1193 subdivision of cryptogenic fibrosing alveolitis. Firstly, histological examination of biopsy material has shown wide differences in cellular content of lung tissue from patients with otherwise apparently similar clinical disease. Secondly, the detection of circulating and fixed immune complexes has been found’to correlate remarkably well with the lung cellularity, suggesting that fibrosing alveolitis may occur in two forms-as an inflammatory, cellular, immune-complex-mediated disease, and as predominant fibrosis, without evidence of inflammatory cells or immune complexes. The American study4 makes a sharp distinction between these two types; the fact that no intermediate types were recognised is perhaps surprising, since the disease is widely believed to start as a
predominantly inflammatory condition, gradually progressing to a more fibrotic picture with the passage of time. In Denver the pathologist was able to divide twenty-four patients with known cryptogenic fibrosing alveolitis cleanly into "cellular" and "fibrotic" types. Working independently, immunologists showed that the great majority of the "cellular" patients had raised serum levels of immune complexes, and IgG deposition in the alveolar walls and capillaries. This IgG deposition was detected by indirect immunofluorescence, whereas circulating immune complexes were found by Raji-cell radioimmunoassay.s The Raji-cell technique is one of the better validated for detection of circulating complexes. It depends on the ability of Raji cells (a human lymphoblastoid line) to bind IgG-Fc and complement; immune complexes containing complement are therefore picked up, and can be recognised by the addition of radio-labelled anti-human IgG in a second step. Compared with the many other techniques now available,6 it is reasonably sensitive, the main drawback being interference from aggregated IgG and rheumatoid factor. Is this new immunopathological division of cryptogenic fibrosing alveolitis relevant to therapy? In a short follow-up of a few patients, the Denver workers saw a response to high doses of corticosteroids more often in the patients with immune complexes and cellular biopsy appearances than in the fibrotic group. British experience in this area has been mixed: it is always difficult to define response to treatment in a disease which ftuctuates so widely in its natural rate of progression.2’7 If supported, these American findings will add considerably to our understanding of fibrosing alveolitis ; they point firmly to an immunological pathogenesis and should pave the way for an intensive search for the antigen component of the immune complexes. A possible clue comes from the work of Crystal and his colleagues,8,9 who have reported abnormal peripherallymphocyte responses to collagen (type I) in these patients. These investigations also support therapeutic use of immunosuppressive drugs during the cellular phase of the illness. The tendency nowadays is to use high doses of corticosteroids (e.g., prednisolone 1 mg/kg daily) and azathioprine 2-5 mg/kg when lesser doses ofcorticoster-
5
Theofilopoulos, 169.
6.
Zubler,
R. 1 (edited
A.
N., Wilson, C. B., Dixon,
F.
J. J.
clin. Invest. 1976,
57,
H., Lambert, P. H. in Recent Advances in Clinical Immunology by R A. Thompson); p. 125. Edinburgh, 1977. 7. Scadding,J.G.,Hinson,K.F.W.Thorax,1967, 22, 291. 8. Kravis, T. C., Ahmed, A., Brown, T. E., J. clin. Invest. 1976, 58, 1223. 9. Crystal, R. G., Fulmer, J. D., Roberts, W. C., Moss, M. L., Line, B. R., Reynolds, H. Y. Ann. intern. Med 1976, 85, 769.
Pulmonary
function needs to be monitored during these trials, with particular attention to vital capacity and transfer factor. oids
give carefully
no
response.
HOSPICE CARE
people engaged in hospice care meet, their approach become immediately apparent. Equally apparent is that the basic principles of hospice care are the same and, even more important, are at last being interpreted in the sphere of general care as well as in specialist medicine. Soon incompetence in terminal care will be recognised for what it is. The sixth annual conference on Caring for the Dying, held on May 12, at St. Joseph’s Hospice, Hackney, was attended by people from thirty-three established hospices or home-care teams and from nine groups who are planning homeWHENEVER
diversities of
units. In the United States over two hundred involved in the hospice movement. The palliative-care unit in Montreal is in operation and there are interested groups in Australia, Denmark, Israel, Norway, South Africa, and Sweden. The hospice movement is now worldwide. The approach to pain control in patients with terminal malignant disease depends, like any other good medical practice, on careful clinical assessment, followed by the correct use of analgesics and other drugs (such as anxiolytics and antidepressants) and frequent critical review. Too often those in charge, particularly doctors, are guilty of what Dr Robert Twycross, of Sir Michael Sobell House, Oxford, referred to as tunnel vision in their view of the disease. His plea was for broad-spectrum pain control. At its simplest, pain is a dual phenomenon-a reaction between body and mind-and any attempt to control it that concentrates exclusively on its physical aspect, ignoring the mental, social, and spiritual components of the person’s anguish, cannot hope to succeed. The conference underlined the enormous contribution that the National Society for Cancer Relief is making in Britain, particularly by its support of the continuing-care units being set up in various parts of the country. At St. Joseph’s Hospice the MacMillan Home Care Team (supported by the N.S.C.R.) is looking after, at any one time, about seventy patients in their own homes. They have six back-up beds in the hospice and probably need twelve. Like the other home-care teams already at work, they find they can keep patients at home long after hospital admission would otherwise have become necessary. Home-care teams are one of the most important components of hospice care. Another major development is the establishment of symptomcontrol teams in general centres who are available for consultation whenever symptoms, in the widest sense of the word, of a patient with terminal malignant disease are no longer being adequately controlled. Perhaps the last word for this year’s conference was said by Dr Cicely Saunders. Against a background of improving symptom control and an increasing understanding of what is involved in terminal disease, not only for the patient but also for his family, Dr Saunders insisted that hospice care must not be allowed to become an eclectic specialty. It must be integrated into the care that most of us hope will come our way wherever we die.
