Detecting autoreactive B cells in the peripheral blood of people with type 1 diabetes using ELISpot.

Type 1 diabetes mellitus (T1D) is an autoimmune disorder where T lymphocytes damage the islet beta cells but B lymphocytes also play an important role. Although changes in peripheral B cell phenotype have been observed, little is known about the B cells that secrete the autoantibodies. We developed a sensitive B cell enzyme-linked immunospot assay (ELISpot assay) to detect individual B cell antibody responses to glutamic acid decarboxylase (GAD) and islet antigen-2 (IA-2). We found that even healthy donors have B cells that secrete antibodies in response to GAD and IA-2 in the ELISpot. There was increased B cell reactivity to autoantigens in the peripheral blood of individuals with newly-diagnosed, but not long-standing, type 1 diabetes. However, no correlation with serum autoantibody levels was found, indicating that additional factors such as antigen affinity or exposure to antigens in vivo are required for antibody secretion, and that even healthy donors have potentially autoreactive B cells.

The coming of age of a joint elderly medicine-psychiatric ward: 18 years' experience.

INTRODUCTION: There is a large population of elderly medical inpatients with co-existent medical and mental health disorders who pose a significant management challenge for medical, nursing and allied staff. Our hospital has a joint elderly medicine-psychiatry unit to cater for this patient group; this article reviews how this unit was set up and presents a representative sample of inpatients. RESULTS: The mean age was 81 years with a female preponderance. The mean length of stay was 44 days. The commonest medical conditions were cerebrovascular disease, urinary tract infections, chest infections and falls. The commonest mental health diagnoses were cognitive impairment, delirium and depression. The mortality rate was 21%; of the remainder, 55% were discharged to long-term care, 40% returned home and 5% were transferred to the local psychiatric hospital. DISCUSSION: This cohort of elderly patients has complex medical, nursing and therapy needs in addition to complex discharge planning needs. Our unit has a shared care approach, with joint responsibility shared by a consultant in Medicine for the Elderly and a Consultant in Old Age Psychiatry. This, in combination with a multidisciplinary team approach, provides an effective means of delivering care to this patient group. CONCLUSION: A joint elderly medicine-old age psychiatry ward provides a high standard of care for elderly patients with co-existent physical and mental health needs. We hope that the information presented in this article will be of use to those hoping to set up a similar unit in their own hospitals.

The use of titanium non-penetrating clips to close the spinal dura.

We present the results of our initial experience in the use of non-penetrating titanium clips in the closure of spinal dura. A retrospective analysis of case notes of patients identified from the unit database was carried out, limited to adults. A proforma that included demographic details, the diagnosis, the procedure undertaken, whether or not additional dural closure methods were used, the use of bed rest and any complications, including cerebrospinal fluid (CSF) leak. There were 58 patients with a mean age of 53 years. The commonest diagnoses were meningioma, ependymoma and neurofibroma. Eight patients had additional methods of dural closure used and approximately half the patients had a period of postoperative bed rest. Eight patients (13.7%) had a CSF leak. Our early experience with the use of non-penetrating clips for the closure of the spinal dura is presented. We have found them easy to use, especially in anatomically-restricted spaces and rapid in their application. However, our results have revealed an unexpectedly high complication rate. A further prospective study to evaluate them more fully is planned.

External ventricular drain infection: the effect of a strict protocol on infection rates and a review of the literature.

External ventricular drains (EVDs), like any surgically-implanted foreign body, are at risk of infection. We present the results of a completed audit loop following introduction of an evidence-based protocol for their insertion and management. There were two phases over a 2-year period. Phase 1 was a retrospective audit of our EVD infection rate. Phase 2 was a prospective audit of the infection rate subsequent to the introduction of a protocol for the insertion and management of EVDs. In phase 1, the infection rate was 27%. In phase 2, the infection rate was 12%. This was a statistically significant reduction (p < 0.05, Chi-squared test). EVD infection is unfortunately a common clinical problem and associated with potential morbidity and mortality. This study demonstrates that adherence to an evidence-based protocol for their insertion and management is associated with a significant reduction in the infection rate.

Cerebellopontine angle meningioma resulting in middle-ear polyp.

Extracranial spread of meningiomas to involve the middle ear is very rare. We present the case of a 43-year-old woman with a known cerebellopontine angle meningioma who subsequently presented with left-sided otalgia and a middle-ear mass extruding through the tympanic membrane due to local invasion of the meningioma. The tumour was excised surgically. A discussion of the relevant literature is also presented.

Immature teratoma arising from a benign cortical abnormality.

CASE REPORT: The authors report the case of an immature teratoma of the left parieto-occipital region in a 13-year-old girl. The patient had a computed tomographic (CT) scan of the brain aged 10 months old, following a minor head injury. This demonstrated an abnormality in the same region, which had been reported as 'a cortical malformation'. DIAGNOSIS: We propose that the lesion on the original imaging is a mature teratoma or other silent dystopic germ cell element that subsequently transformed into the immature teratoma. DISCUSSION: The potential triggers for such a transformation and the management of patients with similar incidental radiological findings are discussed.

The 2-week wait for suspected cancer: time for a rethink?

The 2-week rule, stating that patients with suspected cancer should be seen by a specialist within 2 weeks of referral by their General Practitioner, was introduced in the UK in 2000. Although it has been the subject of much interest in the literature, to date there has been no review of the literature. A thorough literature review was undertaken using the medline database, from January 2000; further references were obtained from the reference lists of relevant papers. Some studies have demonstrated a reduction in the waiting times to see specialists, and in some cases time to treatment, and have commented on the potential psychological benefits to patients. However, concerns have been raised over the often low yield of malignancy and the high proportion of malignancies still being diagnosed outside the 2-week wait system. There is, as yet, no evidence that the initiative impacts on survival.

