Morphological studies of baseline needle biopsies from living donor kidneys: light microscopic, immunohistochemical and ultrastructural findings

Fifty-seven consecutive living donors (31 women and 26 men aged 20.7-72.3 years, mean 50.6 years) were subjected to needle biopsy during nephrectomy, immediately before removal of the kidney. By light microscopy, semiquantitative scoring (0-3) was performed for arteriosclerosis, arteriolar hyalinosis (hyalin arteriolosclerosis), glomerulosclerosis, interstitial mononuclear cell infiltration, and interstitial fibrosis/tubular atrophy. Whereas vascular changes were striking in many biopsies (arteriosclerosis grades 2-3: 28/54 cases, arteriolar hyalinosis grades 2-3: 15/55 cases), glomerular and tubulointerstitial changes were mostly low grade. The morphological changes tended to be more pronounced in middle-aged and older individuals, but, in particular, vascular changes were seen also in the younger age group. Immunofluorescence microscopy revealed glomerular granular staining for IgM in 52.7% of the cases, IgA in 9.1%), IgG in 1.8%, and C3 in 12.7%. The main ultrastructural finding was glomerulosclerosis; one case with diffuse glomerular IgA showed distinct dense deposits, and one case showed similar dense deposits without IgA deposition. Arteriolar wall deposition of C3 was found in 58.2% of the cases, and IgM in 10.9%. Especially C3 occurred both with arteriolar hyalinosis and in arterioles without light microscopic alterations. The observation of significant vascular changes in baseline biopsies is relevant especially in the differential diagnosis of chronic rejection and cyclosporine nephropathy. The immunohistochemical findings strongly indicate the occurrence of immunoglobulins and complement factor C3 in both glomeruli and arterioles without clinical or morphological signs of renal disease. The possible pathophysiological significance of such deposits remains, however, uncertain.

Review of mental health law must be courageous

It has been announced recently that a team of 10 people is to review the Mental Health Act 1983. The review is being carried out in response to public and government concern that some people with mental illness have been discharged without proper supervision into the community rendering them, in some cases, a danger to themselves and to others.

Government once again side steps over nurses' pay

Frank Dobson, the Health Secretary, announced at the recent Labour Party Conference that action to carry out the Government's election manifesto pledge to reduce the length of NHS waiting lists is still going from strength to strength. He promised to provide a further £320 million from the NHS £5 billion modernization fund to help the Government's ‘relentless war on waiting’. He also announced a national inquiry to ascertain how many NHS beds are needed in total, and the use to which they should be put, combined with a new award scheme as part of a £10 million programme designed to ‘spread best practice’ (see p. 1064).

Nursing must hold fast to its long-term vision

The concept of the consultant nurse was one of a number of initiatives proposed by Tony Blair, the Prime Minister, in a speech given at the recent RCN/Nursing Standard awards ceremony in London. The concept of a nurse consultant and the return to a hierarchical clinical structure within nursing is wholly to be welcomed. The problems of a lack of nursing leadership and subsequent professional disorientation were, in part, caused when nursing's clinical hierarchy was abandoned in the 1970s.

Reducing NHS waiting lists: a political ploy?

It has been announced recently that the number of people currently on NHS waiting lists has fallen by over 45 000. Frank Dobson, Health Secretary, has stated that 83 000 more hospital cases were treated from April to June 1998, compared with the same period in 1997. It is also claimed that nobody is having to wait longer than 18 months on a waiting list for hospital treatment.

Gluten induces an intestinal cytokine response strongly dominated by interferon gamma in patients with celiac disease

BACKGROUND & AIMS

Celiac disease appears to be a T cell-mediated enteropathy induced by gluten in genetically predisposed individuals. Duodenal biopsy specimens from patients with celiac disease and histologically normal controls were investigated to see if cytokine expression is related to disease activity.

METHODS

Cytokine messenger RNA (mRNA) expression was determined by quantitative reverse-transcription polymerase chain reaction and in situ expression by immunohistochemistry.

