107
the
had
patient
pains in his
knee and ankle
joints, abdominal
discomfort, and a rash over both feet. He was pyrexial (37-5°C) and had a maculopapular vasculitic rash, confined to his shins, ankles, and the dorsum of both feet. Urinalysis revealed haematuria and proteinuria +; the red blood cells were confirmed on urine
microscopy. Blood and urine cultures were negative. Plasma urea, electrolytes and creatinine were unchanged. Autoantibodies, rheumatoid factor, and anti-neutrophil cytoplasmic antibodies were negative.
Immunoglobulins and complement were normal. Skin biopsy a leucocytoclastic vasculitis with deposition of IgA and
revealed
complement (C3) within dermal capillary walls. Urinalysis returned to normal by day 12. The patient was discharged on day 13 with the rash resolving but with persisting arthralgia. These results are consistent with Henoch-Schonlein-like vasculitis triggered by APSAC. Such a vasculitis can lead to serious renal and systemic damage. We recommend urinalysis as part of the late follow-up of patients on fibrinolytic therapy during the management of myocardial infarction. This should apply to the newer agents, such as APSAC, as well as to SK.
Duchess of Cornwall Renal Unit, Truro, Cornwall TR1 3LJ, UK
False alarms of breast
A. ALI J. N. BARNES A. J. W. DAVISON E. H. MOSTAFID Y. SIVATHONDAN
cancer
SIR,-Dr Devitt’s article (Nov 25,-p 1257) raises several issues. While questioning the real cost of searching for breast carcinoma, he assesses the morbidity associated with false alarms and suggests methods of decreasing morbidity. We believe Devitt’s data suggest that the analysis of a personal series may well reflect local attitudes rather than generally accepted principles. Devitt says that "87% (2532/2923) of signs/symptoms of breast cancer were false alarms". We ask, what are the signs and symptoms of breast cancer? In our experience, most patients have signs and symptoms of non-specific breast disease, and with proper communication should not experience the same anguish as those with breast cancer. Delay in referral and definitive management may cause unnecessary anxiety. At our unit, where about 1200 new patients are seen annually, urgent referrals can be seen within 4 days. Fine-needle aspiration cytology (omitted in Devitt’s investigation) and conventional mammography are available at 72 h, and a definitive diagnosis can be made one week after the initial practitioner visit. In the absence of cytological confirmation we believe that the patient should be "told that she may have breast cancer" only when there is very firm clinical evidence of cancer. Devitt does not mention biopsy specimen compression and image enhancement, which enable early confirmation that areas of abnormal density without microcalcification have been excised. We feel that self-examination of the breast should be encouraged from an early age in women at risk. Routine physical examination before the age of 45 is not standard practice in the UK, and breast cancer in this age group is therefore often discovered by the patient. Many women do not comply with breast self-examination,’ and early cancers will therefore be missed. Women aged 45 or less who visit their general practitioner for other reasons could have their breasts examined routinely. Of the last 100 non-screen detected cancers at our unit 19 were seen in women aged under 45, and all but 2 were classified as over Tia. 89 % of these cancers would have been
palpable. We think Devitt is incorrect to discourage routine mammography before the age of 60. Studies in North America and Sweden have clearly demonstrated reduced mortality in the over 50 age groUpS.2,3 Whether early detection and screening are worthwhile needs to be established. Various groups have concluded that a properly organised service that uses mammography reduces deaths in women aged 50-64 years.4.5 Benefit from mammographic screening for women under 50 years is unclear. Data from the Health Insurance Plan study6
showed mortality reductions of 31 % for women aged 40-44 years and 14% for women aged 45-49, but since few women were seen late in follow-up, a substantial mortality reduction was not proven. Devitt’s 44% frequency of screen detected cancers and similar TNM pathological staging between accidental and mammographically detected cancers contrasts with the findings of others.7 In addition, mammography has become more sensitive and safe. Reports have shown 55 cancers per 1000 women screened,’ 66 per 1000 (UK breast screening programme, unpublished), and 2 73 per 1000. Perhaps Devitt’s principal message in the need for improvement in public attitudes towards breast cancer, while educating personnel towards greater awareness of the associated potential morbidity. Despite the UK Government’s recognition of the need for counsellors and correct information and advice, most patients with diagnosed breast cancer do not yet have this help preoperatively on a properly funded basis. Academic Department of Surgery, Royal Free Hospital and Medical School, London NW3 2QG
D. J. HEHIR S. P. PARBHOO
1. UK Breast Cancer Group: trial of early-detection of breast cancer. Br J Cancer 1981; 44: 618. 2. Shapiro S. The status of breast cancer screening: a quarter of a century of research.
