- Email: [email protected]
SMALLPOX IN AN ITALIAN MUMMY
816
example, the "key worker" or "core team" screening out patients in need. "Efforts should be made to ensure that hospital staff do not continue to dominate multidisciplinary teams".10 What should be the spearhead of community support may become a hotbed of role rivalry, encroachment, and jockeying for political position, cutting across the doctor’s traditional links and lines of authority with his medical and paramedical colleagues, and generally leading to a breakdown in communication. In many, if not most, community mental handicap teams the patients are never seen by the team. The psychiatric care of the mentally handicapped in the community is being deliberately devolved to non-specialists and, indeed, non-professionals, while the subspecialty of the psychiatry of mental handicap is being run down along with the mental handicap hospitals. If this de-specialisation, de-professionalisation, and general de-resourcing continues, the mental health of these already vulnerable people will inevitably suffer.
RA may have little or nothing to do with mycobacterial antigens since, in this situation, DR4, or a linked HLA antigen, could be acting as a restriction element for an, as yet, unidentified antigenic epitope. I would suggest that the lymphocyte data of Holoshitz and colleagues can be best explained by a predominance of DR4 positive RA patients and that the most appropriate controls are individuals without RA but who are DR4 positive. Finally, I would also suggest that the prevalence of DR4 be looked for in populations with overt clinical disease due to M tuberculosis; ifDR4 positive individuals are underrepresented then DR4 could be a "protective" factor in the development of disease while if DR4 positive individuals are overrepresented then DR4 could be involved in disease pathogenesis by a heightened host immune response to a mycobacterial antigen-a concept which Cohen and his group have done much to popularise with their work on adjuvant arthritis in the that DR4 is linked
to
rat.
Botleys Park Hospital, Chertsey, Surrey KT16 0QA
H. G. KINNELL
Rheumatology Unit, Division of Medicine, United Medical and Dental Schools,
1. Anon. Memorandum on mental handicap. Bull Roy Coll Psychiat 1978 (April), 56-61. 2. Gillberg C, Persson E, Grufman M, Themner U. Psychiatric disorder in mildly and severely mentally retarded urban children and adolescents: Epidemiological aspects. Br J Psychiatry 1986; 149: 68-74. 3. British Paediatric Association. Report of the Working Party on Mental Subnormality. London: BPA, 1970. 4. Lee-Evans JM, Wilson GL. Ethical issues in behaviour modification. British Society for the Study of Mental Subnormality newsletter, 1983. 5. Day KA. A hospital based psychiatric unit for mentally handicapped adults. Mental Handicap 1984; 11: 137-40. 6. Day KA. Service provision for mentally handicapped people with psychiatric problems. In: Care in the community: Keeping it local (report of MIND’s 1983 annual conference). 7. Anon. Mental handicap services: the future. Bull Roy Coll Psychiat 1983; 7: 131. 8. Mayer C. Mental handicap, psychosis and thyrotoxicosis: a demonstration of the usefulness of an integrated community and hospital service. J Ment Deficiency Res 1985; 29: 275-80. 9. Anon. Mentally handicapped are "ignored" by young doctors. Hospital Doctor 1985 (no 18): 1. 10. Plank M. Teams for mentally handicapped people. London: Campaign for Mentally Handicapped People, 1982.
RHEUMATOID ARTHRITIS AND TUBERCULOSIS
SiR,—Two papers (p 305 and p 310) and an editorial (p 321) in your issue of Aug 9 on immunity to mycobacterial antigens, HLA-DRA, and the pathogenesis of rheumatoid arthritis (RA) must be both a journalistic as well as a scientific landmark in the study of this perplexing disease. However, some caution is needed, otherwise overinterpretation of interesting but preliminary data may lead to uncritical theorising. First, the fact that rabbit antisera and a mouse monoclonal antibody recognise common idiotypes on M tuberculosis antigens and cartilage proteoglycans does not automatically lead to the conclusion that the same cross-reactivity can be recognised by the human immune repetoire and, indeed, Holoshitz and colleagues (p 305) were unable to detect differences in antibody levels to mycobacterial or proteoglycan antigen between rheumatoid and control
G. S. PANAYI
SMALLPOX IN AN ITALIAN MUMMY
SIR,-Professor Fornaciari and Dr Marchetti (Sept 13, p 625) describe the electron microscope appearances of the poxvirus-like particles observed in thin sections of the skin lesions from a 16th century mummy but an illustration would have been more helpful. Immune electron microscopy, which is illustrated, has obscured the structure of the particles and morphological identification is impossible. A human antiserum was used. Limited experience in this laboratory of testing human sera for vaccinia antibodies after smallpox vaccinations leads me to suspect that the poxvirus antibody titre of such sera may be insufficient for their use as diagnostic reagents in this way. When human tissue is the substrate the use of a human antiserum makes the specificity of the result uncertain. Moreover, the controls are not specified. I hope that this potentially very interesting material will be subjected to the more usual smallpox diagnostic procedures. Tests that would probably work well upon such material are: electron microscopy of tissue homogenates by negative staining; antigenic tests upon extracted tissue by gel diffusion using a high-titred animal antiserum; probing for poxviral nucleic acid sequences; and virus culture. The last is important for public health reasons and, together with other diagnostic tests, would have to be done in a laboratory equipped and authorised to handle the smallpox virus. The so far incomplete study may cause unfounded concern amongst those in certain occupations. Virus Reference Laboratory, Central Public Health Laboratory, London NW9 5HT
1. Macrae
ANNE M. FIELD
AD, Field AM, McDonald JR, Meurisse EV, Porter AA. Laboratory diagnosis of vesicular skin rashes. Lancet 1969; ii: 313-16.