care
centres are
predominantly inflammatory condition, gradually progressing to a more fibrotic picture with the passage of time. In Denver the pathologist was able to divide twenty-four patients with known cryptogenic fibrosing alveolitis cleanly into "cellular" and "fibrotic" types. Working independently, immunologists showed that the great majority of the "cellular" patients had raised serum levels of immune complexes, and IgG deposition in the alveolar walls and capillaries. This IgG deposition was detected by indirect immunofluorescence, whereas circulating immune complexes were found by Raji-cell radioimmunoassay.s The Raji-cell technique is one of the better validated for detection of circulating complexes. It depends on the ability of Raji cells (a human lymphoblastoid line) to bind IgG-Fc and complement; immune complexes containing complement are therefore picked up, and can be recognised by the addition of radio-labelled anti-human IgG in a second step. Compared with the many other techniques now available,6 it is reasonably sensitive, the main drawback being interference from aggregated IgG and rheumatoid factor. Is this new immunopathological division of cryptogenic fibrosing alveolitis relevant to therapy? In a short follow-up of a few patients, the Denver workers saw a response to high doses of corticosteroids more often in the patients with immune complexes and cellular biopsy appearances than in the fibrotic group. British experience in this area has been mixed: it is always difficult to define response to treatment in a disease which ftuctuates so widely in its natural rate of progression.2’7 If supported, these American findings will add considerably to our understanding of fibrosing alveolitis ; they point firmly to an immunological pathogenesis and should pave the way for an intensive search for the antigen component of the immune complexes. A possible clue comes from the work of Crystal and his colleagues,8,9 who have reported abnormal peripherallymphocyte responses to collagen (type I) in these patients. These investigations also support therapeutic use of immunosuppressive drugs during the cellular phase of the illness. The tendency nowadays is to use high doses of corticosteroids (e.g., prednisolone 1 mg/kg daily) and azathioprine 2-5 mg/kg when lesser doses ofcorticoster-
5
Theofilopoulos, 169.
6.
Zubler,
R. 1 (edited
A.
N., Wilson, C. B., Dixon,
F.
J. J.
clin. Invest. 1976,
57,
H., Lambert, P. H. in Recent Advances in Clinical Immunology by R A. Thompson); p. 125. Edinburgh, 1977. 7. Scadding,J.G.,Hinson,K.F.W.Thorax,1967, 22, 291. 8. Kravis, T. C., Ahmed, A., Brown, T. E., J. clin. Invest. 1976, 58, 1223. 9. Crystal, R. G., Fulmer, J. D., Roberts, W. C., Moss, M. L., Line, B. R., Reynolds, H. Y. Ann. intern. Med 1976, 85, 769.
Pulmonary
function needs to be monitored during these trials, with particular attention to vital capacity and transfer factor. oids
give carefully
no
response.
HOSPICE CARE
people engaged in hospice care meet, their approach become immediately apparent. Equally apparent is that the basic principles of hospice care are the same and, even more important, are at last being interpreted in the sphere of general care as well as in specialist medicine. Soon incompetence in terminal care will be recognised for what it is. The sixth annual conference on Caring for the Dying, held on May 12, at St. Joseph’s Hospice, Hackney, was attended by people from thirty-three established hospices or home-care teams and from nine groups who are planning homeWHENEVER
diversities of
units. In the United States over two hundred involved in the hospice movement. The palliative-care unit in Montreal is in operation and there are interested groups in Australia, Denmark, Israel, Norway, South Africa, and Sweden. The hospice movement is now worldwide. The approach to pain control in patients with terminal malignant disease depends, like any other good medical practice, on careful clinical assessment, followed by the correct use of analgesics and other drugs (such as anxiolytics and antidepressants) and frequent critical review. Too often those in charge, particularly doctors, are guilty of what Dr Robert Twycross, of Sir Michael Sobell House, Oxford, referred to as tunnel vision in their view of the disease. His plea was for broad-spectrum pain control. At its simplest, pain is a dual phenomenon-a reaction between body and mind-and any attempt to control it that concentrates exclusively on its physical aspect, ignoring the mental, social, and spiritual components of the person’s anguish, cannot hope to succeed. The conference underlined the enormous contribution that the National Society for Cancer Relief is making in Britain, particularly by its support of the continuing-care units being set up in various parts of the country. At St. Joseph’s Hospice the MacMillan Home Care Team (supported by the N.S.C.R.) is looking after, at any one time, about seventy patients in their own homes. They have six back-up beds in the hospice and probably need twelve. Like the other home-care teams already at work, they find they can keep patients at home long after hospital admission would otherwise have become necessary. Home-care teams are one of the most important components of hospice care. Another major development is the establishment of symptomcontrol teams in general centres who are available for consultation whenever symptoms, in the widest sense of the word, of a patient with terminal malignant disease are no longer being adequately controlled. Perhaps the last word for this year’s conference was said by Dr Cicely Saunders. Against a background of improving symptom control and an increasing understanding of what is involved in terminal disease, not only for the patient but also for his family, Dr Saunders insisted that hospice care must not be allowed to become an eclectic specialty. It must be integrated into the care that most of us hope will come our way wherever we die.
care
centres are