World J Surg 1989; 13: 9-18. 3. Tabar L, Fagerberg CJG, Gad A. Reduction in mortality from breast cancer after mass screening with mammography. Lancet 1985; i: 830-32. 4. Netherlands Ministry of Welfare, Health and Cultural Affairs, Health and Safety Directorate of the Commission of the European Community. Report of an international workshop on health policy in relation to mass screening for breast cancer by mammography. Meeting, Noordwijk, Netherlands, December, 1986. 5. Working group report to the Health Ministers of England, Wales, Scotland and Northern Ireland. Breast cancer screening. London: HM Stationery Office, 1987. 6. Habbema J, et al. Age specific reduction in breast cancer mortality by screening: an analysis of the results of the Health Insurance Plan of Greater New York study. J Natl Cancer Inst 1986; 77: 317. 7. Baker LH. Breast cancer detection demonstration projects’ five year summary report. Cancer 1982; 32: 194-225.
Long-term blood glucose control and diabetic retinopathy SiR,—Dr McCance and colleagues (Oct 7,
p
824) conclude that
besides
being a good indicator of long-term plasma glucose concentration, can predict either development or progression of retinopathy in insulin-dependent diabetic subjects. However, a link between metabolic control and vascular complications seems to be an oversimplified conclusion with respect to McCance and colleagues’ table vn. Indeed, from the multiple regression analysis in that table (left without comment), it is apparent that not only HbAl but also age and sex, among other factors, have significant weight in the determination of diabetic retinopathy. No information is presented on the sex ratio in the diabetic group, although it is claimed that this variable plays an important part in both the pathogenesis of diabetes and the development of its complications.’ 1 HbAl has proved to differ between diabetic female and male subjects despite similar plasma glucose concentrations, thus suggesting a role for gender in metabolic contro!.2 From McCance and colleagues’ table vu it also seems that age is negatively related to retinopathy; patients with retinopathy were significantly older than those without retinopathy. Retinopathy cannot be completely explained by the level of metabolic control since the highest frequency of background retinopathy in cohort III (13-18 years of diabetes) is associated with a mean HbA, value much the same as or lower than that of cohorts II and I (7-12 years and 1-6 years of diabetes, respectively). Moreover, subjects without retinopathy show similar mean HbAl values, independently of age and duration of disease, suggesting other factors are implicated in the determination of retinopathy or in protection from its progression. The severity of retinopathy is presented as causally linked to an increased HbA1 mean value, without any mention of the possible affect of other variables. New findings on the glucose transporter indicate that the glycosylation process is dependent not only on plasma glucose
HbAl measurement over time,
concentration but also on the presence of either external stimuli3.4 or
the
had
patient
pains in his
knee and ankle
joints, abdominal
discomfort, and a rash over both feet. He was pyrexial (37-5°C) and had a maculopapular vasculitic rash, confined to his shins, ankles, and the dorsum of both feet. Urinalysis revealed haematuria and proteinuria +; the red blood cells were confirmed on urine
microscopy. Blood and urine cultures were negative. Plasma urea, electrolytes and creatinine were unchanged. Autoantibodies, rheumatoid factor, and anti-neutrophil cytoplasmic antibodies were negative.
Immunoglobulins and complement were normal. Skin biopsy a leucocytoclastic vasculitis with deposition of IgA and
revealed
complement (C3) within dermal capillary walls. Urinalysis returned to normal by day 12. The patient was discharged on day 13 with the rash resolving but with persisting arthralgia. These results are consistent with Henoch-Schonlein-like vasculitis triggered by APSAC. Such a vasculitis can lead to serious renal and systemic damage. We recommend urinalysis as part of the late follow-up of patients on fibrinolytic therapy during the management of myocardial infarction. This should apply to the newer agents, such as APSAC, as well as to SK.
