at relatively high risk of developing systemic lupus erythematosus. Several health authorities have a high proportion of ethnic groups. Moreover, the expanding younger generations of ethnic minorities are reaching the age when end stage renal failure can develop. Health authorities will need to take these factors into account when planning future demand on the renal services. It is also important not to forget what might be achieved by measures to improve the control and treatment of hypertension, noninsulin dependent diabetes, and systemic lupus erythematosus, which may help to prevent or delay the onset of end stage renal failure. Dr Feest and colleagues may wish to reassure some health districts that they are starting to meet the real need as their acceptance rates approach 78 per million per year. There are clearly other districts, however, particularly in urban areas, where the incidence and thus demand on the renal services may be higher than the authors estimate. In future data on ethnic minorities should be included in renal information systems such as that of the European Dialysis and Transplant Association so that end stage renal failure in ethnic minorities can be monitored and studied further. JANE MELIA ROGER BEECH TONY SWAN United Medical and Dental Schools of Guy's and St Thomas's Hospitals, London SEI 7EH I McGeown MG. Prevalence of advanced renal failure in Northern Ireland. BMJf 1990;301:901-3. (20 October.) 2 Feest TG, Mallick NP, Mistry C. Incidence of advanced chronic renal failure and the need for end stage renal replacement treatment. BM3' 1990;301:897-900. (20 October.) 3 Rosansky SJ, Eggers PW. Trends in the US end stage renal disease population: 1973-1983. Amj Kidnev Dis 1987;9:91-7. 4 European Dialysis and Transplant Association, European Renal Association. Combined report on regular dialysis and transplantation in Europe, XIX? 1988. Nephrol Dial Transplant 1989;4(suppl 4). 5 Selby JV, FitzSimmons SC, Newman JM, Katz PP, Sepe S, Showstack J. The natural history and epidemiology of diabetic
nephropathy._7AMA 1990;263:1954-61.
Tubal pregnancy SIR,-Professor James Owen Drife discussed the diagnosis and treatment of ectopic pregnancy.' Fortunately the increased incidence of ectopic pregnancy has been associated with a fall in mortality from this condition, an important consideration for those concerned with microsurgery. We recently followed up our first 200 patients treated with microsurgery for infertility; all were operated on between 1979 and 1984. These women were unselected, microsurgery being offered however severe the tubo-ovarian disease. Sixty seven pregnancies were achieved, 10 of which were ectopic, an incidence of five per cent. The rate of ectopic pregnancy varied according to the operation that had been performed (table). In patients treated by proximal block many ectopic pregnancies occurred close to the site of the anastomosis, suggesting that a more radical excision of the damaged tube is required. We used sphnts only in deep proximal blocks. Although women requiring deep proximal blocks had a low pregnancy rate, this technique does not seem to be associated with an increased risk of ectopic pregnancy, and none of the women who had this
operation have had an ectopic pregnancy. The high incidence of ectopic pregnancy and poor live birth rates after reversal of sterilisation reflect poor selection criteria, most of these women having been investigated at and referred from other hospitals. The rates of ectopic pregnancy after salpingostomy and operations for mixed tubal problems were similar to those after proximal blocks, but our good results in patients with mixed tubal problems make treatment of this group the most encouraging. With improved methods of diagnosis the proportion of unruptured ectopic pregnancies treated is steadily rising. Assuming that they want to become pregnant again, we believe that these women are best treated conservatively. We incise the posteroinfero surface of the tube over the ectopic pregnancy with a microcautery needle; shell the pregnancy out, taking care to remove all trophoblastic tissue; and control bleeding with bipolar diathermy or fine prolene sutures. Because of the intense local tissue reaction we do not believe that formal reconstruction is usually successful at this stage and just close the tubal peritoneum with a continuous, fine subperitoneal prolene suture. Should further pregnancy fail to occur, formal microsurgical reconstruction of the tube at a later date is usually straightforward. We condemn the use of expectant treatment in ectopic pregnancy because of the risk of progressive tubo-ovarian damage and adhesions, which will require salpingo-oophorectomy some weeks later. This can result in expensive medicolegal action. MICHAEL BURKE CALLY NWOSU North Tyneside General Hospital, Tyne and Wear NE29 8NH
No of cases
Coroner's refusal or case continuing 14 Cardiac arrest 13 Relatives against donation, too distressed, or not found 9 Religious or cultural 4 No recipient 9 Transplant team unavailable 3 No intensive care bed available 2 Not enough time for arrangements: new surgeon in training I Donor had had cancer I Not suitable I Permission to approach family refused I No reason I
Coroner's refusal and intervening cardiac arrest were the main logistical reasons preventing organ donation. Reasons such as relatives against donation, too distressed, or not found and religious or cultural are not strictly logistical. They reflect a poorly worded question as well as respondents' wish to explain relatives' refusal. No recipient, no transplant team, or no intensive care bed was the third main grouping of proper logistical reasons preventing organ donation. SHEILA M GORE MRC Biostatistics Unit, Cambridge CB2 2BW
1 Gentleman D, Easton J, Jennett B. Brain death and organ donation in a neurosurgical unit: audit of recent practice. BM7 1990;301:1203-6. (24 November.) 2 Gore SM, Hinds CJ, Rutherford AJ. Organ donation from intensive care units in England. BMJ 1989;299:1193-7.
