department. There is a weekly combined psychiatric/geriatric round, involving day as well as inpatients, somaking combined assessment possible without admission.There is little transfer of patient between unit, since
facilities and advice are available to both. There arevarious ways of dealing with misplacement-dependentupon circumstances-without extra facilities or personnel,provided there is enough mutual interest.
Department ofGeriatric Psychiatrics andDepartment of Geriatrics,
TONY WHITEHEADGANESH MANKIKAR.
SULPHATE INCORPORATION OFLEUCOCYTES FROM PATIENTS WITH
SiR,-Your editorial of Aug. 11 (p. 307) comments onthe suspected genetic heterogeneity of cystic fibrosis (c.F.).In preliminary studies of short-term leucocyte culturesusing Na2 35S0 4 incorporation into cetyl-pyridinium-chloride (c.P.c.)-precipitable material (presumably glycos-aminoglycans, G.A.G.), we have found significant variationamong c.F. patients and their parents (obligate hetero-zygotes). This biochemical heterogeneity is comparable towhat has been reported in fibroblast cultures 1-3 andserum. 4
20-40 ml. of blood was collected by venepuncture and theleucocytes, predominantly neutrophils (83%), were isolated asdescribed by Stjernholm. The cells were incubated (in duplicatesamples) in Fischers medium for leukaemic mice cells (GIBCO)with 50 ILC Na.35S04 (specific activity 350 mC per mmol) at aconcentration of about 5 x 10. cells per 10 ml. medium for 4 hoursat 37C. After incubation the cells were separated from themedium by centrifugation, and subjected to R.N.A.se, D.N.A.se, andpapain digestion following the procedure of Olsson.. This wasfollowed by addition of 1 mg. of chondroitin sulphate as carrierand precipitation with 1.5 ml. of 0-1% c.P.c. The precipitatewas washed 5 times with 10 ml. of distilled water to removeexcess Na.DS04 and then resuspended in 150 ILL 0-1% c.P.c.and dissolved in 200 1. of n-propanol. Radioactivity was deter-mined in a Packard liquid scintillation counter after addition of* Aquasol . 1 mg. of chondroitin sulphate was added as carrierto 1 ml. of incubation medium (l.M.) and the G.A.G. precipitatedwith 1-5 ml. of 0-1% c.P.c., washed 5 times with 10 ml. of water,dissolved, and counted as described for the cell fraction.
The results were:
* Normal donors were matched for age and sex.
The Students t test was applied to the data:
1. Danes, B. S., Beam, A. G. J. exp. Med. 1969, 129, 775.2. Danes, B. S., Beam, A. G. Biochem. biophys. Res. Comm. 1969,
36, 919.3. Matalon, R., Dorfman, A. ibid. 1968, 33, 954.4. Conover, J. H., Conod, E. F., Hirschhorn, K. Lancet, 1973, i, 1122.5. Stjernholm, R. L., Dimitrov, N. V., Pijanoswki, L. J. J. reticuloend.
Soc. 1969, 6, 194.6. Olsson, I., Gardell, S. Biochim. biophys. Acta, 1967, 141, 348.
The amount of Na235S04 incorporated into G.A.G.material found in both the incubation medium and the cellsfrom c.F. patients is significantly increased over normals.A similar analysis between normals and heterozygotesshows no significant difference in Na, 35SO, incorporationinto G.A.G. material of the cells. However, 4 out of 6heterozygotes appeared to show a pattern of increasedincorporation:into:material found in the incubation medium(indicated by a higher mean than the normal donors).
