The nominal group technique: a research tool for general practice?

Qualitative methods are increasingly recognized as valuable, yet practitioners face difficult decisions in their choice of method and the process of analysis. The nominal group technique combines quantitative and qualitative data collection in a group setting, and avoids problems of group dynamics associated with other group methods such as brainstorming, Delphi and focus groups. Idea generation and problem solving are combined in a structured group process, which encourages and enhances the participation of group members. The stages involved in conducting a nominal group are described, and practical problems of its use in a health care setting are discussed with reference to a study of the priorities of care of diabetic patients, carers and health professionals. Some potential applications of the technique in audit and exploratory research are also outlined.

Activation of mucosal V beta 3+ T cells and tissue damage in human small intestine by the bacterial superantigen, Staphylococcus aureus enterotoxin B

Staphylococcus aureus enterotoxin B (SEB) was added to explants of fetal human intestine in organ culture or administered into the lumen of fetal small intestine prior to culture. Both routes produced a massive increase in lamina propria T cells expressing V beta 3, and to a lesser extent, those expressing V beta 5 and V beta 12. SEB-activated lamina propria T cells produced interleukin-2 and interferon-gamma and T cell activation was accompanied by tissue damage, which was inhibited by FK506.

Ontogeny and induction of adhesion molecule expression in human fetal intestine

In this study we examined the distribution of the adhesion molecules ICAM-1, VCAM-1 and E-selectin in human fetal intestine, to determine whether they may have a role in the development of gut-associated lymphoid tissue. Secondly, we studied the tempo of induction of these molecules after T cell activation in explants of human fetal intestine cultured in vitro. In the fetus from 11 to 20 weeks gestation, endothelial expression of ICAM-1 and diffuse staining of VCAM-1 was observed in the lamina propria. In contrast, there was intense expression of ICAM-1 and VCAM-1 in the developing Peyer's patches, suggesting that these molecules may be involved in the accumulation or organization of lymphoid tissue in the gut. After T cell activation in fetal intestinal explants, the expression of ICAM-1 and VCAM-1 was increased on most endothelial cells, leucocytes, and stromal cells in the lamina propria. Expression was maintained for at least 4 days. In contrast, the induction of E-selectin was rapid, and the expression was transient, despite the continuing presence of activated T cells and macrophages. This suggests that other factors are required to prevent the down-regulation of E-selectin to maintain the sustained expression sometimes observed in vivo.

Proliferation and differentiation of tumour cells from B-cell lymphoma of mucosa-associated lymphoid tissue in vitro

Several characteristics of lymphomas of mucosa-associated lymphoid tissue (MALT type) suggest that they are antigen-dependent and that their growth parodies a normal immune response. We have previously shown that three cases of low-grade B-cell MALT-type lymphoma recognize autoantigens. In this study, we investigated the response of three low-grade and one high-grade case of MALT-type lymphoma to anti-idiotypic antibody as a model of antigen binding either alone or as a co-stimulus with B-cell mitogens. We also studied the response of tumour cells to interleukin-6 (IL-6), which induces differentiation to immunoglobulin-producing cells in many systems. Of the four cases studied, one low-grade case showed markedly enhanced proliferation in response to anti-idiotype alone. This could not be increased by the addition of mitogens. In the remaining two low-grade cases, mitogen responsiveness was observed which was affected by anti-idiotype either by an enhancement or by a reduction in the proliferative response. The high-grade case failed to respond to the stimuli studied. No response to IL-6 was observed. This study supports the suggestion that antigen may affect the pathogenesis of low-grade tumours of MALT type.

Creating a death register for general practice

General practitioners complete approximately 26% of death certificates themselves but have considerable difficulty obtaining prompt and accurate information about their other patients who die. A random survey of district health authorities in England revealed that all were able to compile death lists but none included general practitioner details. This paper reviews the flow of information on patient deaths and describes a project to assess the feasibility of providing Newcastle general practitioners with comprehensive death registers. With the collaboration of the family health services authority and the district health authority, and with data from the regional perinatal mortality survey the creation each week of complete lists of patient deaths, broken down by general practitioner, is feasible. Death registers allow general practitioners to undertake audit of the quality of death certification and of the care of the recently deceased, and to improve the continuing care of the bereaved.

Immunoglobulin specificity of low grade B cell gastrointestinal lymphoma of mucosa-associated lymphoid tissue (MALT) type

The specificity of the tumor cell immunoglobulin in three cases of low grade B cell gastrointestinal mucosa-associated lymphoid tissue (MALT) lymphoma has been studied. Using anti-idiotypic antibodies to detect the reactivity of tumor immunoglobulin in tissue sections from the patients and other individuals, we observed specificity for normal tissue components in all three cases studied. Reactivity in one case was with follicular dendritic cells, in the second case with a novel antigen on mucosal post capillary venules, and, in the third case, a broad pattern of reactivity was observed. This study suggests that autoimmunity may play a role in the pathogenesis of gastric lymphoma.

