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Elderly driversSIR,-Dr O’Neill (Jan 4, p 41) draws attention to the growing

concern 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 researchgroup reviewed the last 22 consecutive patients with a diagnosis ofprobable Alzheimer’s disease and found that 10 were currentdrivers. The patients were all physically healthy and able to walk fairdistances, had a carer in attendance, generally lived within easyreach of good public transport, and were visited at home forassessment. These characteristics would tend to reduce any biastowards car use. The sample consisted of 12 men (mean age 71-7years, mean mini-mental state examination [MMSE] score1 21-9)and 10 women (mean age 72-8, mean MMSE 19-4). All the driverswere men (men vs women drivers, p =0’0001, Fisher’s exact test).This sex difference in a small group may reflect attitudes and

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 ofphysical and psychological impairments with driving ability, butmay also lead to a further stigmatisation of conditions such asAlzheimer’s disease. We feel that, to draw an analogy withhypercholesterolaemia, it may be more appropriate for healthworkers to seek to change general behaviour rather than attempt toidentify those most at risk.

University Department of Psychiatry,Royal Edinburgh Hospital,Edinburgh EH10 5HF, UK SUSAN INCH

Geriatric Unit,City Hospital, Edinburgh JOHN M. STARR

1. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method forgrading the cognitive states of patients for the clinician. J Psychiatr Res 1975; 12:189-98.

Secrecy and product information!R,—Malcolm Dean’s J an 4 report on information about Hnush

medicine is timely, but should also be seen from the continentalEuropean view. Most studies of information on medicines forpatients show that that received from the doctor is most important.But doctors can tell their patient the full story only if they have beengiven it by the manufacturer or, better, by the regulatory agency.The attitude of the European Community to restrict productinformation is unacceptable. The prescribing doctor should knowall reasons for licensing the drug and reservations that somemembers of the Committee might have had. Doctors are alsoentitled to know if the new drug was better than others in

unpublished comparative studies used in the application. Such dataare, in contrast to what Malcolm Dean reports, not available in

Germany. The continental experience with obligatory packageinserts is not nearly as good as he claims. A survey has shown that15% of interviewed patients did not take their medicine, beingfrightened by the long list of adverse effects, even when these werevery rare. Since there are still no patient-friendly package inserts,the patient often misunderstands the pseudoscientific languageused. The shelf-life of medicines can be up to 5 years, so a packageinsert could be that old and probably misleading. If doctors couldtake time to explain why patients should take the prescribedmedicine and what happens if they do not or take them irregularly,and what the signs of adverse effects are, we would be much betteroff without a package insert.Develgonne 92c,2000 Hamburg, Germany KARL H. KIMBEL

Nursing researchSiR,—I welcome 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 unfortunatelytrue in that our funds for research are limited and intenselycompeted for by the research community. The Council does in factfund some research in nursing, as it does in other areas of health and

health care. The Council supports research that is relevant to thesubstantial changes in the practice and organisation of health careand to policy initiatives such as those represented by the Health ofthe Nation consultative document.Your readers might like to know about a proposed development

that may have a bearing on nursing research. The ESRC, whichundertakes research training in the form of postgraduate awards andother schemes, is developing a scheme for applied fellowships in thesocial sciences. This scheme will provide advanced training inresearch for practitioners from various specialties, including thosein nursing, perhaps at mid-career stage, and enable them to returnor convert to research and teaching, and to develop and undertakeresearch of academic quality. The scheme may therefore increasethe ability of nursing (and other) research to compete on more equalterms than hitherto.

Economic and Social Research Council,Polaris House,Swindon SN21UJ, UK HOWARD NEWBY

X-linked lymphoproliferative diseaseSIR,-A paper by Dr Henter and Dr Elinder (Jan 11, p 104), on

male and female siblings thought to have familial haemophagocyticlymphohistiocytosis, stated that we1 had diagnosed the X-linkedlymphoproliferative disease (XLP) in one of the girls and a brother.Not so: XLP occurs only in boys, and it is due to an immunedeficiency to Epstein-Barr virus (EBV) which is attributable to agenetic defect in the X chromosome at Xq25.’ Clearly, otherpatients have autosomal recessive hereditary immunodeficienciesthat can result in fatal infectious mononucleosis in siblings.3 Henterand Elinder did not mention that EBV was found in tissues of the

boy we studied. They state that the other two males in their studydid not have XLP but give no evidence for this assertion. Now thatRFLP linkage analysis to the XLP gene can be done, other malefamily members should be studied who might have

hypogammaglobulinaemia, malignant B-cell lymphoma, or otherphenotypes ofXLP .4,5 Some patients within the enigmatic group ofhaemophagocytic familial lymphohistiocytoses probably do haveimmune deficiency. Triggering of lymphocytic proliferation andactivation of histiocytes is a common response to viral infection inimmunocompromised patients.Department of Pathology and Microbiology,University of Nebraska Medical Center,Omaha, Nebraska 68198, USA DAVID T. PURTILO

1. Purtilo DT, Sakamoto K, Saemundsen AK, et al. Documentation of Epstein-Barrvirus infection in immunodeficient patients with life-threatening

lymphoproliferative diseases by clinical, virological, and immunopathologicalstudies. Cancer Res 1981; 41: 4226.

2. Purtilo DT, Grierson HL, Davis JR, Okano M. The X-linked lymphoproliferativedisease: from autopsy toward cloning the gene 1975-1990. Pediatric Pathol 1991;11: 685.

3. McClain K, Gehrz R, Grierson H, Purtilo DT, Filipovich A. Virus-associatedhistiocytic proliferations in children. Am J Pediatr Hematol/Oncol 1988; 10: 196.

4 Purtilo DT, Grierson HL, Ochs H, Skare J. Detection of X-linkedlymphoproliferative disease using molecular and immunovirological markers AmJ Med 1989; 87: 421.

5. Skare JC, Grierson HL, Sullivan JL, et al. Linkage analysis of seven kindreds with theX-linked lymphoproliferative syndrome confirms that the XLP locus is nearDXS42 and DXS37. Hum Genet 1989; 82: 354.

Pristinamycin for Enterococcus faeciumresistant to vancomycin and gentamicinSiR,--0ur continued 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 gentamicinresistance,l has supported our prediction that strains with high-level resistance to both gentamicin and vancomycin would emergeand pose difficulties for antimicrobial therapy. Since February,1991, we used standard microbiological methods to detect resistantstrains of E faecium in more than 1620 specimens taken on clinicalgrounds and in 500 specimens from screening.

In July of that year the first isolate of a vancomycin-resistant Efaecium was detected in a vaginal swab from a liver transplantpatient. Within the next 14 weeks, a further 23 patients with