Within the group of c.F. patients, variation was observedin the amounts of 35S04 incorporated into G.A.G. materialfound inside the cells and in the I.M. The variation insulphate incorporation could not be correlated with clinicalstatus, age, or sex of the patients. Therefore, the patientswere arranged in what appeared to be three distinct groupsbased on values recorded for i.m.-35SO, G.A.G. as follows:
Group 1 shows a normal 35S0 incorporation patterninto G.A.G. from both the cells and l.M., group 2 showsincreased 35S0 incorporation of cellular G.A.G. with normalincorporation into G.A.G. found in the l.M., while group 3shows an increase over normal in 35S0 incorporation intoG.A.G. from both the cells and l.M.A correlation of these results with the presence of meta-
chromasia would be of interest. Additional studies needto be carried out to determine whether the increase in
35S0 labelling is correlated with a quantitative increase inG.A.G. or in increased sulphation of G.A.G. or other sulphatedcompounds present in the leucocytes.These results suggest yet another system to study the
effects of the c.F. gene. The incorporation of Na235S04into G.A.G. material of C.F. leucocyte cultures gives additionalevidence for the genetic heterogeneity in this disorder.
This study was supported by a U.S.P.H.S. grant, N.I.H.Ca-13214. The help of Dr Robert Stern and the Department ofPediatrics, Rainbow Babies and Childrens Hospital, Cleveland,Ohio, is gratefully acknowledged.
Department of Anatomy,Case Western Reserve
University,Cleveland, Ohio 44106, U.S.A MARGARET CAUDILL.
Department of Pediatrics,Cleveland Metropolitan General
Hospital,Cleveland, Ohio. IRWIN SCHAFER.
Department of Biochemistry,Case Western Reserve
University,Cleveland, Ohio. RUNE STJERNHOLM.
" HIGH ISOLATION " ACCOMMODATIONFOR INFECTIOUS DISEASES
SIR,-Professor Grists invitation (Dec. 8, p. 1340) forviews on the containment of infectious diseases by un-sophisticated and inexpensive methods prompts me toreport what we have been doing, apparently with completesuccess, in the childrens ward at Amersham for the pastten years.
Two of the cubicles have French windows. When used forisolation purposes the doors of these cubicles to the ward corridorare bolted. The infectious child is admitted through the window.A notice is put on the cubicle door " Isolation, use outsideentrance ". No caps, masks, or gowns are used. Parents areallowed to stay or come and go as they please, but they and othervisitors and all members of staff must enter and leave only bythe French windows.
The ward has a very rapid turnover and it is possible thatcross-infection may have occurred without our being aware ofit, but in four cases of chickenpox admitted in this way postcardfollow-up of susceptibles failed to reveal any secondary cases.
Isolation units in childrens wards which are approachedfrom the inside, whatever their ventilation arrangements,are in my opinion expensive ineffectual anachronisms.One of these is nearing completion in a hospital not farfrom Amersham, and it will be interesting to see whether itproves to be as effective as our simple arrangements.Amersham General HospitalAmersham, Bucks. HP7 0JD. DONALD GARROW.
INCREASED SUSCEPTIBILITY OF RED-BLOOD-CELL LIPIDS TO AUTOXIDATION IN
THALASSMIA MAJORSIR,-Stocks et a1.l found in 6 cases of thalassacmia
major an increased tendency to autoxidation of red-blood-cell lipids. They used a test based on the breakdown ofautoxidised fats to malonyldialdehyde. Others 2 are of theopinion that this test is only an indirect index of oxidation.
TOTAL AND FRACTIONATED LIPIDS (mg. per 100 ml. OF PACKEDRED CELLS) AND FRACTIONATED PHOSPHOLIPIDS (% OF TOTALPHOSPHOLIPIDS) IN 20 PATIENTS AFFECTED BY THALA&S/E.MIAMAJOR AND IN 20 NORMAL SUBJECTS
We studied by thin-layer chromatography the compositionof lipids in the red cells of 20 children with thalassxmiamajor living in the north of Sardinia. Precautions were usedto avoid an altered distribution of lipids. Samples werecollected in tubes containing vitamin E, and chromato-graphic solvents were added with 2,6-di-tert-butyl-p-cresol,as suggested by Dodge and Phillips,3 to prevent oxidation.The results, compared with normal controls (see table),show a significant increase of sphingomyelin and phos-phatidylcholine and a significant reduction of phosphatidyl-ethanolamine.These findings, the result of autoxidation of lipids,3
confirm the results of Stocks and his colleagues. Furtherinvestigation could be useful, in view of the possible use ofantioxidant agents to prevent haemolysis.
