- Email: [email protected]
" HIGH ISOLATION " ACCOMMODATION FOR INFECTIOUS DISEASES
32
department. There is a weekly combined psychiatric/ geriatric round, involving day as well as inpatients, so making combined assessment possible without admission. There is little transfer of patient between unit, since There are facilities and advice are available to both. various ways of dealing with misplacement-dependent upon circumstances-without extra facilities or personnel, provided there is enough mutual interest. Department of Psychiatrics and Department of Geriatrics, Geriatric
TONY WHITEHEAD GANESH MANKIKAR.
Brighton Sussex.
SULPHATE INCORPORATION OF LEUCOCYTES FROM PATIENTS WITH CYSTIC FIBROSIS
The amount of Na235S04 incorporated into G.A.G. material found in both the incubation medium and the cells from c.F. patients is significantly increased over normals. A similar analysis between normals and heterozygotes shows no significant difference in Na, 35SO, incorporation into G.A.G. material of the cells. However, 4 out of 6 heterozygotes appeared to show a pattern of increased incorporation:into:material found in the incubation medium (indicated a higher mean than the normal donors). Within the group of c.F. patients, variation was observed in the amounts of 35S04 incorporated into G.A.G. material found inside the cells and in the I.M. The variation in sulphate incorporation could not be correlated with clinical status, age, or sex of the patients. Therefore, the patients were arranged in what appeared to be three distinct groups based on values recorded for i.m.-35SO, G.A.G. as follows:
by
SiR,-Your editorial of Aug. 11 (p. 307) comments on suspected genetic heterogeneity of cystic fibrosis (c.F.). preliminary studies of short-term leucocyte cultures
the In
incorporation into cetyl-pyridinium(c.P.c.)-precipitable material (presumably glycosaminoglycans, G.A.G.), we have found significant variation among c.F. patients and their parents (obligate hetero-
using Na2 35S04 chloride
zygotes). This biochemical heterogeneity is comparable to what has been reported in fibroblast cultures 1-3 and serum.4 20-40 ml. of blood was collected by venepuncture and the leucocytes, predominantly neutrophils (83%), were isolated as described by Stjernholm. The cells were incubated (in duplicate samples) in Fischer’s medium for leukaemic mice cells (GIBCO) with 50 ILC Na.35S04 (specific activity 350 mC per mmol) at a concentration of about 5 x 10. cells per 10 ml. medium for 4 hours 37°C. After incubation the cells were separated from the medium by centrifugation, and subjected to R.N.A.se, D.N.A.se, and papain digestion following the procedure of Olsson.. This was followed by addition of 1 mg. of chondroitin sulphate as carrier and precipitation with 1.5 ml. of 0-1% c.P.c. The precipitate was washed 5 times with 10 ml. of distilled water to remove excess Na.’DS04 and then resuspended in 150 ILL 0-1% c.P.c. and dissolved in 200 1. of n-propanol. Radioactivity was determined in a Packard liquid scintillation counter after addition of * Aquasol ’. 1 mg. of chondroitin sulphate was added as carrier to 1 ml. of incubation medium (l.M.) and the G.A.G. precipitated with 1-5 ml. of 0-1% c.P.c., washed 5 times with 10 ml. of water, dissolved, and counted as described for the cell fraction. at
The results
Group 1 shows a normal 35S0 incorporation pattern into G.A.G. from both the cells and l.M., group 2 shows increased 35S0 incorporation of cellular G.A.G. with normal incorporation into G.A.G. found in the l.M., while group 3 shows an increase over normal in 35S0 incorporation into G.A.G. from both the cells and l.M. A correlation of these results with the presence of metachromasia would be of interest. Additional studies need to be carried out to determine whether the increase in 35S0 labelling is correlated with a quantitative increase in G.A.G. or in increased sulphation of G.A.G. or other sulphated compounds present in the leucocytes. These results suggest yet another system to study the effects of the c.F. gene. The incorporation of Na235S04 into G.A.G. material of C.F. leucocyte cultures gives additional evidence for the genetic heterogeneity in this disorder. This study was supported by a U.S.P.H.S. grant, N.I.H. Ca-13214. The help of Dr Robert Stern and the Department of Pediatrics, Rainbow Babies’ and Children’s Hospital, Cleveland, Ohio, is gratefully acknowledged.
