740
increased violence when a ward population diminished and staff/patient ratios increasedand the findings described here support such a result. Changes in staffing may predispose to violent behaviour, but only if other conditions are satisfied. Nurses less familiar with patients are assaulted most often and lack of consistency and stability in the care of psychiatric patients leads to disturbed behaviour.6 these findings have implications for service provision and planning. Further prospective studies are required. Free Hospital, London NW3 2QG, UK
SURFACE PHENOTYPE OF PERIPHERAL BLOOD LYMPHOCYTES
Royal
A. K. SHAH
Fineberg NA, James JV, Shah AK. Agency nurses and violence in a psychiatric ward. Lancet 1988; i: 474. 2. James DV, Fineberg NA, Shah AK, Priest RG. An increase in violence on an acute J 1990; 156: 846-52. psychiatric ward. A study of associated factors. Br Psychiatry 3. Shah AK, Piachaud J. Violence, nursing and inpatient psychiatry. Lancet 1988; i: 940. 4. Depp FC. Assaults in a public mental hospital. In: Lion JR, Reid WH, eds. Assaults within psychiatric facilities. New York: Grune and Stratton, 1983: 21-43. 5. Hodgkinson PE, McIvor L, Phillips M. Patient assaults on staff in a psychiatric hospital: a two year retrospective study. Med Sci Law 1985; 25: 288-94. 6. Crammer JL. The special characteristics of suicide in hospital in-patients. BrJ Psychiatry 1984; 145: 460-76. 1.
Psychoanalysis and the couch SIR,-Dr Ryle’s review (Dec 15, p 1475) of my book Further Learning from the Patient: the Analytic Space and Process contains
inaccuracy. Unlike many analysts I do question whether the necessarily "the best or only way to listen to or to help patients". That is why at least one-third of my own work, and half of the psychotherapy work that I supervise, is with patients who do not use the couch: nor are they expected to. The ways of listening that I describe have been developed within this mixed practice. Your an
couch is
reviewer suggests the reverse and thinks it necessary to warn the reader that, in his opinion "the listening skills referred to are those designed for ... those who have consented to be horizontal for several hours each week in the presence of the unseen, interpreting
analyst". 122 Mansfield Road, London NW3 2JB, UK
PATRICK CASEMENT
Spontaneous regression of CD4-CD8- cells bearing T-cell receptor &agr;&bgr; SIR,-Dr Hattori and colleagues (Jan 12, p 76) report a patient with adult T-cell leukaemia (ATL) who had a novel T-cell subpopulation lacking CD4 and CD8 but bearing the &agr;&bgr; form of T-cell receptor (TCR). We describe here an HTLV-I carrier in whom this T-cell subpopulation (CD4-CD8- TCR&agr;&bgr;+), which was not infected with HTLV-I, showed monoclonal proliferation in the peripheral blood for more than 3 years and then disappeared spontaneously. A 54-year-old man was admitted to hospital in March, 1987, with cervical lymphadenopathy. The histopathological diagnosis was eosinophilic granuloma (Kimura’s disease). A bone marrow smear showed no abnormality, and no lymph node swelling other than in the cervical region was detected. However, peripheral blood lymphocytes (PBL) had greatly increased CD4-CD8-TCR&agr;&bgr;+ T cells. The absence of CD4 and CD8 expression was confirmed by monoclonal antibodies OKT4 + Leu3a and OKT8 + Leu2a. After resection of the enlarged lymph nodes, the patient remained stable without any lymphadenopathy or other symptoms until September, 1990, when general malaise and low-grade fever developed. These symptoms persisted for about 2 months and then disappeared spontaneously. From May, 1987, to September, 1990, CD4-CD8-TCR&agr;&bgr;+ T cells accounted for 60-75% of PBL, but in November, 1990, no CD4 CD8 TCR&agr;&bgr;+ T cells were found (table) and this situation has persisted up to February, 1991. A single rearranged band was detected in September, 1987, by Southern blot analysis of PBL using the TCR &bgr;-chain gene, showing that proliferation of CD4-CD8- TCR&agr;&bgr;+ T cells was monoclonal. No such rearranged band was detected in December, 1990. The patient was seropositive for HTLV-I, but ATL-like convoluted nuclear cells were rarely found on peripheral blood
smears.
Integration of HTLV-1 proviral DNA was not detected in
CD4- CD8- TCR&agr;&bgr;+ T cells but was found in a CD4" T-cell line established from the patient’s PBL. He was diagnosed as an HTLV-I carrier. It has been found that CD4 - CD8 -TCR&agr;&bgr;+ T cells are increased in active systemic lupus erythematosus,l though massive proliferation of this novel T-cell subpopulation in peripheral blood is very rare.2 Although the mechanisms involved in the proliferation and regression of double-negative TCR&agr;&bgr; T cells are unclear, the present case may throw light on diseases caused by this newly defined T-cell subpopulation and on defensive mechanisms against the
neoplastic lymphocyte proliferation.
