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 BM7.

* 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.

The health of the nation SIR,-The chief medical officer has called on doctors in England to respond to the government's green paper The Health of the Nation.' 2 Its main thrust is away from the intractable problems of the NHS towards preventive medicine, particularly with regard to the big killers (coronary heart disease, stroke, cancers, and accidents) which are thought to be suitable for mass intervention. Other factors such as smoking, diet, and alcohol are also highlighted. I wish to query some of the unstated assumptions of the thesis. Breast cancer-The green paper accepts that screening for breast and cervical cancer is effective. The target is to reduce deaths from breast cancer in the screened population by 25% by 2000 compared with 1990. The contrary view, based on a recent seven year study in Edinburgh,3 is that "there is no statistically sound evidence that breast cancer screening has ever saved a life in the United Kingdom . the only trials of screening in this country have been reported as statistically nonsignificant."4 Carcinoma of the cervix-The target is to screen all eligible women for carcinoma of the cervix by the end of 1993. The view that such screening harms women by causing increased anxiety in those with positive results while falsely reassuring those whose results are negative is not heeded. Holland and Stewart's review on screening notes that 25 years after its introduction screening for cervical cancer has failed to reduce the 2000 deaths caused by this disease annually in the United Kingdom.5 Skrabanek, reviewing Holland and Stewart's book, is more blunt6: "In the UK, after some 60 million cervical smears, there is nothing to show in 'lives saved' . . . by this monumental folly." My comment is that for a disease that is largely preventable by good personal hygiene to screen all adult women is a flawed strategy. Coronary heart disease-The target is to reduce deaths from coronary heart disease among people aged under 65 by 30% between 1988 and 2000. The package for healthy living includes consuming less saturated fat, less fat overall, and less alcohol and reducing obesity. The Department of Health's official policy on coronary heart disease and blood cholesterol testing7 is that priority should be given to opportunistic measurement of blood cholesterol concentration in people at high overall risk of the disease. All risk factors, including smoking, raised blood pressure, and obesity, should be tackled together with blood cholesterol concentration. Unfortunately, many members of the general public have been persuaded to place undue weight on cholesterol alone. The problem is that merely reducing the blood cholesterol concentration does not help. Oliver stated: "At present, available data indicate that total mortality is unchanged when hypercholesterolaemia is lowered; the fall in cardiac mortality is offset by an apparent increase in

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non-cardiac deaths."8 Jones said: "Unfortunately, evidence that lowering cholesterol concentrations lowers mortality does not exist." An editorial in the Lancet concurred with these appraisals."' The ideology of the consultative document is preventive medicine and screening; it is doomed to failure. The risks and dangers of screening are not addressed. The ratio of harm to benefit in screening is much more unfavourable than that in "ordinary" medicine. For screening for breast cancer one estimate was a ratio of 62:1.11 The plan to reduce coronary heart disease may produce some benefit provided we can get away from the obsession with cholesterol. There is now a danger that public health experts will do to medicine what sociologists have done elsewhere: impose their ill conceived ideology, without regard to the facts, on an unsuspecting public. P J N HOWORTH

Department of Pathology, Victoria Hospital, Blackpool FY3 8NR 1 Department of Health. The health of the nation: a consultative documentfor health in England. London: HMSO, 1991. 2 Delamothe T. Health manifestos: the government. BMJ 1991;302:1355-6. (8 June.) 3 Roberts MM, Alexander FE, Anderson TJ, Chetty U, Donnan PT, Forrest APM, et al. The Edinburgh trial of screening for breast cancer: mortality at seven years. Lancet 1990;335: 241-6. 4 Rodgers A. Breast cancer screening: the current position. BMJ 1991;302:1401-2. (8 June.) S Holland WW, Stewart S. Screening in health care: benefit or bane? London: Nuffield Provincial Hospitals Trust, 1990. 6 Skrabanek P. Screening in health care: benefit or bane? Lancet 1991;337: 100. 7 Standing Medical Advisory Committee to the Secretary of State for Health. Blood cholesterol testing: the cost-effectiVeness of opporntunstic cholesterol testing. London: DHSS, 1990. 8 Oliver MF. Might treatnent of hypercholesterolaemia increase non-cardiac mortality? Lancet 1991;337:1529-31. 9 Jones IG. The Scots and their hearts. Lancet 1990;336:684. 10 Anonymous. Secondary prevention of coronary heart disease with lipid-lowering drugs [Editorial]. Lancet 1989;i:473-4. 11 Wright CJ. Breast cancer screening: a different look at the evidence. Surgery 1986;100:594-8.

