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Neopterin, immune activation, and psoriasis
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including the type of headache, sensitivity to light and noise, fatigue, and impotence, are shared by patients with depression, not trauma. The most probable reason that psychosocial factors are irrelevant is that almost anybody is susceptible to this syndrome, in certain circumstances. These factors are commonly associated with highly emotional conditions, and often a well-meaning ambulance attendant or policeman at the scene of the accident will advise the patient, who feels otherwise well, that he should go to hospital just in case he has whiplash. The syndrome is not seen in playing-field injuries, however severe, or however trivial. The syndrome is also rarely seen without pending medicolegal compensation, which is often associated with a deep sense of grievance. The few patients who do not recover after the court settlement continue to nurse their grievance against the company or against the other driver because they feel they were inadequately compensated. This recurrent topic of a common problem is highly controversial. Much of the confusion has arisen from the observations of orthopaedic surgeons who know too little psychiatry, or psychiatrists who know too much. Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada M4N 3M5
Treatment of the ligaments is only logical in persistent ligamentous injuries. The only known treatment is prolotherapy. The first description of the efficacy of this treatment in cervical injuries was in the early 1960s.3 Treatment based on the principles outlined them as well as to chronic ligament injuires in the low back,4has been the subject of a reports showing substantial benefit to these patients, further demystifying a simple mechanical difficulty. The whole subject has also been reviewed.’ 1041 Murray Avenue, San Luis Obispo, California 93405, USA
THOMAS A. DORMAN
1 Hirsch SA, Hirsch PJ, Hiramoto H, et al. Whiplash syndrome, fact or fiction? Orthop Clin North Am 1988; 19. 2 Balla J, Karnaghan J. Whiplash headache. Clin Exp Neurol 1987; 23: 179-82. 3. Kayfetz DO, Blumental LS, Hackett GS, et al. Whiplash injury and other ligamentous headache: its management with prolotherapy. Headache 1963; 3: 1. 4. Ongley MJ, Klein RG, Dorman TA, et al. A new approach to the treatment of chronic back pain. Lancet 1987; ii: 143-46 5. Dorman TA. Treatment for spinal pain ansing m ligaments using prolotherapy: a retrospective survey. J Orthop Med (in press). 6. Dorman T Diagnosis and infection techniques m orthopedic medicine. Baltimore: 1991 Williams & Wilkins,
J. W. NORRIS
Neopterin, immune activation, and psoriasis SiR,—Dr Radanov and colleagues seem to suggest, from a rather small sample of 78 cases, that psychosocial problems are not important in persistent whiplash symptoms. Nevertheless they note (table n) that patients with residual symptoms six months after the injury had significantly more frequent dysfunctional families, poor school performance, previous behavioural problems, and current stress, compared with those who recovered quickly. Radanov et al do not provide details of preexisting conditions or treatment received, so we do not know whether these were factors in delayed
recovery.’1 Mills and Home2 noted ten times as many reported neck-sprain injuries (4321), in Victoria, Australia, than in a roughly equal population and equal accident frequency in New Zealand (424). Also, the Journal of the American Medical Association has published papers on whiplash injury since 1953,3 but 33 years passed before Deans and colleagues’ described the injury in the British Medical Journal, and more time elapsed before the Lancet discussed whiplash in British patients. Such a gap suggests that whiplash injury was not a substantial problem in the UK for many years and was partly the result of social copying in the USA, as it was in Victoria, Australia.2 305-7031 Westminster
MICHAEL LIVINGSTON
1. Farbmann AA. Neck sprain: associated factors. JAMA 1973; 223: 1010-15. H, Home G. Whiplash: manmade disease? N Z Med 1986; 99: 373-74. 3. Gay JR, Abbott KH. Common whiplash mjuires of the neck. JAMA 1953; 152: 1698-704. 4 Deans GT, McGailliard JN, Rutherford WH. Incidence and duration of neck pain among patients injured m car accidents. Br Med J 1986; 292: 94-95. 2. Mills
SIR,-Would it be simplistic to suggest to your readers that the of pain in whiplash injuries after rear-end automobile collisions is from injury to the ligaments and fasciae in the neck? The severity of pain, the associated symptoms of headache, shoulder pain, a numb-like feeling in the arms, and radiating dorsal pain are proportionate to the severity of the injury. The duration of symptoms and the inability to work is also longer in severe cases. There should, therefore, be no surprise at Dr Radanov and colleagues’ findings that psychological measures are a useless clinical predictor in these injuries. Other ligament sprains-for instance, an inversion injury of an ankle in a soccer me—are commonly accompanied by pain, swelling, and dysfunction some time after the acute event. The delay is characteristic, of ligament injuries and has been noted before in neck injury. As your accompanying editorial points out, measurements have been made of disruption of the longissimus colli and cervical sympathetic nerves from the "whip" part of the whiplash-but the posterior ligamentous structures in the neck are undoubtedly also damaged in the "lash" component. cause
