1256 SPERM LYMPHOCYTE CULTURE: TREATMENT OF SPERM WITH ANTI-HLA-B ANTISERA
Al 1,BW22,CW 1,DW 1 te donor-HLA All,BW22CWlDWlt donor-HLAgenotype and lymphocyte
All,BW22,CW1,DWlt
*A: sperm
and anti-BW20,
AW32,BW40,CW3,DW3j
respectively.
tAs determined by Robinette et al.6 DW’X’ likely heterogeneity of DW1.
=
Unknown allele
at
D locus. Note that E, who is
superior to the existing methods because any male donor can provide two typing cells whereas HLA-D homozygous lymphocytes are rare. It has the special advantage that spermatozoa can be put directly into culture with lymphocytes without X irradiation or chemical treatment, resulting in the elimination of blastogenic factor with a low background, no "typing response", and excellent discrimination. We have also been able to use stored spermatozoa which potentially makes this a method of choice for HLA-D typing. We thank Antonio Arnaiz-Villena, Anwer Halim, Johnny Sachs, Eva Wolf, Paul Evans, Janet Pritchard, and Jeanne Burke and the donors for their cooperation and help, and the Cancer Research Campaign, National Kidney Research Fund, and Department of Health and Social Security for financial support. Tissue Immunology Unit, London Hospital Medical College, Turner Street, London E1 2AD.
KAMAL HALIM HILLIARD FESTENSTEIN
ALCOHOL-ASSOCIATED PANCREATITIS IN A 15-YEAR-OLD
SiR,—Teenage alcohol intake is increasing,’ so alcohol-related disease in young people will more frequently pose diagnostic problems. We report a case of acute pancreatitis initially considered to be acute appendicitis. A 15-year-old boy was admitted as an emergency with a 36 h history of generalised abdominal pain, anorexia, nausea, and vomiting. There was no previous history of serious illness or previous episodes of abdominal pain and vomiting. On examination facial flushing8 was evident, temperature 37°C, heart-rate 120/min,
120/80
The abdomen was soft but diffuse tenderness was present and this was maximal in the right iliac fossa. Bowel sounds were normal and rectal examination was negative. He was taken to theatre with a provisional diagnosis of retrocaecal appendicitis. Through a Lanz incision 500 ml of straw-coloured peritoneal fluid was aspirated, but appendix, caecum, and ileum were normal. Appendicectomy was performed and the incision was closed without drainage. While this was being done samples of blood and peritoneal fluid were sent for amylase estimation and the results were 4350 units/I and 20 000 units/1, respectively (normal serum value 70-300 units/1). These results together with the operative findings were considered an adequate base for a diagnosis of acute pancreatitis. Full supportive measures for
6.
B.P.
mm
c.p.m. of cultured sperm alone 75±12 and 79±10 after
Hg.
Robinette, M., Sachs, J. A., Burke, J. M., Festenstein, H. in Proceedings of
the Sixth International Histocompatibility Workshop Conference. Copenhagen (in the press). 7. Report of the Departmental Committee on Scottish Licensing Laws. H.M. Stationery Office, 1973. 8. Imrie, C. W. Br. med. J. 1974, iv, 593.
not
DW1, also failed
to
..
treatment
with anti-BW40
respond to DWl stimulating sperm, indicating
the patient’s pancreatitis was instituted, paying particular attention to the twin dangers of early respiratory and renal insufficiency. He made good progress and was allowed home on the sixth postoperative day. The cause of his pancreatitis has been investigated, and the morning after surgery direct questioning revealed a heavy alcohol intake approximately 20 h before illness (one full bottle of cheap wine and quarter bottle of whisky). His habit for several months was to play cards once weekly with three friends, each providing a bottle of cheap wine. On this occasion one boy added a full bottle of whisky to the alcohol shared by the group. None of the others suffered any ill-effects. In this patient cholecystogram, mineral metabolism, lipoprotein, and viral screening have all been negative. There is no family history of the disease and no history of recent blunt abdominal trauma. Strong evidence therefore exists for an alcohol ietiology in this patient. Viral, hereditary, and traumatic aetiologies for acute pancreatitis in young people are well recorded. Unfortunately, it would seem likely that alcohol-related acute pancreatitis may become a more common cause for acute pancreatitis in this younger age-group, unless the disturbing trend of "under-age" alcohol intake is reversed. W. O. THOMSON Department of Surgery, C. W. IMRIE Royal Infirmary, S. N. JOFFE Glasgow G4 0SF.