First Department of Internal Medicine, Ehime University School of Medicine, Shigenobu, Ehime 791-02, Japan
MASAKI YASUKAWA AKIRA INATSUKI TAKAAKI HATO SHIGERU FUJITA YUZURU KOBAYASHI
S, Tsokos GC, Datta SK. T cell receptor &agr;/&bgr; expressing double-negative (CD4-/CD8-) and CD4+ T helper cells in humans augment the production of pathogenic anti-DNA autoantibodies associated with lupus nephritis. J Immunol
1. Shivakumar
1989; 143: 103-12. 2. Wirt DR, Brooks EG, Vaidya S, et al. Novel T-lymphocyte population in combined immunodeficiency with features of graft-versus-host disease. N Engl J Med 1989; 321: 370-74.
Reduced portal hypertension by mechanical increase in liver portal blood flow SIR,—We read with interest the short report by Mr Habib and colleagues (Jan 5, p 16); we too have investigated the relation between pressure, flow, and resistance in an isolated perfused rat liver preparation. We monitored portal venous pressure with a controlled flow rate recirculation system and a cellular perfusate (bicarbonate buffer, 61% v/v), bovine serum albumin (100 mg/l, 26% v/v), and washed aged human red cells (13% v/v). Flow rate was varied randomly at 2·5 ml/min increments between 2·5 and 17·5 ml/min. Both normal rat liver preparations and those rendered cirrhotic by phenobarbitone and intragastric carbon tetrachloride1 were examined. We found a linear relation between portal pressure and perfusate flow rate in both the cirrhotic and control preparations
(figure). We agree that measures based on flow reduction alone may not always result in clinically significant falls in portal pressure. For instance, a 50% reduction in portal flow from 15 to 7·5 ml/min was accompanied by only an 18% fall in portal pressure from 15·4 to 12·7 cm water (figure). A rise in hepatic resistance may be expected to follow a fall in portal flow because of elastic recoil and collapse of small vessels, which tends to offset the effect of flow reduction on portal pressure. Thus, a substantial reduction in flow was required to produce a fall in portal pressure. Since more patients with cirrhosis die from hepatic failure than from gastrointestinal bleeding,2 these results have clinical importance. However, unlike Habib and colleagues, we found evidence of barotrauma at high perfusion pressures in our experimental preparation, with disruption of vascular architecture. Damage to the liver from high
increased violence when a ward population diminished and staff/patient ratios increasedand the findings described here support such a result. Changes in staffing may predispose to violent behaviour, but only if other conditions are satisfied. Nurses less familiar with patients are assaulted most often and lack of consistency and stability in the care of psychiatric patients leads to disturbed behaviour.6 these findings have implications for service provision and planning. Further prospective studies are required. Free Hospital, London NW3 2QG, UK
SURFACE PHENOTYPE OF PERIPHERAL BLOOD LYMPHOCYTES
Royal
A. K. SHAH
Fineberg NA, James JV, Shah AK. Agency nurses and violence in a psychiatric ward. Lancet 1988; i: 474. 2. James DV, Fineberg NA, Shah AK, Priest RG. An increase in violence on an acute J 1990; 156: 846-52. psychiatric ward. A study of associated factors. Br Psychiatry 3. Shah AK, Piachaud J. Violence, nursing and inpatient psychiatry. Lancet 1988; i: 940. 4. Depp FC. Assaults in a public mental hospital. In: Lion JR, Reid WH, eds. Assaults within psychiatric facilities. New York: Grune and Stratton, 1983: 21-43. 5. Hodgkinson PE, McIvor L, Phillips M. Patient assaults on staff in a psychiatric hospital: a two year retrospective study. Med Sci Law 1985; 25: 288-94. 6. Crammer JL. The special characteristics of suicide in hospital in-patients. BrJ Psychiatry 1984; 145: 460-76. 1.
