Histiocytic lymphoma occurring in a patient with dermatitis herpetiformis

A patient with long-standing dermatitis herpetiformis (DH) developed histiocytic lymphoma of the small bowel. This is the twelfth reported case of lymphoma occurring in association with dermatitis herpetiformis.

Rectal mucosal plasma cells in inflammatory bowel disease

To achieve optimum staining and reproducible counts of plasma cells in paraffin embedded tissue with the immunoperoxidase technique we have found it essential to obtain a plateau count by titration of antisera for each specimen. This modification was used to study IgA, IgM, IgE, and IgG plasma cells in rectal biopsies from 20 controls, 20 patients with ulcerative proctocolitis, 20 with Crohn's colitis, 20 with non-specific proctitis, 15 with bacterial colitis, and seven with Crohn's disease but no apparent large bowel involvement. Counts were correlated with the characteristic histological features of inflammatory bowel disease. In controls the ratio of the mean counts for IgA, IgM, IgE, and IgG plasma cells was 8:3:3:1. All types of plasma cells were very significantly increased in the patients with ulcerative proctocolitis, Crohn's colitis, and non-specific proctitis and counts correlated with the severity of inflammation. There was no significant difference between the counts in these three groups. All counts tended to be higher in bacterial colitis than in controls, the difference being significant for IgA and IgE. When matched for severity of inflammation there was no significant difference between the counts in bacterial colitis and inflammatory bowel disease. The counts in patients with Crohn's disease but no large bowel involvement were not significantly different from controls. These results suggest that changes in plasma cell counts in inflammatory bowel disease are a non-specific response to mucosal damage, possible by a luminal irritant, and do not differentiate the type of inflammatory bowel disease.

Apparent suicide by carbon monoxide poisoning in a case of insulinoma

A woman, found dead in her garage, had a fatal level of carboxyhaemoglobin in her blood. Her recent medical history tended to support a suspicion of suicide but at autopsy a small islet cell tumour was discovered in her pancreas. Further investigations indicated that she had a high blood insulin level, sufficient to produce lethargy or coma, at the time of death. In the light of these findings it was concluded that her death was accidental. The techniques available for investigating the significance of islet cell tumours found at post-mortem are discussed.

Gastro-oesophageal candidiasis

A prospective search for gastro-oesophageal candidiasis was made by histological examination of all the biopsies taken from 465 patients endoscoped consecutively during a 12 month period. The criterion for diagnosis was the demonstration of infiltration of tissue or ulcer slough by yeasts and hyphae. Nineteen cases of candidiasis were found giving an overall incidence of 4%. There were 12 cases with oesophageal candidiasis, two with both oesophageal and gastric candidiasis, and five with gastric candidiasis. In none of the patients was candidiasis suspected before endoscopy. Symptoms referable to the candidiasis were uncommon and radiology was not helpful in diagnosis. There was associated local pathology (particularly peptic ulceration and carcinoma of the stomach or oesophagus) in all except two patients, which suggests that the candidiasis is usually secondary to mucosal damage. In the series, candidiasis was present in 27% of patients with oesophageal cancer, 20% of patients with gastric cancer, 16% of patients with benign gastric ulcers, and 15% of patients with oesophagitis.

Role of T-cells in the mechanism of reactivity of the microplate leukocyte adherence inhibition assay

To characterize the role of mononuclear cells in the microplate leukocyte adherence inhibition assay, enriched populations of T-cells, B-cells, macrophages, and a nylon wool-adherent fraction consisting of B-cells and macrophages were prepared by a two-stage adherence procedure from spleen cells of normal C57BL/6J mice and mice bearing progressively growing murine colon adenocarcinoma 38 (MCA-38) tumors. These studies indicate that the reactive cell undergoing specific antigen-induced adherence inhibition was present in the macrophage fraction. This cell was programmed to undergo specific antigen-induced adherence inhibition by an MCA-38-sensitized B-cell. An enriched population of MCA-38-sensitized T-cells but not normal T-cells abolished the in vitro leukocyte adherence inhibition response of MCA-38-reactive cells. Pretreatment of the MCA-38-sensitized T-cell fraction with anti-Thy 1:2 serum and complement but not anti-immunoglobulin and complement or carbonyl iron to selectively deplete macrophages abolished the regulatory effect of the MCA-38-sensitized T-cell fraction. MCA-38-sensitized T-cells could prevent MCA-38-sensitized B-cells from programming normal macrophages in vitro but could not abolish the leukocyte adherence inhibition response of presensitized macrophages. Temporal studies of suppressor T-cell activity were performed throughout different phases of progressive tumor growth. Suppressor T-cell could be detected as early as 4 days post-MCA-38 tumor cell inoculation and persisted throughout MCA-38 progressive tumor growth. Titration studies of suppressor T-cells revealed the need for 4 times the number of MCA-38-sensitized T-cells from small tumor bearers (Day 4) in comparison to large tumor bearers (Day 20) to achieve the same degree of suppression. Thus, in the MCA-38 system, sensitized T-cells programming of normal macrophages. This negative regulatory influence increased in magnitude with the progressive growth of the MCA-38 tumor.