Duchess of Cornwall Renal Unit, Truro, Cornwall TR1 3LJ, UK
False alarms of breast
A. ALI J. N. BARNES A. J. W. DAVISON E. H. MOSTAFID Y. SIVATHONDAN
cancer
SIR,-Dr Devitt’s article (Nov 25,-p 1257) raises several issues. While questioning the real cost of searching for breast carcinoma, he assesses the morbidity associated with false alarms and suggests methods of decreasing morbidity. We believe Devitt’s data suggest that the analysis of a personal series may well reflect local attitudes rather than generally accepted principles. Devitt says that "87% (2532/2923) of signs/symptoms of breast cancer were false alarms". We ask, what are the signs and symptoms of breast cancer? In our experience, most patients have signs and symptoms of non-specific breast disease, and with proper communication should not experience the same anguish as those with breast cancer. Delay in referral and definitive management may cause unnecessary anxiety. At our unit, where about 1200 new patients are seen annually, urgent referrals can be seen within 4 days. Fine-needle aspiration cytology (omitted in Devitt’s investigation) and conventional mammography are available at 72 h, and a definitive diagnosis can be made one week after the initial practitioner visit. In the absence of cytological confirmation we believe that the patient should be "told that she may have breast cancer" only when there is very firm clinical evidence of cancer. Devitt does not mention biopsy specimen compression and image enhancement, which enable early confirmation that areas of abnormal density without microcalcification have been excised. We feel that self-examination of the breast should be encouraged from an early age in women at risk. Routine physical examination before the age of 45 is not standard practice in the UK, and breast cancer in this age group is therefore often discovered by the patient. Many women do not comply with breast self-examination,’ and early cancers will therefore be missed. Women aged 45 or less who visit their general practitioner for other reasons could have their breasts examined routinely. Of the last 100 non-screen detected cancers at our unit 19 were seen in women aged under 45, and all but 2 were classified as over Tia. 89 % of these cancers would have been
palpable. We think Devitt is incorrect to discourage routine mammography before the age of 60. Studies in North America and Sweden have clearly demonstrated reduced mortality in the over 50 age groUpS.2,3 Whether early detection and screening are worthwhile needs to be established. Various groups have concluded that a properly organised service that uses mammography reduces deaths in women aged 50-64 years.4.5 Benefit from mammographic screening for women under 50 years is unclear. Data from the Health Insurance Plan study6
showed mortality reductions of 31 % for women aged 40-44 years and 14% for women aged 45-49, but since few women were seen late in follow-up, a substantial mortality reduction was not proven. Devitt’s 44% frequency of screen detected cancers and similar TNM pathological staging between accidental and mammographically detected cancers contrasts with the findings of others.7 In addition, mammography has become more sensitive and safe. Reports have shown 55 cancers per 1000 women screened,’ 66 per 1000 (UK breast screening programme, unpublished), and 2 73 per 1000. Perhaps Devitt’s principal message in the need for improvement in public attitudes towards breast cancer, while educating personnel towards greater awareness of the associated potential morbidity. Despite the UK Government’s recognition of the need for counsellors and correct information and advice, most patients with diagnosed breast cancer do not yet have this help preoperatively on a properly funded basis. Academic Department of Surgery, Royal Free Hospital and Medical School, London NW3 2QG
D. J. HEHIR S. P. PARBHOO
1. UK Breast Cancer Group: trial of early-detection of breast cancer. Br J Cancer 1981; 44: 618. 2. Shapiro S. The status of breast cancer screening: a quarter of a century of research.
World J Surg 1989; 13: 9-18. 3. Tabar L, Fagerberg CJG, Gad A. Reduction in mortality from breast cancer after mass screening with mammography. Lancet 1985; i: 830-32. 4. Netherlands Ministry of Welfare, Health and Cultural Affairs, Health and Safety Directorate of the Commission of the European Community. Report of an international workshop on health policy in relation to mass screening for breast cancer by mammography. Meeting, Noordwijk, Netherlands, December, 1986. 5. Working group report to the Health Ministers of England, Wales, Scotland and Northern Ireland. Breast cancer screening. London: HM Stationery Office, 1987. 6. Habbema J, et al. Age specific reduction in breast cancer mortality by screening: an analysis of the results of the Health Insurance Plan of Greater New York study. J Natl Cancer Inst 1986; 77: 317. 7. Baker LH. Breast cancer detection demonstration projects’ five year summary report. Cancer 1982; 32: 194-225.
Long-term blood glucose control and diabetic retinopathy SiR,—Dr McCance and colleagues (Oct 7,
p
824) conclude that
besides
being a good indicator of long-term plasma glucose concentration, can predict either development or progression of retinopathy in insulin-dependent diabetic subjects. However, a link between metabolic control and vascular complications seems to be an oversimplified conclusion with respect to McCance and colleagues’ table vn. Indeed, from the multiple regression analysis in that table (left without comment), it is apparent that not only HbAl but also age and sex, among other factors, have significant weight in the determination of diabetic retinopathy. No information is presented on the sex ratio in the diabetic group, although it is claimed that this variable plays an important part in both the pathogenesis of diabetes and the development of its complications.’ 1 HbAl has proved to differ between diabetic female and male subjects despite similar plasma glucose concentrations, thus suggesting a role for gender in metabolic contro!.2 From McCance and colleagues’ table vu it also seems that age is negatively related to retinopathy; patients with retinopathy were significantly older than those without retinopathy. Retinopathy cannot be completely explained by the level of metabolic control since the highest frequency of background retinopathy in cohort III (13-18 years of diabetes) is associated with a mean HbA, value much the same as or lower than that of cohorts II and I (7-12 years and 1-6 years of diabetes, respectively). Moreover, subjects without retinopathy show similar mean HbAl values, independently of age and duration of disease, suggesting other factors are implicated in the determination of retinopathy or in protection from its progression. The severity of retinopathy is presented as causally linked to an increased HbA1 mean value, without any mention of the possible affect of other variables. New findings on the glucose transporter indicate that the glycosylation process is dependent not only on plasma glucose
HbAl measurement over time,
concentration but also on the presence of either external stimuli3.4 or
