Abstract: CLINICAL/METHODICAL ISSUE: Clinical examination and laboratory results are often insufficient to support therapeutic decisions. STANDARD RADIOLOGICAL METHODS: Diagnosis and organ-related imaging may provide important additional information for initial diagnosis (differential diagnoses), follow-up and prognosis. Especially functional imaging techniques, such as ultrasound and magnetic resonance imaging are becoming more and more important for early diagnosis. METHODICAL INNOVATIONS: Imaging is already recognized in the classification criteria of several rheumatic diseases and new criteria for spondyloarthritis and polymyalgia rheumatica aim more and more at early diagnosis using functional imaging techniques, such as ultrasound and magnetic resonance imaging. PERFORMANCE: Specific imaging findings are helpful for eliminating differential diagnoses. During follow-up disease control the status as well as progression of structural damage can be documented. In selected diseases imaging allows prognostic statements on both disease progression and therapeutic response to specific medication. ACHIEVEMENTS: The evidential value of imaging results varies with the rheumatological expectations. PRACTICAL RECOMMENDATIONS: Overall rheumatological expectations on imaging differ widely and therefore support a differentiated use of imaging techniques.
Abstract: The objective of this study was to develop EULAR/ACR classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of RF and/or ACPA (2 points), and absence of peripheral joint pain (1 point). A score â¥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score â¥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients â¥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness>45 minutes, elevated CRP and/or ESR and new hip pain. These criteria are not meant for diagnostic purposes.
Abstract: OBJECTIVE: To prospectively evaluate the disease course and the performance of clinical, patient-reported outcome (PRO) and musculoskeletal ultrasound measures in patients with polymyalgia rheumatica (PMR). METHODS: The study population included 85 patients with new-onset PMR who were initially treated with prednisone equivalent dose of 15 mg daily tapered gradually, and followed for 26 weeks. Data collection included physical examination findings, laboratory measures of acute-phase reactants, and PRO measures. Ultrasound evaluation was performed at baseline and Week 26 to assess for features previously reported to be associated with PMR. Response to corticosteroid treatment was defined as 70% improvement in PMR on visual analog scale (VAS). RESULTS: At baseline, 77% had hip pain in addition to shoulder pain and 100% had abnormal C-reactive protein or erythrocyte sedimentation rate. On ultrasound, 84% had shoulder findings and 32% had both shoulder and hip findings. Response to corticosteroid treatment occurred in 73% of patients by Week 4 and was highly correlated with percentage improvement in other VAS measures. Presence of ultrasound findings at baseline predicted response to corticosteroids at 4 weeks. Factor analysis revealed 6 domains that sufficiently represented all the outcome measures: PMR-related pain and physical function, an elevated inflammatory marker, hip pain, global pain, mental function, and morning stiffness. CONCLUSION: PRO measures and inflammatory markers performed well in assessing disease activity in patients with PMR. A minimum set of outcome measures consisting of PRO measures of pain and function and an inflammatory marker should be used in practice and in clinical trials in PMR.
Abstract: Pro-inflammatory, cytotoxic CD4(+)CD28(-) T-cells with known defects in apoptosis have been investigated as markers of premature immuno-senescence in various immune-mediated diseases. In this study we evaluated the influence of polyclonal antilymphocyte globulins (ATG-Fresenius, ATG-F) on CD4(+)CD28(-) T-cells in vivo and in vitro.
Principal Findings: Surface and intracellular three colour fluorescence activated cell sorting analyses of peripheral blood
mononuclear cells from 16 consecutive transplant recipients and short-term cell lines were performed. In vivo, peripheral
levels of CD3+CD4+CD28- T-cells decreased from 3.7+/-7.1% before to 0+/-0% six hours after ATG-F application (P = 0.043) in 5 ATG-F treated but not in 11 control patients (2.9+/-2.9% vs. 3.9+/-3.0%). In vitro, ATG-F induced apoptosis even in CD4+CD28- T-cells, which was 4.3-times higher than in CD4+CD28+ T-cells. ATG-F evoked apoptosis was partially reversed by the broadspectrum caspase inhibitor benzyloxycarbonyl (Cbz)-Val-Ala-Asp(OMe)-fluoromethylketone (zVAD-fmk) and prednisolon-21-hydrogensuccinate. ATG-F triggered CD25 expression and production of pro-inflammatory cytokines, and induced downregulation
of the type 1 chemokine receptors CXCR-3, CCR-5, CX3CR-1 and the central memory adhesion molecule CD62L predominately in CD4+CD282 T-cells.
Conclusion: In summary, in vivo depletion of peripheral CD3+CD4+CD28- T-cells by ATG-F in transplant recipients was paralleled in vitro by ATG-F induced apoptosis. CD25 expression and chemokine receptor down-regulation in CD4+CD28- Tcells
only partly explain the underlying mechanism.
Abstract: The objective of this study was to develop European League Against Rheumatism/American College of Rheumatology classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new-onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of rheumatoid factor and/or anti-citrullinated protein antibody (2 points), and absence of peripheral joint pain (1 point). A score â¥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score â¥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients â¥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness >45 minutes, elevated C-reactive protein and/or erythrocyte sedimentation rate, and new hip pain. These criteria are not meant for diagnostic purposes.
Abstract: The challenges of diagnosing rheumatic diseases are the high prevalence of certain rheumatic diseases, the existence of orphan disease, and the different pathophysiological backgrounds including infection and autoimmune mechanisms. During recent decades, more and more attention has been drawn to early diagnosis and achievement of full remission. Accordingly, new classification criteria have been developed and more biomarkers introduced into clinical practice. Specific laboratory parameters as well as wider use of functional imaging tools like ultrasound and magnetic resonance further support the early diagnostic process. Besides diagnosis early after disease onset, achievement of remission during follow-up is another important clinical aim of rheumatologists. In parallel with the development of new therapeutic approaches, both quality of life and treatment outcome especially of chronic inflammatory diseases could be improved. Both specific outcome parameters and global disease activity assessments are important to verify treatment goals of (full) remission, and at the same time may also predict response to treatment regimens.
Abstract: Both polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) present with a broad spectrum of clinical manifestations and almost exclusively occur in the population aged over 50 years. After rheumatoid arthritis, PMR is the second most common autoimmune rheumatic disorder. Visual loss is the most feared complication in temporal arteritis, and extracranial arteries and/or aorta are more often involved in GCA than previously estimated. No specific laboratory parameter exists for diagnosis of PMR. Imaging techniques such as ultrasonography, MRI or 18F-fluorodeoxyglucose PET may be helpful in the diagnosis and evaluation of the extent of vascular involvement in these diseases. This article highlights upcoming new classification criteria for PMR, recent advances of diagnostic and therapeutic procedures as well as ongoing research on biomarkers and corticosteroid-sparing medications, which should improve management of PMR and GCA.
Abstract: To compare current definitions of remission and relapse in polymyalgia rheumatica (PMR) with items resulting from a Delphi-based expert consensus.
Abstract: Large vessel vasculitis occurs in a subgroup of patients with Behçet's disease who are at high risk for disease-related morbidity and mortality. Recognition of patients at risk, early detection of vasculitis, and aggressive treatment are essential for optimal care of these patients. We review the expanding knowledge on large vessel problems in Behçet's disease, highlighting recent contributions.
Abstract: Aim:â Behçet's disease (BD) is an autoimmune disorder associated with HLA-B51 positivity. Serologic/genomic findings have suggested microbes as possible causative agents and the geographical distribution suggests environmental influences. Methods:â We performed comparative analyses of 40 patients with BD or related symptoms not fulfilling BD criteria. Patients originating from different regions of Iran were tested by molecular/serological methods for human herpes viruses and parvovirus B19, two Chlamydiae species, as well as Coxiella, Listeria, Yersinia, Leptospira and Mycobacterium paratuberculosis. Human leukocyte antigen-typing was performed: testing of cytokine profiles and immune mediators representative for the cellular immune system, including neopterin/kynurenine production. Results:â No apparent differences in interleukin (IL)-4, 6, 8 and 10 were observed, whereas production of soluble IL-2-receptor and tumor necrosis factor (TNF)-alpha were more pronounced in the BD group. Neopterin/kynurenine production was comparable, although both groups showed twice the levels of healthy people. No significant differences of herpes simplex virus (HSV) antibody titres were observed but higher titres against Chlamydophila pneumoniae were found in the controls. In 20 BD patients and controls neither parvovirus B19 DNA was detected nor bacterial DNA. Viral DNA of Epstein-Barr virus (EBV), cytomegalovirus (CMV) and human herpes virus (HHV)8 was detected more frequently in the BD group, whereas HSV DNA was only found in the controls, indicating that stomatitis might be caused by HSV. Conclusion:â Although no significant association of BD was detected with a single pathogen, our findings suggest that detection of HSV DNA or Chlamydiae would rather argue against classic BD. Whether there is a discriminative potential of the tested immune mediators/receptors has to be elucidated in further studies.
Abstract: Immunologic memory is a critical feature of the adaptive immune system to fight recurrent infections. However, the mechanisms that shape the composition and function of the human memory T-cell pool remain incompletely understood. We here demonstrate that post-thymic human T-cell differentiation was associated with the downregulation, but not loss, of the inhibitory molecule CD5. The sensitivity of human CD8(+) and CD4(+) memory T cells to interleukin (IL)-15 was inversely associated with the level of CD5 expression. CD5 expression was downregulated by IL-15-mediated signaling in vitro and CD5(lo) memory T cells accumulated in the bone marrow. Persistent antigenic stimulation, as in the case of cytomegalovirus infection and rheumatoid arthritis (RA), was also associated with an increased number of CD5(lo) memory T cells. In conclusion, CD5 may be a useful marker to identify memory T-cell subsets with distinct responsiveness to the homeostatic cytokine IL-15.
