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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. 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: 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.

References

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).

K. H. SHWE,
Consultant Haematologist.
M. BHAVNANI,
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

Editor,
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

References
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
THE NETHERLANDS

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

References:

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: CAGE questionnaire allows doctors to avoid focusing on specifics of drinking John A Ewing. 316:doi 10.1136/bmj.316.7147.1827

EDITOR - In continuation with the point raised by Professor Ewing1 regarding non-citation of his original paper on CAGE2 in many scientific publications, I am afraid this unfortunate tradition is going on even in latest review articles in reputed journals such as the one by O'Connor and Schottenfeld3. The latter further perpetuated the misleading notion of putting the
CAGE questionnaire in Step 3 of their "Screening approaches in medical settings", after the step 2 : "a detailed history
regarding quantity and frequency of (alcohol) use" .3, p.594 As emphasized by Prof.Ewing, this is like putting the cart before the horse.

A related and perhaps more important issue often not highlighted in alcoholism screening research is the cross-cultural applicability and validity of CAGE. It is well known that there are appreciable differences in various cultures regarding drinking norms, perception of social vis-a-vis pathological use or dependence, and community response to alcohol-related problems. 4,5 This heterogeneity poses obstacles in the way of developing a truly "culture-free" screening questionnaire. Questionnaires based on actual quantity-frequency index of drinking are obviously unsuitable because of vast differences in culturally sactioned drinking patterns. Items in questionnaires tapping help-seeking behavior can similarly be problematic, e.g., the item no.3 in the Brief Michigan Alcoholism Screening Test (B-MAST)6 ("have you ever attended a meeting of Alcoholics Anonymous" (AA)?) would not be applicable in rural India where AA does not practically exist. Culturally sensitive research, by altering various
items in a questionnaire to suit the local needs may improve internal validity at the cost of external validity, i.e. cross-cultural comparability and generalizability of results.

In this regard, we found CAGE to be a very useful instrument while screening for alcohol abuse in a community in India7. Used on a sample of 500 residents in and around Chandigarh, a cut-off score of 2 and above on CAGE yielded a sensitivity of 94% and specificity of 89.4%. There were 10.6% false positive and 6% false negative responses with this cut-off score. More importantly, all the questions were easily understood and well endorsed by the respondents. This was in sharp contrast to B-MAST in which the item no.3 (above) and item no.4 ("have you ever lost girlfriends or boyfriends because of drinking?") were endorsed by 1 and 2 percent of the respondents respectively.

Thus, the CAGE questionnaire, in addition to being simple, short and non-confrontative 1,2, also seems to be a close
approximation to an ideal "universal" or "culture-free" screening questionnaire for alcoholism. We advocate larger use of the CAGE questionnaire in cross-cultural research ( and the publications should cite the original author,
always!).

Debasish Basu, Assistant professor
Anil Malhotra, Additional Professor

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

E-mail :
References

1. Ewing JA. CAGE questionnaire allows doctors to avoid focusing on specifics of drinking. BMJ 1998; 316:1827.

2. Ewing JA. Detecting alcoholism - the CAGE questionnaire. JAMA 1984; 252 : 1905-7.

3. O’Connor PG, Schottenfeld RS. Patients with alcohol problems. N Engl J Med 1998; 338 : 592-602.

4. Ritson, EB. Community response to alcohol-related problems. Review of an international study. Public Health Papers No.81. Geneva : WHO.

5. Krahl W, Kuethmann A, Ollesch B. Comparative psycho-social cultural aspects of alcohol consumption in
Bavaria and in indigenous societies of North America. In, Social Psychiatry : A Global Perspective (eds. Varma
VK, Kulhara P, Masserman CM, Malhotra A, Malik SC). New Delhi : Macmillan India Limited, 1998 : 89-93.

6. Pokorny AD, Miller BA, Kaplan HB. The Brief MAST : a shortened version of the Michigan Alcoholism Screening Test. Am J Psychiatry 1972; 129 : 118-21.

7. Varma VK, Malhotra A, Basu D, Sethi S. Alcohol abuse in the community : screening by CAGE and MAST. In, Social Psychiatry : A Global Perspective (eds. Varma VK, Kulhara P, Masserman CM, Malhotra A, Malik SC). New Delhi : Macmillan India Limited, 1998 : 94-9.

