Scleroderma "en coup de sabre": pathological evidence of intracerebral inflammation

Linear scleroderma "en coup de sabre" (LScs) is associated with neurological complications, the pathogenesis of which is uncertain. A 27 year old woman is reported on who developed epilepsy and focal neurological signs in association with LScs. Brain MRI demonstrated predominantly ipsilateral relapsing and remitting grey and white matter lesions. Analysis of CSF and pathology obtained at brain biopsy provides evidence of an inflammatory process which may be amenable to immunosuppressive treatment.

Temporal artery biopsy: is there any value in examining biopsies at multiple levels?

AIMS

To analyse the cost-effectiveness of three strategies for examining temporal artery biopsies based on data from cases examined over the past 10 years.

METHODS

Of a total of 172 temporal artery biopsies, five were unsuitable for further analysis, 47 had already had levels cut, and 120 had levels cut as part of the study. All the biopsies were examined blind before and after levels. A tree with eventual diagnostic outcomes for different strategies was constructed and economic and sensitivity analyses performed. Welcan units were used to assess technical workload.

RESULTS

Only one of the 132 initially normal cases and two of 14 diagnosed with periarterial lymphocytic infiltration (PALI) revealed giant cell arteritis after examining the tissue at multiple levels. Fifteen cases (8.9%) showed PALI not previously observed. The marginal cost for each extra case of giant cell arteritis detected was 83.5 Welcan units for a strategy of routine levels on all sections, and 21 Welcan units for a strategy of only cutting levels if PALI was present on the initial section. These costs were sensitive to the frequency of giant cell arteritis in cases with PALI and to the relative extra cost of moving from cutting single section to routine levels.

CONCLUSIONS

Routinely examining a temporal artery biopsy at multiple levels does not increase the diagnostic yield of the test, although selective further examination may be indicated in some cases. The significance of PALI is uncertain. The cost-benefit of the different strategies in terms of clinical decision making revolve around the perceived risk inherent in not making a diagnosis of giant cell arteritis.

Malignant transformation in pleomorphic xanthoastrocytoma--a report of two cases

Pleomorphic xanthoastrocytomas (PXA) with malignant transformation are reported in two adult men with a long history of seizures, recent onset of neurological symptoms and superficially located, temporal lobe lesions. Although PXA is generally described as having relatively benign behaviour, this report adds two further cases of malignant transformation to the literature.

Meningioangiomatosis: a case report and review of the literature

A case of cerebral meningioangiomatosis in an adult man without any stigmata of neurofibromatosis is reported. A 22 year-old man with no previous neurological history, presented with adversive seizures; clinical examination and electro-encephalogram were normal. CT showed nodular calcified masses in the left frontal lobe and in the left posterior parietal area. A craniotomy was performed and the frontal lesion was excised. Histological examination showed a predominantly intracerebral tumour involving both grey and white matter, with a complex picture of variable cellularity, dense calcification and prominent perivascular arrangements of reticulin-rich spindle cell fascicles with palisade formation widely involving the brain tissue. Immunohistochemistry for S100 protein varied between different parts of the tumour; there was focal positivity for S100 protein and smooth muscle actin in the lesion with no reaction for GFAP or EMA. Immunostaining for Factor 8-related antigen highlighted the perivascular arrangement of lesional cells and demonstrated an increase in the number of small vessels in other areas. Electron microscopy of the main mass showed elongated spindle cells with formation of pericellular basal lamina. The literature on meningioangiomatosis was reviewed. The evidence for meningeal, perivascular neural plexus or pericyte origin does not appear to be well founded. The present case further illustrates the difficulty in identifying an exact histogenetic cell and probably reflects an origin from a primitive perivascular mesenchymal cell.

Major trauma workload within an English Health Region

The incidence, distribution and clinical patterns of life-threatening and multiple injuries were evaluated within an English Regional Health Authority area. Cases of major injury were identified retrospectively for the 12 month period October 1988 to September 1989 using data from the 16 Accident and Emergency (A&E) units within the Yorkshire Health Region, and coroners' records. There were 968 cases of fatal and serious injury, meeting the criterion of an injury severity score greater than 15, 67 per cent (645) being due to road traffic incidents. Thirty-five per cent (337) died at the scene or before reaching hospital, whilst 65 per cent (631) survived to reach an A&E unit (0.082 per cent of the Region's annual A&E case load), 75 per cent arriving outside of normal office hours. Eleven per cent (72) died prior to ward admission and 34 per cent (213) were immediately transferred to a secondary medical referral centre. Three hundred and sixty-seven patients (38 per cent) survived to be discharged from acute hospital care whilst 188 (19 per cent) died as in-patients. Major injuries were found to be distributed throughout the Authority area in rough proportion to district population density with a regional incidence of 27 cases per 100,000. This study has quantified a group of patients with very specific and specialized needs, but further research and debate is required to decide how these needs are best met.

