- Email: [email protected]
GALACTOSYLATION OF IgG ASSOCIATED OLIGOSACCHARIDES
1401
diabetic patients with end-stage renal failure, the degree of
complications from other organs is not uniform. Some patients are in a much better general condition than many subjects with long-standing diabetes without nephropathy. The point of no return, beyond which all efforts are in vain, could therefore not be defined on the basis of the patient’s renal function. The results of the two studies do not exclude the possibility of long-term beneficial effects from normoglycaemia. It seems reasonable to assume that any such effects would be more pronounced in patients with previously poor metabolic control than in those with near normoglycaemia. When thoroughly informed many uraemic diabetic patients, considering the short-term result alone, find the extra risk inherent in a pancreas graft operation well worth taking. Others do not. Let it be their choice, not their physician’s or their surgeon’s. Department of Nephrology and Transplant Unit, Sahlgrenska Hospital, S-413 45 Goteborg, Sweden
GUDRUN NYBERG BENGT FRISK
Ramsey RC, Goetz FC, Sutherland DER, et al. Progression of diabetic retinopathy after pancreas transplantation for insulin-dependent diabetes mellitus. N Engl J Med 1988; 318: 208-14. 2. Solders G, Wilczek H, Gunnarson R, Tyden G, Persson A, Groth C-G. Effects of combined pancreatic and renal transplantation on diabetic neuropathy; a two-year follow-up study. Lancet 1987; ii: 1232-35. 3. Hanssen KF, Dahl-Jørgensen K, Lauritzen T, et al. Diabetic control and microvascular complications. the near-normoglycaemic experience. Diabetologia 1986; 29: 677-84. 4. Hillbom M, Wennberg A. Prognosis of alcoholic peripheral neuropathy. J Neurol Neurosurg Psychiatry 1984; 47: 699-703.
Medical social workers from a cytology research centre and auxilliary nurse/midwives and health visitors from a primary health centre in Alipur, Delhi, were trained by a gynaecologist (M. R.) to recognise cervical lesions. The emphasis was on recognising an abnormal cervix. The training consisted of six lectures with visual aids and practical demonstrations on patients. The technique of taking Papanicolaou smear was also taught. The training lasted for 12 weeks. 45 women
were examined by medical social workers in the gynaecological outpatients department of a teaching hospital and 59 women were examined by auxiliaries at the primary health centre (PHC). Overall agreement on the clinical diagnosis between gynaecologist and medical social workers was 76% while agreement between gynaecologist and auxiliaries was 81 % (table). After the short period of training these women could differentiate between a normal and an abnormal cervix. They overdiagnosed cervical erosions and underdiagnosed chronic cervicitis, which suggests that they require more practice in picking up cases of chronic cervicitis; but clearly health personnel such as these can be trained to make correct referrals for further investigation and management.
1.
Cytology Research Centre (ICMR), Maulana Azad Medical College Campus, New
Delhi-110 002, India
USHA K. LUTHRA MEERA ROY ASHOK SEHGAL
1. Anon. National cancer control programme for India. New Delhi: Directorate General of health and Family Welfare, 1984. 2. Anon. Control of cancer of uterine cervix: Report of a WHO meeting. Geneva: World Health Organisation, 1986
3. Stanley K. Clinical downstage screening. Presented at Technology Programme, held in New Delhi, India, in February, 1986.