RESULTS

In normal controls, mRNA levels were usually below the quantitative limit, even after in vitro gluten stimulation. By contrast, interferon (IFN)-gamma mRNA was increased more than 1000-fold in untreated disease. In vitro gluten stimulation of specimens from treated patients (gluten-free diet) increased IFN-gamma mRNA to the levels of untreated patients. In addition, increased mRNA levels for interleukin (IL)-2, IL-4, IL-6, and tumor necrosis factor alpha were found after such stimulation, whereas mRNA for IL-5, IL-10, and IL-12p40 was usually below the quantitative level. Biopsy specimens from untreated patients contained on average 10-fold more lamina propria cells positive for IFN-gamma than normal controls, whereas cells containing IL-4 were rare in both subject groups.

CONCLUSIONS

The results show that mucosal gluten exposure in patients with celiac disease rapidly elicits high levels of IFN-gamma expression and lower levels of IL-2, IL-4, IL-6, and tumor necrosis factor alpha even in the virtual absence of IL-12.

Nursing is not a very attractive career option

An ENB report (ENB, 1998) has highlighted that the number of students in preregistration nursing education has decreased by 15% in the past 4 years. The reason for this is a decline in applicants. There were 45 589 nurses training in March 1998, 2447 fewer than in the previous year, and the number of trainees has fallen by 8188 since 1994.

Nurses must start writing so as to be understood

The Foundation of Nursing Studies, a charity that aims to put research findings into practice, has just launched a campaign to promote plain words for nurses as it is felt that the nursing literature is dominated by language that is inaccessible to the everyday practising nurse. The gap that exists between the ideals stated in the theory of nursing and the actual practice of nursing gives weight to the argument that nursing theory and its academic writing remains either useless or unused.

Nursing must find its raison d'etre

At a time when the NHS is celebrating its 50th anniversary it is perhaps time to re-examine what it is to be a nurse. No succinct, commonly accepted statement of what it is to be a nurse exists. In order to create a definition, it is necessary to capture what is unique about that which is being defined. Nobody has succeeded in creating a definition of the uniqueness of nursing, such that, if a person in the street was asked to state the role of the nurse, a clear answer would be given in reply. The same could not be said of the police or the teaching profession, both of which have clear and accepted roles, respectively, enforcing the law and teaching the national curriculum.

The use of remifentanil in general anaesthesia for caesarean section in a patient with mitral valve disease

We report the use of remifentanil as part of a general anaesthetic technique for a patient with mixed mitral valve disease, asthma and pre-eclampsia presenting for an emergency Caesarean section. The use of remifentanil was associated with stable haemodynamic variables during general anaesthesia. No clinically significant respiratory depression was noted in the neonate.

As entries into nursing fall questions must be asked

Statistics relating to applications for entry into higher education in the academic period 1997–98 have been released by the Universities and Colleges Admission Service which show a 2.4% decrease in the number of people applying for entry onto nursing degree courses, combined with a 15% drop in mature student applications to nursing (Gulland, 1998). There is also a parallel shortfall in applications for entry onto nursing diploma courses. In the academic period 1996–97 there were 15 400 applications for 16 100 nursing diploma places. Students appear to be opting for more lucrative and socially prestigious careers in business, engineering and marketing (Gulland, 1998).

Consultation on a strategy for nursing

The Government has set out the background and issues for consultation to inform the development of a strategy for nursing, midwifery and health visiting (Health Service Circular (HSC), 1998) as part of its programme to implement its White and Green Papers (Department of Health (DoH), 1997a,b).

Tissue transglutaminase selectively modifies gliadin peptides that are recognized by gut-derived T cells in celiac disease

The action of tissue Transglutaminase (TGase) on specific protein-bound glutamine residues plays a critical role in numerous biological processes. Here we provide evidence for a new role of this enzyme in the common, HLA-DQ2 (and DQ8) associated enteropathy, celiac disease (CD). The intestinal inflammation in CD is precipitated by exposure to wheat gliadin in the diet and is associated with increased mucosal activity of TGase. This enzyme has also been identified as the main target for CD-associated anti-endomysium autoantibodies, and is known to accept gliadin as one of its few substrates. We have examined the possibility that TGase could be involved in modulating the reactivity of gliadin specific T cells. This could establish a link between previous reports of the role of TGase in CD and the prevailing view of CD as a T-cell mediated disorder. We found a specific effect of TGase on T-cell recognition of gliadin. This effect was limited to gliadin-specific T cells isolated from intestinal CD lesions. We demonstrate that TGase mediates its effect through an ordered and specific deamidation of gliadins. This deamidation creates an epitope that binds efficiently to DQ2 and is recognized by gut-derived T cells. Generation of epitopes by enzymatic modification is a new mechanism that may be relevant for breaking of tolerance and initiation of autoimmune disease.