Department of Anatomy, Case Western Reserve
University, Cleveland, Ohio 44106, U.S.A Department of Pediatrics, Cleveland Metropolitan General Hospital,
were:
Cleveland, Ohio.
MARGARET CAUDILL.
IRWIN SCHAFER.
Department of Biochemistry, Case Western Reserve
University, Cleveland, Ohio.
RUNE
STJERNHOLM.
" HIGH ISOLATION " ACCOMMODATION FOR INFECTIOUS DISEASES *
Normal donors
The Student’s
were
t test was
matched for age and
applied
to
sex.
the data:
SIR,-Professor Grist’s invitation (Dec. 8,
p. 1340) for the containment of infectious diseases by unsophisticated and inexpensive methods prompts me to report what we have been doing, apparently with complete success, in the children’s ward at Amersham for the past
views
on
ten years. 1. Danes, B. 2. Danes, B.
S., Beam, A. G. J. exp. Med. 1969, 129, 775. S., Beam, A. G. Biochem. biophys. Res. Comm. 1969,
36, 919. 3. Matalon, R., Dorfman, A. ibid. 1968, 33, 954. 4. Conover, J. H., Conod, E. F., Hirschhorn, K. Lancet, 1973, i, 1122. 5. Stjernholm, R. L., Dimitrov, N. V., Pijanoswki, L. J. J. reticuloend. Soc. 1969, 6, 194. 6. Olsson, I., Gardell, S. Biochim. biophys. Acta, 1967, 141, 348.
Two of the cubicles have French windows. When used for isolation purposes the doors of these cubicles to the ward corridor are bolted. The infectious child is admitted through the window. A notice is put on the cubicle door " Isolation, use outside entrance ". No caps, masks, or gowns are used. Parents are allowed to stay or come and go as they please, but they and other visitors and all members of staff must enter and leave only by the French windows.
33 The ward has a very rapid turnover and it is possible that cross-infection may have occurred without our being aware of it, but in four cases of chickenpox admitted in this way postcard follow-up of susceptibles failed to reveal any secondary cases.
Isolation units in children’s wards which are approached from the inside, whatever their ventilation arrangements, are in my opinion expensive ineffectual anachronisms. One of these is nearing completion in a hospital not far from Amersham, and it will be interesting to see whether it proves to be as effective as our simple arrangements. Amersham General Hospital Amersham, Bucks. HP7 0JD.
DONALD GARROW.
INCREASED SUSCEPTIBILITY OF RED-BLOODCELL LIPIDS TO AUTOXIDATION IN THALASSÆMIA MAJOR
SIR,-Stocks et a1.l found in 6 cases of thalassacmia major an increased tendency to autoxidation of red-bloodcell lipids. They used a test based on the breakdown of autoxidised fats to malonyldialdehyde. Others2 are of the opinion that this test is only an indirect index of oxidation. TOTAL AND FRACTIONATED LIPIDS RED
CELLS)
PHOSPHOLIPIDS) MAJOR
(mg.
per 100 ml. OF PACKED
AND FRACTIONATED PHOSPHOLIPIDS
AND IN
IN
20
20
PATIENTS
NORMAL
AFFECTED
BY
(%
OF TOTAL
of the rectal stump which is returned to the pelvis: restoration to be undertaken at a later date. This procedure should, however, be reserved for those cases in which the lesion is relatively high in the sigmoid colon. If the growth is lower, the surgeon would be well advised to abandon this method and rely upon the traditional transverse
colostomy.
In the light of recent experience, if the rectosigmoid and upper rectum are mobilised out of the sacral hollow, restoration of continuity may be extremely difficult, and even hazardous, owing to extensive adhesions of small bowel to the pelvic floor. Difficulty may also be experienced in finding the buried rectal stump. Royal United Hospital, Combe Park,
P. J. JEFFERY.
Bath.