Psychoanalysis and the couch SIR,-Dr Ryle’s review (Dec 15, p 1475) of my book Further Learning from the Patient: the Analytic Space and Process contains
inaccuracy. Unlike many analysts I do question whether the necessarily "the best or only way to listen to or to help patients". That is why at least one-third of my own work, and half of the psychotherapy work that I supervise, is with patients who do not use the couch: nor are they expected to. The ways of listening that I describe have been developed within this mixed practice. Your an
couch is
reviewer suggests the reverse and thinks it necessary to warn the reader that, in his opinion "the listening skills referred to are those designed for ... those who have consented to be horizontal for several hours each week in the presence of the unseen, interpreting
analyst". 122 Mansfield Road, London NW3 2JB, UK
PATRICK CASEMENT
Spontaneous regression of CD4-CD8- cells bearing T-cell receptor &agr;&bgr; SIR,-Dr Hattori and colleagues (Jan 12, p 76) report a patient with adult T-cell leukaemia (ATL) who had a novel T-cell subpopulation lacking CD4 and CD8 but bearing the &agr;&bgr; form of T-cell receptor (TCR). We describe here an HTLV-I carrier in whom this T-cell subpopulation (CD4-CD8- TCR&agr;&bgr;+), which was not infected with HTLV-I, showed monoclonal proliferation in the peripheral blood for more than 3 years and then disappeared spontaneously. A 54-year-old man was admitted to hospital in March, 1987, with cervical lymphadenopathy. The histopathological diagnosis was eosinophilic granuloma (Kimura’s disease). A bone marrow smear showed no abnormality, and no lymph node swelling other than in the cervical region was detected. However, peripheral blood lymphocytes (PBL) had greatly increased CD4-CD8-TCR&agr;&bgr;+ T cells. The absence of CD4 and CD8 expression was confirmed by monoclonal antibodies OKT4 + Leu3a and OKT8 + Leu2a. After resection of the enlarged lymph nodes, the patient remained stable without any lymphadenopathy or other symptoms until September, 1990, when general malaise and low-grade fever developed. These symptoms persisted for about 2 months and then disappeared spontaneously. From May, 1987, to September, 1990, CD4-CD8-TCR&agr;&bgr;+ T cells accounted for 60-75% of PBL, but in November, 1990, no CD4 CD8 TCR&agr;&bgr;+ T cells were found (table) and this situation has persisted up to February, 1991. A single rearranged band was detected in September, 1987, by Southern blot analysis of PBL using the TCR &bgr;-chain gene, showing that proliferation of CD4-CD8- TCR&agr;&bgr;+ T cells was monoclonal. No such rearranged band was detected in December, 1990. The patient was seropositive for HTLV-I, but ATL-like convoluted nuclear cells were rarely found on peripheral blood
smears.
Integration of HTLV-1 proviral DNA was not detected in
CD4- CD8- TCR&agr;&bgr;+ T cells but was found in a CD4" T-cell line established from the patient’s PBL. He was diagnosed as an HTLV-I carrier. It has been found that CD4 - CD8 -TCR&agr;&bgr;+ T cells are increased in active systemic lupus erythematosus,l though massive proliferation of this novel T-cell subpopulation in peripheral blood is very rare.2 Although the mechanisms involved in the proliferation and regression of double-negative TCR&agr;&bgr; T cells are unclear, the present case may throw light on diseases caused by this newly defined T-cell subpopulation and on defensive mechanisms against the
neoplastic lymphocyte proliferation.
First Department of Internal Medicine, Ehime University School of Medicine, Shigenobu, Ehime 791-02, Japan
MASAKI YASUKAWA AKIRA INATSUKI TAKAAKI HATO SHIGERU FUJITA YUZURU KOBAYASHI
S, Tsokos GC, Datta SK. T cell receptor &agr;/&bgr; expressing double-negative (CD4-/CD8-) and CD4+ T helper cells in humans augment the production of pathogenic anti-DNA autoantibodies associated with lupus nephritis. J Immunol
1. Shivakumar
1989; 143: 103-12. 2. Wirt DR, Brooks EG, Vaidya S, et al. Novel T-lymphocyte population in combined immunodeficiency with features of graft-versus-host disease. N Engl J Med 1989; 321: 370-74.
Reduced portal hypertension by mechanical increase in liver portal blood flow SIR,—We read with interest the short report by Mr Habib and colleagues (Jan 5, p 16); we too have investigated the relation between pressure, flow, and resistance in an isolated perfused rat liver preparation. We monitored portal venous pressure with a controlled flow rate recirculation system and a cellular perfusate (bicarbonate buffer, 61% v/v), bovine serum albumin (100 mg/l, 26% v/v), and washed aged human red cells (13% v/v). Flow rate was varied randomly at 2·5 ml/min increments between 2·5 and 17·5 ml/min. Both normal rat liver preparations and those rendered cirrhotic by phenobarbitone and intragastric carbon tetrachloride1 were examined. We found a linear relation between portal pressure and perfusate flow rate in both the cirrhotic and control preparations
(figure). We agree that measures based on flow reduction alone may not always result in clinically significant falls in portal pressure. For instance, a 50% reduction in portal flow from 15 to 7·5 ml/min was accompanied by only an 18% fall in portal pressure from 15·4 to 12·7 cm water (figure). A rise in hepatic resistance may be expected to follow a fall in portal flow because of elastic recoil and collapse of small vessels, which tends to offset the effect of flow reduction on portal pressure. Thus, a substantial reduction in flow was required to produce a fall in portal pressure. Since more patients with cirrhosis die from hepatic failure than from gastrointestinal bleeding,2 these results have clinical importance. However, unlike Habib and colleagues, we found evidence of barotrauma at high perfusion pressures in our experimental preparation, with disruption of vascular architecture. Damage to the liver from high