Health and health care of rural populations in the UK: is it better or worse?

OBJECTIVE--To review available evidence on the problems facing rural health care in the UK. In particular, to determine whether the health of rural populations is worse than that of town dwellers and how the quality of health care is influenced by rurality. CRITERIA FOR INCLUSION AND EXCLUSION OF ARTICLES--A wide variety of publications and data sources were used. A number of computerised databases with different specialisations (for example medical, health care management) were used to identify relevant published articles. In addition, reports, reviews, and surveys produced by agencies for local circulation were identified by approaching academic, service, and voluntary bodies thought likely to have an interest in rural health. Although this "grey" literature is not subject to peer review, the relative lack of relevant UK publications made it a useful data source for illustrative purposes. Similarly, published articles based on rural health in other developed countries were used when UK data were lacking. CONCLUSIONS--Although the evidence concerning the health and health care of the UK rural populations is suggestive, it is very general and further research is needed. Levels of urban health seem to be generally worse than in rural areas, but contradictions do exist. The evidence on quality of care suggests that service accessibility is a central problem, and rural populations have poorer access than others. Within rural populations, such disadvantage is not uniformly experienced--it affects some groups more than others. In addition, the NHS does not seem to have a consistent policy about whether rurality should influence resource allocation, and how it should be incorporated.

Extracorporeal photochemotherapy in progressive systemic sclerosis

BACKGROUND

Extracorporeal photochemotherapy, an immune-modulating form of therapy, has been shown to be effective in the treatment of autoimmune diseases. We evaluated the effects of extracorporeal photochemotherapy in the treatment of patients with progressive systemic sclerosis (PSS).

METHODS

Nine patients with active progressive systemic sclerosis were treated with extracorporeal photochemotherapy on 2 successive days monthly. The duration of therapy ranged from 6 to 21 months.

RESULTS

A significant improvement was noted in the skin, musculoskeletal system, functional index, and symptoms including Raynaud's phenomenon, dyspnea, fatigue, dysphagia, and arthralgias, as well as improvement of cutaneous ulcers. Stabilization of the pulmonary function studies was also noted in the majority of patients over the course of therapy. No serious side effects were noted throughout the course of therapy in the 9 patients.

CONCLUSIONS

The results suggest that photopheresis may be beneficial in selected early cases of progressive systemic sclerosis.

The potential requirement for HIV counselling and voluntary testing in women of childbearing age

This paper compares estimates of the potential HIV counselling and testing requirements in a genito-urinary medicine (GUM) clinic, where a formal HIV counselling service is provided, and in an antenatal clinic (ANC), where there is no formal HIV counselling service. Data were collected by means of questionnaires completed by women attending both clinics. Only 31% and 16% of counselling needs were being met at the GUM clinic and antenatal clinic respectively. At the GUM clinic 11% of respondents had had an HIV antibody test, and at the antenatal clinic 1% had been tested. In contrast 68% and 58% of respondents at the GUM and antenatal clinics respectively would accept the offer of an HIV antibody test. In low prevalence areas the universal offer of testing would greatly increase specialist counselling requirements, but alternative models of provision and selective testing may lead to a more efficient use of resources.

Mast cells, nerves and fibrosis in the appendix: a morphological assessment

Mast cells are closely associated with nerves in the mucosa of the appendix vermiformis, and obliteration of the appendiceal lumen by fibrous tissue is accompanied by neurogenous hyperplasia. However, changes in the density of mast cells in this process have not been reported. Accordingly, fibrosis was graded in haematoxylin and eosin sections from 46 samples of human appendix. This was compared with mast cell number in toluidine blue-stained slides and nerve density in PGP9.5-immunoreactive sections. In the mucosa, the mast cell number in the samples with minimal fibrosis was three times greater than in those classified as normal (P less than 0.0001), and this declined in the more fibrotic samples. The mucosal nerve scores paralleled the mucosal mast cell changes, and stereological analysis revealed a correlation of mast cell number and nerve density within the lamina propria of the same specimens (r = 0.49-0.90). In the submucosa, mast cell numbers and nerve scores were not significantly different in the different histological grades and obliterated samples resembled normal submucosa, except that a dense axial block of nerve staining was often present. The progressive fibrotic changes in appendices provide a human model for studying the relationships of nerves, mast cells, and fibrosis in the gastrointestinal tract.