I Clinica Pediatrica,Universit di Roma,
Via le Regina Elena 324,00161, Roma.
Istituto di Puericoltura,Universit di Sassari,
OMERO GIARDINIMASSIMO CASTROGIORGIO MAGGIONI.
TREATMENT OF OBSTRUCTION DUE TO
CARCINOMA OF THE COLON
SiR,There is a school of thought which advocatesimmediate resection for acutely obstructing carcinomatouslesions of the left colon. A method was described bySames 4,5 with resection of the lesion, formation of an endcolostomy in the upper end of the wound, and oversewing
1. Stocks, J., Kemp, M., Dormandy, T. L. Lancet, 1971, i, 266.2. Shohet, S. B. New Engl. J. Med. 1972, 286, 638.3. Dodge, J. T., Phillips, G. B. J. Lipid Res. 1966, 7, 387.4. Sames, C. P. Lancet, 1960, ii, 948.5. Sames, C. P. Proc. R. Soc. Med. 1968, 61, 374.
of the rectal stump which is returned to the pelvis: restora-tion to be undertaken at a later date.
This procedure should, however, be reserved for thosecases in which the lesion is relatively high in the sigmoidcolon. If the growth is lower, the surgeon would be welladvised to abandon this method and rely upon the traditionaltransverse colostomy.
In the light of recent experience, if the rectosigmoidand upper rectum are mobilised out of the sacral hollow,restoration of continuity may be extremely difficult, andeven hazardous, owing to extensive adhesions of small bowelto the pelvic floor. Difficulty may also be experienced infinding the buried rectal stump.
Royal United Hospital,Combe Park,
Bath. P. J. JEFFERY.
BILE CANALICULI ANTIBODIES : BENIGNOR PATHOLOGICAL ?
SIR,-As reiterated earlier this year,l.2 various types ofcirculating anti-tissue antibodies (autoantibodies) have beendescribed in patients with liver disease. While these reportsoffer further confirmation to previous reports 3.4 of the
FREQUENCY AND RANGES IN INDIRECT IMMUNOFLUORESCENT (I.F.)STAINING TITRES OF BILE CANALICULAR ANTIBODY IN PATIENTS
WITH CARCINOMA OF THE PROSTATE *
* Adapted from Ablin and Soanes.st Classification of stage of carcinoma of the prostate according to
For example, 4 (80%) means that 4 patients or 80% had indirect i.a.
staining titres of antibodies to bile canaliculi on rabbit liver rangingfrom 1/40 to 1/80.
presence of antibody to bile canaliculi in liver disease andseem to support the suggested association of
" autoaller-gic w-tiological factors in liver disease ,1 the demonstrationof antibody to bile canaliculi in the absence of any confirmedliver abnormality in patients with carcinoma of the prostate 11raises the question of the pathophysiological specificity ofthese antibodies. As summarised in the accompanyingtable, variable titres of antibody reactive with bile canaliculiof rabbit liver have been noted by the method of indirect(" sandwich ") immunofluorescence in a significant pro-portion (17 out of 24) of patients with various clinically andhistologically staged carcinoma of the prostate.s
Observations such as these suggest that we may be
observing antibodies which are pathologically related tonormal processes of ageing rather than a specific diseaseentity. That is, with the decline of humoral and cell-mediated immunological capability with age, does the host
1. MacSween, R. N. M., Armstrong, E. M., Gray, K. G., Mason, M.Lancet, 1973, i, 1419.
2. Diederichsen, H. ibid. 1973, ii, 326.3. Bumbalo, T. S., Bellanti, J. A., Terplan, K. L. Pediatrics, Springfield,
1961, 29, 191.4. Diederichsen, H. Acta med. scand. 1969, 186, 299.5. Ablin, R. J., Soanes, W. A. Ann. clin. Res. 1971, 3, 226.6. Flocks, R. H J. Urol. 1969, 101, 741.