differential
sera.
Second, the demonstration that rheumatoid lymphocytes proliferate to mycobacterial antigens (Holoshitz et al) does not lead the conclusion that these cells are also capable of responding to cartilage proteoglycan since this cross-reactivity has not so far been demonstrated at the cellular level for humans but only in rodents. It is also disquieting to note that significant reactivity to mycobacterial antigen could be demonstrated only for patients with disease of more than one year and less than ten years’ duration. This time "window" requires explanation. Third, the demonstration that HLA-DR4 positive leprosy patients are able to mount a strong delayed cutaneous hypersensitivity reaction to a M tuberculosis antigen preparation (Ottenhoff et al, p 310) must, surely, be a milestone in the study of class II MHC antigens as it suggests that DR4 is a restriction element in the response of an individual to such an antigen. The fact
to
Shepherd’s House, Guy’s Hospital, London SE1 9RT
RISK OF TRANSMISSION OF HUMAN PAPILLOMAVIRUS BY VAGINAL SPECULA
SIR,-In response to Skegg and Paul’s warning* we investigated the risk of iatrogenic transmission of human papillomavirus (HPV) via specula inserted into the vaginal vault of women with subclinical HPV infection. We investigated the possibility that HPV could be detected in cells adhering to specula after colposcopic examination of women with premalignant disease of the cervix (cervical intraepithelial neoplasia [CIN grades I to III]) associated with HPV infection. Many of these women also have HPV infection in other areas of the lower genital tract. The specula, after colposcopic examination and removal from the vaginal vault, were rinsed briefly in an aqueous solution of chlorhexidine to remove excess mucus and
example, the "key worker" or "core team" screening out patients in need. "Efforts should be made to ensure that hospital staff do not continue to dominate multidisciplinary teams".10 What should be the spearhead of community support may become a hotbed of role rivalry, encroachment, and jockeying for political position, cutting across the doctor’s traditional links and lines of authority with his medical and paramedical colleagues, and generally leading to a breakdown in communication. In many, if not most, community mental handicap teams the patients are never seen by the team. The psychiatric care of the mentally handicapped in the community is being deliberately devolved to non-specialists and, indeed, non-professionals, while the subspecialty of the psychiatry of mental handicap is being run down along with the mental handicap hospitals. If this de-specialisation, de-professionalisation, and general de-resourcing continues, the mental health of these already vulnerable people will inevitably suffer.
RA may have little or nothing to do with mycobacterial antigens since, in this situation, DR4, or a linked HLA antigen, could be acting as a restriction element for an, as yet, unidentified antigenic epitope. I would suggest that the lymphocyte data of Holoshitz and colleagues can be best explained by a predominance of DR4 positive RA patients and that the most appropriate controls are individuals without RA but who are DR4 positive. Finally, I would also suggest that the prevalence of DR4 be looked for in populations with overt clinical disease due to M tuberculosis; ifDR4 positive individuals are underrepresented then DR4 could be a "protective" factor in the development of disease while if DR4 positive individuals are overrepresented then DR4 could be involved in disease pathogenesis by a heightened host immune response to a mycobacterial antigen-a concept which Cohen and his group have done much to popularise with their work on adjuvant arthritis in the that DR4 is linked
to
rat.