BILE CANALICULI ANTIBODIES : BENIGN OR PATHOLOGICAL ?
SIR,-As reiterated earlier this year,l.2 various types of circulating anti-tissue antibodies (autoantibodies) have been described in patients with liver disease. While these reports offer further confirmation
to
THALA&S/E.MIA
SUBJECTS
FREQUENCY
previous reports
3.4
of the
AND RANGES IN INDIRECT IMMUNOFLUORESCENT
(I.F.)
STAINING TITRES OF BILE CANALICULAR ANTIBODY IN PATIENTS WITH CARCINOMA OF THE PROSTATE
We studied by thin-layer chromatography the composition of lipids in the red cells of 20 children with thalassxmia major living in the north of Sardinia. Precautions were used to avoid an altered distribution of lipids. Samples were collected in tubes containing vitamin E, and chromatographic solvents were added with 2,6-di-tert-butyl-p-cresol, as suggested by Dodge and Phillips,3 to prevent oxidation. The results, compared with normal controls (see table), show a significant increase of sphingomyelin and phosphatidylcholine and a significant reduction of phosphatidylethanolamine. These findings, the result of autoxidation of lipids,3 confirm the results of Stocks and his colleagues. Further investigation could be useful, in view of the possible use of antioxidant agents to prevent haemolysis. I Clinica Pediatrica, Università di Roma, Via le Regina Elena 324, 00161, Roma. Istituto di Puericoltura, Università di Sassari, Sardinia.
OMERO GIARDINI MASSIMO CASTRO GIORGIO MAGGIONI.
TREATMENT OF OBSTRUCTION DUE TO CARCINOMA OF THE COLON
SiR,—There is
a
school of
thought which
advocates
immediate resection for acutely obstructing carcinomatous lesions of the left colon. A method was described by Sames 4,5 with resection of the lesion, formation of an end colostomy in the upper end of the wound, and oversewing 1. 2. 3. 4. 5.
Stocks, J., Kemp, M., Dormandy, T. L. Lancet, 1971, i, 266. Shohet, S. B. New Engl. J. Med. 1972, 286, 638. Dodge, J. T., Phillips, G. B. J. Lipid Res. 1966, 7, 387. Sames, C. P. Lancet, 1960, ii, 948. Sames, C. P. Proc. R. Soc. Med. 1968, 61, 374.
*
* Adapted from Ablin and Soanes.s t Classification of stage of carcinoma of the
according
to
4 (80%) means that 4 patients or 80% had indirect
i.a.
prostate
Flocks.6 ‡ For
example,
staining titres of antibodies from 1/40 to 1/80.
to
bile canaliculi
on
rabbit liver ranging
to bile canaliculi in liver disease and " the support suggested association of autoallergic w-tiological factors in liver disease ’’,1 the demonstration of antibody to bile canaliculi in the absence of any confirmed liver abnormality in patients with carcinoma of the prostate11 raises the question of the pathophysiological specificity of these antibodies. As summarised in the accompanying table, variable titres of antibody reactive with bile canaliculi of rabbit liver have been noted by the method of indirect (" sandwich ") immunofluorescence in a significant proportion (17 out of 24) of patients with various clinically and histologically staged carcinoma of the prostate.s Observations such as these suggest that we may be observing antibodies which are pathologically related to normal processes of ageing rather than a specific disease entity. That is, with the decline of humoral and cellmediated immunological capability with age, does the host
presence of
antibody
seem to
MacSween, R. N. M., Armstrong, E. M., Gray, K. G., Mason, M. Lancet, 1973, i, 1419. 2. Diederichsen, H. ibid. 1973, ii, 326. 3. Bumbalo, T. S., Bellanti, J. A., Terplan, K. L. Pediatrics, Springfield, 1961, 29, 191. 4. Diederichsen, H. Acta med. scand. 1969, 186, 299. 5. Ablin, R. J., Soanes, W. A. Ann. clin. Res. 1971, 3, 226. 6. Flocks, R. H J. Urol. 1969, 101, 741. 1.
department. There is a weekly combined psychiatric/ geriatric round, involving day as well as inpatients, so making combined assessment possible without admission. There is little transfer of patient between unit, since There are facilities and advice are available to both. various ways of dealing with misplacement-dependent upon circumstances-without extra facilities or personnel, provided there is enough mutual interest. Department of Psychiatrics and Department of Geriatrics, Geriatric
TONY WHITEHEAD GANESH MANKIKAR.