Transfer
CLINICAL DOWNSTAGING OF UTERINE CERVIX BY PARAMEDICAL PERSONNEL
SIR,--Cervical cancer is the commonest cancer in Indian women,’ with about 92 000 new cases every year. In India, as in other developing countries, there are not enough trained staff to allow a cytological screening programme for all women at risk, and even if the number were to increase 12-fold only 25% of women at Z risk could be covered by cytoscreening by the turn of the century.2 An alternative strategy, suggested by the World Health Organisation, is "downstage screening"-ie, the clinical examination of the cervix in symptomless women in a primary health care setting.2 The objective of such screening is to recognise cervical cancer earlier, before symptoms present, and so improve the prognosis. 75% of stage I/II cervical cancers have erosions that clearly visible at the time of diagnosis50-80% of cases of carcinoma of the cervix in India are diagnosed at stages III or IV. If women seeking primary health care for whatever reason were to be given a pelvic examination, including speculum examination with a good light, these lesions could be picked up for further evaluation. However, India has too few doctors (especially women doctors), particularly in rural areas, for such a policy of clinical examination. The only alternative is to train paramedical personnel. are
CLINICAL DOWNSTAGE SCREENING: AGREEMENT IN DIAGNOSIS BETWEEN GYNAECOLOGIST AND MEDICAL SOCIAL WORKERS AND AUXILIARY NURSES, MIDWIVES, AND HEALTH VISITORS
GALACTOSYLATION OF IgG ASSOCIATED OLIGOSACCHARIDES
SIR,-Dr Parekh and colleagues (April 30, p 966) report reduced of IgG in immune mediated inflammatory conditions. The simplest interpretation must be that galactosylation is a function of the circulation time of the IgG molecule, and reduced galactosylation reflects increased turnover. A precedent for such a mechanism is the glycosylation of haemoglobin, reflecting both plasma glucose levels and red-cell lifespan.’ Evidence in favour of this interpretation presented by Parekh et al includes: (1) the inverse relation between galactosylation and disease activity across a wide range of diseases; (2) the sequential increase in proportion of galactosylated IgG in the juvenile arthritis patients entering remission; and (3) lower galactosylation during childhood (when recurrent infections sustain immunoglobulin synthesis and consumption) and after middle-age (when an increase in autoimmune activity and perhaps also malignancy would increase immunogloulin secretion and consumption). The hypothesis that a congenital or acquired defect in glycosylation of IgG is of aetiological relevance to inflammatory arthritis is not easily compatible with these normal data or with the sequential changes with disease activity. The only argument presented against this interpretation is that normal results have been reported in systemic lupus erythematosus (SLE) and leprosy, but other data suggest that, in SLE at least, galactosylation is reduced.2 It may be worth reassessing this assay as a measure of IgG turnover: as such it would provide a useful monitor for therapeutic management of the humoral immune (as opposed to the secondary inflammatory) components of this group
galactosylation
of disorders. Rheumatism Rehabilitation Research
School of Medicine, University of Leeds, Leeds LS2 9NZ
Unit,
ANDREW HARVEY
RM, Freedman DB, Liyanage SP, Dandona P. Glycosylated haemoglobin in rheumatoid arthritis Ann Rheum Dis 1982; 41: 604-06. 2 Tomana M, Schrohenloher RE, Koopman WJ, et al Abnormal glycosylation of serum IgG from patients with chronic inflammatory diseases. Arthritis Rheum 1988; 31: 333-38. 1 Bernstein
diabetic patients with end-stage renal failure, the degree of
complications from other organs is not uniform. Some patients are in a much better general condition than many subjects with long-standing diabetes without nephropathy. The point of no return, beyond which all efforts are in vain, could therefore not be defined on the basis of the patient’s renal function. The results of the two studies do not exclude the possibility of long-term beneficial effects from normoglycaemia. It seems reasonable to assume that any such effects would be more pronounced in patients with previously poor metabolic control than in those with near normoglycaemia. When thoroughly informed many uraemic diabetic patients, considering the short-term result alone, find the extra risk inherent in a pancreas graft operation well worth taking. Others do not. Let it be their choice, not their physician’s or their surgeon’s. Department of Nephrology and Transplant Unit, Sahlgrenska Hospital, S-413 45 Goteborg, Sweden
GUDRUN NYBERG BENGT FRISK
Ramsey RC, Goetz FC, Sutherland DER, et al. Progression of diabetic retinopathy after pancreas transplantation for insulin-dependent diabetes mellitus. N Engl J Med 1988; 318: 208-14. 2. Solders G, Wilczek H, Gunnarson R, Tyden G, Persson A, Groth C-G. Effects of combined pancreatic and renal transplantation on diabetic neuropathy; a two-year follow-up study. Lancet 1987; ii: 1232-35. 3. Hanssen KF, Dahl-Jørgensen K, Lauritzen T, et al. Diabetic control and microvascular complications. the near-normoglycaemic experience. Diabetologia 1986; 29: 677-84. 4. Hillbom M, Wennberg A. Prognosis of alcoholic peripheral neuropathy. J Neurol Neurosurg Psychiatry 1984; 47: 699-703.
Medical social workers from a cytology research centre and auxilliary nurse/midwives and health visitors from a primary health centre in Alipur, Delhi, were trained by a gynaecologist (M. R.) to recognise cervical lesions. The emphasis was on recognising an abnormal cervix. The training consisted of six lectures with visual aids and practical demonstrations on patients. The technique of taking Papanicolaou smear was also taught. The training lasted for 12 weeks. 45 women
were examined by medical social workers in the gynaecological outpatients department of a teaching hospital and 59 women were examined by auxiliaries at the primary health centre (PHC). Overall agreement on the clinical diagnosis between gynaecologist and medical social workers was 76% while agreement between gynaecologist and auxiliaries was 81 % (table). After the short period of training these women could differentiate between a normal and an abnormal cervix. They overdiagnosed cervical erosions and underdiagnosed chronic cervicitis, which suggests that they require more practice in picking up cases of chronic cervicitis; but clearly health personnel such as these can be trained to make correct referrals for further investigation and management.