Competing interests: No competing interests

03 September 1998
Debasish Basu
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Re: Should doctors perform an elective caesarean section on request?Yes, as long as the woman is fully informedMaternal choice alone should not determine method of delivery Sara Paterson-Brown, Olubusola Amu, Sasha Rajendran, Ibrahim I Bolaji. 317:doi 10.1136/bmj.317.7156.462

Public debate stimulated by publication of two papers about changing attitudes towards offering caesarean section on the basis of maternal choice alone is welcome and timely. Rates of caesarean have risen dramatically in the past decade reaching 15.5 per cent of all deliveries in England in 1994/95 and 16.7 per cent of all singleton births in Scotland in 1996/97 . There is a lack of knowledge about what is fuelling this increase. With the likelihood of more liberal use of elective caesarean section for normal birth, several important issues require consideration.

For example, little is known about maternal morbidity associated with elective, or indeed any, caesarean. The importance of considering morbidity before advocating unrestricted use of any care option is underlined in obstetrics by the parallel with the history of episiotomy. Liberal use of episiotomy was primarily justified because it was claimed to lower the risk of morbidity for mother and baby. These reasons are similar to those now being applied to elective caesarean. Extensive international evaluation has shown that liberal use of episiotomy in normal vaginal birth is no more effective than restricted use in terms of short-term postnatal maternal and neonatal morbidity. Equally important, long-term morbidity is actually more common amongst groups of women exposed to policies of liberal episiotomy .

Decision makers must consider the balance between costs and outcomes when determining optimal care strategies. Neither Paterson-Brown (1998) nor Amu et al (1998) recognised that the opportunity costs associated with an increased elective caesarean rate would be considerable. The estimated mean cost of hospital delivery and postnatal care for elective caesareans performed in the North West Thames Region was almost three times the estimated cost for all vaginal deliveries . Even if the cost differences between alternative modes of delivery were relatively minor, an increase in the elective caesarean section rate would still have important resource implications which could potentially restrict the use of other clinically effective care options.

In an era when all health care demands cannot be met, unlimited choice in all areas is neither feasible nor appropriate. Before advocating more liberal use of a major surgical intervention in normal birth it is essential to be sure that the desired outcomes are, at least, benign. Good quality multi-disciplinary research about both emergency and elective caesarean section is urgently required.

Yours sincerely

Rona McCandlish,Research Fellow
Leslie Davidson,Director
Alison Macfarlane,Reader in Statistics and Public Health
Stavros Petrou,Economist

1.Paterson-Brown S should doctors perform an elective caesarean section request? Yes, as long as the woman is fully informed. BMJ 1998;317:462-3
2.Amu O, Rajendran S, Bolaji I. Maternal choice alone should not determine method of delivery. BMJ 1998;317:463-4
3.Department of Health. NHS Maternity Statistics England:1989-90 to 1994-95: Department of Health, London 1997
4.Macfarlane A. At last - maternity statistics for England. BMJ 1998;316:566-7
5.ISD Scotland. Scottish health statistics 1997. ISD Edinburgh. 1998
6.Carroli G, Belizan J, Stamp G. Episiotomy policies in vaginal births (Cochrane Review). In: The Cochrane Library, Issue 3 1998. Oxford. Update Software
7.Clark L, Mugford M, Paterson C. How does the mode of delivery affect the cost of maternity care? Br J Obstet Gynaecol 1991;98:519-523

Competing interests: No competing interests

03 September 1998
Rona McCandlish
Research Fellow
National Perinatal Epidemiology Unit, Radcliffe Infirmary, Oxford OX2 6HE, UK
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Re: Should doctors perform an elective caesarean section on request?Yes, as long as the woman is fully informedMaternal choice alone should not determine method of delivery Sara Paterson-Brown, Olubusola Amu, Sasha Rajendran, Ibrahim I Bolaji. 317:doi 10.1136/bmj.317.7156.462

In the debate on caesarian section on "maternal request"1 2 rather than for obstetric indications, there is agreement that a woman's choice should be respected both for ethical reasons and because, in light of current evidence, such operations can be regarded as clinically justifiable.3 Paterson-Brown and Amu et al are in agreement on this provided that the patient is making an appropriately informed choice.

The resource implications have been alluded to briefly by Paterson-Brown by referring to the 4% of Italian women who make this choice and the speculation that only a small minority of British women would choose likewise. However, it has been suggested that the current increase in caesarian section rate may already be partly influenced by patients' requests4 and there may be a further escalation if the results of the survey of female obstetrician's personal preferences5 becomes widely appreciated by the public. If the demand does escalate we can expect a new pressure on obstetric and anaesthetic resources.

An unusual situation we have experienced was of a multiparous woman who had planned for an elective caesarian section but presented in spontaneous labour late at night at a time when the delivery suite staff were very busy. The situation was regarded as an "obstetric emergency" in that a caesarian section had to be performed quickly enough to avert a vaginal delivery, thus removing staff from other duties.