November.)
New prison health service Vitamin A and risk of birth defects SIR, - Dr Michael Nelson advises pregnant women to restrict their weekly consumption of liver sausage or pate to about 100 g a week to avoid the risk of fetal damage.' In fact, pregnant women should not be eating pate at all because of the possible risk of acquiring listeriosis. This advice was issued in press releases from the Department of Health in July and August 1989 and still stands. SUSAN M HALL
Communicable Disease Surveillance Centre, London NW9 5EQ I Nelson M. Vitamin A, liver consumption, and risk of birth defects. BM7 1990;301:1176. (24 November.)
Organ donation in a neurosurgical unit SIR,-Mr Douglas Gentleman and colleagues reported that of 109 medically suitable potential donors, only two were lost because of legal implications.' In 1989, 1014 potential donors were reported to the English audit. The table summarises 66 affirmative answers to the question on
Bilateral cuff salpingectomy
52
Logistical reasons preventing organ donation among 1014 potential donors
1 Drife JO. Tubal pregnancy. BMJ 1990;301:1057-8. (10
Rate ofectopic pregnancy according to operation perforned for infertility
No of women No of women having one or more successful pregnancies No (%) of total ectopic pregnancies
the audit form2 "Was organ donation prevented by logistical reasons? If yes, please specify."
62 5 3 (5)
Bilateral proximal blocks 22 9 2 (9)
Operation for mixed Reversal of tubal tubal tie problems 25 7 3 (12)
71 19 3 (12)
Repeat operation 20 1
SIR,-Dr Richard Smith's report of the scrutiny team's findings' prompts us to write. As retired full time members of the prison medical service we have always aspired to a better regarded service. Unfortunately, the nature of our work has prevented this from occurring. Several reviews and investigations of the medical service have taken place during the past 25 years, and we have experienced their effects first hand. Each raised our hopes for future wellbeing and organisation, only to dash them later because either the investigating body failed to grasp fully the complexity of the task or worthwhile recommendations were not followed through: once the spotlight had moved on other priorities soon took over. Society tends increasingly to use prisons as receptacles for its unwanted and difficult members. Furthermore, as many such prisoners are ill in mind or body, or both, and are often rejected by the NHS because of their behavioural problems an adequate medical service is needed to care for them. Thus prisons require a high level of medical resources and staffing, which raises Home Office costs. Of course we all accept that prisoners must receive medical attention to the same standard as that provided by the NHS, but society must realise that achieving this is not just a matter of better management of existing resources but one of large capital outlay. Furthermore, persistent offenders are unlikely to be materially changed by medical intervention, yet costly attempts must be made to identify and help those of them who might be. Treating prisoners, however, is open to exploitation by the patient and to the constant hazard of complaint and litigation, both of which waste time, effort, and money. Therefore although public safety is of paramount importance, we believe that whenever possible all treatment should be carried
BMJ VOLUME 302
5 JANUARY 1991
nephropathy._7AMA 1990;263:1954-61.
Tubal pregnancy SIR,-Professor James Owen Drife discussed the diagnosis and treatment of ectopic pregnancy.' Fortunately the increased incidence of ectopic pregnancy has been associated with a fall in mortality from this condition, an important consideration for those concerned with microsurgery. We recently followed up our first 200 patients treated with microsurgery for infertility; all were operated on between 1979 and 1984. These women were unselected, microsurgery being offered however severe the tubo-ovarian disease. Sixty seven pregnancies were achieved, 10 of which were ectopic, an incidence of five per cent. The rate of ectopic pregnancy varied according to the operation that had been performed (table). In patients treated by proximal block many ectopic pregnancies occurred close to the site of the anastomosis, suggesting that a more radical excision of the damaged tube is required. We used sphnts only in deep proximal blocks. Although women requiring deep proximal blocks had a low pregnancy rate, this technique does not seem to be associated with an increased risk of ectopic pregnancy, and none of the women who had this
operation have had an ectopic pregnancy. The high incidence of ectopic pregnancy and poor live birth rates after reversal of sterilisation reflect poor selection criteria, most of these women having been investigated at and referred from other hospitals. The rates of ectopic pregnancy after salpingostomy and operations for mixed tubal problems were similar to those after proximal blocks, but our good results in patients with mixed tubal problems make treatment of this group the most encouraging. With improved methods of diagnosis the proportion of unruptured ectopic pregnancies treated is steadily rising. Assuming that they want to become pregnant again, we believe that these women are best treated conservatively. We incise the posteroinfero surface of the tube over the ectopic pregnancy with a microcautery