1.
Cytology Research Centre (ICMR), Maulana Azad Medical College Campus, New
Delhi-110 002, India
USHA K. LUTHRA MEERA ROY ASHOK SEHGAL
1. Anon. National cancer control programme for India. New Delhi: Directorate General of health and Family Welfare, 1984. 2. Anon. Control of cancer of uterine cervix: Report of a WHO meeting. Geneva: World Health Organisation, 1986
3. Stanley K. Clinical downstage screening. Presented at Technology Programme, held in New Delhi, India, in February, 1986.
Transfer
CLINICAL DOWNSTAGING OF UTERINE CERVIX BY PARAMEDICAL PERSONNEL
SIR,--Cervical cancer is the commonest cancer in Indian women,’ with about 92 000 new cases every year. In India, as in other developing countries, there are not enough trained staff to allow a cytological screening programme for all women at risk, and even if the number were to increase 12-fold only 25% of women at Z risk could be covered by cytoscreening by the turn of the century.2 An alternative strategy, suggested by the World Health Organisation, is "downstage screening"-ie, the clinical examination of the cervix in symptomless women in a primary health care setting.2 The objective of such screening is to recognise cervical cancer earlier, before symptoms present, and so improve the prognosis. 75% of stage I/II cervical cancers have erosions that clearly visible at the time of diagnosis50-80% of cases of carcinoma of the cervix in India are diagnosed at stages III or IV. If women seeking primary health care for whatever reason were to be given a pelvic examination, including speculum examination with a good light, these lesions could be picked up for further evaluation. However, India has too few doctors (especially women doctors), particularly in rural areas, for such a policy of clinical examination. The only alternative is to train paramedical personnel. are
CLINICAL DOWNSTAGE SCREENING: AGREEMENT IN DIAGNOSIS BETWEEN GYNAECOLOGIST AND MEDICAL SOCIAL WORKERS AND AUXILIARY NURSES, MIDWIVES, AND HEALTH VISITORS
GALACTOSYLATION OF IgG ASSOCIATED OLIGOSACCHARIDES
SIR,-Dr Parekh and colleagues (April 30, p 966) report reduced of IgG in immune mediated inflammatory conditions. The simplest interpretation must be that galactosylation is a function of the circulation time of the IgG molecule, and reduced galactosylation reflects increased turnover. A precedent for such a mechanism is the glycosylation of haemoglobin, reflecting both plasma glucose levels and red-cell lifespan.’ Evidence in favour of this interpretation presented by Parekh et al includes: (1) the inverse relation between galactosylation and disease activity across a wide range of diseases; (2) the sequential increase in proportion of galactosylated IgG in the juvenile arthritis patients entering remission; and (3) lower galactosylation during childhood (when recurrent infections sustain immunoglobulin synthesis and consumption) and after middle-age (when an increase in autoimmune activity and perhaps also malignancy would increase immunogloulin secretion and consumption). The hypothesis that a congenital or acquired defect in glycosylation of IgG is of aetiological relevance to inflammatory arthritis is not easily compatible with these normal data or with the sequential changes with disease activity. The only argument presented against this interpretation is that normal results have been reported in systemic lupus erythematosus (SLE) and leprosy, but other data suggest that, in SLE at least, galactosylation is reduced.2 It may be worth reassessing this assay as a measure of IgG turnover: as such it would provide a useful monitor for therapeutic management of the humoral immune (as opposed to the secondary inflammatory) components of this group
galactosylation
of disorders. Rheumatism Rehabilitation Research
School of Medicine, University of Leeds, Leeds LS2 9NZ
Unit,
ANDREW HARVEY
RM, Freedman DB, Liyanage SP, Dandona P. Glycosylated haemoglobin in rheumatoid arthritis Ann Rheum Dis 1982; 41: 604-06. 2 Tomana M, Schrohenloher RE, Koopman WJ, et al Abnormal glycosylation of serum IgG from patients with chronic inflammatory diseases. Arthritis Rheum 1988; 31: 333-38. 1 Bernstein