INCIDENCE OF PANCREATITIS
SIR,-Mr Bourke (Nov. 15, p. 967) reports that the annual incidence of acute pancreatitis in Nottingham has varied by fourfold over a six-year period, and he cannot explain this variation. One possible cause, not mentioned by Mr Bourke, is variation in the rate of diagnosis rather than in the incidence of the disease. Around 1950 a medical student working in the chemistry laboratory of the Boston City Hospital studied requests for urinary and blood amylase sent in by the physicians on the wards and noted a sharp increase for several months after a lecture on acute pancreatitis in the weekly house-officers’ educational series. (I do not think the data were ever published, and I cannot remember the name of the man who did the work.) In other words, the tests were ordered much more frequently in patients with obscure abdominal pain, and presumably patients with mild attacks of pancreatitis that would not otherwise have been diagnosed were picked up by the increased awareness of the physicians on the wards. Could the increase in rate of diagnosis in Nottingham have followed, stimulating postgraduate session on acute pancreatitis ? Relating the number of tests ordered per month to such lectures might give a clue to this possible eetiological factor; on the other hand, the rate of ordering the test may also reflect
1257 OFFSPRING OF PARENTS WITH SPINA BIFIDA OCCULTA
the rate at which patients are presenting with obvious acute pancreatitis as a result of some other aetiological factor. Mount Sinai Medical Center, New York, 10029, U.S.A.
SiR,—The incidence of vertebral anomalies is higher than normal among parents and sibs of offspring with anencephaly and spina bifida cystica.12 A child born to an adult survivor of spina bifida cystica faces a 3% risk of neural-tube malformation.34 Couples of whom one partner has spina bifida occulta also seem to be at risk of producing affected offspring. We have encountered 4 affected parents. 2 of these, a man of 24 and a woman of 22, married to partners with normal vertebne, and their first children, both girls, were anencephalic. In each case the subsequent pregnancy was monitored by amniotic-nuid ot-fetoprotein estimations and ultrasound, and they yielded, respectively, a normal male and a normal female. Another woman, aged 29, with spina bifida occulta, who had had two laminectomies and a spinal fusion, had a girl with open spina bifida, a miscarriage, and a boy, born prematurely, who died soon after birth. The 4th subject is the elderly father of a man now aged 23 who had meningocele and no neurological deficit. The father was found on X-ray to have spina bifida occulta. On the basis of this experience we have counselled 5 more couples in which one partner has spina bifida occulta that there is a small, definite, but as yet unquantified risk of a seriously affected child and have offered them antenatal
THOMAS C. CHALMERS
INCIDENCE OF
CONJOINED TWINNING SiR,—Iread with interest the paper by Dr Bhettay and others’ suggesting a possible epidemic of conjoined twins in southern Africa. I have reviewed the literature for estimates of the frequency of conjoined twinning. Contrary to the statement by Dr Bhettay and his colleagues, there are many welldocumented reports’-6 from different parts of the world which indicate that this defect is more common than they suggest (see accompanying table). Indeed, one of these reports’ is from Rhodesia. Reports’suggesting that such defects are extremely rare have usually been based on incomplete ascertainment from birth certificates. Recently the experience with these embryonic duplications was reviewed for the metropolitan Atlanta area.2 Seven pairs of conjoined twins were born to residents of the 5-county metropolitan Atlanta area between Jan. 1, 1968, and Dec. 31, 1972. This gave a 5-year case-rate of 1 per 20 084 total births. These investigators were unable to identify any significant geographical or temporal clustering or other epidemiological factors which would suggest an environmental aetiology. It is difficult to compute an exact incidence of conjoined twins in southern Africa from the data of Dr Bhettay and his associates. Using their figures for the population of the area concerned (30 000 000), it may be conservatively estimated that 550 000 total births occur in any 15-month period (e.g., Jan. 1, 1974, to March 31, 1975). This would give an approximate incidence of 1 case per 50 000 total births: a figure vir30-year experience in Chicago9 and tually identical to Potter’s other large series.1o " Furthermore, the fact that 3 cases were born in Cape Town is uninformative without knowing the population base served by this area. This is not to say that environmental factors may not play a role in the aetiology of twinning and its errors. However, it seems likely that variations in the ascertainment of these malformations is the most probable cause for this apparent in-
screening. While the search for
a
specific environmental teratogen con-
tinues, ultimately the identification of the at-risk parent lies in the elucidation of a genetic marker or specific antibody system. In
a
preliminary study we found no association between anen-
cephaly/spina-bifida and maternal-serum HLA. The implication that the population at risk for neural-tube defects may be identified before the birth of an affected child has important applications in the discussion centring on mass antenatal screening’ and on their prevention by selective termination of affected pregnancies. Department of Preventive and Social Medicine, University of Sydney, New South Wales 2006.