Laryngeal inflammatory pseudotumour: an unusual cause of airway obstruction.

We report a rare case of a laryngeal pseudotumour in a child presenting with stridor, which was treated by endoscopic laryngeal resection, without the need for a tracheostomy. A short review of the literature is also presented. Although rare, laryngeal pseudotumour should be considered as part of the differential diagnosis of stridor and upper airway obstruction in children.

Squamous cell carcinoma of the bladder presenting as vulvitis and cliteromegaly.

INTRODUCTION: Clitoral metastases are exceptionally rare. We present a case of a squamous cell carcinoma of the bladder presenting with a clitoral metastasis. CASE REPORT: We report the case of an 84-year-old lady with frequency, dysuria and a clitoral mass, which was found to be a poorly differentiated carcinoma on fine needle aspiration cytology. Cystoscopy revealed a moderate to poorly differentiated squamous cell carcinoma of the bladder. CONCLUSION: This is the first reported case of a squamous cell carcinoma of the bladder with clitoral metastasis. Clitoral metastases are exceptionally rare, with only seven previous cases reported in the literature. Although the commonest cause of cliteromegaly is hormonal, a metastatic carcinoma should be considered as part of the differential diagnosis in the elderly female.

A study of 13 cases of near-hanging presenting to an Accident and Emergency Department.

This paper reports 13 cases of near-hanging presenting to the Accident and Emergency (A + E) Department of a District General Hospital over a 52-month period. The purpose of the study was to analyse the epidemiology, methods, outcomes and complications of near-hanging. There were 13 cases in the study period, 12 of whom were male and 1 female. The mean age was 31 years. The most common method used was rope (five cases). The estimated mean duration of hanging was 5 min. Height of fall data was poorly recorded but only one fall was recorded as being more than 3 ft. Many had a very poor clinical picture on arrival of the ambulance crews: seven had a Glasgow Coma Score (GCS) of less than or equal to 8 on scene, of which five required intubation. Five patients required ventilation and a period of treatment on the Intensive Therapy Unit (ITU). There were no cervical spine (C-spine) injuries, nor neurological complications. There were two incidences of aspiration pneumonia. All of the patients made a full recovery. It is concluded that patients presenting with this injury go on to make a full recovery, despite an often dismal initial clinical picture.

Effects of reducing submandibular blood flow on secretory responses to parasympathetic stimulation in anaesthetized cats.

Submandibular secretory responses to stimulation of the parasympathetic chorda-lingual nerve were investigated in five anaesthetized cats before, during and after withdrawal of blood (ca 20 ml kg-1) in order to investigate the consequences of a reduced blood flow through the gland. Stimulation at different frequencies (2, 4, 6 and 8 Hz) evoked a frequency-dependent increase in the flow of submandibular saliva, sodium concentration, electrolyte and protein output. When the blood pressure was reduced (by about 50%) there was a significant reduction in submandibular blood flow and the secretion of both saliva and protein during stimulation. Under each set of conditions the flow of saliva was linearly related to the blood flow through the gland. It is concluded that submandibular secretory responses to electrical stimulation of the parasympathetic innervation can be significantly attenuated when the blood flow through the gland is reduced under the conditions employed in this study.

The role of nitric oxide in the control of protein secretion in the parotid gland of anaesthetized sheep.

Parotid secretion has been investigated in anaesthetized lambs in the presence and absence of N omega-nitro-L-arginine methyl ester (L-NAME) and sodium nitroprusside to block de novo synthesis of nitric oxide (NO). Following administration of L-NAME the basal rate of flow was unaffected and changes in electrolyte secretion failed to achieve statistical significance but there was a significant fall in the basal rate of protein secretion. The flow of parotid saliva which occurred in response to stimulation of the parasympathetic innervation was reduced by 34% and sodium output was reduced in approximately the same proportion. L-NAME had no significant effect on these parameters during stimulation of the sympathetic innervation. During combined stimulation of the parasympathetic and sympathetic innervations L-NAME caused a reduction in parotid salivary flow and sodium output which was roughly the same as that observed during parasympathetic stimulation alone. However, L-NAME caused a much greater reduction in protein output during each of these experimental protocols: -92% during parasympathetic stimulation, =63% during sympathetic stimulation, and -60% during combined stimulation. Whereas the absolute amount of protein secreted was reduced after L-NAME in each instance, the extent of potentiation of protein output recorded during combined stimulation was increased roughly fivefold. It is concluded that the output of protein in response to autonomic stimulation exhibits a greater No dependence than either the flow of saliva or secretion of electrolytes in this gland.

Cervical cancer: changing trends in the Wellington region.

AIM: To identify changes in patient and tumour characteristics of women with carcinoma of the cervix treated through the Wellington Regional oncology unit between 1975-89. METHODS: The medical records of the patients treated between 1985-9 were reviewed. The age and stage of disease was noted in each case and results compared with the previous two 5-year cohorts. RESULTS: Over the 15 year period there was no obvious reduction in the incidence of cervical cancer. There was a significant trend towards women presenting with earlier stage disease. In the 1985-9 cohort, patients less than 40 years old were significantly more likely to present with earlier stage disease, and there was no detectable difference between the incidence of cervical cancer in Maori and nonMaori. CONCLUSIONS: The results indicate that cervical screening has not yet made an impact on the incidence of cervical cancer in the greater Wellington region, and possible reasons for this are discussed.