Development of the cerebellum with particular reference to cellular differentiation in the external granular layer

Immunocytochemical evidence of differentiation in developing human cerebellum is presented in this study. Antibodies to neuron specific enolase, neurofilament protein, glial fibrillary acidic protein, vimentin, cytokeratin, epithelial membrane antigen and lymphoid markers, DLC and Leu 7 were used. The external granular layer showed positivity with neuronal markers between 27 weeks gestation and 4 months postnatal, but was negative for all other markers including glial fibrillary acidic protein. Characteristic staining reactions were noted in the other cerebellar layers. Monoclonal antibodies, UJ13A (pan-neuroectodermal marker) and G10 (localising microtubule-associated protein MAP1x) were also used in a limited number of cryostat sections and were positive and negative, respectively, in the external granular layer. The results of this study are discussed in relation to the theory that the external granular layer may be one source of medulloblastomas.

Immunohistochemical localisation of tissue plasminogen activator in human brain tumours

The distribution of tissue plasminogen activator (t-PA) has been studied in a series of 38 human brain tumours and two specimens of cerebral cortex, using the monoclonal antibody ESP6. t-PA was localised in vascular endothelium in the majority of tumours and both the cortical specimens, confirmed by double staining with Ulex europaeus lectin (Uel) and Factor 8-related antigen. Nineteen out of 22 high grade astrocytomas showed strong endothelial staining whereas staining was weak or absent in the four low grade astrocytomas studied. No consistent relationship was found between the pattern of staining and tumour grade in the other tumours, although strong staining of the three metastatic lesions with Uel was observed. Among the astroglial tumours only one glioblastoma showed any tumour cell staining for t-PA, which raises questions concerning the origin of t-PA producing cells derived from human gliomas in vitro. Studies of t-PA in brain tumours should take account of this vascular localisation before concluding that the activity is derived from neoplastic cells.

Status epilepticus complicating migraine

We describe 2 patients who developed status epilepticus in association with migraine attacks. One patient died and at the autopsy had ischaemic changes confined to the occipital lobes. The second patient made an uneventful recovery.

The evolution of an oligodendroglioma into a primitive neuroectodermal tumour

Oligodendrogliomas may comprise a biologically heterogenous group of tumours. There is disagreement about the relationship between their histological features and subsequent behaviour, and evolution of histologically typical oligodendrogliomas into more malignant neoplasms has been described. We describe a supratentorial oligodendroglioma in a 4-year-old boy which recurred 9 months after initial resection when it showed foci of histologically primitive cells, not present in the initial specimen. It recurred again at the same site 20 months later following a course of radiotherapy, but showed on this occasion the appearances of a primitive neuroectodermal tumour (PNET) with astrocytic and ependymal, but not oligodendroglial, differentiation. The evidence suggests evolution of an oligodendroglioma into a PNET, and raises the possibility that some oligodendrogliomas may arise by differentiation from a pool of proliferating primitive cells which may occasionally become the dominant population.

S-100 protein in Schwann cells of the developing human peripheral nerve. An immunohistochemical study

From approximately 7 weeks gestational age in developing human peripheral nerve, as in adult nerve, S-100 protein was found to be expressed solely and uniformly by Schwann cells associated with axons. In embryos younger than 7 weeks S-100 was much less constant and many cells did not show clear staining. The trigger for the initial appearance of the protein at around this age remains unclear although a relationship of S-100 expression in Schwann cells to close axonal contact is suggested. The value of S-100 protein in distinguishing Schwann cells from perineurial cells in normal nerves and nerve sheath tumours remains unclear.

Paraplegia due to massive asbestos-related pleural and mediastinal fibrosis

A case of massive pleural and mediastinal fibrosis related to occupational exposure to asbestos is presented. The terminal illness was marked by the acute onset of paraplegia. Autopsy revealed occlusive lesions of upper intercostal arteries within sheets of dense fibrous tissue and an ischaemic myelopathy. The presence of vascular lesions suggests a relationship with idiopathic mediastinal fibrosis.

