312
Elderly drivers SIR,-Dr O’Neill (Jan 4, p 41) draws attention to the growing caused by old people with dementia continuing to drive. We have found the issue of fitness to drive is often raised by carers, who are most aware of the risk. The Edinburgh dementia research group reviewed the last 22 consecutive patients with a diagnosis of probable Alzheimer’s disease and found that 10 were current drivers. The patients were all physically healthy and able to walk fair distances, had a carer in attendance, generally lived within easy reach of good public transport, and were visited at home for concern
These characteristics would tend to reduce any bias The sample consisted of 12 men (mean age 71-7 years, mean mini-mental state examination [MMSE] score1 21-9) and 10 women (mean age 72-8, mean MMSE 19-4). All the drivers were men (men vs women drivers, p =0’0001, Fisher’s exact test). This sex difference in a small group may reflect attitudes and
assessment.
towards
car use.
expectations common among elderly people. The identification of old people likely to have car accidents may not only prove difficult, because of the complex interaction of physical and psychological impairments with driving ability, but may also lead to a further stigmatisation of conditions such as Alzheimer’s disease. We feel that, to draw an analogy with hypercholesterolaemia, it may be more appropriate for health workers to seek to change general behaviour rather than attempt to identify those most at risk. University Department of Psychiatry, Royal Edinburgh Hospital, SUSAN INCH
Edinburgh EH10 5HF, UK Geriatric Unit,
JOHN M. STARR
City Hospital, Edinburgh
1. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive states of patients for the clinician. J Psychiatr Res 1975; 12: 189-98.
Secrecy and product information !R,—Malcolm Dean’sJ an 4 report on information about Hnush medicine is timely, but should also be seen from the continental European view. Most studies of information on medicines for patients show that that received from the doctor is most important. But doctors can tell their patient the full story only if they have been given it by the manufacturer or, better, by the regulatory agency. The attitude of the European Community to restrict product information is unacceptable. The prescribing doctor should know all reasons for licensing the drug and reservations that some members of the Committee might have had. Doctors are also entitled to know if the new drug was better than others in unpublished comparative studies used in the application. Such data are, in contrast to what Malcolm Dean reports, not available in Germany. The continental experience with obligatory package inserts is not nearly as good as he claims. A survey has shown that 15% of interviewed patients did not take their medicine, being frightened by the long list of adverse effects, even when these were very rare. Since there are still no patient-friendly package inserts, the patient often misunderstands the pseudoscientific language used. The shelf-life of medicines can be up to 5 years, so a package insert could be that old and probably misleading. If doctors could take time to explain why patients should take the prescribed medicine and what happens if they do not or take them irregularly, and what the signs of adverse effects are, we would be much better off without a package insert. Develgonne 92c, Hamburg, Germany
KARL H. KIMBEL
2000
Nursing research SiR,—Iwelcome your Jan 4 editorial on nursing research, not least because it draws attention to an important matter. Your comment about the position of the Economic and Social Research Council in relation to nursing research is unfortunately true in that our funds for research are limited and intensely competed for by the research community. The Council does in fact fund some research in nursing, as it does in other areas of health and
health care. The Council supports research that is relevant to the substantial changes in the practice and organisation of health care and to policy initiatives such as those represented by the Health of the Nation consultative document. Your readers might like to know about a proposed development that may have a bearing on nursing research. The ESRC, which undertakes research training in the form of postgraduate awards and other schemes, is developing a scheme for applied fellowships in the social sciences. This scheme will provide advanced training in research for practitioners from various specialties, including those in nursing, perhaps at mid-career stage, and enable them to return or convert to research and teaching, and to develop and undertake research of academic quality. The scheme may therefore increase the ability of nursing (and other) research to compete on more equal terms than hitherto. Economic and Social Research Council, Polaris House, Swindon SN21UJ, UK
X-linked
HOWARD NEWBY
lymphoproliferative disease