Abstract: Early loss of thymic function may be crucial for the development of immune-mediated diseases. According to this concept premature collapse of thymic output is compensated by homeostatic proliferation of peripheral T-cells, driven by recognition of self antigens and finally resulting in the expansion of autoreactive, senescent T-cell clones. Such senescent T-cells are characterized by the loss of the co-stimulatory receptor CD28 and the gain of new immunomodulatory molecules such as natural killer cell receptors and toll-like receptors. The immune system may compensate for these changes by regulatory mechanisms, including the evolvement of regulatory T-cells. However, the aging process may also affect these regulatory T-cells leading to a second âhitâ of the immune system. Current therapeutic approaches in patients with immune-mediated diseases target common end pathways of inflammation, driven by proinflammatory cytokines and effector cells. Future directions will include the aim to reset the immune system, by restoring the ability to repopulate the immune system with young and adaptable lymphocytes as well as by strengthening the effect of regulatory T-cells.
Abstract: Objective: To assess the association of clinical and/or serological parameters with ultrasound-defined disease activity in rheumatoid arthritis (RA). Methods: Retrospective analysis of 149 consecutive RA patients routinely assessed by sonography of the wrists, metacarpo-phalangeal, and proximal interphalangeal joints. Semiquantitative scoring of synovial hypertrophy/effusion and power Doppler (PD) signals was performed. Sonographic remission was defined by the absence of PD signals. Number of tender and swollen joints, global assessment of disease activity by the physician (VAS-phys) and patient (VAS-pt), C-reactive protein (CRP), erythrocyte sedimentation rate, duration of morning stiffness (MS), simplified disease activity index, disease activity score for 28 joints, clinical disease activity index, and health assessment questionnaires were recorded. Results: PD signals as a sign of active disease were observed in 117 (78.5%) RA patients. CRP, erythrocyte sedimentation rate, and MS were higher in patients with PD signals than in patients in remission. CRP >5.0 mg/L (normal values 0-5.0 mg/L), MS >15 minutes, or the combination of both revealed odds ratios of 5.0, 3.0, or 18.9, respectively, to indicate sonography-defined active disease. The other parameters showed no association with the presence or absence of PD-signals. Conclusions: Sonography-defined disease activity is associated with CRP and MS, whereas current composite scores and its clinical components did not match this definition.
Abstract: Modern ultrasonography enables clinicians to sensitively assess the progression of inflammatory joint and tendon disease, and to investigate vasculitides, connective tissue diseases and nerve lesions. Despite the advantages of musculoskeletal ultrasonography for diagnostic, prognostic and monitoring purposes, fewer than 10% of European rheumatologists use this technique in routine clinical practice. The reliability and limitations of rheumatic ultrasonography remain a concern, although good interobserver and intraobserver agreement in results from ultrasonography have been demonstrated among experienced sonographers. International recommendations for assessments and ultrasonography training courses are available, and will improve the standardization of the use of these techniques. In clinical practice, ultrasonography can complement the diagnostic evaluation of patients with rheumatic disease and might have value in confirming and extending clinical findings. Musculoskeletal ultrasonography can also be a valuable follow-up tool to monitor disease activity and support treatment decisions for specific patients. Furthermore, ultrasonography-guided articular injections provide better precision and a higher success rate for synovial fluid aspiration than clinically-guided injections. In the future, three-dimensional ultrasonography techniques, the fusion of ultrasonography and other imaging methods, and real time sonoelastography will be interesting new fields of investigation.
Abstract: Objective of this study is to retrospectively compare the third generation anti-cyclic citrullinated peptide (anti-CCP3) test with the second generation (anti-CCP2) assay as markers of disease activity and predictors of clinical response in rheumatoid arthritis (RA) patients treated with TNF-alpha blocking agents. This study was performed in 42 RA patients treated either with infliximab (n = 11), etanercept (n = 7) or adalimumab (n = 24). Serum anti-CCP3 and anti-CCP2 levels were tested before and 6 months after starting a TNF-alpha blocking treatment using commercially available ELISA kits. Anti-CCP3 and anti-CCP2 antibody levels did not significantly change after 6 months of TNF-alpha blocking treatment. Furthermore, neither anti-CCP3 nor anti-CCP2 was useful to predict anti-TNF-alpha treatment response using receiving operating characteristic curve and logistic regression analyses. Both anti-CCP3 and anti-CCP2 are not differentially influenced by TNF-alpha blocking agents in RA patients and failed to predict anti-TNF-alpha treatment response.
Abstract: Due to complex physical and psychological changes in aging, pain measurement and therapeutic treatment of older and geriatric patients present a special challenge. Nevertheless, even for this category of patients, good treatment results are achievable if age-related particulars and problems are consistently heeded and accounted for. That includes adverse sensory and cognitive effects as much as multimorbidity and the polypharmacy that is frequently related to it. An essential prerequisite for adequate pain therapeutic care in elderly patients is consistent pain measurement. While numerical and verbal scales have also proven their usefulness for patients in advanced age who are not cognitively impaired, instruments must be applied for older people with communicative and/or cognitive restrictions with which the observed behavior of those involved can be surveyed in a multidimensional way.
Abstract: To define relevant disease parameters and their respective limits indicating the initiation of TNF-alpha-blockers in individual patients. Subsequently, to analyze retrospectively patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) or ankylosing spondylitis (AS), who started TNF-alpha inhibition in 2006. Points to consider, regarded relevant for individual treatment decisions as well as their assessment methods, were ascertained by experts' consensus applying the Delphi technique. Subsequently, these parameters' thresholds with respect to the initiation of a TNF-alpha-blocker were identified. Thereafter, the rheumatologists representing 12 centres all over Austria agreed to retrospectively analyze their patients started on a TNF-alpha-blocker in 2006. Experts' opinion regarding disease parameters relevant to initiate TNF-alpha-blockers in RA patients only slightly differed from those applied in clinical trials, but the parameters' threshold values were considerably lower. For PsA patients, some differences and for AS patients, considerable differences between experts' opinion and clinical studies appeared, which held also true for decisive parameters' means and thresholds. Six hundred and fifty patients, started on TNF-blockers in 2006, could be analyzed retrospectively, 408 RA patients (53.3 years mean, 340 females), 93 PsA patients (48.9 years mean, 59 males) and 149 AS patients AS (42.2 years mean, 108 males), representing approximately 25% of all Austrian patients initiated on a TNF-blocker in this respective year. Far more individualized, patient-oriented treatment approaches, at least in part, are applied in daily routine compared with those derived from clinical trials or recommendations from investigative rheumatologists.
Abstract: We sought to assess vascularity in wrist tenosynovitis by using power Doppler ultrasound (PDUS) and to compare detection of intra- and peritendinous vascularity with that of contrast-enhanced grey-scale ultrasound (CEUS).
Abstract: The objective of the present study was to assess the prevalences of naive, memory, memory/effector, regulatory and activated T-cells in peripheral blood (PB) and synovial fluid (SF) of patients with spondyloarthritis (SpA), rheumatoid arthritis (RA), polymyalgia rheumatica/giant cell arteritis (PMR/GCA) and healthy controls (HC). Twenty-two patients with SpA, 15 patients with RA, 38 patients with PMR/GCA and 17 HC were prospectively enrolled. The expression of differentiation and activation markers (CD3, CD4, CD8, CD25, CD28, CD45RA, CD45RO) characterizing T-cell subsets were analyzed by flow cytometry. The frequency of CD3(+)CD4(+)CD28(-) memory/effector T-cells was increased in PB of patients with SpA (median 1.1%, range 0.1-69.6), RA (2.5%, 0-42.9) and PMR/GCA (2.7%, 0-49.5) when compared with HC (0.7%, 0-38.0) and tended to be higher in SF of SpA patients (4.5%, 0.2-7.2, P = 0.084). CD28(+)CD45RA(+)CD4(+) (9.6%, 4.1-10.3) and CD28(+)CD45RA(+)CD8(+) naive T-cells (15.0%, 12.9-26.2) were reduced and CD28(+)CD45RO(+)CD4(+) (93.5%, 51.0-99.0), CD28(+)CD45RO(+)CD8(+) memory (81.2%, 38.9-83.5), CD8(+)CD25(+) activated T-cells (10.9%, 2.7-13.8) and CD4(+)CD25(hi) TREGs (10.2%, 7.0-13.3) were increased in SF compared to PB (P < 0.05 each). These findings demonstrate altered T-cell subsets in patients with immune-mediated disease, particularly at sites of inflammation.
Abstract: PURPOSE: To evaluate if image fusion, a technology matching real-time ultrasonography (US) and a previously obtained computed tomographic (CT) scan, is a feasible aid for sacroiliac (SI) joint injections in cadavers and patients. MATERIALS AND METHODS: This study was approved by institutional review board, and written informed consent was obtained from each patient. In five human cadavers (10 joints) and seven consecutive patients (10 joints; four male, three female patients; mean age, 33.6 years; range, 22-44 years), SI joint injections were performed by using image fusion guidance technology. Registration errors were calculated automatically by the software and reported as mean registration error. In cadavers, needle placement was confirmed by means of CT, while in patients, a subjective rating of pain (score of 0-10) was recorded before and 3 months after injection. Procedure time was calculated. RESULTS: Matching of real-time US and CT images by image fusion software was reliable in all tests (mean registration error, 0.3 mm). In all cadavers, correct intraarticular needle positioning by using image fusion guidance was confirmed on CT scans. In patients, no intraprocedural complications were noted, and 3 months after injection pain score decreased (mean pain score before procedure, 8.05; after, 0.3). In patients, mean time for the whole procedure was 20.4 minutes (range, 17-22 minutes), with a mean duration of 15.4 minutes (range, 14-17 minutes) for image matching and 5 minutes (range, 3-7 minutes) for needle placement. CONCLUSION: Image fusion of real-time US and previously obtained CT scans is feasible to guide needle insertion into the SI joint.
