach in the first instance in suitable cases. It acknowledges that this approach may not always be successful and concludes that "drug therapy may ultimately be considered appropriate for persons with persistently high levels." The report does not recommend 10 mmolIl as an absolute cut off point-it states that "drugs should not normally be prescribed for people with levels below 10 mmol/l." This reflects the view of the group that in the vast majority of patients with cholesterol concentrations between the target of 6 5 mmol/l and 10 mmolI treatment with drugs would prove unnecessary. The incidence of coronary heart disease in Scotland is too high for its reduction to be jeopardised by semantic disagreements among doctors. Both the working group and Dr Dunnigan are concerned that this incidence be reduced. For the sake of the population of Scotland let us go forward together with a single protocol. W KEITH DAVIDSON
Glasgow G33 6DE I Scottish Home and Health Department, Scottish Health Service Advisory Council. Prevention of coronarv heart disease in Scotland. Edinburgh: HMSO, 1990. 2 Dunnigan MG. Prevention of coronary heart disease in Scotland.
by a relentless fall in all age groups since then (table). In the case of younger men these falls have been precipitous. What happened in the early 1960s to bring this about? The report is silent on this. Moreover, the report does not comment on the wealth of conflicting evidence, some of which has been gathered by members of the working party itself or by those who gave evidence to it, which challenges the strategy advocated. For example, the Scottish heart health study showed that mortality from coronary heart disease in the 22 Scottish districts studied could not be accounted for by differences in cigarette smoking habits, cholesterol concentrations, amount of exercise, or blood pressure,' and the results of a study of north Glasgow and Edinburgh showed that the difference in mean serum total cholesterol concentration between the centres was in the opposite direction to that expected.4 Until the cause or causes of coronary heart disease have been identified medical advice to the general public about its prevention should be circumspect. The report is, in general, much too directive and bases its recommendations on flimsy evidence. IAN G JONES
Department of Community Health, Fife Health Board, Glenrothes KY7 5PB
BrMedJ7 1990;300:1583. (16 June.)
SIR,-Dr M G Dunnigan's criticisms' of the publication entitled The Prevention of Coronary Heart Disease in Scotland2 are misdirected. There is no convincing evidence that treating patients with serum cholesterol concentrations higher than 10 mmol/Il-or, indeed, 7-8 mmol/l, as he seems to advocate-influences total mortality in any way. I, too, have serious reservations about the report but see its saving graces as its advocacy of a holistic approach to health and the avoidance of a population screening programme for coronary heart disease. Among its principal failures are its advocacy of a coronary prevention programme based on dietary change, stopping smoking, treatment of high blood pressure, and increased physical exercise when the evidence that such a strategy will work is at best tenuous. Curiously, the report dismisses the secular trends in mortality from coronary heart disease in Scotland, published annually by the Registrar General, which show a steady rise in mortality until around 1973 followed Mortality from ischaemic heart disease* in Scottish men during 1940-88 according to age. Figures are numbers of deaths/lOO 000 population
Total audit of preventive practices SIR,-None of the 45 practices that Dr Martin Lawrence and colleagues audited had attained the upper target of 90% uptake for the preschool booster immunisation.' Have the targets for this immunisation been set for administrative tidiness -to equal that for the primary course-with no evidence of their attainability? It seems to be the Cinderella of childhood immunisations: we had previously been unable to find any published figures on its uptake, and there was no specific mention of it in the regular review article on
immunisation.2
Age Year
35-
45-
55-
65-
75-
885
1940-2 1950-2 1960-2 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988
23 46 72 79 85 77 83 95 87 91 79 69 73 72 73 69 67 55 58 53 60 55 53 48
101 212 300 331 324 337 359 359 373 365 347 339 342 350 361 333 358 308 325 297 268 279 268 248
269 632 836 850 900 898 884 %0 968 952 904 929 892 899 903 873 856 861 894 834 829 829 801 761
728 1428 1795 1945 1946 1897 1940 2046 2038 1988 1964 1976 1882 1991 1936 1796 1874
1736 3254 3601 3663 3722 3615 3589 3932 3824 3809 3693 3905 3657 3768
3452 7161 7814 6734 7427 7118 6464 7251 6628 7145 6520 6329 5998 6707 5900 5307 5017
1884
3453 3355
1882 1899 1927 1842 1810 1747
3422 3401 3425 3313 3350 3227 3260 3215
5384 5291 5544 5485 5599 5616 5071
*International Classification of Diseases, ninth revision, Nos 410-4.