SIR,-A paper by Dr Henter and Dr Elinder (Jan 11, p 104), on male and female siblings thought to have familial haemophagocytic lymphohistiocytosis, stated that we1 had diagnosed the X-linked lymphoproliferative disease (XLP) in one of the girls and a brother. Not so: XLP occurs only in boys, and it is due to an immune deficiency to Epstein-Barr virus (EBV) which is attributable to a genetic defect in the X chromosome at Xq25.’Clearly, other patients have autosomal recessive hereditary immunodeficiencies that can result in fatal infectious mononucleosis in siblings.3Henter and Elinder did not mention that EBV was found in tissues of the boy we studied. They state that the other two males in their study did not have XLP but give no evidence for this assertion. Now that RFLP linkage analysis to the XLP gene can be done, other male family members should be studied who might have hypogammaglobulinaemia, malignant B-cell lymphoma, or other phenotypes ofXLP .4,5 Some patients within the enigmatic group of haemophagocytic familial lymphohistiocytoses probably do have immune deficiency. Triggering of lymphocytic proliferation and activation of histiocytes is a common response to viral infection in immunocompromised patients. Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
DAVID T. PURTILO
et al. Documentation of Epstein-Barr immunodeficient patients with life-threatening lymphoproliferative diseases by clinical, virological, and immunopathological studies. Cancer Res 1981; 41: 4226. 2. Purtilo DT, Grierson HL, Davis JR, Okano M. The X-linked lymphoproliferative disease: from autopsy toward cloning the gene 1975-1990. Pediatric Pathol 1991;
1. Purtilo
DT, Sakamoto K, Saemundsen AK,
virus
infection
in
11: 685. 3. McClain K, Gehrz
R, Grierson H, Purtilo DT, Filipovich A. Virus-associated histiocytic proliferations in children. Am J Pediatr Hematol/Oncol 1988; 10: 196. 4 Purtilo DT, Grierson HL, Ochs H, Skare J. Detection of X-linked lymphoproliferative disease using molecular and immunovirological markers Am J Med 1989; 87: 421. 5. Skare JC, Grierson HL, Sullivan JL, et al. Linkage analysis of seven kindreds with the X-linked lymphoproliferative syndrome confirms that the XLP locus is near DXS42 and DXS37. Hum Genet 1989; 82: 354.
Pristinamycin for Enterococcus faecium resistant to vancomycin and gentamicin microbiological surveillance of immunocompromised patients at the Institute of Liver Studies, King’s College Hospital, where we have lately recorded the emergence of Enterococcus faecium with high-level gentamicin resistance,l has supported our prediction that strains with highlevel resistance to both gentamicin and vancomycin would emerge and pose difficulties for antimicrobial therapy. Since February, 1991, we used standard microbiological methods to detect resistant strains of E faecium in more than 1620 specimens taken on clinical grounds and in 500 specimens from screening. In July of that year the first isolate of a vancomycin-resistantE faecium was detected in a vaginal swab from a liver transplant patient. Within the next 14 weeks, a further 23 patients with SiR,--0ur
continued
Elderly drivers SIR,-Dr O’Neill (Jan 4, p 41) draws attention to the growing caused by old people with dementia continuing to drive. We have found the issue of fitness to drive is often raised by carers, who are most aware of the risk. The Edinburgh dementia research group reviewed the last 22 consecutive patients with a diagnosis of probable Alzheimer’s disease and found that 10 were current drivers. The patients were all physically healthy and able to walk fair distances, had a carer in attendance, generally lived within easy reach of good public transport, and were visited at home for concern
These characteristics would tend to reduce any bias The sample consisted of 12 men (mean age 71-7 years, mean mini-mental state examination [MMSE] score1 21-9) and 10 women (mean age 72-8, mean MMSE 19-4). All the drivers were men (men vs women drivers, p =0’0001, Fisher’s exact test). This sex difference in a small group may reflect attitudes and
assessment.
towards
car use.
expectations common among elderly people. The identification of old people likely to have car accidents may not only prove difficult, because of the complex interaction of physical and psychological impairments with driving ability, but may also lead to a further stigmatisation of conditions such as Alzheimer’s disease. We feel that, to draw an analogy with hypercholesterolaemia, it may be more appropriate for health workers to seek to change general behaviour rather than attempt to identify those most at risk. University Department of Psychiatry, Royal Edinburgh Hospital, SUSAN INCH
Edinburgh EH10 5HF, UK Geriatric Unit,
JOHN M. STARR
City Hospital, Edinburgh
1. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive states of patients for the clinician. J Psychiatr Res 1975; 12: 189-98.