Helping clients in their sexual expression

At the RCN Congress the RCN Learning Disabilities Forum (LDF) put forward the resolution that the Council should develop a nursing code of practice to guide professionals who assist clients with disabilities towards expressing their sexuality in an appropriate and non-harmful way. The resolution was passed by 89% indicating that nurses are at least concerned about this issue and require guidelines to clarify their position regarding this matter.

Government nursing initiatives are not enough

At the 1998 RCN Congress, Frank Dobson, the Health Secretary, announced a number of initiatives for nursing. These included: extending nurse prescribing at a cost of £14 million; a new National Strategy for Nursing, Midwifery and Health Visiting; a £5 million increase in non-means tested bursaries for nursing and midwifery diploma students; and an extra £4 million to provide ‘return to practice’ courses.

The need to distinguish between specialties

It has taken a great deal of time but it is finally becoming more accepted that the specialties of mental health nursing and nursing of clients with learning disabilities are distinct from each other. The process of change has been partly brought about by the structure of Project 2000 diploma education which encourages the separation of specialties and partly the active work of mental health and learning disability nurses themselves.

The NHS can seriously damage your health

The NHS was created to improve the nation's health and wellbeing, but in so doing it appears to be having a detrimental effect on the health of its own staff. A new report, commissioned by The Nuffield Trust, on behalf of the Partnership on the Health of the NHS Workforce, has highlighted that NHS staff are suffering from acute levels of psychological and physical morbidity in comparison to other professional sectors, which is leading to a demotivated workforce and rising rates of sickness.

Effects of ischemic tolerance on mRNA levels of IP3R1, beta-actin, and neuron-specific enolase in hippocampal CA1 area of the gerbil brain

Global cerebral ischemia induced to Mongolian gerbils by ligation of common carotid arteries (CCAs) is known to result in injury to the hippocampal CA1 region. In this study, we examined whether neuronal injury can be depicted by measuring levels of mRNA encoding inositol 1,4,5-trisphosphate receptor type 1 (IP3R1), neuron specific enolase (NSE) and beta-actin and whether these measurements can be use to assess ischemic tolerance. Gerbils were subjected either to cerebral ischemia induced by ligation of both CCAs for 5 min, or to an ischemic tolerance paradigm in which a 2 min ischemic preconditioning was performed 24 hr prior to the 5 min ischemia. At 48 hr after the 5 min ischemic insult, significant decreases in mRNA levels for IP3R1 (26%), NSE (38%) and beta-actin (50%) could be observed in the hippocampal CA1 region. Although levels of mRNA in the preconditioning group were decreased as compared to the sham control, the levels were significantly higher than those in the ischemic group. These results indicate the feasibility of using mRNA measurement as a parameter to assess cerebral ischemic damage. In addition, based on the differences in the decline in mRNA levels between the ischemia group and the preconditioned ischemia group, it can be concluded that this ischemic tolerance paradigm could offer partial protection (around 45%) against the injury due to the 5 min cerebral ischemic insult.

Substance misuse and risk of aggression and offending among the severely mentally ill

BACKGROUND

The aim of this study was to investigate whether 'dual diagnosis' (substance misuse and severe mental illness) is associated with aggression and offending.

METHOD

Twenty-seven people meeting the criteria for both psychotic illness and a substance use disorder and 65 people with psychosis only were interviewed. Case notes were also examined and keyworkers asked to rate substance misuse and aggression.

RESULTS

The severity of aggression and offending among this community treatment sample was low. Individuals with a dual diagnosis were significantly more likely than those with psychosis only to report any history of committing an offence (P = 0.001), or recent hostile behaviour (P = 0.001). Keyworkers were more likely to report recent aggression among the dually diagnosed (P = 0.01). Significant differences persisted when we used logistic regression to control for potentially confounding demographic and clinical variables.