Brighton Sussex.
SULPHATE INCORPORATION OF LEUCOCYTES FROM PATIENTS WITH CYSTIC FIBROSIS
The amount of Na235S04 incorporated into G.A.G. material found in both the incubation medium and the cells from c.F. patients is significantly increased over normals. A similar analysis between normals and heterozygotes shows no significant difference in Na, 35SO, incorporation into G.A.G. material of the cells. However, 4 out of 6 heterozygotes appeared to show a pattern of increased incorporation:into:material found in the incubation medium (indicated a higher mean than the normal donors). Within the group of c.F. patients, variation was observed in the amounts of 35S04 incorporated into G.A.G. material found inside the cells and in the I.M. The variation in sulphate incorporation could not be correlated with clinical status, age, or sex of the patients. Therefore, the patients were arranged in what appeared to be three distinct groups based on values recorded for i.m.-35SO, G.A.G. as follows:
by
SiR,-Your editorial of Aug. 11 (p. 307) comments on suspected genetic heterogeneity of cystic fibrosis (c.F.). preliminary studies of short-term leucocyte cultures
the In
incorporation into cetyl-pyridinium(c.P.c.)-precipitable material (presumably glycosaminoglycans, G.A.G.), we have found significant variation among c.F. patients and their parents (obligate hetero-
using Na2 35S04 chloride
zygotes). This biochemical heterogeneity is comparable to what has been reported in fibroblast cultures 1-3 and serum.4 20-40 ml. of blood was collected by venepuncture and the leucocytes, predominantly neutrophils (83%), were isolated as described by Stjernholm. The cells were incubated (in duplicate samples) in Fischer’s medium for leukaemic mice cells (GIBCO) with 50 ILC Na.35S04 (specific activity 350 mC per mmol) at a concentration of about 5 x 10. cells per 10 ml. medium for 4 hours 37°C. After incubation the cells were separated from the medium by centrifugation, and subjected to R.N.A.se, D.N.A.se, and papain digestion following the procedure of Olsson.. This was followed by addition of 1 mg. of chondroitin sulphate as carrier and precipitation with 1.5 ml. of 0-1% c.P.c. The precipitate was washed 5 times with 10 ml. of distilled water to remove excess Na.’DS04 and then resuspended in 150 ILL 0-1% c.P.c. and dissolved in 200 1. of n-propanol. Radioactivity was determined in a Packard liquid scintillation counter after addition of * Aquasol ’. 1 mg. of chondroitin sulphate was added as carrier to 1 ml. of incubation medium (l.M.) and the G.A.G. precipitated with 1-5 ml. of 0-1% c.P.c., washed 5 times with 10 ml. of water, dissolved, and counted as described for the cell fraction. at
The results
Group 1 shows a normal 35S0 incorporation pattern into G.A.G. from both the cells and l.M., group 2 shows increased 35S0 incorporation of cellular G.A.G. with normal incorporation into G.A.G. found in the l.M., while group 3 shows an increase over normal in 35S0 incorporation into G.A.G. from both the cells and l.M. A correlation of these results with the presence of metachromasia would be of interest. Additional studies need to be carried out to determine whether the increase in 35S0 labelling is correlated with a quantitative increase in G.A.G. or in increased sulphation of G.A.G. or other sulphated compounds present in the leucocytes. These results suggest yet another system to study the effects of the c.F. gene. The incorporation of Na235S04 into G.A.G. material of C.F. leucocyte cultures gives additional evidence for the genetic heterogeneity in this disorder. This study was supported by a U.S.P.H.S. grant, N.I.H. Ca-13214. The help of Dr Robert Stern and the Department of Pediatrics, Rainbow Babies’ and Children’s Hospital, Cleveland, Ohio, is gratefully acknowledged.
