To speak for the dead, to protect the living

myocardial infarction, syncope, transient ischaemic attacks, generalised convulsions, and monocular vision. Many doctors dealing with ill older drivers have had no training in advising on driving and only 1 in 4 is aware of information resources to help with decision making. Doctors might also be unaware of the increasing proportion of older people who drive.’’ Hospital doctors should routinely ask their patients about driving practices. They require training about guidelines for fitness to drive, as well as periodic updates of changes in the regulations. A brief summary of driving regulations might usefully be inserted in pocket guides for junior hospital doctors, as well as contact numbers for the medical section of driver licencing authorities. Desmond O’Neill, Thomas Crosby, Alistair Shaw, Richard Haigh, Timothy J Hendra Age-Related Health Care, Meath Hospital, Dublin 8, Ireland; Department of Care of the Elderly, Frenchay Hospital, Bristol; and Hallamshire Hospital, Sheffield

range,5 the surgical option might

not be

such

choice for

are not

especially severe.

Angela

women

whose symptoms

an

obvious

Coulter

Fund Centre for Health Services Development, 126 Albert Street, London NW1 7NF, UK

King’s

1

2

3

4

Department of Care of the Elderly, Royal 5

Coulter A, Peto V, Doll H. Patients’ preferences and general practitioners’ decisions in the treatment of menstrual disorders. Fam Pract 1994; 11: 67-74. Rankin L, Steinberg L. Transcervical resection of the endometrium: a review of 400 consecutive patients. Br J Obstet Gynaecol 1992; 99: 911-14. Dwyer N, Hutton J, Stirrat G. Randomised controlled trial comparing endometrial resection with abdominal hysterectomy for the surgical treatment of menorrhagia. Br J Obstet Gynaecol 1993; 100: 237-43. Milsom I, Anderson K, Andersch B, Rybo G. A comparison of flurbiprofen, tranexamic acid, and a levonorgestrel-releasing intrauterine contraceptive device in the treatment of idiopathic menorrhagia. Am J Obstet Gynaecol 1991; 164: 879-83. Fraser IS. The treatment of menorrhagia with mefenamic acid. Res Clin Forums 1983; 5: 93-99.

1 Department of Transport.

The older driver: measures for reducing the number of casualties among older people on our roads. London: Department of Transport, 1991. 2 O’Neill D. Physicians, elderly drivers, and dementia. Lancet 1992; 339: 41-43. 3 Raffle A, ed. Medical aspects of fitness to drive. London: HM Stationery Office, 1985: 92-93. 4 MacMahon M, Lawson J, O’Neill D, Kenny RA. Syncope and driving. Age Ageing 1994; 23 (suppl 4): 12. 5 Cartwright A. Medicine taking by people aged 65 or more. Br Med Bull 1990; 46: 63-76.

Trends in

gynaecological surgery

SiR-Bridgman’s

suggestion

(Sept

24,

p

893)

that

endometrial ablation is creating an additional demand for surgery instead of replacing hysterectomy is in accord with an analysis of data from Oxford Regional Health Authority

(table). Rates of endometrial ablation increased ninefold between 1988/89 and 1991/92, but hysterectomy rates also increased. In the latest figures endometrial ablation was more common than vaginal hysterectomy. As Bridgman suggests, it seems that the threshold for surgery has been reduced. Gynaecologists might be responding to a new demand from patients who would not have been willing to undergo hysterectomy. In other words, endometrial ablation might be substituting for drug therapy rather than hysterectomy.

Rates per 10 000

women.

Table: Hysterectomy and endometrial ablation, Oxford 1988-91

Patients’ preferences do influence decisions in the 1 management of menorrhagia,’ and minimally invasive surgery has generated considerable interest in the lay press. Women choosing this option should be given full information about the risks, benefits, and uncertainties of the treatment and its alternatives. We do not have evidence from long-term follow-up after endometrial ablation, but studies with short follow-up indicate that reoperation is necessary in 10-20% of cases and not all patients are satisfied with the results.2.3Since drugs are available that can reduce menstrual blood loss by about 50%/ and since many patients referred to gynaecology clinics with a complaint of heavy bleeding turn out to have losses within the normal