Abstract: OBJECTIVES: Macrophages and pro-inflammatory CD3+CD4+CD28- T lymphocytes are involved in atherosclerotic plaque destabilization. Whether neopterin, a macrophage-specific activation-marker, and circulating CD3+CD4+CD28- cells are also related to the severity and extent of coronary artery disease (CAD) in stable patients is still unclear. METHODS: Coronary angiograms of 30 patients with stable angina pectoris were graded using the Gensini severity and an extent score. Patients were grouped according to the median of each score. Lymphocyte subsets were determined by FACS analysis and neopterin by radioimmunoassay. Peripheral endothelial function of the brachial artery (FMD) shown to correlate with cardiovascular risk factors was evaluated using high-resolution ultrasound. RESULTS: More extensive CAD was associated with increased neopterin levels (8.3 +/- 3.3 vs. 5.5 +/- 1.2 nmol/L, p < 0.001) and increased CD3+CD4+CD28- cells (3.1 +/- 1.6 vs. 2.0 +/- 1.2%, p < 0.05). A high Gensini severity score was associated with increased neopterin levels (7.8 +/- 2.7 vs. 6.3 +/- 1.7 nmol/L, p < 0.05), but not with CD3+CD4+CD28- cells. Neopterin correlated with both the extent (r = 0.59, p < 0.001) and the Gensini score (r = 0.57, p < 0.003). FMD was not correlated with both scores. CONCLUSIONS: Neopterin and CD3+CD4+CD28- lymphocytes are associated with CAD extent in stable patients, thereby emphasizing the inherent role of inflammation in atherogenesis itself beyond plaque destabilization. Neopterin's correlation with CAD severity might be additionally useful in identifying patients eligible for revascularization procedures.
Abstract: A 73-year-old female patient was referred to our department because of gouty arthritis in the right first toe. The patient suffered from progressive renal failure because of pauci-immune necrotising glomerulonephritis. As severe hyperuricaemia would further worsen progredient renal insufficiency and therapy with allopurinol was contraindicated because of renal insufficiency and previous pancytopenia, the patient was treated twice with intravenous rasburicase. This therapy was well tolerated by the patient and led to the decrease of serum uric acid below the detection limit within 24 hours.
Abstract: BACKGROUND: Norovirus is easily spread from person to person by the fecal-oral route and through aerosols or by vehicles such as contaminated food or water. The virus is able to survive in the environment for many days, which enables outbreaks to be prolonged. We describe a norovirus outbreak and its control measures in an Austrian secondary-level hospital during December 2006 - February 2007. METHODS: A descriptive-epidemiological investigation of the outbreak was undertaken. We also determined outbreak costs, including the estimated lost revenue associated with department closures and the cost of sick leave and cleaning expenses. Selected stool specimens were tested for norovirus RNA. RESULTS: In the hospital, 90 persons with symptoms and signs consistent with norovirus gastroenteritis with clinical onset between December 1, 2006 and February 13, 2007 were identified. Out of these, 56 patients and 14 persons among the hospital staff fulfilled the definition of an outbreak case (77.8%), and 20 cases (22.2%) were identified as non-outbreak cases including 13 community-acquired cases of norovirus gastroenteritis and 7 clinical-suspected cases of norovirus gastroenteritis associated with health care facilities other than the affected hospital. The Department of Internal Medicine was the mainly affected department (46 patient-cases and 6 staff-cases). Considering hospital patients, who have been hospitalised between December 1, 2006 and February 13, 2007 as cohort at risk of nosocomial norovirus infection, the nosocomial hospital outbreak attack-rate was 5.9% (56/947). A total of 120 hospital staff members worked in the period from December 1 to February 13, which makes an attack-rate among the hospital staff of 11.7% (14/120). Norovirus strain GII.4 variant 2006b was detected, which has been circulating widely in Europe since 2006. The total cost of the outbreak for the Department of Internal Medicine was <euro> 80,138. CONCLUSIONS: The significant disruption of patient care and the cost of this single nosocomial outbreak support strict implementations of adequate and timely control measures based on evidence-based recommendations.
Abstract: Giant cell arteritis is the most common systemic vasculitis and affects large and medium-sized vessels. Glucocorticoids are the current standard in the therapy of giant cell arteritis. To reduce the glucocorticoid dose the European League Against Rheumatism (EULAR) suggests the addition of disease-modifying antirheumatic drugs. Of these, methotrexate represents the best investigated drug; possible alternatives include azathioprine, tumor necrosis factor-alpha inhibitors and cyclophosphamide.
Abstract: Polymyalgia rheumatica (PMR) is a common chronic inflammatory rheumatic disease with unknown aetiology, affecting predominately people of middle age and older. Besides clinical symptoms and diagnostics, imaging techniques including sonography and magnetic resonance imaging may provide evidence of typical inflammatory lesions with bilateral bursitis subdeltoidea or subacromialis, tenosynovitis of the biceps tendon sheath and/or synovitis of the shoulder joints and thus may support the diagnosis of this disease in difficult cases. Corticosteroids are the cornerstone of treatment of PMR, but adverse events because of chronic corticosteroid use are observed in more than 50% of treated patients. Whether immunosuppressants, such as methotrexate and tumour necrosis factor-alpha inhibitors are effective in the therapy of PMR has still not yet been clarified.
Abstract: We read with great interest the comments of Avanzas et al. on our recent article. In acute coronary syndromes, inflammatory markers such as neopterin - a macrophage-specific activation marker - reflect plaque instability, i.e. disease activity. In stable coronary artery disease (CAD) patients, inflammatory markers such as C-reactive protein (CRP) not only predict the incidence of future events, but are also associated with disease prevalence and severity. In our study population including male, non-diabetic patients with stable CAD, neopterin serum concentrations also correlated with angiographically evaluated CAD. In contrast to our study, Avanzas et al. did not find such an association in 297 stable CAD patients, but neopterin serum levels were predictive for the incidence of a combined clinical endpoint. Different patient populations, e.g. the inclusion of diabetic patients and women, the higher event rate as well as the correction for age in the multivariate analyses in the latter study might explain the divergent results. In light of these observations, the association of neopterin or of other inflammatory markers with CAD activity, severity and/or extent should probably not be separated from each other and might be interpreted in the context of the broad spectrum of clinically stable CAD.
Abstract: Abatacept is the first drug in a new class of disease-modifying anti-rheumatic drugs known as selective modulators of T-cell costimulation. The efficacy of abatacept in the treatment of rheumatoid arthritis (RA) has been shown in several clinical phase II and phase III trials, wherein abatacept was used in monotherapy, either in combination with methotrexate (MTX) after MTX-failure, in combination with MTX after failure of anti-TNF-alpha therapy or in combination with TNF-alpha blockers. In addition, the combination of abatacept/MTX was directly compared with infliximab/MTX. Current data on abatacept demonstrate an encouraging safety profile of this drug. The number of adverse events in patients on abatacept is comparable to that in patients treated with other biologics. Severe infections, however, are more common in abatacept-treated patients than in placebo-treated patients. Opportunistic infections are rare in patients with abatacept and the frequency of malignancies is not higher than expected in RA-patients. Additional studies are now warranted to get more information on rare adverse events and long-term unwanted effects.
Abstract: On the 24th of October 2006, the European Medicines Agency (EMEA) stated that "it cannot be excluded that non-selective non-steroidal anti-inflammatory drugs (nsNSAIDs) may be associated with a small increase in the absolute risk for thrombotic events". Reviewing the most recent literature including meta-analyses of randomized clinical studies and pharmacoepidemiological studies show that this statement contrasts with the 2005 EMEA evaluation of cyclooxygenase-2 inhibitors, which contained a number of regulations including several contraindications for coxibs. Recent clinical data indicate that the entire substance group of NSAIDs may have cardiovascular side effects but to different degrees. Results of basic research support these observations showing that the increase for cardiovascular risk not only depends on the ratio of inhibition of thromboxan and prostacyclin but also on other mechanisms including blood pressure elevation and cyclooxygenase independent actions. In clinical practice, many patients require anti-inflammatory therapy with NSAIDs but are at high cardiovascular and gastrointestinal risk. The combination of nsNSAIDs with proton pump inhibitors shows comparable safety to coxibs in averting upper gastrointestinal events, but evidence is increasing coxibs have advantages regarding lower gastrointestinal side effects. Concomitant therapy with aspirin is another issue. There is a negative effect on gastrointestinal safety, as well as the influence of nsNSAIDs on the cardioprotective effect of aspirin. As the contraindications for coxibs announced by the EMEA may prevent some patients from receiving optimal treatment, a warning for the entire substance group, as issued by the American Food and Drug Administration, with no contraindictions, would certainly be more reasonable.
Abstract: OBJECTIVE: Sacroiliitis is often caused by rheumatic diseases, and besides other therapeutic options, treatment consists of intraarticular injection of corticosteroids. The purpose of this study was to assess the feasibility of ultrasound (US)-guided sacroiliac joint (SI joint) injection at 2 different puncture levels in cadavers and patients when defined sonoanatomic landmarks were considered. METHODS: After defining sonoanatomic landmarks, US-guided needle insertion was performed in 10 human cadavers (20 SI joints) at 2 different puncture sites. Upper level was defined at the level of the posterior sacral foramen 1 and lower level at the level of the posterior sacral foramen 2. In 10 patients with unilateral sacroiliitis, injection at the most feasible level was attempted. RESULTS: Computed tomography confirmed correct intraarticular needle placement in cadavers by showing the tip of the needle in the joint and intraarticular diffusion of contrast media in 16 (80%) of 20 SI joints (upper level 7 [70%] of 10; lower level 9 [90%] of 10). In all 4 cases in which needle insertion failed, intraarticular SI joint injection at the other level was successful. In patients, 100% of US-guided injections were successful (8 lower level, 2 upper level), with a mean pain relief of 8.6 after 3 months. CONCLUSION: US guidance of needle insertion into SI joints was feasible at both levels when defined sonoanatomic landmarks were used. If SI joint alterations do not allow for direct visualization of the dorsal joint space of the lower level, which is easier to access, the upper level might offer an appropriate alternative.
Abstract: Patients with inflammatory rheumatic diseases frequently report symptoms that may indicate an involvement of central and peripheral nervous system in addition to the known musculoskeletal symptoms. The possible symptoms can be as varied as the disease mechanism which causes them. Early correct diagnosis, adequate therapy and regular monitoring of these patients are necessary to prevent permanent disability. This article summarizes current literature on the diagnosis and therapy of neurological manifestations of inflammatory rheumatic diseases including systemic Lupus erythematodes, Behçet's disease, Sjögren's syndrome, systemic vasculitides and sarcoidosis.