BARBARA FIELD CHARLES KERR
crease.
ELDERLY FATHERS AND THE FREQUENCY OF Dysmorphology Unit, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington 98195, U.S.A.
RECESSIVE CONDITIONS
SiR,—The list of dominant conditions which may arise by mutation associated with advancing paternal age is growing. Some X-linked recessive conditions have been likewise associ-
JAMES W. HANSON
ated.6
1. Bhettay, E., Nelson, M. M., Beighton, P. Lancet, Oct. 18, 1975, p. 741. 2. Center for Disease Control. Congenital Malformations Surveillance, November/December, 1972. February, 1973. 3. Mudaliar, A. L. J. Obstet. Gynec. Br. Emp. 1930, 37, 753. 4. Emanuel, I., Huang, S. W., Gutman, L. T., et al. Teratology, 1972, 5, 159. 5. Bland, K. G., Hammer, B. Cent. Afr. J. Med. 1962, 8, 371. 6. Ryden, A. L. Zbl. Gynak. 1934, 58, 972. 7. Potter, E. L. Pathology of the Fetus and the Infant. Chicago, 1961. 8. Robertson, E. C. Archs. Neurol. Psychiat. 1953, 70, 189. 9. Compton, H. L. Obstet. Gynec. 1971, 37, 27. 10. Milham, S. J. Pediat. 1966, 69, 643. 11. Bender, C. ibid. 1967, 70, 1010. INCIDENCE OF
1.
Laurence, K. M., Bligh, A. S., Evans, K. T. Devl. Med. Child Neurol. 1968,
suppl. 16, 107. 2. Sever Lowell, E. J. med. Genet. 1974 11, 94. 3. Carter, C. O. Lancet, 1973, ii, 924. 4. Carter, C. O., Evans, K. A., Campbell, S. ibid. 1975, i, 685. 5. Brock, D. J. H., Scrimgeour, J. B. ibid. p. 745. 6. Jones, K. L., Smith, D. W., Harvey, M. A. S., Hall, B. Pediat. 1975, 86, 84.
CONJOINED
*Year of report.
N.A.=not
TWINS
applicable.
D., Quan, L. J.
Al 1,BW22,CW 1,DW 1 te donor-HLA All,BW22CWlDWlt donor-HLAgenotype and lymphocyte
All,BW22,CW1,DWlt
*A: sperm
and anti-BW20,
AW32,BW40,CW3,DW3j
respectively.
tAs determined by Robinette et al.6 DW’X’ likely heterogeneity of DW1.
=
Unknown allele
at
D locus. Note that E, who is
superior to the existing methods because any male donor can provide two typing cells whereas HLA-D homozygous lymphocytes are rare. It has the special advantage that spermatozoa can be put directly into culture with lymphocytes without X irradiation or chemical treatment, resulting in the elimination of blastogenic factor with a low background, no "typing response", and excellent discrimination. We have also been able to use stored spermatozoa which potentially makes this a method of choice for HLA-D typing. We thank Antonio Arnaiz-Villena, Anwer Halim, Johnny Sachs, Eva Wolf, Paul Evans, Janet Pritchard, and Jeanne Burke and the donors for their cooperation and help, and the Cancer Research Campaign, National Kidney Research Fund, and Department of Health and Social Security for financial support. Tissue Immunology Unit, London Hospital Medical College, Turner Street, London E1 2AD.
KAMAL HALIM HILLIARD FESTENSTEIN
ALCOHOL-ASSOCIATED PANCREATITIS IN A 15-YEAR-OLD
SiR,—Teenage alcohol intake is increasing,’ so alcohol-related disease in young people will more frequently pose diagnostic problems. We report a case of acute pancreatitis initially considered to be acute appendicitis. A 15-year-old boy was admitted as an emergency with a 36 h history of generalised abdominal pain, anorexia, nausea, and vomiting. There was no previous history of serious illness or previous episodes of abdominal pain and vomiting. On examination facial flushing8 was evident, temperature 37°C, heart-rate 120/min,
120/80
The abdomen was soft but diffuse tenderness was present and this was maximal in the right iliac fossa. Bowel sounds were normal and rectal examination was negative. He was taken to theatre with a provisional diagnosis of retrocaecal appendicitis. Through a Lanz incision 500 ml of straw-coloured peritoneal fluid was aspirated, but appendix, caecum, and ileum were normal. Appendicectomy was performed and the incision was closed without drainage. While this was being done samples of blood and peritoneal fluid were sent for amylase estimation and the results were 4350 units/I and 20 000 units/1, respectively (normal serum value 70-300 units/1). These results together with the operative findings were considered an adequate base for a diagnosis of acute pancreatitis. Full supportive measures for
6.
