gramme were met, including rates of up-take (actual 71-3%), recall (6-2%), biopsy(0-89%), and cancer detection (6-2 per 1000women screened); moreover, perhaps re-flecting greater experience with mammo-graphy and more comprehensive peer re-view, the positive predictive value for

biopsy increased from 50% during the1988/1989 NHSBSP campaign to 70% lastyear. As might be expected, there wassignificant regional variation in programmeperformance. Uptake rates in North EastThames region were 58%, compared with81 % in East Anglia, and cancer detectionrates were nearly twice as high in Wales(9-3% per 1000) as in Yorkshire (5-1). :Although no predictions on UK breastcancer mortality were made on the basis ofthis report, researchers from Scandinaviahave recently observed that for womenaged 50-69 undergoing screening mammo-graphy, breast cancer mortality declined by29%.2

David H Frankel

1 Chamberlain J, Moss SM, Kirkpatrick AE, Johns L. National health service breast screening programme results for 1991-92. BMJ 1993; 307: 353-56.

2 Nystrom L, Rutqvist LE, Wall S, et al. Breast cancer screening with mammography:overview of Swedish randomised trials. Lancet 1993; 341: 973-78.

Road accidents in Jordan

Concern over the rise in number of roadtraffic accidents (RTAs) in Jordan led thegovernment to hold a symposium inAmman last month to look into ways of

tackling the increase. According to Dr

Nidhal Kattamin, there were 19 000 RTAsin 1991 resulting in 379 deaths. Last yearthis increased to 20 000 with 388 fatalities.Kattamin pointed out that this is a veryhigh figure for a small country like Jordanwith a population of only 3-3 million. Therate of increase was about three times theworldwide average. These accidents costthe economy nearly z65 million a year, asum Jordan can ill afford at the best of

times, let alone now, with the economic

depression and the large influx of Jord-anians and Palestinians since the Gulf War.What emerged during the symposium

was a picture of a country where the rapiddevelopment of road transport is notmatched by public awareness of road

safety. One study presented at the meetingrevealed that 47’5% of pedestrians crossinga road did not check for oncoming trafficeven once before or during the act ofcrossing. Only 11-5% were seen to stop andlook in both directions before crossing theroad. This observation together with thehigh speed with which Jordanians drivetheir cars, is increasingly proving to be afatal combination. :

Peter Kandela .

Choice In maternity care :

After a nine-month gestation period theDepartment of Health’s Expert MaternityGroup has produced its recommendationsfor the management of childbirth inEngland and Wales.1 The group was set uplast year after the government’s response toan all-party select committee’s critical re-port on maternity services (see Lancet 1992;340: 233). The group’s recommendationsare that a woman should have the right tochoose the type of professional who caresfor her, to choose how and where she givesbirth, to be cared for throughout pregnancyby the same person, and to receive clear andunbiased advice in order to make the abovedecisions. Thus, says the group, a womanshould be able to choose a midwife as herlead professional for antenatal care anddelivery. One aim is that within five years75% of women should be cared for inlabour by a midwife they have come toknow during pregnancy. In addition,women will keep their case-notes as"proof’ that they care in charge. :What effect would these recom-

mendations have on the roles of maternityhealth-care professionals? The group sug-gests that obstetricians should concentrateon managing complicated pregnancies andabnormalities, advising and teaching,administration, and research. The role ofobstetric senior house officers (juniordoctors), however, will need reappraisal.The group suggests that senior houseofficers should spend more of their timebeing trained than in service provision,thus the number of trainees may need to be"looked at in more detail". In turn mid-wives would need to take over some seniorhouse officer duties. :The Royal College of Obstetricians and

Gynaecologists has issued a statement out-lining its concern that some of these recom-mendations "may endanger the wellbeingof women and their babies". It warns that ifthe requirement for women to be seen by adoctor (preferably an obstetrician) duringpregnancy is stopped, underlying diseasesmay be missed. Concern is also raised overthe group’s proposal that delivery at home,rather than in a specialist unit, will be areasonable option for some women. In

addition, the college argues that the re-sources needed to implement these pro-posed changes, especially those required tocover the increased number of midwives,were inadequately discussed in the group’sreport. :

The consultation period for these pro-posals runs till the end of October. :

Sarah Ramsay

1 Department of Health. Changing childbirth. London: HM Stationery Office. 1993. Pp 108. £8.50. ISBN 011 321623 8.

APOE gene dose inAlzheimer’s disease

The clearest evidence yet thatAlzheimer’s disease is geneticallydetermined comes from a recent re-

port in Science. It has been known formore than five years that early-onsetAlzheimer’s disease (before the age of60) is associated with mutation of anamyloid precursor protein gene. Inlate-onset disease chromosome 19 is

implicated at the apolipoprotein Elocus (APOE). This locus has threealleles: APOE-2, -3, and -4. To findout which one of these might be

responsible for late-onset Alzheimer’sdisease, Corder and colleagues ass-

essed members of 42 families with a

history of this disease. The proportionof those affected varied from 18-8%for APOE-2/3 genotype to 91-3% forAPOE-4/4; furthermore the 4/4 geno-type was associated with earlier age atonset and more rapid progression ofdisease.

: The effect of the APOE-4 alleleseems to be "dose-related":

Knowing their dose of APOE-4 mayhave important consequences formembers of families in which late-onset Alzheimer’s disease occurs; yetAPOE-4 is not entirely to blame-theauthors emphasise that 12 of 42 fami-lies with affected members had no

APOE-4; and although having 2

APOE-4 alleles carries a very highrisk, a few people still do not go on toget the disease.As in many other diseases, defining

a genetic predisposition offers no

immediate hope of treatment, yetidentifying why the effect of APOE-4is dose related may lead to the fault inneurometabolism that underliesAlzheimer’s disease-and to the en-vironmental or infective agent that

precipitates the disease in predisposedpeople.

John Bignall

1 Corder E, Saunders M, Strittmatter W, etal. Gene dose of apolipoprotein E type 4allele and the risk of Alzheimer disease inlate onset families. Science 1993; 261: 921-23.

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