In vitro heterogeneity in human gliomas. Are all transformed cells of glial origin?

Primary cultures from 30 human gliomas (26 high grade, 3 low grade, and one oligoastrocytoma) were studied to examine the mixture of cells that make up the outgrowth, and their interactions. GFAP + ve Fibronectin - ve cells had a predominantly process forming (PF) morphology and formed complex networks around explants. Fibronectin + ve GFAP-ve cells had a flattened adherent (FA) morphology, tended to increase in time in culture, in 11 tumours showed a transformed pattern of growth, and may derive from perivascular mesenchyme. Neoplastic glial cells in vivo, or in vitro, may influence the behaviour and nature of other cells in tumour tissue which may be of significance in tumour behaviour and progression.

Epithelioid neurilemmoma of the trigeminal nerve: an immunohistochemical and ultrastructural study

A 50-year-old male presented with facial pain due to an extrinsic intracranial tumour involving pontine nerve roots. Biopsy and subsequent partial surgical excision indicated origin from the trigeminal nerve. Histologically the tumour had features of a neurilemmoma but in addition contained a population of epithelioid cells. Immunohistochemical studies demonstrated S100 protein in the non-epithelioid component but no reaction in the epithelioid cells, whilst vimentin was present in both cell types. Ultrastructurally the epithelioid cells showed features consistent with a Schwann cell nature and may represent a less well differentiated cell population derived from a Schwann cell precursor. The significance of these findings in relation to the cell of origin of neurilemmomas is discussed.

Nutrition and health in the first year of life on a Pacific atoll. Observations on Abemama Atoll, Central Pacific

The growth of 50 children on a coral atoll has been studied during their first year of life. Initially the population median weight rose above the international norm, but later declined, resulting in a median weight at 12 months below this norm. Data on age of introduction of foods, diarrhoeal illness and general morbidity indicated an association between growth faltering and episodes of fever between four and 12 months but no association with diarrhoea. No statistically significant relationships were found between the age of introducing solid food and the age of first diarrhoea, or between the ages of introduction of protein or energy foods and growth faltering. The effects of fever on growth are probably mediated by temporary appetite suppression in the context of marginal nutrition accentuated by the difficulties of weaning. Records of village or home treated illnesses highlight the discrepancies between village and health service based records.

Patterns of illness and the use of health services on a coral atoll--observations in Kiribati (Central Pacific)

Attendances over a one-year period at the sole dispensary on a coral atoll (population 2411) have been studied. The patterns of presenting illnesses for those under five years old and those over five years old were studied, and analyses made of usage of the dispensary in relation to distance. Under-5s have disease incidences some four and a half to five and a half times those of over fives, but the apparent detrimental effect of distance is less in the under-fives. The skills required in the management of presenting illnesses are analysed in relation to those available--village health worker, trained nurse, doctor--and most were considered manageable by a nurse or village health worker. The latter appeared to be under-utilized and possible reasons for this are discussed.

Cardiac pathology in chronic myopathy, with particular reference to dystrophia myotonica

Histological changes in the hearts of two patients with dystrophia myotonica and one patient with a familial scapulo-peroneal myopathy are described. The myocardium showed fibre hypertrophy, interstitial fibrosis, vacuolar degeneration of myocardial cells and focal groups of aberrantly orientated myofibres. The AV node in the case of scapulo-peroneal myopathy showed vacuolar fibre degeneration and fatty infiltration. The aberrantly orientated myofibres have not previously been described in this context, and their relationship to similar aberrant fibres in hypertrophic obstructive cardio-myopathy and the electrophysiological and clinical manifestations of cardiac involvement in myotonic dystrophy are discussed.

Prognostic factors in ruptured aneurysms of the circle of Willis: the significance of systemic hypertension

The incidence of essential hypertension has been retrospectively studied in a group of sixty-four fatal cases of ruptured berry aneurysm, and compared with a non-fatal group. Hypertension is more frequent in the fatal group, and is associated with a higher incidence of multiple aneurysms, a smaller size of aneurysm at rupture and a poorer survival after two haemorrhages when comparison is made with normotensive patients. The possible role of hypertension in the development and rupture of aneurysms is discussed, and it is concluded that it may contribute to both. Following rupture it carries a poor prognosis with a resulting over emphasis of its significance in autopsy series. Possible mechanisms for this effect include diffuse vascular disease, and an increased liability to oedema or spasm following rupture of an aneurysm.