B.P.
mm
c.p.m. of cultured sperm alone 75±12 and 79±10 after
Hg.
Robinette, M., Sachs, J. A., Burke, J. M., Festenstein, H. in Proceedings of
the Sixth International Histocompatibility Workshop Conference. Copenhagen (in the press). 7. Report of the Departmental Committee on Scottish Licensing Laws. H.M. Stationery Office, 1973. 8. Imrie, C. W. Br. med. J. 1974, iv, 593.
not
DW1, also failed
to
..
treatment
with anti-BW40
respond to DWl stimulating sperm, indicating
the patient’s pancreatitis was instituted, paying particular attention to the twin dangers of early respiratory and renal insufficiency. He made good progress and was allowed home on the sixth postoperative day. The cause of his pancreatitis has been investigated, and the morning after surgery direct questioning revealed a heavy alcohol intake approximately 20 h before illness (one full bottle of cheap wine and quarter bottle of whisky). His habit for several months was to play cards once weekly with three friends, each providing a bottle of cheap wine. On this occasion one boy added a full bottle of whisky to the alcohol shared by the group. None of the others suffered any ill-effects. In this patient cholecystogram, mineral metabolism, lipoprotein, and viral screening have all been negative. There is no family history of the disease and no history of recent blunt abdominal trauma. Strong evidence therefore exists for an alcohol ietiology in this patient. Viral, hereditary, and traumatic aetiologies for acute pancreatitis in young people are well recorded. Unfortunately, it would seem likely that alcohol-related acute pancreatitis may become a more common cause for acute pancreatitis in this younger age-group, unless the disturbing trend of "under-age" alcohol intake is reversed. W. O. THOMSON Department of Surgery, C. W. IMRIE Royal Infirmary, S. N. JOFFE Glasgow G4 0SF.
INCIDENCE OF PANCREATITIS
SIR,-Mr Bourke (Nov. 15, p. 967) reports that the annual incidence of acute pancreatitis in Nottingham has varied by fourfold over a six-year period, and he cannot explain this variation. One possible cause, not mentioned by Mr Bourke, is variation in the rate of diagnosis rather than in the incidence of the disease. Around 1950 a medical student working in the chemistry laboratory of the Boston City Hospital studied requests for urinary and blood amylase sent in by the physicians on the wards and noted a sharp increase for several months after a lecture on acute pancreatitis in the weekly house-officers’ educational series. (I do not think the data were ever published, and I cannot remember the name of the man who did the work.) In other words, the tests were ordered much more frequently in patients with obscure abdominal pain, and presumably patients with mild attacks of pancreatitis that would not otherwise have been diagnosed were picked up by the increased awareness of the physicians on the wards. Could the increase in rate of diagnosis in Nottingham have followed, stimulating postgraduate session on acute pancreatitis ? Relating the number of tests ordered per month to such lectures might give a clue to this possible eetiological factor; on the other hand, the rate of ordering the test may also reflect
1257 OFFSPRING OF PARENTS WITH SPINA BIFIDA OCCULTA
the rate at which patients are presenting with obvious acute pancreatitis as a result of some other aetiological factor. Mount Sinai Medical Center, New York, 10029, U.S.A.