Abstract: Diagnosis of ankylosing spondylitis (AS) is still delayed for several years in some patients. The correct diagnosis of early disease has always been a challenge, which has become even more important as with the introduction of TNF-alpha inhibitors, very effective new treatments have become available. For diagnosis of AS imaging methods such as conventional radiography and computer tomography are well established. Functional imaging modalities including magnetic resonance imaging and contrast-enhanced colour Doppler ultrasound provide additional information on the presence of active inflammatory changes in the sacroiliac joints and may help to diagnose AS before radiographic changes become visible. Magnetic resonance imaging and sonography also identifiy other non-sacroiliac axial manifestations of AS and peripheral involvement such as enthesitis and synovitis of peripheral joints.
Abstract: OBJECTIVE: This report summarizes the findings from a consensus process to identify potential classification criteria for polymyalgia rheumatica (PMR). METHODS: A 3-stage hybrid consensus approach was used to develop potential PMR classification criteria. The first stage consisted of a facilitated meeting of 27 international experts who anonymously rated the importance of 68 potential criteria. The second stage involved a meeting of the experts, who were provided with the results of the first round of ratings and were then asked to re-rate the criteria. In the third stage, the wider acceptance of the 43 criteria that received > 50% support at round 2 was evaluated using an extended mailed survey of 111 rheumatologists and 53 nonrheumatologists in the United States, Canada, and Northern and Western Europe. RESULTS: A total of 68 and 50 criteria were identified and rated in round 1 and round 2, respectively. In round 2, 43 of the 50 items achieved at least 50% support, including 10 core criteria achieving 100% support. In round 3, over 70% of survey respondents agreed on the importance of 7 core criteria. These were age >or=50 years, duration >or=2 weeks, bilateral shoulder and/or pelvic girdle aching, duration of morning stiffness > 45 min, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and rapid steroid response (> 75% global response within 1 wk to prednisolone/prednisone 15 20 mg daily). Among physical signs, more than 70% of survey respondents agreed on the importance of assessing pain and limitation of shoulder (84%) and/or hip (76%) on motion, but agreement was low for peripheral signs like carpal tunnel, tenosynovitis, and peripheral arthritis. CONCLUSION: There are differences in opinion as to what PMR is and how it should be treated. These findings make it important to develop classification criteria for PMR. The next step is to perform an international prospective study to evaluate the utility of candidate classification criteria for PMR in patients presenting with the polymyalgic syndrome.
Abstract: The efficacy of biological agents has been shown in several randomized clinical trials. However, little is known regarding the performance of these drugs in daily rheumatological care. Totally, 173 patients treated with biological agents (infliximab, etanercept, adalimumab, anakinra) were retrospectively analyzed between November 2001 and December 2005 at an Austrian rheumatic outpatient clinic. In total, 224 courses of treatment with biological agents were followed up. Among the 93 drug discontinuations observed, the most frequent causes were inefficacy (56.5%) and side effects (31.9%). In 74 patients (51%), the first biological agent was withdrawn after a median treatment period of 10.7 (range 0-80) months. A second biological agent was given to 36 patients, a third to 11 and a fourth to 3 patients. Our data underline the necessity of large observational studies to assess the full spectrum of patients treated with biological agents in clinical routine.
Abstract: OBJECTIVE: To examine the diagnostic values of history of chronic enthesitic pain and clinical signs of acutely inflamed entheses to predict ultrasound (US) signs of enthesitis. METHODS: Cohort study of 21 consecutive rheumatic out-patients (female/male 18/3) with suspected multiple enthesitis and 12 controls (female/male 10/2). 429 enthesal sites according to the Maastricht Ankylosing Spondylitis Entheses Score (MASES) were evaluated by history, clinical examination, B-mode and power Doppler US. Sensitivity and specificity of history suggesting chronic enthesitic pain and clinical examination suggesting acute enthesitis were calculated using corresponding US findings as reference standard. RESULTS: Diagnostic accuracy widely varied between different MASES sites. Sensitivity and specificity of selected MASES points were 66.7 - 86.4% and 85.0 - 91.7% for history and 71.4 - 87.0% and 47.4 - 75.0% for clinical examination, respectively (p<0.05 for each). CONCLUSION: At specific enthesal sites, history of chronic enthesitic pain and clinical signs of acute inflammation are sensitive and specific for the diagnosis of chronic and/or acute inflammation.
Abstract: OBJECTIVES: To study the clinical outcome, treatment response, T-cell subsets and functional consequences of a novel tumour necrosis factor (TNF) receptor type 1 (TNFRSF1A) mutation affecting the receptor cleavage site. METHODS: Patients with symptoms suggestive of tumour necrosis factor receptor-associated periodic syndrome (TRAPS) and 22 healthy controls (HC) were screened for mutations in the TNFRSF1A gene. Soluble TNFRSF1A and inflammatory cytokines were measured by ELISAs. TNFRSF1A shedding was examined by stimulation of peripheral blood mononuclear cells (PBMCs) with phorbol 12-myristate 13-acetate followed by flow cytometric analysis (FACS). Apoptosis of PBMCs was studied by stimulation with TNFalpha in the presence of cycloheximide and annexin V staining. T cell phenotypes were monitored by FACS. RESULTS: TNFRSF1A sequencing disclosed a novel V173D/p.Val202Asp substitution encoded by exon 6 in one family, the c.194-14G>A splice variant in another and the R92Q/p.Arg121Gln substitution in two families. Cardiovascular complications (lethal heart attack and peripheral arterial thrombosis) developed in two V173D patients. Subsequent etanercept treatment of the V173D carriers was highly effective over an 18-month follow-up period. Serum TNFRSF1A levels did not differ between TRAPS patients and HC, while TNFRSF1A cleavage from monocytes was significantly reduced in V173D and R92Q patients. TNFalpha-induced apoptosis of PBMCs and T-cell senescence were comparable between V173D patients and HC. CONCLUSIONS: The TNFRSF1A V173D cleavage site mutation may be associated with an increased risk for cardiovascular complications and shows a strong response to etanercept. T-cell senescence does not seem to have a pathogenetic role in affected patients.
Abstract: In a case-control study that included a total of 98 patients and 83 controls, the possible link between various pathogens and abdominal aortic aneurysms was investigated. For 68 patients with abdominal aortic aneurysm and age-matched controls, no differences were detected in the levels of immunoglobulin (Ig)A and IgG Chlamydiaceae and Chlamydophila pneumoniae antibodies. Patients with IgA titers positive for Chlamydophila pneumoniae showed progressive disease (defined as an annual increase of the aneurysm diameter of > or = 0.5 cm) more frequently than patients with negative IgA titers (p = 0.046). Polymerase chain reactions performed to detect DNA for Chlamydophila pneumoniae, Chlamydia trachomatis, Chlamydophila psittaci, human cytomegalovirus, Borrelia burgdorferi and Helicobacter pylori in tissue specimens of 30 patients and 15 controls were negative. In summary, Chlamydophila pneumoniae may contribute to aortic aneurysm disease progression, but DNA of this and other pathogens was not found in patients' specimens.
Abstract: Dose adjustments of NSAIDs according to body weight may be reasonable for an optimal efficacy/tolerance profile in the therapy of musculoskeletal disorders, but are unusual in adults. In this post hoc analysis of a prospective, one-arm clinical study of a short-term treatment with acemetacin, a total of 406 patients with pain because of various musculoskeletal diseases with or without joint inflammation was evaluated for the influence of body mass index (BMI) on the reduction of pain at rest, pain at movement and for mobility restriction between visits one and three (primary outcome parameters). No association was found between BMI and the efficacy of acemetacin regarding the primary outcome parameters and no influence of BMI on the occurrence of adverse events was observed. Dose adjustment of acemetacin according to BMI thus appears not necessary in a short-term treatment of musculoskeletal disorders, but prospective controlled trials are needed to confirm these results.
Abstract: The purpose of this review is to describe the spectrum of sonographic findings in rheumatic diseases with respect to the diagnostic potential using US contrast media which prove activity or inactivity in synovial tissue where new treatment regimes target. Synovial activity can be found in non-erosive and erosive forms of primary and secondary osteoarthritis, and in inflammatory forms of joint diseases like rheumatoid arthritis and peripheral manifestations of spondyloarthritis including, ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis and enteropathic arthritis. It can also be present in metabolic and endocrine forms of arthritis, in connective tissue arthropathies like systemic lupus erythematosus or scleroderma and in infectious arthritis. Ultrasound should be used as first-line imaging modality in suspected early cases of RA and other forms of arthritis, whereas contrast-enhanced ultrasound (CEUS) can further enable for sensitive assessment of vascularity which correlates with disease activity.
Abstract: This study was conducted to assess the use of the European preliminary criteria, the Breiman-classification tree and the American-European criteria for diagnosis of primary Sjögren's Syndrome (pSS) in daily practice. A retrospective analysis of 17 consecutive patients with pSS (European criteria) was performed evaluating the application of the Schirmer test, semiquantitative sialoscintigraphy, immunologic tests, including rheumatoid factor, antinuclear antibodies, Sjögren's syndrome autoantibodies (SS-A, SS-B) and lip biopsy. Out of the 17 patients with pSS according to the European criteria, 15 patients fulfilled the classification tree (=88.2%), and 4 patients fulfilled the American-European criteria (=23.5%, P = 0.001). In the four patients fulfilling the American-European criteria, a positive result of the sialoscintigraphy was not crucial for the diagnosis according to these criteria. In conclusion, the American-European criteria are more stringent than the European preliminary criteria. We assume the role of sialoscintigraphy to be reduced when applying the American-European criteria.