SIR,-The government's consultation document The Health of the Nation aims to focus on "areas" in which we can improve the health of the nation.' Coronary heart disease, stroke, accidents, cancers, mental illness, diabetes, and asthma are all mentioned. Surprisingly, osteoporosis and the health of the nation's bones are not explicitly addressed in the document. We think that osteoporosis should be a specific area for attention. Though osteoporosis and fractures might come within the areas of accidents and physical disability, a more focused approach to the problems of osteoporosis is justified. The incidence of vertebral, wrist, and femoral fractures is increasing. Most of the epidemiological data have been based on deaths and discharges from hospital of patients with femoral fractures (ICD 820), and in South Glamorgan there has been considerable increase over the past 20 years. Even

if the age specific incidences stabilise at the present rates the number of fractures will increase by 17% in the next 10 years because of demographic changes. In additon to the direct costs of femoral fractures (the average length of stay in hospital is 29 days), there is considerable associated morbidity and mortality.23 The lifetime risk of a white postmenopausal woman suffering a femoral fracture is of the order of 15%. The treatment of established disease is difficult, and with a rising incidence prevention is important and should be multifaceted. The risk factors of smoking, alcohol, diet, and exercise should all be addressed, and hormone replacement therapy is clearly effective. The challenge to the health service is to form an integrated approach to preventing osteoporosis; a major step towards this would be to include osteoporosis in the health strategy. D CLEMENTS W D EVANS

University Hospital of Wales, Cardiff CF4 4XW 1 Delamothe T. Health manifestos: the government. BMJ 1991; 302:1355-6. (8 June.) 2 Royal College of Physicians. Fractured neck of femur, prevention and management. London: Royal College of Physicians of London, 1989. 3 Griffin J. Osteoporosis and the risk of fracture. London: Office of Health Economics, 1990. 4 Lindsay R, Cosman F. Epidemiology of osteoporosis. In: Drife JO, Studd JWW, eds. HRT and osteoporosis. London:

Springer-Verlag, 1990:75-86.

Surgeons who are hepatitis B carriers SIR,-We read with sympathy Mr Stuart Kennedy's description of his investigation, and the outcome in terms of his career, after a woman on whom he had operated developed hepatitis B. We have had a colleague with a similar history. During investigation of a personal medical problem he was found to be positive for hepatitis B e antigen. Coincidentally, a 69 year old woman on whom he had performed a small bowel resection five and a half months earlier presented with acute hepatitis B. Further inquiries revealed two other patients of his, without other risk factors, who had developed jaundice after surgery. One, a 63 year old woman, had developed jaundice six years earlier after a cholecystectomy, and the other, a 30 year old woman, had developed it after a subtotal thyroidectomy four years before. Our surgical colleague had not ignored the risk of infection with hepatitis B virus in that he had sought vaccination seven years before, had completed the course, and had been given at least two booster doses. At no time did he have detectable antibody to hepatitis B surface antigen. Because of the prevailing view that staff should not

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be screened for evidence of carriage of hepatitis B virus his serum had not been tested for hepatitis B surface antigen and hence his carrier state was not known. Infection with hepatitis B virus is a recognised hazard for health care workers,2 and in future vaccine should be available for all those at risk of infection. This should considerably reduce if not eliminate the risk to staff and patients of nosocomial transmissions. With the current vaccines, however, the failure rate may be as high as 9% and a further 9% will have a low antibody response (< 10 mIU).3 Some of the non-responders will continue to be at risk and will require hepatitis B immunoglobulin after known exposures. Other non-responders will already be carriers. We suggest that the time has come to identify these non-responders as early as possible after infection so that they can be offered treatment and advice about their career. Treatment has a greater chance of success if given within two years of infection,4 and ideally hepatitis B carriers should be advised to choose a specialty that does not include surgery, obstetrics, or renal medicine. Vaccine should be available for all medical and dental students, and non-responders should be investigated and advised accordingly before firm choices of career have been made. The present policy of redeployment after known transmission to a patient5 could well be challenged in court not only when a surgeon is known to be a hepatitis B carrier but also if the carrier state is not excluded when there is no response to vaccine.