Although most cases of caesarian delivery on maternal request would take place during office hours, obstetric units may not have the staff or financial resources to cope with an increase in workload. At a time when the National Health Service is having to confront the difficult issue of rationing, if it becomes popular, caesarian section on request may need to be added to the growing list of medical interventions which are important to patients but are not of the highest clinical priority.

Philip Segar Specialist registrar in anaesthesia
Department of Anaesthesia, Royal Devon and Exeter Hospital, Exeter EX2 5DW.

Colin B Berry Consultant in anaesthesia
Department of Anaesthesia, Royal Devon and Exeter Hospital, Exeter EX2 5DW.

1. Paterson-Brown S. Yes, as long as the woman is fully informed. BMJ 1998;317:462-3. (15 August.)
2. Amu O, Rajendran S, Bolaji I. Maternal choice alone should not determine method of delivery. BMJ 1998;317:463-5. (15 August.)
3. Tranquilli A, Garzetti G. A new ethical and clinical dilemma in obstetric practice: Cesarean section "on maternal request". Am J Obstet Gynecol 1997;177:245-6.
4. Mould T, Chong S, Spencer J, Gallivan S. Women's involvement with the decision preceding their caesarian section and their degree of satisfaction. Br J Obstet Gynaecol 1996;103:1074-7.
5. Al-Mufti R, McCarthy A, Fisk N. Survey of obstetricians' personal preference and discretionary practice. Eur J Obstet Gynecol Reprod Biol 1997;73:1-4.

Competing interests: No competing interests

03 September 1998
Philip Segar
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Re: Will new diagnostic criteria for diabetes mellitus change phenotype of patients with diabetes? Reanalysis of European epidemiological data . 317:doi 10.1136/bmj.317.7155.371

Editor- Borch-Johnsen et al on behalf of the DECODE group(1) have shown that of the 1517 individuals who had diabetes according to the American Diabetes Association
(ADA) criteria (2) and World Health Organisation (WHO) criteria (3), only 473 (31.17%) had diabetes according to the WHO criteria alone, 613 (40.4%) according to the ADA criteria alone and the rest (431 (28.41%)) had diabetes according to both criteria. They further conclude that the ADA criteria is best suited to diagnosing diabetes in patients aged under 65 years and the obese, while the WHO criteria was more likely to diagnose diabetes in lean individuals who would be more likely to have a high post load glucose value.
Diabetes is one of the commonest chronic diseases and a major contributor to cardio-vascular disease(4). It has always been the intention of diabetologists and health care
workers alike that diabetes is diagnosed as early as possible so that microvascular complications can be prevented through strict glycaemic control(5) and modifiable risk factors like hypertension and hyperlipidaemia tackled early leading to reduction in the incidence of late complications reducing misery as well as overall treatment costs.

The crux of the problem , however, is which diagnostic criteria to use as both have their strengths and weaknesses. I would therefore suggest that it might be better to
target the lean individual with Body Mass Index (BMI) <25 by the WHO criteria ( 2 hour post 75 gm glucose load having a plasma glucose of > 11.1 mmol/l) and people under 65 years with BMI > 25 by a fasting plasma glucose alone (fasting plasma glucose > 7 mmol/l) using the ADA criteria leading to a simplified diagnostic guideline for the 2 subset of patients ensuring that diabetics did not slip through the net.

PULAK SAHAY Consultant Physician
Pontefract General Infirmary, Friarwood Lane, Pontefract, WF8 1PL

Conflict of interest : None

Borch-Johnsen K for DECODE study group on behalf of the European Diabetes Epidemiology Studt Group. Will new diagnostic criteria for diabetes mellitus change phenotype of patients of diabetes ? Reanalysis of European epidemiological data. BMJ 1998 ;317: 371-5.

Expert committee on the diagnosis and classification of diabetes mellitus. Report. Diabetes Care 1997; 20: 1183-97.

World Health Organisation Study Group. Diabetes Mellitus. Who Tech Rep Ser 1985; 727: 1-104. Jarrett RJ, McCartney P, Keen H.

The Bedford survey: ten year mortality rates in
newly diagnosed diabetics, borderline diabetics and normoglycaemic controls and risk indices for coronary heart disease in borderline diabetics. Diabetologia 1982;22:79-84.

Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin diabetes mellitus. N Engl J Med 1993; 329: 977-86.

Competing interests: No competing interests

03 September 1998
Pulak Sahay
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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.

References

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.

References

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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