Botleys Park Hospital, Chertsey, Surrey KT16 0QA
H. G. KINNELL
Rheumatology Unit, Division of Medicine, United Medical and Dental Schools,
1. Anon. Memorandum on mental handicap. Bull Roy Coll Psychiat 1978 (April), 56-61. 2. Gillberg C, Persson E, Grufman M, Themner U. Psychiatric disorder in mildly and severely mentally retarded urban children and adolescents: Epidemiological aspects. Br J Psychiatry 1986; 149: 68-74. 3. British Paediatric Association. Report of the Working Party on Mental Subnormality. London: BPA, 1970. 4. Lee-Evans JM, Wilson GL. Ethical issues in behaviour modification. British Society for the Study of Mental Subnormality newsletter, 1983. 5. Day KA. A hospital based psychiatric unit for mentally handicapped adults. Mental Handicap 1984; 11: 137-40. 6. Day KA. Service provision for mentally handicapped people with psychiatric problems. In: Care in the community: Keeping it local (report of MIND’s 1983 annual conference). 7. Anon. Mental handicap services: the future. Bull Roy Coll Psychiat 1983; 7: 131. 8. Mayer C. Mental handicap, psychosis and thyrotoxicosis: a demonstration of the usefulness of an integrated community and hospital service. J Ment Deficiency Res 1985; 29: 275-80. 9. Anon. Mentally handicapped are "ignored" by young doctors. Hospital Doctor 1985 (no 18): 1. 10. Plank M. Teams for mentally handicapped people. London: Campaign for Mentally Handicapped People, 1982.
RHEUMATOID ARTHRITIS AND TUBERCULOSIS
SiR,—Two papers (p 305 and p 310) and an editorial (p 321) in your issue of Aug 9 on immunity to mycobacterial antigens, HLA-DRA, and the pathogenesis of rheumatoid arthritis (RA) must be both a journalistic as well as a scientific landmark in the study of this perplexing disease. However, some caution is needed, otherwise overinterpretation of interesting but preliminary data may lead to uncritical theorising. First, the fact that rabbit antisera and a mouse monoclonal antibody recognise common idiotypes on M tuberculosis antigens and cartilage proteoglycans does not automatically lead to the conclusion that the same cross-reactivity can be recognised by the human immune repetoire and, indeed, Holoshitz and colleagues (p 305) were unable to detect differences in antibody levels to mycobacterial or proteoglycan antigen between rheumatoid and control
G. S. PANAYI
SMALLPOX IN AN ITALIAN MUMMY
SIR,-Professor Fornaciari and Dr Marchetti (Sept 13, p 625) describe the electron microscope appearances of the poxvirus-like particles observed in thin sections of the skin lesions from a 16th century mummy but an illustration would have been more helpful. Immune electron microscopy, which is illustrated, has obscured the structure of the particles and morphological identification is impossible. A human antiserum was used. Limited experience in this laboratory of testing human sera for vaccinia antibodies after smallpox vaccinations leads me to suspect that the poxvirus antibody titre of such sera may be insufficient for their use as diagnostic reagents in this way. When human tissue is the substrate the use of a human antiserum makes the specificity of the result uncertain. Moreover, the controls are not specified. I hope that this potentially very interesting material will be subjected to the more usual smallpox diagnostic procedures. Tests that would probably work well upon such material are: electron microscopy of tissue homogenates by negative staining; antigenic tests upon extracted tissue by gel diffusion using a high-titred animal antiserum; probing for poxviral nucleic acid sequences; and virus culture. The last is important for public health reasons and, together with other diagnostic tests, would have to be done in a laboratory equipped and authorised to handle the smallpox virus. The so far incomplete study may cause unfounded concern amongst those in certain occupations. Virus Reference Laboratory, Central Public Health Laboratory, London NW9 5HT
1. Macrae
ANNE M. FIELD
AD, Field AM, McDonald JR, Meurisse EV, Porter AA. Laboratory diagnosis of vesicular skin rashes. Lancet 1969; ii: 313-16.
differential
sera.
Second, the demonstration that rheumatoid lymphocytes proliferate to mycobacterial antigens (Holoshitz et al) does not lead the conclusion that these cells are also capable of responding to cartilage proteoglycan since this cross-reactivity has not so far been demonstrated at the cellular level for humans but only in rodents. It is also disquieting to note that significant reactivity to mycobacterial antigen could be demonstrated only for patients with disease of more than one year and less than ten years’ duration. This time "window" requires explanation. Third, the demonstration that HLA-DR4 positive leprosy patients are able to mount a strong delayed cutaneous hypersensitivity reaction to a M tuberculosis antigen preparation (Ottenhoff et al, p 310) must, surely, be a milestone in the study of class II MHC antigens as it suggests that DR4 is a restriction element in the response of an individual to such an antigen. The fact
to
Shepherd’s House, Guy’s Hospital, London SE1 9RT
RISK OF TRANSMISSION OF HUMAN PAPILLOMAVIRUS BY VAGINAL SPECULA
SIR,-In response to Skegg and Paul’s warning* we investigated the risk of iatrogenic transmission of human papillomavirus (HPV) via specula inserted into the vaginal vault of women with subclinical HPV infection. We investigated the possibility that HPV could be detected in cells adhering to specula after colposcopic examination of women with premalignant disease of the cervix (cervical intraepithelial neoplasia [CIN grades I to III]) associated with HPV infection. Many of these women also have HPV infection in other areas of the lower genital tract. The specula, after colposcopic examination and removal from the vaginal vault, were rinsed briefly in an aqueous solution of chlorhexidine to remove excess mucus and