psoriasis. They showed raised neopterin concentrations and significant correlation with the psoriasis area and severity index (PASI). Our data do not support these findings. In nine untreated patients with mild to severe psoriasis, immune activation was monitored by serum interleukin-2 (IL-2) receptor, soluble CD27, and neopterin concentrations. Serum IL-2 receptor and soluble CD27 values were raised in all patients, indicating T-cell activation.’ However, neopterin was substantially raised (12-8 nmol/l) in only one patient with mild psoriasis (PASI 6-6). Serum neopterin was not raised in the other eight patients, including three with severe psoriasis (p < 10 nmol/1). Moreover, no correlation (r= -0-05) was found between neopterin and PASI (range 2-9-15-2, mean 9-3) (unpublished results). Ample evidence has been presented that in psoriatic skin immune activation takes place, thus leading to interferon-gamma production by T lymphocytes.2 However, we feel that this is not always sufficient to induce detectable neopterin production and release by monocytes/macrophages in patients with mild to severe psoriasis. Department of Dermatology, University of Amsterdam,
Highway,
Richmond, British Columbia, Canada V6X 1A3
SiR,—Dr Fuchs and co-workers (Sept 21, p 759) report neopterin measurements (serum and urine) in seven patients with
1105 Amsterdam, Netherlands
MENNO A. DE RIE FRED HAMERLINCK JAN D. Bos
1. De Rie MA, Hamerlinck F, Hintzen RQ, et al. Quantition of soluble CD27, a T-cell activation antigen and soluble interleukin 2 receptor in serum from patients with psoriasis. Arch Dermatol Res (in press). 2. Barker JNWN. The pathophysiology of psoriasis. Lancet 1991, ii. 227-30.
Vitamin A supplementation and mortality SiR,—The four published trialsl-4 of vitamin A supplementation, of which Dr Loevinsohn and Dr Solter review selected
methodological aspects (Sept 14, p 701), claimed average reductions in mortality of 0, 30, 34, and 54%, respectively. Any attempt to try to reconcile these striking differences should also take into account the initial vitamin A status of the various populations. Impact of intervention and degree and prevalence of deficiency could be expected to be related. The table shows features of the four studies. There are evident reporting flaws and many inconsistencies between the methods used in the four trials. In trial IV (results) the prevalence of different signs is provided, but the percentage of cases in trials 1-111 cannot be compared with this. None of the trials used serum retinol, although this is recommended by the World Health Organisation.6 Since 1980, when the technical meeting that produced that report was held, a new dimension of the importance of vitamin A defiency at the subclinical level has been realised in relation to morbidity and mortality. Novel biochemical and histological techniques are being widely used in field studies and here too there is a need for standardisation. On two occasions WHO
including the type of headache, sensitivity to light and noise, fatigue, and impotence, are shared by patients with depression, not trauma. The most probable reason that psychosocial factors are irrelevant is that almost anybody is susceptible to this syndrome, in certain circumstances. These factors are commonly associated with highly emotional conditions, and often a well-meaning ambulance attendant or policeman at the scene of the accident will advise the patient, who feels otherwise well, that he should go to hospital just in case he has whiplash. The syndrome is not seen in playing-field injuries, however severe, or however trivial. The syndrome is also rarely seen without pending medicolegal compensation, which is often associated with a deep sense of grievance. The few patients who do not recover after the court settlement continue to nurse their grievance against the company or against the other driver because they feel they were inadequately compensated. This recurrent topic of a common problem is highly controversial. Much of the confusion has arisen from the observations of orthopaedic surgeons who know too little psychiatry, or psychiatrists who know too much. Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada M4N 3M5
Treatment of the ligaments is only logical in persistent ligamentous injuries. The only known treatment is prolotherapy. The first description of the efficacy of this treatment in cervical injuries was in the early 1960s.3 Treatment based on the principles outlined them as well as to chronic ligament injuires in the low back,4has been the subject of a reports showing substantial benefit to these patients, further demystifying a simple mechanical difficulty. The whole subject has also been reviewed.’ 1041 Murray Avenue, San Luis Obispo, California 93405, USA
THOMAS A. DORMAN
1 Hirsch SA, Hirsch PJ, Hiramoto H, et al. Whiplash syndrome, fact or fiction? Orthop Clin North Am 1988; 19. 2 Balla J, Karnaghan J. Whiplash headache. Clin Exp Neurol 1987; 23: 179-82. 3. Kayfetz DO, Blumental LS, Hackett GS, et al. Whiplash injury and other ligamentous headache: its management with prolotherapy. Headache 1963; 3: 1. 4. Ongley MJ, Klein RG, Dorman TA, et al. A new approach to the treatment of chronic back pain. Lancet 1987; ii: 143-46 5. Dorman TA. Treatment for spinal pain ansing m ligaments using prolotherapy: a retrospective survey. J Orthop Med (in press). 6. Dorman T Diagnosis and infection techniques m orthopedic medicine. Baltimore: 1991 Williams & Wilkins,
J. W. NORRIS
