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approach is to carry out bulk staining of biopsy specimens, with subsequent microdissection and One

of individual crypts and villi villus area correlates very well with the gold standard of surface epithelial measurements, the number of epithelial cells per villus." Two such studies have been done, and both confirm the reports of reduced villus size in most HIV-infected patients.12,13 In the absence of other infections, crypts are short with a low mitotic activity; when there is associated opportunistic infection, the villi are short with slightly longer crypts, although these have inappropriately low mitotic activity in relation to the villus damage present. Studies of mucosal lymphocytes in duodenal biopsy specimens from HIV-infected patients have shown low counts of mucosal T cells, with a reduction in the T4 helper subset.14,15 Separate examination of the intraepithelial and lamina propria microenvironments gives a much clearer picture:16 within the epithelium T4 cells are absent in HIV infection whereas they comprise some 20% of IEL in normal individuals. Intraepithelial T8 cells are not depleted in AIDS. In the lamina propria there is striking depletion of T4 cells accompanied by a significant rise, two-fold or three-fold above control, in the number of T8 cells Markers of activated T cells--eg, IL-2 receptor expression-are absent.12 Control studies with other T-cell markers show that the loss of stainable T4 cells is not due to blocking of lymphocyte T4 receptors by HIV. There is one report of plasma cells in AIDS that shows a striking reduction in IgA cells with a concomitant increase in IgM plasma cells.l’ Further reports of intestinal secretory immunity are awaited. Abnormalities of the enterocytes that cover the shortened villi have been revealed by quantitative histochemistry. Thus, 15 of 25 HIV-infected patients had no detectable lactase activity in the duodenal brush border. 12 Ullrich et al do not mention the prevalence of clinical lactose intolerance in their patients, but clearly such investigations are merited. Undiagnosed lactose intolerance can lead to substantial morbidity when it is associated with other gastrointestinal diseases, yet is readily treated by

measurements

simple dietary manipulation. 10.

Ferguson A, Sutherland A, MacDonald TT, Allan F. Technique for microdissection and measurement in biopsies of human small intestine. J Clin Pathol 1977; 30: 1068-73.

11. Hasan

M, Ferguson A. Measurements of intestinal villi in non-specific and ulcer-associated duodenitis—correlation between area of microdissected villus and villus epithelial cell count. J Clin Pathol 1981; 34: 1181-86. 12. Ullrich R, Zeitz M, Heise W, L’age M, Hoffken G, Riecken EO. Small intestinal structure and function in patients infected with human immunodeficiency virus (HIV): evidence for HIV-induced enteropathy. Ann Intern Med 1989; 111: 15-21. 13. Cummins AG, LaBrooy JT, Stanley DP, Rowland R, Shearman DJC. A quantitative histological study of enteropathy associated with HIV infection. Gut (in press). 14. Ridgers VD, Fassett R, Kagnoff MF. Abnormalities in intestinal mucosal T cells in homosexual populations including those with the lymphadenopathy syndrome and acquired immunodeficiency syndrome. Gastroenterology 1986; 90: 552-58. 15. Budhraja M, Levendoglu H, Kocka F, Mangkornkanok M, Sherer R. Duodenal mucosal T cell subpopulation and bacterial cultures in acquired immune deficiency syndrome. Am J Gastroenterol 1987; 82: 427-31. 16. Ellakany S, Whiteside TL, Schade RR, van Thiel DH. Analysis of intestinal lymphocyte subpopulations in patients with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex. Am J Clin Pathol 1987; 87: 356-64. 17. Kotler DP, Scholes JV, Tiemey AR. Intestinal plasma cell alterations in acquired immunodeficiency syndrome. Dig Dhs Sci 1987; 32: 129-38.