SiR,—The incidence of vertebral anomalies is higher than normal among parents and sibs of offspring with anencephaly and spina bifida cystica.12 A child born to an adult survivor of spina bifida cystica faces a 3% risk of neural-tube malformation.34 Couples of whom one partner has spina bifida occulta also seem to be at risk of producing affected offspring. We have encountered 4 affected parents. 2 of these, a man of 24 and a woman of 22, married to partners with normal vertebne, and their first children, both girls, were anencephalic. In each case the subsequent pregnancy was monitored by amniotic-nuid ot-fetoprotein estimations and ultrasound, and they yielded, respectively, a normal male and a normal female. Another woman, aged 29, with spina bifida occulta, who had had two laminectomies and a spinal fusion, had a girl with open spina bifida, a miscarriage, and a boy, born prematurely, who died soon after birth. The 4th subject is the elderly father of a man now aged 23 who had meningocele and no neurological deficit. The father was found on X-ray to have spina bifida occulta. On the basis of this experience we have counselled 5 more couples in which one partner has spina bifida occulta that there is a small, definite, but as yet unquantified risk of a seriously affected child and have offered them antenatal
THOMAS C. CHALMERS
INCIDENCE OF
CONJOINED TWINNING SiR,—Iread with interest the paper by Dr Bhettay and others’ suggesting a possible epidemic of conjoined twins in southern Africa. I have reviewed the literature for estimates of the frequency of conjoined twinning. Contrary to the statement by Dr Bhettay and his colleagues, there are many welldocumented reports’-6 from different parts of the world which indicate that this defect is more common than they suggest (see accompanying table). Indeed, one of these reports’ is from Rhodesia. Reports’suggesting that such defects are extremely rare have usually been based on incomplete ascertainment from birth certificates. Recently the experience with these embryonic duplications was reviewed for the metropolitan Atlanta area.2 Seven pairs of conjoined twins were born to residents of the 5-county metropolitan Atlanta area between Jan. 1, 1968, and Dec. 31, 1972. This gave a 5-year case-rate of 1 per 20 084 total births. These investigators were unable to identify any significant geographical or temporal clustering or other epidemiological factors which would suggest an environmental aetiology. It is difficult to compute an exact incidence of conjoined twins in southern Africa from the data of Dr Bhettay and his associates. Using their figures for the population of the area concerned (30 000 000), it may be conservatively estimated that 550 000 total births occur in any 15-month period (e.g., Jan. 1, 1974, to March 31, 1975). This would give an approximate incidence of 1 case per 50 000 total births: a figure vir30-year experience in Chicago9 and tually identical to Potter’s other large series.1o " Furthermore, the fact that 3 cases were born in Cape Town is uninformative without knowing the population base served by this area. This is not to say that environmental factors may not play a role in the aetiology of twinning and its errors. However, it seems likely that variations in the ascertainment of these malformations is the most probable cause for this apparent in-
screening. While the search for
a
specific environmental teratogen con-
tinues, ultimately the identification of the at-risk parent lies in the elucidation of a genetic marker or specific antibody system. In
a
preliminary study we found no association between anen-
cephaly/spina-bifida and maternal-serum HLA. The implication that the population at risk for neural-tube defects may be identified before the birth of an affected child has important applications in the discussion centring on mass antenatal screening’ and on their prevention by selective termination of affected pregnancies. Department of Preventive and Social Medicine, University of Sydney, New South Wales 2006.
BARBARA FIELD CHARLES KERR
crease.
ELDERLY FATHERS AND THE FREQUENCY OF Dysmorphology Unit, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington 98195, U.S.A.
RECESSIVE CONDITIONS
SiR,—The list of dominant conditions which may arise by mutation associated with advancing paternal age is growing. Some X-linked recessive conditions have been likewise associ-
JAMES W. HANSON
ated.6
1. Bhettay, E., Nelson, M. M., Beighton, P. Lancet, Oct. 18, 1975, p. 741. 2. Center for Disease Control. Congenital Malformations Surveillance, November/December, 1972. February, 1973. 3. Mudaliar, A. L. J. Obstet. Gynec. Br. Emp. 1930, 37, 753. 4. Emanuel, I., Huang, S. W., Gutman, L. T., et al. Teratology, 1972, 5, 159. 5. Bland, K. G., Hammer, B. Cent. Afr. J. Med. 1962, 8, 371. 6. Ryden, A. L. Zbl. Gynak. 1934, 58, 972. 7. Potter, E. L. Pathology of the Fetus and the Infant. Chicago, 1961. 8. Robertson, E. C. Archs. Neurol. Psychiat. 1953, 70, 189. 9. Compton, H. L. Obstet. Gynec. 1971, 37, 27. 10. Milham, S. J. Pediat. 1966, 69, 643. 11. Bender, C. ibid. 1967, 70, 1010. INCIDENCE OF
1.
Laurence, K. M., Bligh, A. S., Evans, K. T. Devl. Med. Child Neurol. 1968,
suppl. 16, 107. 2. Sever Lowell, E. J. med. Genet. 1974 11, 94. 3. Carter, C. O. Lancet, 1973, ii, 924. 4. Carter, C. O., Evans, K. A., Campbell, S. ibid. 1975, i, 685. 5. Brock, D. J. H., Scrimgeour, J. B. ibid. p. 745. 6. Jones, K. L., Smith, D. W., Harvey, M. A. S., Hall, B. Pediat. 1975, 86, 84.
CONJOINED
*Year of report.
N.A.=not
TWINS
applicable.
D., Quan, L. J.