Neopterin, immune activation, and psoriasis SiR,—Dr Radanov and colleagues seem to suggest, from a rather small sample of 78 cases, that psychosocial problems are not important in persistent whiplash symptoms. Nevertheless they note (table n) that patients with residual symptoms six months after the injury had significantly more frequent dysfunctional families, poor school performance, previous behavioural problems, and current stress, compared with those who recovered quickly. Radanov et al do not provide details of preexisting conditions or treatment received, so we do not know whether these were factors in delayed
recovery.’1 Mills and Home2 noted ten times as many reported neck-sprain injuries (4321), in Victoria, Australia, than in a roughly equal population and equal accident frequency in New Zealand (424). Also, the Journal of the American Medical Association has published papers on whiplash injury since 1953,3 but 33 years passed before Deans and colleagues’ described the injury in the British Medical Journal, and more time elapsed before the Lancet discussed whiplash in British patients. Such a gap suggests that whiplash injury was not a substantial problem in the UK for many years and was partly the result of social copying in the USA, as it was in Victoria, Australia.2 305-7031 Westminster
MICHAEL LIVINGSTON
1. Farbmann AA. Neck sprain: associated factors. JAMA 1973; 223: 1010-15. H, Home G. Whiplash: manmade disease? N Z Med 1986; 99: 373-74. 3. Gay JR, Abbott KH. Common whiplash mjuires of the neck. JAMA 1953; 152: 1698-704. 4 Deans GT, McGailliard JN, Rutherford WH. Incidence and duration of neck pain among patients injured m car accidents. Br Med J 1986; 292: 94-95. 2. Mills
SIR,-Would it be simplistic to suggest to your readers that the of pain in whiplash injuries after rear-end automobile collisions is from injury to the ligaments and fasciae in the neck? The severity of pain, the associated symptoms of headache, shoulder pain, a numb-like feeling in the arms, and radiating dorsal pain are proportionate to the severity of the injury. The duration of symptoms and the inability to work is also longer in severe cases. There should, therefore, be no surprise at Dr Radanov and colleagues’ findings that psychological measures are a useless clinical predictor in these injuries. Other ligament sprains-for instance, an inversion injury of an ankle in a soccer me—are commonly accompanied by pain, swelling, and dysfunction some time after the acute event. The delay is characteristic, of ligament injuries and has been noted before in neck injury. As your accompanying editorial points out, measurements have been made of disruption of the longissimus colli and cervical sympathetic nerves from the "whip" part of the whiplash-but the posterior ligamentous structures in the neck are undoubtedly also damaged in the "lash" component. cause
psoriasis. They showed raised neopterin concentrations and significant correlation with the psoriasis area and severity index (PASI). Our data do not support these findings. In nine untreated patients with mild to severe psoriasis, immune activation was monitored by serum interleukin-2 (IL-2) receptor, soluble CD27, and neopterin concentrations. Serum IL-2 receptor and soluble CD27 values were raised in all patients, indicating T-cell activation.’ However, neopterin was substantially raised (12-8 nmol/l) in only one patient with mild psoriasis (PASI 6-6). Serum neopterin was not raised in the other eight patients, including three with severe psoriasis (p < 10 nmol/1). Moreover, no correlation (r= -0-05) was found between neopterin and PASI (range 2-9-15-2, mean 9-3) (unpublished results). Ample evidence has been presented that in psoriatic skin immune activation takes place, thus leading to interferon-gamma production by T lymphocytes.2 However, we feel that this is not always sufficient to induce detectable neopterin production and release by monocytes/macrophages in patients with mild to severe psoriasis. Department of Dermatology, University of Amsterdam,
Highway,
Richmond, British Columbia, Canada V6X 1A3
SiR,—Dr Fuchs and co-workers (Sept 21, p 759) report neopterin measurements (serum and urine) in seven patients with
1105 Amsterdam, Netherlands
MENNO A. DE RIE FRED HAMERLINCK JAN D. Bos
1. De Rie MA, Hamerlinck F, Hintzen RQ, et al. Quantition of soluble CD27, a T-cell activation antigen and soluble interleukin 2 receptor in serum from patients with psoriasis. Arch Dermatol Res (in press). 2. Barker JNWN. The pathophysiology of psoriasis. Lancet 1991, ii. 227-30.
Vitamin A supplementation and mortality SiR,—The four published trialsl-4 of vitamin A supplementation, of which Dr Loevinsohn and Dr Solter review selected
methodological aspects (Sept 14, p 701), claimed average reductions in mortality of 0, 30, 34, and 54%, respectively. Any attempt to try to reconcile these striking differences should also take into account the initial vitamin A status of the various populations. Impact of intervention and degree and prevalence of deficiency could be expected to be related. The table shows features of the four studies. There are evident reporting flaws and many inconsistencies between the methods used in the four trials. In trial IV (results) the prevalence of different signs is provided, but the percentage of cases in trials 1-111 cannot be compared with this. None of the trials used serum retinol, although this is recommended by the World Health Organisation.6 Since 1980, when the technical meeting that produced that report was held, a new dimension of the importance of vitamin A defiency at the subclinical level has been realised in relation to morbidity and mortality. Novel biochemical and histological techniques are being widely used in field studies and here too there is a need for standardisation. On two occasions WHO