Abstract: OBJECTIVE: To examine serum levels of type 1 and type 2 chemokines and lymphocytic expression of chemokine receptors, and to compare the results with lymphocytic cytokine production in patients with ankylosing spondylitis (AS). METHODS: Twelve patients with AS (mean (SD) age 44.9 (14.7) years) and 27 healthy controls (46.4 (12.8) years) were enrolled into the study. The expression of chemokine receptors (CCR-5, CXCR-3, CCR-4) and cytokines (interferon gamma (IFNgamma), interleukin (IL)2, IL4, IL10, tumour necrosis factor alpha (TNFalpha)) on CD28(+) and CD28(-) T cell subtypes was analysed by a three colour FACS technique of peripheral blood samples. Serum ELISAs were performed to detect the CCR-5 ligands CCL-5, CCL-3; the CXCR-3 ligands CXCL-10, CXCL-9; and the CCR-4 ligand, CCL-17 before and after administration of the TNFalpha blocking agent infliximab. RESULTS: CD4(+)CD28(-) T cells had higher ratios of CXCR-3 to CCR-4 than CD4(+)CD28(+) T cells. Both, CD4(+) and CD8(+)CD28(-) T cells of patients with AS produced more IFNgamma, TNFalpha, and IL10 than their CD28(+) counterparts (p<0.05), and lacked the production of IL2 and IL4. Serum levels of CXCL-9 were increased in patients with AS to 59.2 pg/ml (34.1-730.5) compared with 32.5 pg/ml (20.0-79.5) in healthy controls (p = 0.016). The levels of both type 1 (CCL-5, CXCL-9) and type 2 chemokines (CCL-17) decreased under blockade of TNFalpha (p<0.05). CONCLUSIONS: The profile of chemokine receptor expression and cytokine production by CD28(-) T cells suggests a type 1 immune reaction in AS, although IL10 is frequently produced by CD28(-) T cells. Treatment with TNFalpha blocking antibodies decreased both types of chemokines in patients' sera.
Abstract: The breakdown of mechanisms assuring the recognition of self and non-self is a hallmark feature of autoimmune diseases. In the past 10 years, there has been a steadily increasing interest in a subpopulation of regulatory T cells, which exert their suppressive function in vitro in a contact-dependent manner and preferentially express high levels of CD25 and forkhead and winged-helix family transcription factor forkhead box P3 (FOXP3) (TREGs). Recent findings of changed prevalences and functional efficiencies indicate that these TREGs play a unique role in autoimmune diseases. Clinical findings in patients with mutated FOXP3 genes and a specific polymorphism in the promotor region of FOXP3 also support the role of FOXP3 as a 'master control gene' in the development and functioning of TREGs. Both altered generation of TREGs and insufficient suppression of inflammation in autoimmune diseases are considered to be crucial for the initiation and perpetuation of disease. TREG-related somatic cell therapy is considered as an intriguing new intervention to approach autoimmune diseases.
Abstract: BACKGROUND: Coronary atherosclerosis includes an activation of circulating T lymphocytes. Statins exert anti-inflammatory effects beyond lipid lowering. Whether these properties influence systemic T lymphocytes is unclear. METHODS: To investigate the effect of atorvastatin on circulating T-lymphocyte subsets producing proinflammatory and anti-inflammatory cytokines (interferon gamma [IFN-gamma(+)], interleukin 2 [IL-2(+)], IL-4(+), and IL-10(+)) and on the T-cell-activating soluble CD40 ligand (sCD40L), 30 hypercholesterolemic patients with angiographically documented stable coronary artery disease (CAD) were randomized to placebo or atorvastatin (20 mg/d) for 3 months. Eight healthy volunteers served as controls. Levels of peripheral cytokine-producing CD4+ and CD8+ T cells and their CD28- subsets were determined by FACS. Serum soluble CD40L was measured with ELISA. RESULTS: IL-2(+) T lymphocytes and sCD40L levels were higher in patients with CAD compared with controls, whereas IFN-gamma(+) and anti-inflammatory IL-4(+) and IL-10(+) T lymphocytes were similar. Levels of IL-2(+), IFN-gamma(+), IL-4(+), and IL-10(+) T-cell subsets as well as CD28- T lymphocytes were neither changed by atorvastatin nor by placebo, whereas sCD40L was lowered only in atorvastatin-treated patients (P < .01). CONCLUSION: Circulating IL-2(+) T lymphocytes are increased in patients with stable CAD reflecting an activation of the global immune system, but are not influenced by atorvastatin therapy. The elevated levels of platelet-derived T-lymphocyte-stimulating sCD40L are decreased by atorvastatin probably reflecting an atheroprotective effect. Hence, sCD40L may be an additional biomarker to be considered when evaluating the treatment effects of statins in patients with stable CAD.
Abstract: PURPOSE OF REVIEW: To review recent studies on the immune-mediated pathogenesis of abdominal aortic aneurysms, opening a wide field for possible new therapeutic approaches. RECENT FINDINGS: Immune-mediated processes including involvement of neutrophils, interferon-gamma producing T cells and proinflammatory cytokines play an important role especially in the initiation of abdominal aortic aneurysm disease. C-reactive protein was associated with aneurysm size and is possibly produced by the aneurysmal tissue itself. From the clinical perspective, both inflammatory and noninflammatory abdominal aortic aneurysms are associated with various autoimmune diseases. Preliminary data of F-FDG positron emission tomography imaging of abdominal aortic aneurysms suggest focal uptake of F-FDG within the aneurysm wall in patients with either large, rapidly expanding or symptomatic aneurysms that are prone to rupture. Thus basic research findings and clinical research focusing on the underlying immune-mediated mechanisms of abdominal aortic aneurysms will likely pave the way for new medical therapies in the future. In animal models the effects of rapamycin as an immunosuppressive agent, modulation of estrogen receptors by tamoxifen as well as gene therapy using decoy oligonucleotides binding to the transcription factor ets has already proved helpful in decreasing aneurysm expansion rates. SUMMARY: Pathophysiological, immunogenetical and interventional studies support the concept of abdominal aortic aneurysm as an immune-mediated process, which will help to identify more laboratory and imaging signs of development in the future. Further research will now assess the possible benefit of antiinflammatory therapeutic approaches, especially in patients with small abdominal aortic aneurysms.
Abstract: There is increasing evidence for an active and 'dominant' tolerance mediated by regulatory T-cells. Out of these CD4+ 'naturally occurring' regulatory T-cells (TREGs) are currently the main research focus in this field. TREGs exert their suppressive function in vitro in a contact-dependent manner and preferentially express high levels of CD25 and the forkhead and winged-helix family transcription factor forkhead box P3 (FOXP3). Age-related increment of the prevalences of CD4+ CD25(hi) TREGs were described controversially, and whether such changes explain immune dysfunction in the elderly is still unclear. During aging thymic TREG output may decrease with significant loss of thymic capacity to generate new T-cells, and TREG homeostasis has been shown to be sustained by alternative pathways like peripheral generation of TREGs. An imbalance of TREG homeostasis would then predispose to immune dysfunction in aged individuals explaining their higher risk of immune-mediated diseases, cancer or infections.
Abstract: High-frequency sonography enables excellent detection of early erosions and synovial proliferations. Power Doppler sonography (PDUS) allows for an improved characterization of articular and peritendinous augmented volume, because detection of hypervascularity correlates with inflammatory activity and further is helpful in differentiation from effusion and inactive pannus. The use of contrast media improves the sensitivity of vascularity detection, because they allow for a delineation of vessels at the microvascular level. This is of increased interest, as the development of new therapeutic options targeting the microvascular level calls for earlier diagnosis and optimal assessment of disease activity. Because of good availability, cost effectiveness, and patient acceptance, sonography facilitates early diagnosis of synovial proliferations and erosions as well as therapy follow-up.
Abstract: Animal models for abdominal aortic aneurysms (AAAs), immunogenetical and pathophysiological studies support the importance of immune-mediated processes in the pathogenesis of AAA disease. Neutrophils, natural killer (NK) cells, monocytes/macrophages, and proinflammatory cytokines are involved in the complex and dynamic tissue remodeling of the AAA vessel wall. Our group showed an increased prevalence of circulating interferon-gamma (IFN-gamma) producing CD28(-) T cells especially in smaller AAAs, thus supporting the concept of a T cell-mediated pathophysiology of AAAs, especially during the early development of AAAs. Further research should now assess the possible benefit of anti-inflammatory therapeutic approaches in AAA patients, especially with small AAAs.
Abstract: Antibodies directed against citrullinated vimentin are members of the family of autoantibodies reactive with citrullinated proteins and are among the most specific serological markers for the diagnosis of rheumatoid arthritis (RA). This study was performed to test the diagnostic value of a newly developed enzyme-linked immunosorbent assay (ELISA) for the detection of antibodies against a genetically modified citrullinated vimentin (anti-MCV) in comparison with a second-generation anti-cyclic citrullinated peptides (anti-CCP2) ELISA test system. Blinded sera from 631 patients (409 consecutive out-patients and 222 randomly selected stored sera) with RA (n = 164) and non-RA (osteoarthritis [n = 120], polymyalgia rheumatica/giant cell arteritis [n = 80], spondyloarthritis [n = 36], and other inflammatory rheumatic or non-inflammatory disease [n = 67]) were tested for the presence of anti-MCV and anti-CCP2 antibodies according to the manufacturers' instructions. The diagnostic performance of the anti-MCV was comparable with the anti-CCP2 assay for the diagnosis of RA according to the calculated area under the curve (0.824; 95% confidence interval (CI) 0.778-0.870 versus 0.818; 95% CI 0.767-0.869) as analysed by receiving operating characteristic curve. When categorised with a cutoff value of 20.0 U/ml (as recommended by the manufacturer), sensitivity and specificity of the anti-MCV ELISA were 69.5% (95% CI 61.9%-76.5%) and 90.8% (86.9%-93.8%), respectively, compared with 70.1% (62.5%-77.0%) and 98.7% (96.7%-99.6%) of the anti-CCP2 assay. Using the cutoff values of 19.0 U/ml and 81.5 U/ml for the anti-MCV test to obtain a sensitivity and specificity identical to the anti-CCP2 assay, showed a reduced specificity (89.8%; 85.8%-92.9%) and sensitivity (53.7%; 45.7%-61.5%), respectively, of the anti-MCV ELISA compared with the anti-CCP2 test. In conclusion, the serum ELISA testing for anti-MCV antibodies as well as the anti-CCP-2 assay perform comparably well in the diagnosis of RA. In the high-specificity range, however, the anti-CCP2 assay appears to be superior to the anti-MCV test.