have shown a methods Microdissection characteristic pattern of small-bowel mucosal abnormalities in HIV infection, with short, small villi and relative hypoplasia of the crypts. Is a diagnostic pathologist likely to recognise that such specimens are abnormal and different from coeliac disease? Probably yes, if the biopsy specimen is reasonably large and well-oriented. However, similar features are encountered in other conditions--eg, malnutrition, and after chemotherapy or radiotherapy. Only further investigations will show if there are specific histopathological characteristics that can differentiate HIV disease from these other hypoplastic

enteropathies. Homelessness BY definition the underprivileged of a settled society, the single homeless, attract as well as defy categorisation or the prescription of general remedies. Although the most superficial acquaintance suggests that individuals in this grey periphery are widely heterogeneous, it is only within the past few decades that serious efforts at investigation have been made. As long ago as 1906 Kraepelin pointed out that"... it is mere loss of labour to try to guide this heterogeneous crowd into the straight road ... so far as it is possible at all, it can only be done by treating each of these groups in accordance with its own special character. The first step in this direction is their scientific ...

investigation".1 Surveys in various settings have shown a high morbidity for physical illness, psychiatric disorder, and social disadvantage, both current and from the adverse circumstances of childhood. 2-5 Homeless single women constitute a small proportion of the population, around 10%. A characteristic group consists of middle-aged or elderly men who have gravitated into homelessness with the accumulation of adverse factors.6 Loss of employment, break-up of marriage (although most have never married), physical or mental ill-health, or a period of institutionalisation such as a prison sentence are all commonly found.7-12 Yet these factors of themselves can hardly account for homelessness; in addition, there is often earlier evidence of personality abnormality expressed in poor interpersonal relationships, and a solitary, feckless, or haphazard way of life and occupational history, as well perhaps as alcoholism or a criminal record. Such a person has been unable through life to build up resources of 1.

Kraepelin E. Clinical psychiatry: revised and edited by Thomas Johnston. 2nd English edition. London: Baillière Tindall & Cox, 1906. E, Mattick I, Bandler LS, Stein MR, Mintz NL. The drifters, children of disorganized lower-class families. In: Pavenstedt E, ed. The drifters International Psychiatry Clinics, no 4. Boston: Little, Brown, 1967. Hewetson J. Homeless people as an at-risk group. Proc R Soc Med 1978; 68: 9-13 Pnest RG. The Edinburgh homeless: a psychiatric survey. Am J Psychotherapy 1971, 25: 194-213. Lodge Patch IC. Homeless men—a London survey. Proc R Soc Med 1970; 63: 437-41. Bogue DJ. Skid row in American cities. Community and Family Study Center, University of Chicago, 1963

2. Malone CA, Pavenstedt

3.

4. 5. 6.

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friendship, family, or property that later on would help him to resist the impact of serious social stress or loss. Often a downward spiral can be traced, in which homelessness is increasingly prominent and the eventual end-point. The early recognition of such a process and its potential threat is a matter of public concern; any contribution to public policy is to be welcomed. initiative was taken in 1986 by the then Department of Health and Social Security, and has now led to a report by Williams and Allen at the Policy Studies Institute.13 These researchers describe the work of two multidisciplinary teams in London (Tower Hamlets and Camden) whose objectives were "to identify and contact as many homeless people as possible ... diagnose and treat their morbidity, [and] secure their admission to the list of a General Medical Practitioner. It was also hoped that the problems of alcoholism and homelessness would be tackled, with a view to rehabilitation where possible". The emphasis of the project lay in the provision of primary care to an unsettled, shifting, and morbid population who were not generally inclined to seek help for themselves. The teams provided their services in the hostels and centres where such men were to be found. They discussed with thirty-four general practitioners the possibilities of including the homeless on their lists and identified many difficulties arising from the population, from the GPs’ attitudes and experience, and from the ordinary administrative arrangements of the health service. Separate chapters record the opinions of different groups-the workers in the pilot schemes, the wardens of the hostels or centres-and in particular their views about the characteristics and needs of the homeless, the work of the two teams, and their proposals for the future. Overall Williams and Allen conclude that such multidisciplinary teams should not establish the pattern for provision of primary care to the homeless. Many could be incorporated into the existing "mainstream" services, given suitable encouragement and support as well as an educational programme for GPs and others to foster a change of attitude toward the homeless. These recommendations are naturally most appropriate for people who are not established in the homeless life, or whose personalities are well preserved, or those whose problems could be permanently solved simply by providing suitable housing. Unfortunately, for many or most, such