Department of Anatomy, Case Western Reserve
University, Cleveland, Ohio 44106, U.S.A Department of Pediatrics, Cleveland Metropolitan General Hospital,
were:
Cleveland, Ohio.
MARGARET CAUDILL.
IRWIN SCHAFER.
Department of Biochemistry, Case Western Reserve
University, Cleveland, Ohio.
RUNE
STJERNHOLM.
" HIGH ISOLATION " ACCOMMODATION FOR INFECTIOUS DISEASES *
Normal donors
The Student’s
were
t test was
matched for age and
applied
to
sex.
the data:
SIR,-Professor Grist’s invitation (Dec. 8,
p. 1340) for the containment of infectious diseases by unsophisticated and inexpensive methods prompts me to report what we have been doing, apparently with complete success, in the children’s ward at Amersham for the past
views
on
ten years. 1. Danes, B. 2. Danes, B.
S., Beam, A. G. J. exp. Med. 1969, 129, 775. S., Beam, A. G. Biochem. biophys. Res. Comm. 1969,
36, 919. 3. Matalon, R., Dorfman, A. ibid. 1968, 33, 954. 4. Conover, J. H., Conod, E. F., Hirschhorn, K. Lancet, 1973, i, 1122. 5. Stjernholm, R. L., Dimitrov, N. V., Pijanoswki, L. J. J. reticuloend. Soc. 1969, 6, 194. 6. Olsson, I., Gardell, S. Biochim. biophys. Acta, 1967, 141, 348.
Two of the cubicles have French windows. When used for isolation purposes the doors of these cubicles to the ward corridor are bolted. The infectious child is admitted through the window. A notice is put on the cubicle door " Isolation, use outside entrance ". No caps, masks, or gowns are used. Parents are allowed to stay or come and go as they please, but they and other visitors and all members of staff must enter and leave only by the French windows.
33 The ward has a very rapid turnover and it is possible that cross-infection may have occurred without our being aware of it, but in four cases of chickenpox admitted in this way postcard follow-up of susceptibles failed to reveal any secondary cases.
Isolation units in children’s wards which are approached from the inside, whatever their ventilation arrangements, are in my opinion expensive ineffectual anachronisms. One of these is nearing completion in a hospital not far from Amersham, and it will be interesting to see whether it proves to be as effective as our simple arrangements. Amersham General Hospital Amersham, Bucks. HP7 0JD.
DONALD GARROW.
INCREASED SUSCEPTIBILITY OF RED-BLOODCELL LIPIDS TO AUTOXIDATION IN THALASSÆMIA MAJOR
SIR,-Stocks et a1.l found in 6 cases of thalassacmia major an increased tendency to autoxidation of red-bloodcell lipids. They used a test based on the breakdown of autoxidised fats to malonyldialdehyde. Others2 are of the opinion that this test is only an indirect index of oxidation. TOTAL AND FRACTIONATED LIPIDS RED
CELLS)
PHOSPHOLIPIDS) MAJOR
(mg.
per 100 ml. OF PACKED
AND FRACTIONATED PHOSPHOLIPIDS
AND IN
IN
20
20
PATIENTS
NORMAL
AFFECTED
BY
(%
OF TOTAL
of the rectal stump which is returned to the pelvis: restoration to be undertaken at a later date. This procedure should, however, be reserved for those cases in which the lesion is relatively high in the sigmoid colon. If the growth is lower, the surgeon would be well advised to abandon this method and rely upon the traditional transverse
colostomy.
In the light of recent experience, if the rectosigmoid and upper rectum are mobilised out of the sacral hollow, restoration of continuity may be extremely difficult, and even hazardous, owing to extensive adhesions of small bowel to the pelvic floor. Difficulty may also be experienced in finding the buried rectal stump. Royal United Hospital, Combe Park,
P. J. JEFFERY.
Bath.