CONCLUSIONS

Dual diagnosis may be an important factor in aggression and offending among severely mentally ill individuals in inner-city areas. Accurate risk assessment requires examination of substance use.

A population-based study of abdominal wall defects in South Australia and Western Australia

The purpose of this study was to determine the prevalence, clinical characteristics, prenatal diagnosis and occurrence of other birth defects with abdominal wall defects in births and terminations of pregnancy in South Australia (SA) and Western Australia (WA) over the period 1980-90. Cases of gastroschisis, exomphalos, bladder exstrophy, cloacal exstrophy and body stalk anomaly were ascertained from the WA Birth Defects Registry (1980-90) and the SA Birth Defects Register (1986-90). The registers are comparable population-based data collections with information on livebirths and stillbirths of at least 400 g birthweight or 20 weeks' gestation, and terminations of pregnancy for fetal abnormality. The prevalence of gastroschisis was 1.65/10,000 births (59 cases) and of exomphalos 2.90/10,000 births (104 cases). There was no significant difference in prevalence of exomphalos or gastroschisis between SA and WA for the years 1986-90. However, if data from WA for the years 1980-85 were included, SA had a significantly higher prevalence of exomphalos (prevalence ratio 1.71, confidence interval [CI] 1.16-2.55), although not of gastroschisis (prevalence ratio 1.35, CI 0.79-2.32). Exomphalos was significantly more common in mothers < 20 years (odds ratio [OR] 2.45, CI 1.22-4.86) and in mothers of 40 years or older (OR 5.65, CI 1.69-16.77). Gastroschisis was more common in younger mothers (OR 8.76, CI 4.02-19.32). Both exomphalos and gastroschisis were associated with low birthweight, prematurity, intrauterine growth retardation and caesarean section. The reason for the higher prevalence of exomphalos in SA than WA was not clear, but may be related to differences in prenatal diagnosis. The association between maternal age < 20 years and exomphalos raises the possibility of common factors in the aetiology of gastroschisis and exomphalos.

Government launches new recruitment campaign

The latest phase of the Government's nurse recruitment campaign has just been launched by the Department of Health (DoH). The £50 000 recruitment resource pack Sharing Ideas, part of a £2.5 million ongoing national campaign, is aimed at helping trusts to recruit and retain nurses. The pack contains a video for use in schools and careers offices, a cassette of advertisements for local radio and a computer disk for printing promotional posters. It addresses employment issues such as family-friendly policies, equal opportunities, professional and personal development and selection and recruitment programmes. Baroness Jay, Minister for Health, voiced the Government's intention to ‘support familyfriendly policies which include…flexible shifts or nursery provision’ (DoH, 1998).

Nurses must not adopt medical roles piecemeal

The creation of four new nursing posts funded by the South West Regional Health Authority's Junior Doctors' Task Force as an innovative attempt to reduce junior doctors' hours might also be seen as an abuse of nursing expertise in the interest of making the doctors' life less intolerable.

Polymorphonuclear elastase in human colorectal carcinoma

proteinases are required for invasion through the extracellular matrix (ECM) during tumor invasion and metastasis. Polymorphonuclear (PMN) elastase can degrade ECM components and modulate other proteinases. In the present study PMN elastase activity was found in tissue extracts from 8 of 15 human colorectal carcinomas. Immunoreactive PMN elastase was demonstrated in all carcinoma biopsies with particular enrichment at the tumor-host interface. Immunofluorescence staining localized immunoreactive PMN elastase mainly to neutrophile granulocytes. The human colon carcinoma cell lines Caco-2 and HT-29 did not express PMN elastase. An interaction between tumor cells and elastase producing leukocytes is suggested.

Crisis in London's in-patient mental health services

A recent survey of London's inpatient services for people with severe mental illness conducted by the RCN and the Institute of Psychiatry (1998) has highlighted severe staff shortages, a lack of experienced specialist nurses and high staff turnover which has led to insufficient therapeutic in-patient care. A further finding is that one in four acute psychiatric wards are too full to admit severely disturbed patients. This combination, in the words of the survey authors, has created a ‘time bomb waiting to go off’.