Abstract: High-frequency sonography enables excellent detection of early erosions and synovial proliferations. Power Doppler sonography (PDUS) allows for an improved characterization of articular and peritendinous augmented volume, because detection of hypervascularity correlates with inflammatory activity and further is helpful in differentiation from effusion and inactive pannus. The use of contrast media improves the sensitivity of vascularity detection, because they allow for a delineation of vessels at the microvascular level. This is of increased interest, as the development of new therapeutic options targeting the microvascular level calls for earlier diagnosis and optimal assessment of disease activity. Because of good availability, cost effectiveness, and patient acceptance, sonography facilitates early diagnosis of synovial proliferations and erosions as well as therapy follow-up.
Abstract: Immune system activation is known to be involved in the progression of rheumatoid arthritis (RA). The proinflammatory cytokine interferon-gamma in various cells, including monocytes, induces the enzyme indoleamine (2,3)-dioxygenase (IDO), which converts tryptophan to kynurenine. In sera of 22 patients (17 women and 5 men) with RA stages 1 to 4 according to Steinbrocker, the concentrations of tryptophan and kynurenine were measured by high-pressure liquid chromatography. To estimate IDO activity, the kynurenine to tryptophan ratio (kyn/trp) was calculated. In parallel, concentrations of the macrophage activation marker neopterin were determined by enzyme-linked immunosorbent assay. Tryptophan concentrations were lower in patients with RA, and the decrease in serum tryptophan correlated with increase in stage (p<0.05). Kyn/trp correlated well with neopterin concentrations, which were elevated in most patients. Whereas higher C-reactive protein concentrations and erythrocyte sedimentation rates were observed in patients with greater disease activity, tryptophan and neopterin concentrations did not differ between patients with different subjective disease activity graded by the physician. Deficiency of the essential amino acid tryptophan in patients with RA most likely results from immune activation involved in the pathogenesis of the disease. It could also be relevant for the mood of patients, as tryptophan is the precursor of serotonin.
Abstract: OBJECTIVES: Diagnosis of ankylosing spondylitis (AS) can be difficult, and a specific laboratory test has not yet been introduced as a routine diagnostic tool. Our aim was to evaluate the diagnostic value of antibodies specifically binding to a recombinant 28-kDa antigen for the diagnosis of AS. METHODS: Blinded sera were tested for antibodies binding to the procaryotically expressed 28-kDa protein using an enzyme-linked immunosorbent assay (ELISA). This purified 28-kDa protein is produced by a specific clone from an embryonic Drosophila hydei Xgtl I c-DNA library and is bound by human antibodies cross-reacting with both a 36-kDa protein of chromosomes from Drosophila melanogaster and a 69-Da HeLa S3 protein potentially involved in signal transduction pathways. RESULTS: Serum concentrations of antibodies cross-reacting with this specific antigen were increased in 371 patients with AS compared with 37 healthy controls (39.5 vs 22.6 U/ml; P = 0.004). The positive predictive values of this ELISA test for AS were between 95.1% (95% confidence interval 90.6-97.9%) for a cut-off level of 50 U/ml and 97.4% (92.7-99.5%) for a cut-off level of 75 U/ml, and the sensitivities were between 42.1% (37.0-47.3%) for a cut-off level of 50 U/ml and 30.7% (26.1-35.7%) for a cut-off level of 75 U/ml. CONCLUSIONS: Serum ELISA tests for antibodies cross-reacting with the 28-kDa antigen show a high positive predictive value for AS of more than 95%.
Abstract: OBJECTIVE: To assess the possible role of proinflammatory CD28- T cells in abdominal aortic aneurysms (AAAs). Animal studies and human tissue studies suggest a role for interferon (IFN)-gamma-producing T cells in the development and progression of AAAs. METHODS AND RESULTS: Fluorescence-activated cells sorter analysis of peripheral blood samples and measurement of AAA size using sonography were performed in 101 AAA patients and 38 healthy controls. Peripheral percentages of CD28- T cells of the CD3+CD4+ and the CD3+CD8+ were enriched in AAA patients with 7.8+/-8.8% and 41.9+/-15.7% compared with healthy controls with 2.2+/-6.1% and 24.9+/-15.5%, respectively (P=0.002 and P<0.001, respectively). Both CD4+CD28- and CD8+CD28- T cells produced large amounts of IFN-[gamma] and perforin. Patients with small AAAs (<4 cm) showed higher peripheral levels of CD4+CD28- T cells than those with larger AAAs (P=0.025). Immunohistological examinations revealed 39.1+/-17.2% CD4+CD28- and 44.0+/-13.8% CD8+CD28- in AAA tissue specimens with inflammatory infiltratestes. CONCLUSIONS: IFN-gamma- and perforin-producing CD28- T cells are present in the periphery and the vessel wall of a majority of AAAs. This observation in humans favors the concept of a T cell-mediated pathophysiology of AAAs, especially during the early development of AAAs.
Abstract: PURPOSE OF REVIEW: Large vessel vasculitis occurs in a subgroup of patients with Behçet disease at high risk for disease-related morbidity and mortality. Recognition of patients at risk, early detection of vasculitis, and the need for aggressive treatment are essential for optimal care of these patients. The authors review the clinical spectrum and management of large vessel problems in Behçet disease, highlighting contributions over the past year. RECENT FINDINGS: Vasculo-Behçet patients are at risk for multiple vessel-related complications including thromboses, stenoses, occlusions, and aneurysms. A number of factors may contribute to thrombosis in individual cases, but the primary reason for clot seems to reside in the inflammatory process in the arterial wall, still incompletely understood. An appreciation for the challenges in the perioperative period requires the joint efforts of physicians and surgeons, and fuels the study of alternate, less invasive procedures for Behçet patients. SUMMARY: Because of earlier recognition, aggressive medical treatment, and novel surgical procedures, the morbidity and mortality of large vessel vasculitis in Behçet disease are beginning to change. In the absence of controlled treatment studies, reports of clinical experience remain an important source of information for clinicians. Identification of patients at risk for vascular complications remains a priority.
Abstract: OBJECTIVE: To determine the value of microbubble contrast agents for color Doppler ultrasound (CDUS) compared with magnetic resonance imaging (MRI) in the detection of active sacroiliitis. METHODS: An observational case-control study of 103 consecutive patients (206 sacroiliac [SI] joints) with inflammatory low back pain according to the Calin criteria and 30 controls (60 SI joints) without low back pain was conducted at the University Hospital of Innsbruck. All patients and controls underwent unenhanced and contrast-enhanced CDUS and MRI of the SI joints. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of unenhanced and contrast-enhanced CDUS were evaluated. RESULTS: Forty-three patients (41%) with 70 of 206 SI joints (34%) and none of the controls nor the 60 control SI joints demonstrated active sacroiliitis on MRI. Unenhanced CDUS showed a sensitivity of 17%, a specificity of 96%, a PPV of 65%, and an NPV of 72%; contrast-enhanced CDUS showed a sensitivity of 94%, a specificity of 86%, a PPV of 78%, and an NPV of 97%. Detection of vascularity in the SI joint was increased by contrast administration (P < 0.0001). Clustered receiver operating curve analysis demonstrated that enhanced CDUS (A(z) = 0.89) was significantly better than unenhanced CDUS (A(z) = 0.61) for the diagnosis of active sacroiliitis verified by MRI (P < 0.0001; 2-sided test). CONCLUSION: Microbubble contrast-enhanced CDUS is a sensitive technique with a high NPV for detection of active sacroiliitis compared with MRI.
Abstract: OBJECTIVE: To assess the value of gray-scale ultrasound (US), color Doppler ultrasound (CDUS), contrast-enhanced CDUS, and magnetic resonance imaging (MRI) in the diagnostic evaluation of the hands in patients with remitting seronegative symmetrical synovitis with pitting edema (RS3PE). METHODS: Eight patients (5 men, 3 women; mean +/- SD age 69.3 +/- 7.2 years) with clinical diagnosis of RS3PE syndrome underwent US, CDUS, contrast-enhanced CDUS, and MRI. US was performed with a linear array transducer operating at 12 MHz. The US contrast agent (SHU 508; Levovist, Schering, Germany) was intravenously infused in a concentration of 300 mg/ml at a rate of 1 ml/minute. RESULTS: All patients showed symmetric subcutaneous edema and synovitis of tendons and finger joints on both US and MRI. Vascularity was detected subcutaneously in tendon sheaths and in the joint synovia on CDUS and MRI. Detection of increased vascularity was improved after contrast administration compared with unenhanced CDUS (P < 0.01). CONCLUSION: Ultrasound, CDUS, contrast-enhanced CDUS, and MRI are valuable tools in the diagnostic evaluation of involved anatomic structures in patients with RS3PE. Contrast-enhanced CDUS is superior to CDUS in assessment of inflammatory edema, effusion, and synovitis.
Abstract: Takayasu arteritis (TA) is a chronic inflammatory vasculitis of the aorta and its major branches with a very low incidence in Europe and North America. Our objective was to determine the elastic properties of the affected ascending and descending aortic walls non-invasively in a 14-year-old Iraqi girl with a 3-year history of fever, fatigue, malaise and diffuse pain. Ultrasound and magnetic resonance angiography showed marked thickening of the aortic wall, dilatation of the aortic arch, and decreased luminal diameters of the abdominal aorta and both subclavian arteries, consistent with TA. Ascending and descending aortic elastic properties such as distensibility and stiffness index were markedly reduced compared to a group of healthy controls (n=39): ascending aortic distensibility was 20 kPa(-1) x 10(-3) versus 63+/-23 kPa(-1) x 10(-3) in controls, and the ascending aortic stiffness index 9.6 versus 3.5+/-1.3 in controls. Although the patient's general condition improved rapidly on oral prednisolone and azathioprine and inflammatory parameters normalised within 3 weeks, the aortic elastic parameters did not change during the first 2 weeks of anti-inflammatory treatment. Unfortunately, no further follow-up was possible. CONCLUSION: In patients with Takayasu arteritis, non-invasive quantification of reduced aortic elastic properties can help to assess aortic involvement, and possibly to follow disease activity and vascular response to therapy.