To

speak for the dead, to protect the living

SIR-Cordner’s article (Sept 17, p 799) on the role of coroners’ courts and the inquest procedure is both timely (on the 800th anniversary) and correct in its conclusions that the system may die out unless "the coroner concentrates on identifying and investigating potentially preventable deaths". The discussion, however, is deficient in three respects. The first is the part the inquest plays for the family and friends of the deceased in explaining exactly how the death occurred. The inquest is usually the only place where any type of detailed explanation is given. Death is a pretty big event in all our lives. Surely an objective investigation of any "suspicious death" is not too much to ask of any society? Second, in the UK, some inquests concern themselves with deaths in police custody. Since the coroners’ officers are in fact police officers this itself can prove a problem. When I first researched the role of the coroners courts in accident prevention,’ on contacting coroners in London I found one or two felt themselves "prisoners" of their officers in such investigations. This influence was somewhat formalised’ by legal restrictions on the riders an inquest jury could give after Blair Peach was killed in police custody whilst attending an anti-racist demonstration in the late 1970s. More recently, the verdict of "unlawful killing" by an inquest jury (against the advice of the Coroner) at the Zeebrugge disaster, where 193 lives were lost, was not available to the inquest jury examining the later King’s Cross disaster, where 31 lives were lost. The unavailability of the verdict was due to the publication of the government enquiry (which like the Sheen report on Zeebrugge, published before the inquest, firmly blamed management) after the inquest and due to direct instructions to the coroner from the Lord Chancellor not to offer the jury an "unlawful killing" verdict. A more recent Court of Appeal opinion appears to have restricted the role of coroners’ juries even further.’3 Finally, every year around 500 workplace accidental deaths, and many thousands of deaths due to occupational diseases (eg, asbestosis, mesothelioma, pneumoconiosis), have to be examined by the coroner by law. The Health and Safety Executive have shown that 3 out of 4 of these workplace deaths are preventable;’ usually by management action. The only place these deaths are examined in any detail is at the inquest and studies of such coroners reports’ have contributed to the widespread call for imprisonment for senior managers guilty of negligence resulting in a workplace death.

1367

We need a Royal Commission on the role of coroners In the words of the Coroners Association of Ontario, Canada, "To speak for the dead, to protect the living."

courts.

A JP Dalton 3 Montpelier Grove,

1

Kentish Town, London NW5 2XD. UK

Dalton AJP. Accidental death? Unions

the

at

inquest. Labour Res

1989; 78: 16-17. 2 3

4 5

Stuart RHB. The role of the coroner with special reference to major disasters. Med Sci Law 1988; 28: 275—85. Shaw T. Inquest juries ordered to curb opinions. The Daily Telegraph 1994 April 26. Dalton AJP. Health and safety—an agenda for change. Workers’ Education Association Studies for Trade Unionists 1991; 16: 1-40. Bergman D. Deaths at work, accidents or corporate crime—the failure of inquests and the criminal justice system. London Hazards Centre/Inquest/WEA, 1991.

Cost of medical SIR-I

publishing

interested to read Burton’s complaint (Sept 3, p 690) about publishers who charge for use of "their" copyrighted illustrations. Of course we must be sure that he’s not just the little boy who cries "wolf", but in my view his complaint is justified. The publisher of a colour atlas tried to charge me the c60 administration fee even though the illustration was to be used in a medical journal with no financial benefit to me. Fortunately in this case the same illustration had also been published as a colour transparency by another publisher (a loophole since blocked), so I got free use of the picture from which I hope the journal readers benefited, the author and the generous publisher got their credit, and the greedy publisher got nothing. I am sure most of us willingly allow colleagues to use our unpublished material (knowing that copyright will be lost) because we know that other colleagues will allow us to use their unpublished material, and in the hope that the publishers of such material would make it freely available to any who properly acknowledge its source. Information can only be transmitted efficiently by unfettered exchange of such material. It is difficult to know what can be done. One could refuse to allow unpublished material to be used by a third party, or charge for transfer of copyright. However, this would unnecessarily restrict access to good quality material. As one originator of superb illustrations commented "A sign of the times we now live in!" Market forces-unfortunately. was

Derrick Baxby Department of Medical Microbiology, Liverpool University, Liverpool