I Dunnigan MG. Prevention of coronarv heart disease in Scotland. BrMedJ 1990;300:1583. (16 June.) 2 Working Party on Prevention and Health Promotion. The prevention of coronarv heart disease in Scotland. Edinburgh: HMSO, 1990. 3 Tunstall-Pedoe H, Srith WCS, Crombie IK, Tavendale R. Coronary risk factor and lifestyle variation across Scotland: results from the Scottish heart health study. Scott Med J 1989;34:556-60. 4 Smiith WCS, Crombie IK, Tunstall-Pedoe HD, Tavendale R, Riemersma RA. Cardiovascular risk factor profile and mortality in two Scottish cities. Acta Med Scand 1988; 728(suppl): 1 13-8.
Last December we examined the records of the 99 children aged 5 registered with a city practice. In addition to the expected problems of children known to have moved away (four), believed to have moved away (one), and registered too recently for records to be available (one) we found that six children could not have been given the preschool booster: three had been refused all immunisations by their parents and three had received the last dose of the primary course too late. (The Department of Health recommends giving the booster at least three years later.') The national uptake of measles immunisation has been consistently lower than that of the primary course of diphtheria, tetanus, and polio, partly because it is given several months later when children tend to have less contact with health services and are more likely to have moved. This applies even more by the age of the preschool booster. In this practice and another the uptake of primary immunisation is higher in children born in the practice than in those who have moved into it.4 We found the same for the preschool booster: 74% for the 58 children born in the practice and 57% for
BMJ VOLUME 301
21 JULY 1990
South Western Regional Drug Information Centre, Bristol Royal Infirmary, Bristol BS2 8HW M L ROGERS North East Thames Regional Drug Information Centre, The London Hospital, London E I I BB
1 Tyrer P. Any questions. BrMedj 1990;300:1328. (19 May.) 2 Correspondence. Monoamine oxidase inhibitors and low alcohol or alcohol free drinks. BrMedj 1990;300:1527. (9 June.) 3 Hannah P, Glover V, Sandler M. Tyramine in wine and beer. Lancet 1988;i:879. 4 Murray JA, Walker JF, Doyle JS. Tyramine in alcohol-free beer. Lancet 1988;i:1167-8.
Vitamin B-12 and folate deficiency presenting as leukaemia SIR,-The letter of mine that was published in the issue of 7 July' is not that read and replied to in that issue by Dr J S Dokal and colleagues. In my unedited letter I suggested that a trephine roll would give adequate cellular morphology in cases in which an aspirate was unobtainable, and not that a good trephine biopsy sample would achieve this. Dr Dokal and colleagues "are not convinced that examination of a trephine roll would have given the correct diagnosis." They may well be right, and in this case we shall never know. The crucial issue here is that every effort should be made to obtain cytological preparations before a diagnosis of acute leukaemia is made and, more importantly, before cytotoxic chemotherapy is administered; and a trephine biopsy sample alone can never do this. There were other editorial alterations, which had a more subtle influence on my argument; but I am less concerned with these. For the sake of the readership, however, I think it is important for this mistake to be corrected and for the different diagnostic parts played by these two basic haematological techniques to be clarified. ANNE LENNARD
Department of Haematology, Royal Victoria Infirmary, Newcastle upon Tyne NE 1 4LP I Lennard A. Vitamin B-12 and folate deficiency presenting as
leukaemia. BrMedJ 1990;301:42. (7 July.)
Prevention of coronary heart disease in Scotland SIR,-In his comments on the report on prevention of coronary heart disease in Scotland' Dr M G Dunnigan mistakenly infers that the view expressed by the working group on the use of lipid lowering drugs resulted from Scottish parsimony,2 although it would clearly have been irresponsible of the group to ignore completely the resource implications of its recommendations. The report does not seek to deny treatment with
180
lipid lowering drugs to people with high enough serum cholesterol concentrations to require it but seeks to promote the adoption of a nutritional and general lifestyle approach in the first instance in suitable cases. It acknowledges that this approach may not always be successful and concludes that "drug therapy may ultimately be considered appropriate for persons with persistently high levels." The report does not recommend 10 mmolIl as an absolute cut off point-it states that "drugs should not normally be prescribed for people with levels below 10 mmol/l." This reflects the view of the group that in the vast majority of patients with cholesterol concentrations between the target of 6 5 mmol/l and 10 mmolI treatment with drugs would prove unnecessary. The incidence of coronary heart disease in Scotland is too high for its reduction to be jeopardised by semantic disagreements among doctors. Both the working group and Dr Dunnigan are concerned that this incidence be reduced. For the sake of the population of Scotland let us go forward together with a single protocol. W KEITH DAVIDSON
Glasgow G33 6DE I Scottish Home and Health Department, Scottish Health Service Advisory Council. Prevention of coronarv heart disease in Scotland. Edinburgh: HMSO, 1990. 2 Dunnigan MG. Prevention of coronary heart disease in Scotland.