Diabetes care: who are the experts?

OBJECTIVES

To identify issues that patients and professionals consider important in diabetes care and differences in their priorities for care and to determine patients' and professionals' judgements of the relative importance of their chosen priorities.

DESIGN

Structured group interviews using the nominal group technique.

SETTING

Five district health authorities on Tyneside.

SUBJECTS

Five nominal groups: expert (seven), non-expert (seven) health care professionals; insulin dependent (four), non-insulin dependent patients (eight); and carers of diabetic patients (eight).

MAIN MEASURES

Items important in diabetes care to each nominal group (themes of care), ranked into a series of "top 10" items for each group, and allocated a score according to relative importance to individual members; scores were standardised by individual weighting and group weighting for comparison within and between groups.

RESULTS

Patients and professionals agreed that information given to patients, interaction between professionals and patients, patient autonomy, and access were important for good diabetes care, but the importance assigned to each differed. Thus the professionals emphasised empathy and aspects of good communication and patients the desire to know enough to live a "normal" life. Differences were also found within the patient groups; these related to changes in patients' needs at specific points in the development of their illness and in their orientations to care.

CONCLUSION

Patients differ from professionals in their orientation to diabetes care, and they can, and should, be involved in setting priorities for care. Since these priorities are dynamic further work is needed to explore the nature of patient satisfaction with diabetes care.

Effects of interferon-gamma and tumour necrosis factor-alpha on epithelial HLA class-II expression on jejunal mucosal biopsy specimens cultured in vitro

HLA class-II molecules present antigen to the immune system and are expressed by normal villous enterocytes. Increased expression occurs in inflammatory bowel and coeliac disease, and it is suggested that cytokines may mediate such increased expression. The effects of the cytokines IFN-gamma and TNF-alpha on epithelial HLA class-II expressions have been studied in adult human jejunal mucosal biopsy specimens cultured in vitro. Specimens from nine patients with normal jejunal histology were cultured for 24 h with IFN-gamma, TNF-alpha, or both. Six of nine patients showed increased HLA-DR and HLA-DP expression after culture with the cytokines. We have demonstrated that these cytokines induce increased epithelial HLA class-II expression in adult jejunal mucosal specimens cultured in vitro, a model that most closely resembles the in vivo state. This provides further evidence that such increased expression occurs secondarily to the products of immunologic activation.

Psychiatric diagnostic profiles in hospitalized adolescent and adult Navajo Indians

Diagnostic profiles of 400 adolescent and 1159 adult Navajo Indians consecutively admitted to a psychiatric unit between 1980 and 1989 are presented in this paper. The major discharge diagnoses for adolescents were as follows: adjustment reaction, mixed, and depression, not otherwise specified (NOS), with females accounting for two-thirds of either diagnosis; schizophrenia, with males accounting for 68% of all diagnoses, and personality disorder, NOS, with no gender differences. The four major discharge diagnoses for adults were schizophrenia and depression, NOS, in which there were no gender differences; alcohol withdrawal, syndrome, in which males accounted for 76% of those discharged; and adjustment reaction, mixed, in which females constituted 60% of those discharged. Over the 10-year period, there was a decrease in adult and an increase in adolescent admissions. During the last 2 years (1988 and 1989) adolescents accounted for almost 30% of all admissions compared with 14% during the first 2 years (1981 and 1982).

Phakomatous choristoma of the orbit: a case report

We report the case of a 3-month-old infant with a rare phakomatous choristoma of the orbit. This lesion is believed to be a congenital neoplasm of lenticular anlage. The clinical, radiological, and histopathological findings are presented.

Duodenal ulcer: a model of impaired mucosal defence

There is a new model of chronic duodenal ulcer in which the ulcer is generated by irradiating the lower mediastinum of mice with a single dose of 18 Gy 250 kV x rays. Single ulcers develop in the proximal duodenum of about half the animals. Previous studies have shown a remarkable morphological and behavioural similarity to duodenal ulcer in man. Ulceration occurs because of an imbalance between aggressive and defensive forces within the duodenum and an attempt has been made to elucidate the pathomechanism of this ulcer by determining acid and pepsin secretion. The basal and pentagastrin stimulated secretion of acid, pepsin, and histamine were measured and no changes in acid or pepsin secretion were shown to occur (risk of type II error < 1%). It is therefore concluded that this chronic ulcer is a model of impaired duodenal defence.

Antibody response to canine distemper vaccine in African wild dogs

Antibody levels against canine distemper virus were measured by means of an immunofluorescent antibody test prior to, and after, administration of a modified-live virus booster vaccine to seven African wild dogs (Lycaon pictus). Positive seroconversion with no harmful side-effects was seen in all the animals.

The intraoperative localization of the obscure bleeding site using fluorescein

Despite visceral angiography and radiolabeled gastrointestinal scintigraphy, the localization of gastrointestinal bleeding can still be a challenge. Even preoperative localization with visceral angiography is no guarantee of successful intraoperative localization or subsequent pathological confirmation. We report a case of obscure gastrointestinal bleeding of small bowel origin, which was localized intraoperatively by fluorescein injected via a superselectively placed catheter.