Secrecy and product information !R,—Malcolm Dean’sJ an 4 report on information about Hnush medicine is timely, but should also be seen from the continental European view. Most studies of information on medicines for patients show that that received from the doctor is most important. But doctors can tell their patient the full story only if they have been given it by the manufacturer or, better, by the regulatory agency. The attitude of the European Community to restrict product information is unacceptable. The prescribing doctor should know all reasons for licensing the drug and reservations that some members of the Committee might have had. Doctors are also entitled to know if the new drug was better than others in unpublished comparative studies used in the application. Such data are, in contrast to what Malcolm Dean reports, not available in Germany. The continental experience with obligatory package inserts is not nearly as good as he claims. A survey has shown that 15% of interviewed patients did not take their medicine, being frightened by the long list of adverse effects, even when these were very rare. Since there are still no patient-friendly package inserts, the patient often misunderstands the pseudoscientific language used. The shelf-life of medicines can be up to 5 years, so a package insert could be that old and probably misleading. If doctors could take time to explain why patients should take the prescribed medicine and what happens if they do not or take them irregularly, and what the signs of adverse effects are, we would be much better off without a package insert. Develgonne 92c, Hamburg, Germany
KARL H. KIMBEL
2000
Nursing research SiR,—Iwelcome your Jan 4 editorial on nursing research, not least because it draws attention to an important matter. Your comment about the position of the Economic and Social Research Council in relation to nursing research is unfortunately true in that our funds for research are limited and intensely competed for by the research community. The Council does in fact fund some research in nursing, as it does in other areas of health and
health care. The Council supports research that is relevant to the substantial changes in the practice and organisation of health care and to policy initiatives such as those represented by the Health of the Nation consultative document. Your readers might like to know about a proposed development that may have a bearing on nursing research. The ESRC, which undertakes research training in the form of postgraduate awards and other schemes, is developing a scheme for applied fellowships in the social sciences. This scheme will provide advanced training in research for practitioners from various specialties, including those in nursing, perhaps at mid-career stage, and enable them to return or convert to research and teaching, and to develop and undertake research of academic quality. The scheme may therefore increase the ability of nursing (and other) research to compete on more equal terms than hitherto. Economic and Social Research Council, Polaris House, Swindon SN21UJ, UK
X-linked
HOWARD NEWBY
lymphoproliferative disease
SIR,-A paper by Dr Henter and Dr Elinder (Jan 11, p 104), on male and female siblings thought to have familial haemophagocytic lymphohistiocytosis, stated that we1 had diagnosed the X-linked lymphoproliferative disease (XLP) in one of the girls and a brother. Not so: XLP occurs only in boys, and it is due to an immune deficiency to Epstein-Barr virus (EBV) which is attributable to a genetic defect in the X chromosome at Xq25.’Clearly, other patients have autosomal recessive hereditary immunodeficiencies that can result in fatal infectious mononucleosis in siblings.3Henter and Elinder did not mention that EBV was found in tissues of the boy we studied. They state that the other two males in their study did not have XLP but give no evidence for this assertion. Now that RFLP linkage analysis to the XLP gene can be done, other male family members should be studied who might have hypogammaglobulinaemia, malignant B-cell lymphoma, or other phenotypes ofXLP .4,5 Some patients within the enigmatic group of haemophagocytic familial lymphohistiocytoses probably do have immune deficiency. Triggering of lymphocytic proliferation and activation of histiocytes is a common response to viral infection in immunocompromised patients. Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
DAVID T. PURTILO
et al. Documentation of Epstein-Barr immunodeficient patients with life-threatening lymphoproliferative diseases by clinical, virological, and immunopathological studies. Cancer Res 1981; 41: 4226. 2. Purtilo DT, Grierson HL, Davis JR, Okano M. The X-linked lymphoproliferative disease: from autopsy toward cloning the gene 1975-1990. Pediatric Pathol 1991;
1. Purtilo
DT, Sakamoto K, Saemundsen AK,
virus
infection
in
11: 685. 3. McClain K, Gehrz
R, Grierson H, Purtilo DT, Filipovich A. Virus-associated histiocytic proliferations in children. Am J Pediatr Hematol/Oncol 1988; 10: 196. 4 Purtilo DT, Grierson HL, Ochs H, Skare J. Detection of X-linked lymphoproliferative disease using molecular and immunovirological markers Am J Med 1989; 87: 421. 5. Skare JC, Grierson HL, Sullivan JL, et al. Linkage analysis of seven kindreds with the X-linked lymphoproliferative syndrome confirms that the XLP locus is near DXS42 and DXS37. Hum Genet 1989; 82: 354.
Pristinamycin for Enterococcus faecium resistant to vancomycin and gentamicin microbiological surveillance of immunocompromised patients at the Institute of Liver Studies, King’s College Hospital, where we have lately recorded the emergence of Enterococcus faecium with high-level gentamicin resistance,l has supported our prediction that strains with highlevel resistance to both gentamicin and vancomycin would emerge and pose difficulties for antimicrobial therapy. Since February, 1991, we used standard microbiological methods to detect resistant strains of E faecium in more than 1620 specimens taken on clinical grounds and in 500 specimens from screening. In July of that year the first isolate of a vancomycin-resistantE faecium was detected in a vaginal swab from a liver transplant patient. Within the next 14 weeks, a further 23 patients with SiR,--0ur
continued