Abstract: The purpose of this study way to assess the value of contrast enhanced gray-scale ultrasound (CEUS) in detection of vascularity in joints of patients with rheumatoid arthritis (RA) in a multicenter study of the International Arthritis Contrast Ultrasound (IACUS) study group. We assessed 113 joints in 113 patients (44 men, 69 women; mean age 51+/-14 years) with clinical diagnosis of RA. Gray-scale ultrasound (US), power Doppler US (PDUS) and CEUS, using a low mechanical index US technique, was performed. CEUS was done by bolus administration of the contrast agent SonoVue (Bracco, Milan, Italy) with a dosage of 4.8-ml SonoVue flushed with 10 ml saline. Detection of joint vascularity was performed for differentiation of active synovitis from inactive intra-articular thickening (synovitis/effusion). With the use of US and PDUS, active synovitis could be differentiated from inactive intra-articular thickening in 68/113 joints (60.1%), whereas CEUS enabled differentiation in 110/113 (97.3%) joints (p<0.0001). Thickness measurement of active synovitis was significantly improved after contrast administration (p=0.008). In conclusion, CEUS improves the differentiation of active synovitis from inactive intra-articular thickening. Since CEUS has shown an ability to improve assessment of vascularized synovial proliferation in RA affected joints, this technique may have further potential in monitoring therapy.
Abstract: CD3+CD4+CD28null and CD3+CD8+CD28null T cells are enriched in patients with immune-mediated diseases compared with healthy controls. This study shows that CD4+CD28null T cells express Toll-like receptors recognizing bacterial lipopolysaccharides in ankylosing spondylitis, psoriatic arthritis and rheumatoid arthritis. In ankylosing spondylitis, TLR4 (23.1 +/- 21.9%) and, to a smaller extent, TLR2 (4.1 +/- 5.8%) were expressed on CD4+CD28null T cells, whereas expression was negligible on CD4+CD28+ and CD8+ T cells. CD4+CD28null T cells produced perforin upon stimulation with lipopolysaccharide, and this effect was enhanced by autologous serum or recombinant soluble CD14. Perforin production could be prevented with blocking antibodies directed against CD14 or TLR4. Incubation of peripheral blood mononuclear cells with tumour necrosis factor alpha led to an upregulation of TLR4 and TLR2 on CD4+CD28null T cells in vitro, and treatment of patients with antibodies specifically directed against tumour necrosis factor alpha resulted in decreased expression of TLR4 and TLR2 on CD4+CD28null T cells in vivo. We describe here a new pathway for direct activation of cytotoxic CD4+ T cells by components of infectious pathogens. This finding supports the hypothesis that CD4+CD28null T cells represent an immunological link between the innate immune system and the adaptive immune system.
Abstract: The aim of this work was to study the effects and side effects of gemcitabine (2',2'-difluorodeoxycytidine, dFdC), a pyrimidine synthesis inhibitor, on skin lesions of a herpes simplex virus (HSV)-induced Adamantiades-Behçet's disease (ABD)-like mouse model. For the dose-escalation study, ICR mice were treated intraperitoneally with dFdC over 5 days. For the efficacy study, ICR mice were inoculated with HSV and classified as having ABD according to a revised Japanese classification, and then 18 ABD mice were randomly assigned to placebo, 0.06 or 0.12 microg of dFdC/day over 5 days. Serum levels of interleukin-4 (IL-4), IL-6, IL-10, interferon-gamma (IFN-gamma), and tumor necrosis factor-alpha (TNF-alpha) were determined using enzyme-linked immunosorbent assay. After application of 3 microg of dFdC over 5 days, alanine aminotransferase increased (P = 0.032), but all other kidney and liver parameters were unchanged. In ABD mice, 5 days of dFdC treatment with 0.06 or 0.12 microg of dFdC/day resulted in a dose-dependent improvement of cutaneous manifestations by more than 60% (P = 0.017). There was no significant change in cytokine levels, and none of the cytokine levels correlated with response to treatment. Moreover, dFdC shows promising effects to improve cutaneous lesions in the HSV-induced ABD-like mouse model. In this animal model, effects of dFdC on the cytokine profile remained inconclusive.
Abstract: OBJECTIVE: To assess the value of 2 transducer positions for measurement of finger flexor tendon thickness by sonography. METHODS: Flexor tendon thickness of the third finger was measured sonographically by 2 independent investigators in 20 healthy volunteers (n = 40 fingers) and in 4 cadaveric specimens (n = 4 fingers). Flexor tendon thickness was measured at histologic examination in the cadaveric specimens. We defined the area of the A1 annular pulley as position I and the area of the A2 annular pulley as position II. Sonographic measurements were performed in transverse (dorsovolar and radioulnar) and longitudinal planes. Interobserver and intraobserver variabilities were evaluated by each investigator performing 3 measurements at each position. RESULTS: In position I, volunteers had flexor tendon thickness of 2.7 to 4.0 mm (mean +/- SD, 3.28 +/- 0.26 mm) longitudinally; transversally the thickness was 2.5 to 4.0 mm (mean, 3.34 +/- 0.29 mm) dorsovolar and 5.5 to 8.9 mm (mean, 7.34 +/- 0.71) radioulnar in position I. Position II revealed thickness of 3.2 to 4.2 mm (mean, 3.6 +/- 0.23 mm) longitudinally; transversally the thickness was 2.7 to 4.1 mm (mean, 3.4 +/- 0.27) dorsovolar and 4.3 to 6.8 mm (mean, 5.27 +/- 0.65) radioulnar. Interobserver and intraobserver variability for position I was better than for position II (P < .01 versus P < .05). Sonographic findings correlated excellently with histologic findings (r2 = 0.94). CONCLUSIONS: Standardized transducer positions for sonographic measurements of finger flexor tendon thickness showed good interobserver and intraobserver variability. Position I was found to be more reliable than position II.
Abstract: BACKGROUND: Involvement of the metacarpophalangeal (MP) joints is one of the major problems in patients with rheumatoid arthritis (RA). Although several data about the cumulative influence of steroid intake on bone are available, the course of demineralisation in RA has not been described by quantitative methods until now. PATIENTS AND METHODS: Computed tomography (CT) sections of 96 MP joints in 12 RA patients and of 32 MP joints in four age-matched healthy controls were investigated. Patients were classified according to Steinbrocker. Densitometric evaluation of subchondral bone density was performed by CT osteoabsorptiometry (CT-OAM). Quantitative CT-OAM was used to evaluate mineralisation of the articular surfaces in MP joints. RESULTS: In the distal articular surface of MP joints, the number of density maxima was reduced from 3 to 2.1+/-0.3, 1.9+/-0.5 and 1.3+/-0.3 in RA patients with early, mild to moderate, and severe disease, respectively. Means of calcium concentrations were 633.4+/-35. 3 mg Ca2+/mL, 518.9+/-56.2 mg Ca2+/mL, 497.7+/-23.8 mg Ca2+/mL and 455.1+/-28.6 mg Ca2+/mL for controls and RA patients with early, mild to moderate, and severe RA, respectively. Mineralisation of the distal articular surface was significantly reduced in all groups of RA patients [probability (p) = 0.005]. Regarding the number of density maxima, no differences were detected in the proximal articular surface of normal and RA fingers. However, mineralisation of the proximal articular surface was significantly reduced in all groups of RA patients (p = 0.004). Means of calcium concentrations of the proximal articular surface were 494.1+/-48.5 mg Ca2+/mL, 413.0+/-16.2 mg Ca2+/mL, 406.0+/-51.4 mg Ca2+/mL, 390,4+/-41.1 mg Ca2+/mL for controls and RA patients with early, mild to moderate, and severe RA, respectively. CONCLUSION: Patients with early and untreated RA show loss of mineralisation and altered morphology of the MP joints of the hand, even before corticosteroid therapy. CT-OAM provides evidence for an early alteration of functional anatomy in MP joints.
Abstract: 18F-Fluorodeoxyglucose-positron emission tomography (18F-FDG-PET) is a new functional imaging technique available for clinical and experimental use. 18F-FDG-PET studies can be used for screening, localization and follow-up of hypermetabolic processes including malignancies, infections and autoimmune processes. For several years it has been applied in oncological, cardiological and neurological patients, but nowadays an increasing number of studies favours its use in patients with autoimmune diseases including large vessel arteritis. From the experimental view, this technique has even become more important since the introduction of a small PET scanner for the use in animal models. This review focuses on technical aspects, clinical experiences and experimental and future perspectives of 18F-FDG-PET, with a special emphasis on large vessel vasculitis and other autoimmune diseases.
Abstract: 18F-FDG-PET studies were performed in a 60-year-old female patient with polymyalgia rheumatica resistant to prior corticosteroid treatment. PET studies showed a cervical focus, which was identified histologically and microbiologically as lymph node tuberculosis.
Abstract: Cardiac involvement occurs in less than 5% of Behçet patients, and coincidence of regurgitation of the aortic and mitral valves and myocardial infarctions is rare. This report describes a 49-year-old Turkish man with Behçet disease (BD) of 6 years' duration who presented with reduced left ventricular function. Both aortic and mitral valves had to be replaced. Five months later, the patient presented with non-ST segment elevation myocardial infarction. Only 1 month later, the patient was successfully resuscitated after an acute ST segment elevation inferior myocardial infarction. Coronary arteries were normal in appearance at angiography before valvular replacement and at autopsy 2 years later. This report should increase awareness of cardiac involvement in BD and its potential danger. Even in BD patients without atherothrombotic plaques, myocardial infarctions can happen. Early and adequate immunosuppressive treatment might have reduced cardiac morbidity in this patient.
Abstract: Circulating CD3+CD4+CD28- cells exhibit reduced apoptosis and were found to be more enriched in patients with ankylosing spondylitis than in age-matched healthy control individuals (7.40 +/- 6.6% versus 1.03 +/- 1.0%; P < 0.001). Levels of CD4+CD28- T cells correlate with disease status as measured using a modified metrology score, but they are independent of age and duration of ankylosing spondylitis. CD4+CD28- T cells produce IFN-gamma and perforin, and thus they must be considered proinflammatory and cytotoxic. These T cells share phenotypic and functional properties of natural killer cells, strongly expressing CD57 but lacking the lymphocyte marker CD7. MHC class I recognizing and activating natural killer cell receptors on the surface of CD4+CD28- T cells may be involved in a HLA-B27 mediated co-stimulation of these proinflammatory and cytotoxic cells.