important to emphasise the need for flexibility with regard to this aspect of assisted conception lest the new authority becomes mesmerised by the data it has received to date. The rationale of limiting the number of oocytes or embryos to a finite number in all patients in the hope of achieving a singleton, as opposed to a multiple, pregnancy presupposes that all women have the same prospect of becoming pregnant or of having a multiple pregnancy. This is simply not so-for example, older women have a lower chance of becoming pregnant, and in women in whom gamete intrafallopian transfer is undertaken with suboptimal sperm fewer embryos will be generated. We have evaluated the results of transferring up to four oocytes in 349 gamete intrafallopian transfer cycles in women aged 40-45 in whom the outcome of pregnancy was known. There were no high order multiple births-that is, quadruplets or more-and the incidence of multiple pregnancy was 17% compared with 28-5% in those aged 39 or younger. The table indicates the numbers of pregnancies and deliveries associated with transferring one, two, or three oocytes when only this number were available and a maximum of four oocytes when four or more were available. We do not understand why anyone would wish to restrict the potential for pregnancy to a lower level when there is a minimal chance of a high order multiple birth. We have also reported other circumstances in which flexibility is required.2 We accept that in most cases a limited number of oocytes or embryos is appropriate, but we trust that the Human Fertilisation and Embryology Authority will not act against the interests of some infertile couples but will allow the incorporation within any guidelines of an appropriate clause to cover all circumstances-that is, "except in exceptional circumstances." We strongly recommend that decisions relating to this aspect of treatment should be made by clinicians in conjunction with their embryologists and that these should be based on the biological and clinical variables for individual couples. It would be regrettable if infertile couples were to seek legal advice against the Human Fertilisation and Embryology Authority, whose role is to facilitate treatment and research.

1 Kennedy S. An elementary mistake? BMJ 1991;302:1614. (29 June.) 2 Polakoff S. Acute viral hepatitis B: laboratory reports 1980-4.

BMJ 1986;293:37-8. 3 Hadler SC, Francis DP, Maynard JE, Thompson SE, Judson FN, Echenberg DF, et al. Long-term immunogenicity and efficacy of hepatitis B vaccine in homosexual men. N EnglJ Med 1986;315:209-14. 4 Thomas HC. Treatment of hepatitis B viral infection. In: Viral hepatitis and liverdisease. New York: Alan R Liss, 1988:817-22. 5 Department of Health. Chief medical ofjficer's letter. London: DoH, 1972. (CMO 25/72.)

***For reasons of confidentiality this letter is unsigned.

IAN CRAFT TALHA AL-SHAWAF

Limiting the number of oocytes and embryos transferred in GIFT and IVF

London Fertility Centre and Medicraft Services, London WIN I AF 1 Waterstone J, Parsons J, Bolton V. Elective transfer of two embryos. Lancet 1991;337:975-6.

SIR, -At the recent annual meeting of the Interim Licensing Authority the chairman recommended that the new Human Fertilisation and Embryology Authority coming into force on 1 August should adopt a guideline restricting the number of embryos and oocytes for transfer in in vitro fertilisation and gamete intrafallopian transfer to just two. Some fertility specialists have recommended reducing the present maximum from four to three or even two.' Although the present guidelines are not legally binding, we assume that any clinicians who transfer more than the definitive number selected will have their licence withdrawn even if they are not subject to potential prosecution. It is therefore extremely

2 Craft I. Factors affecting the outcome of assisted conception. BrMed Bull 1990;46:769-82.

Brittle diabetes SIR,-We were interested in Professor Robert Tattersall and colleagues' report on their 12 year follow up of patients with brittle diabetes' as we have also studied such patients, in Newcastle upon Tyne2 and London.3 Professor Tattersall's definition of a patient with brittle diabetes-one "whose life is constantly

No of oocytes transferred

No(%)ofcyclesresultingin pregnancy Outcome of pregnancy: Delivery Miscarriage Biochemical pregnancy only

1

2

3

4

23 (6-6) 2 (8-7)

55 (15-8) 5 (9-1)

46* (13 2) 5 (10-9)

201 (57-6) 46(22-9)

1(4-3)

1 (1.8) 2 2

(4-3)

21(10-4) 16 9

I

2 2 1

*Not included are 24 patients who had more than three oocytes recovered but in whom only three were transferred; four of them (16-6%) became pregnant.