Endoscopic small intestinal biopsy

Ninety-three patients with suspected small bowel disease were investigated by duodenal forceps biopsy via a fiberoptic endoscope. Three biopsies were usually taken from the distal end of the second part of the duodenum, orientated on a square of plastic mesh, and examined by stereomicroscopy and histology. There were no failures or complications. Using strict criteria, sections from 56% of the 299 biopsies were satisfactory for histological interpretation (compared with 76% of 346 biopsies taken via a hydraulic multiple biopsy capsule from a separate group of patients). At least one biopsy was satisfactory from 87% of the patients. A previous study having shown that biopsies from this site are comparable to those from the conventional site at the duodenojejunal junction, it is concluded that endoscopic duodenal biopsy is a valid alternative to conventional suction biopsy and, moreover, has a number of advantages.

An investigation of operating theatre staff exposed to humidifier fever antigens

Sixty staff working in a hospital operating theatre, where a case of humidifier fever had been identified, were studied together with 49 subjects working in other parts of the hospital. They each had a blood test for serology, a skin test, and a chest radiograph and completed a questionnaire. The theatre staff also had pulmonary function tests. The theatre humidifier was found to contain several organisms including amoebae and antigens cross-reacting highly with those implicated in previous outbreaks of humidifier fever. Of the 60 exposed subjects, 25 had developed antibodies, nine had probable symptoms of humidifier fever, and six possible symptoms. There was a strong association between symptoms and antibodies (p = 6 x 10(-5) by Fisher's exact test). The development of antibodies was also related to duration of exposure in the theatre (p less than 0.01 by X2 test for trend) and inversely to smoking (p = 0.0073 by Fisher's exact test) but not to history of atopy. Because of the presence of antigens and because certain biocides added were ineffective in controlling antigenic build-up the humidifier was switched off. Eight months later specific IgG levels in the theatre staff sera, estimated by an enzyme-linked immunosorbent assay technique, had fallen on average by 25%. Inhalation challenge with humidifier water was performed in eight subjects. Four subjects reacted to the challenge, including both those with antibodies and previous symptoms.

Screening for psychosocial problems in health settings

Providing comprehensive care requires identifying the total range of social, psychological, and medical needs that patients present to their health care providers. This study compares two approaches used to screen people for psychosocial problems in a hospital clinic. Findings suggest that a method in which clients identify their own problems yields different results from an alternative method in which professionals identify problem areas.

Social adjustment after rehabilitation: a two year follow-up of patients with severe head injury

Forty-four young adults, admitted to a rehabilitation centre after very severe head injury, were followed-up 2 years after their accident. Comparison with a control group showed that the head injuried had experienced marked changes in work, leisure activities, contact with friends and family life. Though these changes still created problems, the majority of patients and relatives appeared to have made a number of successful adaptations to their altered situation. Neurophysical status, personality change and memory loss all affected work capacity, while presence of personality changes was especially important in the loss of pre-accident friendships.

Multiple endocrine adenomatosis (Type I) and familial hyperparathyroidism

Hyperparathyroidism is the commonest presenting feature in multiple endocrine adenomatosis Type I (MEA Type I), the other manifestations may be delayed for many years or appear only in relatives. A family now diagnosed as MEA Type I, who was previously thought, in 1965, to have familial hyperparathyroidism due to chief cell hyperplasia is now described. The importance is stressed of family surveillance and long-term follow-up in all cases of primary hyperparathyroidism. Those tests that are essential in the long-term surveillance of the patients and their first degree relatives are discussed.

Computer-aided diagnosis of lower abdominal pain in women

This paper describes the use of a system of computer aided diagnosis in an unselected, prospective survey of 393 women suffering from lower abdominal pain of less than 1 week's duration. An accurate diagnosis was made by clinicians at first patient contact in 68-5 per cent of the group of patients. The computer's diagnostic prediction (based on the same data) matched the final diagnosis in 81-6 per cent of the patients. During this survey a marked improvement in diagnostic accuracy was observed amongst the junior clinicians. It is suggested that this is because of the discipline of data collection imposed and the intermittent feedback received, and also that this educational aspect of computer usage may be of wider benefit.

Coronary heart disease in Western Collaborative Group Study. Final follow-up experience of 8 1/2 years

Clinical coronary heart disease (CHD) occurred in 257 subjects during eight to nine years of follow-up (average, 8 1/2 years) in a prospective study of 39- to 59-year-old employed men. Incidence of CHD was significantly associated with parental CHD history, reported diabetes, schooling, smoking habits, overt behavior pattern, blood pressure, and serum levels of cholesterol, triglyceride, and beta-lipoproteins. The type A behavior pattern was strongly related to the CHD incidence, and this association could not be explained by association of behavior pattern with any single predictive risk factor or with any combination of them.