Surgery in Barrett's oesophagus

Surgical treatment for a columnar-lined oesophagus (CLO) may be considered in terms of indications, procedures and risks. Reflux may be an indication for surgery, but does not lead to reversal of epithelium, nor does it eliminate malignant potential. Whether it reduces such potential is not certain. Anti-reflux surgery is therefore based on reflux-related criteria, and not as a treatment for a CLO. Dysplasia is a possible indication for surgery, but as progression to carcinoma may be slow, must not be considered an absolute indication in an elderly, frail patient. Malignancy is a clear indication for operation in a patient deemed fit enough to withstand it. Anti-reflux operations have been standardized over recent years, and aim at exclusion of gastric juice from the oesophagus. Another approach is to alter refluxed material qualitatively by a duodenal diversion procedure. This eliminates bile and pancreatic juice from the oesophagus, with dramatic effects on inflammation but without reversal of a CLO. Reversal of inflammation may facilitate endoscopic surveillance. Either dysplasia or carcinoma are treated by oesophagogastric resection. Newer forms of laparoscopic or thoracoscopic dissection may be particularly applicable with dysplasia or early carcinoma in CLO. Palliative surgery for advanced tumours is not often required today. Risks of anti-reflux surgery must be balanced against symptoms. Risks are reduced if splenectomy is avoided, and operations avoided where possible in the elderly. Resection for dysplasia or carcinoma is high-risk surgery. In the young there is much to gain, and the risks are lower. In the elderly, in the absence of other treatment, risks must be balanced against general health and life expectancy.

Cell-mediated immune injury in the intestine

Epithelial adaptation clearly occurs during the course of intestinal cell-mediated immune responses to alloantigens. The adaptive response is similar to that seen in a number of enteropathies, namely villus atrophy, crypt hypertrophy, and crypt cell hyperplasia. In human fetal gut, polyclonal activation of lamina propria CD4+ T cells produces the same epithelial adaptive responses. Although these data provide overwhelming evidence that cell-mediated immune responses can cause enteropathy, the demonstration of antigen-specific T cells in the lamina propria of patients with enteropathy is still lacking, even in a disease as well-characterized as celiac disease. Epithelial adaptation in experimental and clinical situations, however, must involve a change in the mechanisms and mediators involved in normal intestinal homeostasis, such as epidermal growth factor and transforming growth factor-alpha and -beta, and in the interactions between epithelial cells and the underlying stromal cells.

Properties of human thymic B cells

B cells, distinct from those seen in myasthenia gravis, are present in normal human thymic medulla, concentrated around the Hassall's corpuscles. We have shown that they constitute 33 +/- 4.8% of the total cells in the thymic medulla. In tissue sections they were often seen to have rosettes of thymocytes around them, a relationship which was maintained when the cells were isolated from the thymus. Thymic B cells expressed cytoplasmic immunoglobulins IgD, IgM and IgG but only rarely IgA. Unlike murine thymic B cells, human thymic B cells were CD5-. Freshly isolated thymic B cells were activated cells, but they rapidly became quiescent and died in culture over a 10-day period unless stimulated with mitogens. Thymic B cells responded to polyclonal B-cell activators SAC and TPA and when stimulated, maintained their relationship with thymocytes. Electron microscopic studies showed that two morphologically different thymocyte populations associated with the B cells. The plasma membranes of larger thymocytes were juxtaposed to the B-cell membrane, but smaller thymocytes with darker cytoplasm were associated with the B cells via cytoplasmic strands. Studies in mice have suggested that B cells are involved in thymic negative selection. The close association between activated B cells and thymocytes observed in this study supports this hypothesis.

CT evaluation of lymph node status at presentation of prostatic carcinoma

Computed tomographic (CT) studies performed within a general oncology service in 104 consecutive patients with prostatic carcinoma were reviewed retrospectively to assess the incidence and distribution of lymphadenopathy. All patients were staged with CT at initial presentation, had normal skeletal scintigrams and were candidates for radical radiotherapy. The likelihood of lymphadenopathy was associated with increasing T-stage. 57 of the 92 (62%) patients without lymph node enlargement had local disease confined to the prostate (T2 or less) compared with only two of the 12 (17%) patients with enlarged nodes. Lymph node enlargement was more likely with a primary tumour of poorly differentiated histology. 12 patients (11.5%) had lymphadenopathy by established CT criteria; six with pelvic nodal enlargement alone and six with enlargement of pelvic and retroperitoneal nodes. In all patients pelvic nodal enlargement predominated and no patient had isolated retroperitoneal lymphadenopathy. Our findings indicate that CT staging studies of prostatic cancer do not need to include the retroperitoneum if there is no lymphadenopathy at or below the aortic bifurcation.