by a relentless fall in all age groups since then (table). In the case of younger men these falls have been precipitous. What happened in the early 1960s to bring this about? The report is silent on this. Moreover, the report does not comment on the wealth of conflicting evidence, some of which has been gathered by members of the working party itself or by those who gave evidence to it, which challenges the strategy advocated. For example, the Scottish heart health study showed that mortality from coronary heart disease in the 22 Scottish districts studied could not be accounted for by differences in cigarette smoking habits, cholesterol concentrations, amount of exercise, or blood pressure,' and the results of a study of north Glasgow and Edinburgh showed that the difference in mean serum total cholesterol concentration between the centres was in the opposite direction to that expected.4 Until the cause or causes of coronary heart disease have been identified medical advice to the general public about its prevention should be circumspect. The report is, in general, much too directive and bases its recommendations on flimsy evidence. IAN G JONES
Department of Community Health, Fife Health Board, Glenrothes KY7 5PB
BrMedJ7 1990;300:1583. (16 June.)
SIR,-Dr M G Dunnigan's criticisms' of the publication entitled The Prevention of Coronary Heart Disease in Scotland2 are misdirected. There is no convincing evidence that treating patients with serum cholesterol concentrations higher than 10 mmol/Il-or, indeed, 7-8 mmol/l, as he seems to advocate-influences total mortality in any way. I, too, have serious reservations about the report but see its saving graces as its advocacy of a holistic approach to health and the avoidance of a population screening programme for coronary heart disease. Among its principal failures are its advocacy of a coronary prevention programme based on dietary change, stopping smoking, treatment of high blood pressure, and increased physical exercise when the evidence that such a strategy will work is at best tenuous. Curiously, the report dismisses the secular trends in mortality from coronary heart disease in Scotland, published annually by the Registrar General, which show a steady rise in mortality until around 1973 followed Mortality from ischaemic heart disease* in Scottish men during 1940-88 according to age. Figures are numbers of deaths/lOO 000 population
Total audit of preventive practices SIR,-None of the 45 practices that Dr Martin Lawrence and colleagues audited had attained the upper target of 90% uptake for the preschool booster immunisation.' Have the targets for this immunisation been set for administrative tidiness -to equal that for the primary course-with no evidence of their attainability? It seems to be the Cinderella of childhood immunisations: we had previously been unable to find any published figures on its uptake, and there was no specific mention of it in the regular review article on
immunisation.2
Age Year
35-
45-
55-
65-
75-
885
1940-2 1950-2 1960-2 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988
23 46 72 79 85 77 83 95 87 91 79 69 73 72 73 69 67 55 58 53 60 55 53 48
101 212 300 331 324 337 359 359 373 365 347 339 342 350 361 333 358 308 325 297 268 279 268 248
269 632 836 850 900 898 884 %0 968 952 904 929 892 899 903 873 856 861 894 834 829 829 801 761
728 1428 1795 1945 1946 1897 1940 2046 2038 1988 1964 1976 1882 1991 1936 1796 1874
1736 3254 3601 3663 3722 3615 3589 3932 3824 3809 3693 3905 3657 3768
3452 7161 7814 6734 7427 7118 6464 7251 6628 7145 6520 6329 5998 6707 5900 5307 5017
1884
3453 3355
1882 1899 1927 1842 1810 1747
3422 3401 3425 3313 3350 3227 3260 3215
5384 5291 5544 5485 5599 5616 5071
*International Classification of Diseases, ninth revision, Nos 410-4.
I Dunnigan MG. Prevention of coronarv heart disease in Scotland. BrMedJ 1990;300:1583. (16 June.) 2 Working Party on Prevention and Health Promotion. The prevention of coronarv heart disease in Scotland. Edinburgh: HMSO, 1990. 3 Tunstall-Pedoe H, Srith WCS, Crombie IK, Tavendale R. Coronary risk factor and lifestyle variation across Scotland: results from the Scottish heart health study. Scott Med J 1989;34:556-60. 4 Smiith WCS, Crombie IK, Tunstall-Pedoe HD, Tavendale R, Riemersma RA. Cardiovascular risk factor profile and mortality in two Scottish cities. Acta Med Scand 1988; 728(suppl): 1 13-8.
Last December we examined the records of the 99 children aged 5 registered with a city practice. In addition to the expected problems of children known to have moved away (four), believed to have moved away (one), and registered too recently for records to be available (one) we found that six children could not have been given the preschool booster: three had been refused all immunisations by their parents and three had received the last dose of the primary course too late. (The Department of Health recommends giving the booster at least three years later.') The national uptake of measles immunisation has been consistently lower than that of the primary course of diphtheria, tetanus, and polio, partly because it is given several months later when children tend to have less contact with health services and are more likely to have moved. This applies even more by the age of the preschool booster. In this practice and another the uptake of primary immunisation is higher in children born in the practice than in those who have moved into it.4 We found the same for the preschool booster: 74% for the 58 children born in the practice and 57% for
BMJ VOLUME 301
21 JULY 1990