needle; shell the pregnancy out, taking care to remove all trophoblastic tissue; and control bleeding with bipolar diathermy or fine prolene sutures. Because of the intense local tissue reaction we do not believe that formal reconstruction is usually successful at this stage and just close the tubal peritoneum with a continuous, fine subperitoneal prolene suture. Should further pregnancy fail to occur, formal microsurgical reconstruction of the tube at a later date is usually straightforward. We condemn the use of expectant treatment in ectopic pregnancy because of the risk of progressive tubo-ovarian damage and adhesions, which will require salpingo-oophorectomy some weeks later. This can result in expensive medicolegal action. MICHAEL BURKE CALLY NWOSU North Tyneside General Hospital, Tyne and Wear NE29 8NH
No of cases
Coroner's refusal or case continuing 14 Cardiac arrest 13 Relatives against donation, too distressed, or not found 9 Religious or cultural 4 No recipient 9 Transplant team unavailable 3 No intensive care bed available 2 Not enough time for arrangements: new surgeon in training I Donor had had cancer I Not suitable I Permission to approach family refused I No reason I
Coroner's refusal and intervening cardiac arrest were the main logistical reasons preventing organ donation. Reasons such as relatives against donation, too distressed, or not found and religious or cultural are not strictly logistical. They reflect a poorly worded question as well as respondents' wish to explain relatives' refusal. No recipient, no transplant team, or no intensive care bed was the third main grouping of proper logistical reasons preventing organ donation. SHEILA M GORE MRC Biostatistics Unit, Cambridge CB2 2BW
1 Gentleman D, Easton J, Jennett B. Brain death and organ donation in a neurosurgical unit: audit of recent practice. BM7 1990;301:1203-6. (24 November.) 2 Gore SM, Hinds CJ, Rutherford AJ. Organ donation from intensive care units in England. BMJ 1989;299:1193-7.
November.)
New prison health service Vitamin A and risk of birth defects SIR, - Dr Michael Nelson advises pregnant women to restrict their weekly consumption of liver sausage or pate to about 100 g a week to avoid the risk of fetal damage.' In fact, pregnant women should not be eating pate at all because of the possible risk of acquiring listeriosis. This advice was issued in press releases from the Department of Health in July and August 1989 and still stands. SUSAN M HALL
Communicable Disease Surveillance Centre, London NW9 5EQ I Nelson M. Vitamin A, liver consumption, and risk of birth defects. BM7 1990;301:1176. (24 November.)
Organ donation in a neurosurgical unit SIR,-Mr Douglas Gentleman and colleagues reported that of 109 medically suitable potential donors, only two were lost because of legal implications.' In 1989, 1014 potential donors were reported to the English audit. The table summarises 66 affirmative answers to the question on
Bilateral cuff salpingectomy
52
Logistical reasons preventing organ donation among 1014 potential donors
1 Drife JO. Tubal pregnancy. BMJ 1990;301:1057-8. (10
Rate ofectopic pregnancy according to operation perforned for infertility
No of women No of women having one or more successful pregnancies No (%) of total ectopic pregnancies
the audit form2 "Was organ donation prevented by logistical reasons? If yes, please specify."
62 5 3 (5)
Bilateral proximal blocks 22 9 2 (9)
Operation for mixed Reversal of tubal tubal tie problems 25 7 3 (12)
71 19 3 (12)
Repeat operation 20 1
SIR,-Dr Richard Smith's report of the scrutiny team's findings' prompts us to write. As retired full time members of the prison medical service we have always aspired to a better regarded service. Unfortunately, the nature of our work has prevented this from occurring. Several reviews and investigations of the medical service have taken place during the past 25 years, and we have experienced their effects first hand. Each raised our hopes for future wellbeing and organisation, only to dash them later because either the investigating body failed to grasp fully the complexity of the task or worthwhile recommendations were not followed through: once the spotlight had moved on other priorities soon took over. Society tends increasingly to use prisons as receptacles for its unwanted and difficult members. Furthermore, as many such prisoners are ill in mind or body, or both, and are often rejected by the NHS because of their behavioural problems an adequate medical service is needed to care for them. Thus prisons require a high level of medical resources and staffing, which raises Home Office costs. Of course we all accept that prisoners must receive medical attention to the same standard as that provided by the NHS, but society must realise that achieving this is not just a matter of better management of existing resources but one of large capital outlay. Furthermore, persistent offenders are unlikely to be materially changed by medical intervention, yet costly attempts must be made to identify and help those of them who might be. Treating prisoners, however, is open to exploitation by the patient and to the constant hazard of complaint and litigation, both of which waste time, effort, and money. Therefore although public safety is of paramount importance, we believe that whenever possible all treatment should be carried
BMJ VOLUME 302
5 JANUARY 1991