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GEOFFREY GILL

Diabetes Centre, Walton Hospital, Liverpool L9 IAE GARETH WILLIAMS

Outcome of 349 gamete intrafallopian transfer cycles related to number of oocytes transferred

No(%)of cycles

disrupted by episodes of hyper or hypoglycaemia, whatever the cause"-is in general use.4 Nevertheless, this definition is subjective and open to individual interpretation, and we are surprised that a single centre should identify 25 patients with brittle diabetes during a two year period. Our combined populations of such patients total 34"' and are the result of tertiary referrals from some 30 centres throughout the United Kingdom. The patients had outstandingly poor glycaemic control and a poor quality of life. Many spent several months each year in hospital and were unable to maintain full time employment or attendance at school. Most suffered hyperglycaemic instability with recurrent attacks of ketoacidosis. Psychosocial disturbances and factitious induction of disturbed glycaemic control were common and in some cases may have been primarily responsible for the "brittleness."2 5 7 The discrepancy between our small "national" group and the large "local" Nottingham group seems to be the lax inclusion criteria used by the Nottingham workers-that is, three or more admissions with ketoacidosis or three or more attendances at the casualty department with hypoglycaemia during the two year study. Though not representative of acceptable control, the minimum requirements for inclusion can hardly be described as "life disrupting" and are inconsistent with Professor Tattersall's own definition. In the United Kingdom as a whole the criteria would identify 2000 or more patients with brittle diabetes in any two years. Clinical experience and reported data do not support the existence of so many patients with life disrupting metabolic instability. Another unusual feature of the patients in Nottingham is the almost equal sex distribution; this is in contrast with the female predominance in most other British2 3and American series.' Indeed, the patients with recurrent ketoacidosis at Guy's"9 and Freeman Hospitals25 were all female and in their teens or 20s. Our impression of the Nottingham study is that many patients were classified as having brittle diabetes during self limiting episodes of disturbed control perhaps due to psychosocial problems. We believe that this label should be reserved for those whose lives are truly disrupted by glycaemic instability. The experience in Nottingham does, however, concur with ours in that the long term prognosis of brittle diabetes seems surprisingly good. Our follow up studies confirm that in most of these patients more "normal" diabetic behaviour returns spontaneously as the years pass.69

Department of Medicine, Royal Liverpool University Hospital, Liverpool 1 Tattersall R, Gregory R, Selby C, Kerr D, Heller S. Course of brittle diabetes: 12 year follow up. BMJ 1991;302:1240-3.

(25 May.)

2 Gill GV, Husband DJ, Walford S, Marshall SM, Home PD, Alberti KGMM. Clinical features of brittle diabetes. In: Pickup JC, ed. Brittle diabetes. Oxford: Blackwell, 1985:29-40. 3 Pickup J, Williams G, Johns P, Keen H. Clinical features of brittle diabetic patients unresponsive to optnimsed subcutaneous insulin therapy (continuous subcutaneous insulin infusion). Diabetes Care 1983;6:279-84. 4 Tattersall R. Brittle diabetes. Clin Endocrinol Metab 1977;6: 403-19. 5 Gill GV, Walford S, Alberti KGMM. Brittle diabetes-present concepts. Diabetologia 1985;28:579-89. 6 Gill GV. The outcome of brittle diabetes-a follow up study of young female diabetic patients with recurrent ketoacidosis. DiabeticMed 1990;7(suppl 1):25A. 7 Williams G, Pickup JC, Keen H. Continuous intravenous insulin infusion in diabetic patients unresponsive to continuous subcutaneous insulin infusion. Diabetes Care 1985;8:21-7. 8 Schade DS, Duckworth WC. In search of the subcutaneousinsulin-resistance syndromne. N EnglJ7 Med 1986;315:147-53. 9 Williams G, Pickup JC. The natural history of brittle diabetes. Diabetes Res 1988;7:13-8.

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Surgeons who are hepatitis B carriers.

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...
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