Such

an

7 Leach J,

Wing J. Helping destitute men Tavistock, London: 1980. common lodging houses and the people living m them. Glasgow Glasgow Corporation, 1956. 9. Lodge Patch IC. Homeless men in London. Demographic findings in a lodging house sample. Br J Psychiatry 1971; 118: 313-17. 10 Edwards G, Williamson V, Hawker A, Hensman C, Postoyan S. Census of a reception centre. Br J Psychiatry 1968; 114: 1031-39. 11 Scott R, Gaskell PG, Morrell DC Patients who reside in common lodging houses. Br Med J 1966; ii: 1561-64. 12.National Assistance Board.Homeless single persons. London: HM Stationery Office, 8. Laidlaw SIA. Glasgow

1966. 13.Williams S, Allen I Health Institute, 1989.

care

for

single homeless people. London: Policy Studies

conclusions

are likely to prove superficial or overoptimistic. Leach and Wing’ have described the difficulties of trying to rehabilitate homeless men. Proposals such as providing small homes14 instead of large, anonymous hostels or centres, however appealing, prove to be useful for only a very few individuals, and rehabilitation is, for the long-term homeless, a will-o’-the-wisp.The plight of the homeless will only improve with due of the wide acknowledgment heterogeneity of the population; their need is not for a single "solution" but for various contributions. Moreover, we must recognise that there will be a large residue who either cannot or do not wish to be incorporated again into settled society but whose lot nevertheless cries out for improvement. Unfortunately this report does not add much that is new, perhaps because of the terms of the original brief. Commonsense, confirmed by other surveys,t5-17 indicates a large psychiatric contribution to homelessness. Little cognisance of this fact was

shown in the new survey, and it may be relevant that the community psychiatric nurse found it impossible to work as part of these teams. The recommendation that more psychiatric provision is required is obvious. Today’s homeless are being added to in ways that are of great public concern,18 in particular by the mentally ill who have lost contact with the psychiatric services, and by the young who have lost contact with their social roots. A sustained improvement in their health and social care requires more than specific panaceas, or the commendable altruism displayed by workers in these teams. The report from the Policy Studies Institute will be valuable in focusing interest and in providing-or reiterating-background information. We hope that the Department of Health will proceed to further action in ways that are both nationwide and better informed. The medical and social needs of the homeless will not disappear by "securing their admission to the list of a General Medical Practitioner".

TOPICAL NSAIDs: A GIMMICK OR A GODSEND? THE Reverend Edmund Stone provided his patients with tea-like brew which contained salicin from the bark of the willow tree. He claimed-and no doubt many patients concurred-that this had good effect on the agues and rheumatism of the day.’ Some two hundred years later, and a

S, Orford J. Not quite like home. Small hostels for alcoholics and others. Chichester: John Wiley & Sons, 1978 15. Weller MPI. Mental illness—who cares? Nature 1989; 339: 249-52. 16 Tidmarsh D, Wood S. Psychiatric aspects of destitution: a study of the Camberwell Reception Centre In: Wing JK, Hailey AM, eds. 1972. Evaluating a community psychiatric service. The Camberwell Register 1964-71. Nuffield Provincial Hospitals Trust. London: Oxford University Press, 1971. 17 Reuler JB. Health care for the homeless in a traditional health program Am J Publ Health 1989; 79: 1033-34. 18. Association of Community Health Councils for England and Wales. Homelessness: the effects on health. ACHEW, 30 Drayton Park, London N5 1PB. £3. 1 Flower RJ, Moncada S, Vane JR. Analgesic-antipyretics and anti-inflammatory agents employed in the treatment of gout. In. Gilman AG, Goodman LS, Rall TW, Murad F, eds. Goodman and Gilman’s the pharmacological basis of therapeutics. 7th ed. New York: McMillan, 1985. 674-75. 14. Otto