Effects of interleukin-2 vaccination in uraemic

hepatitis patients on

L69 3BX, UK

B

SiR-Jungers and colleagues report a trial in which uraemic patients, non-responders to previous hepatitis B vaccination, are revaccinated (Sept 24, p 856-57). Half the patients received interleukin-2 after hepatitis B vaccination, the other half received placebo. The reason for this investigation was a pilot study, reported by Meuer et al.’ Jungers et al did not follow the same protocol as Meuer et al, so that the results cannot be compared. Patient-entry criteria differ (uraemic patients versus patients on long-term haemodialysis); and both the vaccine and the interleukin-2 used were of different compositions and doses. In the pilot study H-B-VAX (Merck Sharp & Dohme) 40 jjbg and human 1

1368

Germany; 2-5X10" U/mL in mL) were given intramuscularly. In the placebo-controlled study, GenHevac B (Pasteur-Merieux, 20 fLg), containing the preS2 part of the HBsAg, and recombinant interleukin-2 (Roussel Uclaf; 1 MU in 0-2 mL) were used. Both were given subcutaneously. Considerable differences can exist between the hepatitis B vaccines, as Jungers notes, and natural interleukin-2 (Biotest, 1

between

natural

and

recombinant

interleukin-2

preparations.2 Important changes

to the schedule were also made. The 4-h interval between vaccine and interleukin-2 was changed to 5 min, an adaptation probably more convenient for both the patient and the investigator. Jungers et al reported an unusually high number of responders, in both the placebogroup (80%) and the interleukin-2 group (74%). Usually a third of people respond to a fifth and sixth vaccination in non-responders;’ this raises the question whether eligible patients were really non-responders at entry. To avoid this problem, patients should have been given hepatitis B vaccination shortly before entry to the study. Another explanation might be that the test used to measure anti-HBs was more sensitive than that used for previous determinations in the same patients. Considerable differences exist between anti-HBs tests.The test used in the report is not mentioned. Altogether, we feel that the conclusion of the study should be that recombinant interleukin-2 had no effect on hepatitis B vaccination with this study design, but the positive effect of natural interleukin-2 in Meuer and co-workers’ study is neither confirmed nor refuted.

G J Boland, G C de

Gast, J

van

Hattum

Departments of Gastroenterology and Immunohaematology, University Hospital Utrecht, 3584 CX Utrecht, Netherlands

1

2

3

4

Meuer SC, Dumann H, Meyer zum Büschenfelde K-H, Köhler H. Low-dose interleukin-2 induces systemic immune responses against HBsAg in immunodeficient non-responders to hepatitis B vaccination. Lancet 1989; i: 15-18. Thurman GB, Maluish AE, Rossio JL, et al. Comparative evaluation of multiple and recombinant human interleukin-2 preparations. J Biol Resp Med 1986; 5: 85-107. Wismans P, van Hattum J, Stelling T, Poel J, de Gast GC. Effect of supplementary vaccination in healthy non-responders to hepatitis B vaccination. Hepato-gastroenterol 1988; 35: 78-79. McCartney RA, Harbour J, Roome APCH, Calil EO. Comparison of enhanced chemiluminescence and microparticle enzyme immunoassay for the measurement of hepatitis B surface antibody. Vaccine 1993; 11: 941-45.

SiR Jungers and colleagues refer to our earlier work/,2 including a 1989 paper3in which we had reported that lowdose interleukin-2 induces systemic immune responses against HBsAg in immunodeficient non-responders to hepatitis B vaccination. With the vaccine GenHevacB (Pasteur-Merieux) the workers show that 80% of those who received placebo had seroconverted. This is almost the seroconversion rate found in healthy populations and it seems surprising that the individuals vaccinated here are designated non-responders. The high responsiveness can hardly be attributed to the pre-sAg-containing vaccine alone since a previous controlled study could not find a higher immunogenicity of pre-sAg vaccines in dialysis patients.# Given the high response rate in the placebo group and small differences between placebo and verum groups, 52 patients are by no means enough to detect a difference. Junger and co-workers’ trial cannot be compared with the approach that we took because vaccination was subcutaneous (vs intramuscular [im] in our protocol) with a different vaccine, at a four times higher dose of recombinant interleukin-2 given shortly after vaccination (in our study we had waited 4 h); the patient population we reported