BILE CANALICULI ANTIBODIES : BENIGN OR PATHOLOGICAL ?
SIR,-As reiterated earlier this year,l.2 various types of circulating anti-tissue antibodies (autoantibodies) have been described in patients with liver disease. While these reports offer further confirmation
to
THALA&S/E.MIA
SUBJECTS
FREQUENCY
previous reports
3.4
of the
AND RANGES IN INDIRECT IMMUNOFLUORESCENT
(I.F.)
STAINING TITRES OF BILE CANALICULAR ANTIBODY IN PATIENTS WITH CARCINOMA OF THE PROSTATE
We studied by thin-layer chromatography the composition of lipids in the red cells of 20 children with thalassxmia major living in the north of Sardinia. Precautions were used to avoid an altered distribution of lipids. Samples were collected in tubes containing vitamin E, and chromatographic solvents were added with 2,6-di-tert-butyl-p-cresol, as suggested by Dodge and Phillips,3 to prevent oxidation. The results, compared with normal controls (see table), show a significant increase of sphingomyelin and phosphatidylcholine and a significant reduction of phosphatidylethanolamine. These findings, the result of autoxidation of lipids,3 confirm the results of Stocks and his colleagues. Further investigation could be useful, in view of the possible use of antioxidant agents to prevent haemolysis. I Clinica Pediatrica, Università di Roma, Via le Regina Elena 324, 00161, Roma. Istituto di Puericoltura, Università di Sassari, Sardinia.
OMERO GIARDINI MASSIMO CASTRO GIORGIO MAGGIONI.
TREATMENT OF OBSTRUCTION DUE TO CARCINOMA OF THE COLON
SiR,—There is
a
school of
thought which
advocates
immediate resection for acutely obstructing carcinomatous lesions of the left colon. A method was described by Sames 4,5 with resection of the lesion, formation of an end colostomy in the upper end of the wound, and oversewing 1. 2. 3. 4. 5.
Stocks, J., Kemp, M., Dormandy, T. L. Lancet, 1971, i, 266. Shohet, S. B. New Engl. J. Med. 1972, 286, 638. Dodge, J. T., Phillips, G. B. J. Lipid Res. 1966, 7, 387. Sames, C. P. Lancet, 1960, ii, 948. Sames, C. P. Proc. R. Soc. Med. 1968, 61, 374.
*
* Adapted from Ablin and Soanes.s t Classification of stage of carcinoma of the
according
to
4 (80%) means that 4 patients or 80% had indirect
i.a.
prostate
Flocks.6 ‡ For
example,
staining titres of antibodies from 1/40 to 1/80.
to
bile canaliculi
on
rabbit liver ranging
to bile canaliculi in liver disease and " the support suggested association of autoallergic w-tiological factors in liver disease ’’,1 the demonstration of antibody to bile canaliculi in the absence of any confirmed liver abnormality in patients with carcinoma of the prostate11 raises the question of the pathophysiological specificity of these antibodies. As summarised in the accompanying table, variable titres of antibody reactive with bile canaliculi of rabbit liver have been noted by the method of indirect (" sandwich ") immunofluorescence in a significant proportion (17 out of 24) of patients with various clinically and histologically staged carcinoma of the prostate.s Observations such as these suggest that we may be observing antibodies which are pathologically related to normal processes of ageing rather than a specific disease entity. That is, with the decline of humoral and cellmediated immunological capability with age, does the host
presence of
antibody
seem to
MacSween, R. N. M., Armstrong, E. M., Gray, K. G., Mason, M. Lancet, 1973, i, 1419. 2. Diederichsen, H. ibid. 1973, ii, 326. 3. Bumbalo, T. S., Bellanti, J. A., Terplan, K. L. Pediatrics, Springfield, 1961, 29, 191. 4. Diederichsen, H. Acta med. scand. 1969, 186, 299. 5. Ablin, R. J., Soanes, W. A. Ann. clin. Res. 1971, 3, 226. 6. Flocks, R. H J. Urol. 1969, 101, 741. 1.