Abstract: Circulating CD8(+) CD28(-) T cells were found to be expanded more in patients with ankylosing spondylitis than in an age-matched healthy population (41.2 +/- 17.7% versus 18.6 +/- 7.6%). The level of CD8(+)CD28(-) T cells was dependent on the disease status, but was independent of age. Most of the CD8(+) CD28(-) T cells produced perforin after stimulation in vitro, in contrast to their CD8(+)CD28(+) counterparts. From the clinical perspective, the percentage of the cytotoxic CD8(+) CD28(-) T cells reflected a more severe course of disease, as it correlated with distinct movement restrictions, as well as the metrology score summarizing cervical rotation (in sitting position), chin-to-jugulum distance, thoracic Schober, chest expansion, and fingers-to-floor distance (P = 0.032).
Abstract: OBJECTIVE: A prospective study was performed to assess the usefulness of contrast-enhanced color Doppler ultrasound (CDUS) in the evaluation of intraarticular vascularization of finger joints in patients with rheumatoid arthritis (RA). METHODS: We investigated 198 finger joints in 46 patients with RA, and 80 finger joints in 10 healthy volunteers. Joints with varying levels of clinical activity of inflammation were classified as being active, moderately active, or inactive. CDUS was performed with a high-frequency multi-D linear array transducer. A microbubble-based ultrasound (US) contrast agent (Levovist; Schering, Berlin, Germany) was intravenously infused. Doppler findings were rated on the basis of both unenhanced and contrast-enhanced CDUS images. RESULTS: Healthy joints showed no intraarticular vascularization on either unenhanced or contrast-enhanced CDUS. Unenhanced CDUS detected intraarticular vascularization in 7 (8%) of 83 inactive joints, in 31 (52%) of 60 moderately active joints, and in 32 (58%) of 55 active joints. Contrast-enhanced CDUS detected intraarticular vascularization in 41 (49%) of 83 joints with inactive RA, in 59 (98%) of 60 joints with moderately active RA, and in all 55 joints with active RA. Detection of intraarticular vascularization was improved by administration of the microbubble-based US contrast agent (P < 0.001). Contrast-enhanced CDUS demonstrated differences in intraarticular vascularization between joints with inactive RA and those with active RA (P < 0.001), between joints with inactive RA and those with moderately active RA (P < 0.001), and between joints with moderately active RA and those with active RA (P < 0.001). CONCLUSION: The use of a microbubble-based US contrast agent significantly improved the detection of intraarticular vascularization in the finger joints of patients with RA. This technique seems to be a useful adjunct in the assessment of disease activity.
Abstract: INTRODUCTION: Angiogenesis is important for the pathogenesis of chronic inflammatory diseases in joints. Inflammation itself may upregulate the expression of VEGF in rheumatic diseases. Angiogenesis may become a new target for therapeutic intervention in inflammatory joint disease. AIM OF THE STUDY: To examine plasma levels of VEGF in AS patients and to test a possible correlation with serological and/or clinical parameters. PATIENTS AND METHODS: Sixteen consecutive patients with definite AS were recruited from the Gasteiner Heilstollen Hospital and compared to eight healthy probands as controls. VEGF was determined in EDTA plasma samples by using an ELISA kit. Data are given as mean values (+/- SEM). The Spearman two-sided test was used to test possible correlations. RESULTS: EDTA-plasma levels of VEGF were 75.3 +/- 19.0 pg/ml, compared to 13.8 +/- 4.7 pg/ml measured in the control group (P = 0.001). A significant correlation was found between plasma VEGF of AS patients and the BASMI score (r = 0.665, P = 0.013). Whereas VEGF was elevated in patients without treatment or NSAIDs (88.9 +/- 24.2 pg/ml), lower levels up to 43.8 pg/ml were found in patients treated with corticosteroids (34.7 +/- 4.0 pg/ml, P = 0.039). CONCLUSIONS: Disease status of AS appears to be associated with elevated VEGF plasma levels. Whether this reflects inflammation or a truly angiogenic pathomechanism requires further investigation.
Abstract: OBJECTIVE: To evaluate safety and clinical efficacy of a plant extract from the pentacyclic chemotype of Uncaria tomentosa (UT) in patients with active rheumatoid arthritis (RA). METHODS: Forty patients undergoing sulfasalazine or hydroxychloroquine treatment were enrolled in a randomized 52 week, 2 phase study. During the first phase (24 weeks, double blind, placebo controlled), patients were treated with UT extract or placebo. In the second phase (28 weeks) all patients received the plant extract. RESULTS: Twenty-four weeks of treatment with the UT extract resulted in a reduction of the number of painful joints compared to placebo (by 53.2% vs 24.1%; p = 0.044). Patients receiving the UT extract only during the second phase experienced a reduction in the number of painful (p = 0.003) and swollen joints (p = 0.007) and the Ritchie Index (p = 0.004) compared to the values after 24 weeks of placebo. Only minor side effects were observed. CONCLUSION: This small preliminary study demonstrates relative safety and modest benefit to the tender joint count of a highly purified extract from the pentacyclic chemotype of UT in patients with active RA taking sulfasalazine or hydroxychloroquine.
Abstract: Leukemic hairy cells are clonally proliferating B-lymphoid cells with clonal rearrangements of genes for immunoglobulin chains. We describe a patient with a new hairy-cell clone after treatment with 2-chlorodeoxyadenosine (2-CdA). In this patient, a single course of 2-CdA resulted in good partial remission of hairy-cell leukemia, but Southern blot analysis of bone marrow biopsies and polymerase chain reaction using seminested amplifications with consensus primers revealed a new rearranged band 4 months after therapy with 2-CdA. Four years after therapy, the patient is in complete clinical remission and both bands disappeared during follow-up. The new rearranged band might have been related to prior treatment of hairy-cell leukemia with 2-CdA.
Abstract: CD4(+)CD28(null) T cells are oligoclonal lymphocytes rarely found in healthy individuals younger than 40 yr, but are found in high frequencies in elderly individuals and in patients with chronic inflammatory diseases. Contrary to paradigm, they are functionally active and persist over many years. Such clonogenic potential and longevity suggest altered responses to apoptosis-inducing signals. In this study, we show that CD4(+)CD28(null) T cells are protected from undergoing activation-induced cell death. Whereas CD28(+) T cells underwent Fas-mediated apoptosis upon cross-linking of CD3, CD28(null) T cells were highly resistant. CD28(null) T cells were found to progress through the cell cycle, and cells at all stages of the cell cycle were resistant to apoptosis, unlike their CD28(+) counterparts. Neither the activation-induced up-regulation of the IL-2R alpha-chain (CD25) nor the addition of exogenous IL-2 renders them susceptible to Fas-mediated apoptosis. These properties of CD28(null) T cells were related to high levels of Fas-associated death domain-like IL-1-converting enzyme-like inhibitory protein, an inhibitor of Fas signaling that is normally degraded in T cells following activation in the presence of IL-2. Consistent with previous data showing protection of CD28(null) cells from spontaneous cell death, the present studies unequivocally show dysregulation of apoptotic pathways in CD4(+)CD28(null) T cells that favor their clonal outgrowth and maintenance in vivo.
Abstract: BACKGROUND: 2',2' -difluorodeoxycytidine (dFdC, gemcitabine) is a pyrimidine antimetabolite with antineoplastic activity against a wide range of solid tumors. The immunosuppressive activities of this compound have not been described to date. METHODS: The in vitro effects on activated T lymphocytes were studied with a lymphocyte colony-forming assay in a microagar culture system. Heart transplantations were performed in the fully allogeneic Lewis/ Brown Norway combination. dFdC was administered once daily at various dosages from the time of surgery until day 50. RESULTS: Phytohemagglutinin-induced lymphocyte proliferation was inhibited 50% by dFdC at a concentration of 3.25+/-0.9 nmol/L. Allografts of untreated animals survived for 7.5 (7-8) days and those with 25, 50, and 75 microg/kg body weight dFdC for 7.3 (7-8), 9.3 (8-10), and 16.3 (10-38) days, respectively. Treatment with 100 or 125 microg/kg body weight of dFdC, however, prolonged allograft survival until day 152.8 (129-178). Dose-dependent leukopenia was the main toxicity. CONCLUSIONS: DFdC is a new immunosuppressive agent that can successfully prevent cardiac rejection in a rat transplantation model.
Abstract: Chronic myeloid leukemia (CML) is a clonal neoplastic disease that originates in a pluripotent stem cell. Selection of normal progenitors by graft-purging may improve the outcome after autologous transplantation. In our methylcellulose assays, the nucleoside analogs cladribine (2-CdA) and gemcitabine (dFdC) showed more prominent inhibitory effects on CML than normal bone marrow (BM) progenitors. For dFdC, however, long-term incubations were necessary to achieve complete inhibition. Deoxycytidine kinase, the key enzyme of both 2-CdA and dFdC metabolisms, was only partially responsible for this differential sensitivity. We suggest that 2-CdA and dFdC might be helpful in purging of CML BM cells before autologous BM transplantation. Further studies on more primitive cells are warranted.
Abstract: Cross-resistance patterns between chemotherapeutic agents have implications for the treatment of hematologic and other diseases. Previous in vitro models have shown cross-resistance between the purine analog 2-chlorodeoxyadenosine (cladribine) and the pyrimidine analogs 2',2'-difluorodeoxycytidine (gemcitabine) and 1-beta-D-arabinofuranosylcytosine (cytosine arabinoside, cytarabine) with reduced deoxycytidine kinase (dCK) activity as the underlying determinant of resistance. In this study, we continuously exposed the human promyelocytic leukemia cell line HL60 to as much as 1024 nM cladribine. After limiting dilution, the cladribine concentrations that caused 50% growth inhibition (IC50) of the two clones R13 and R23 were 33.3- and 18.7-fold, respectively, higher than the IC50 of the parental HL60 cells (8.7+/-1.3 nM). These cladribine-resistant clones, however, showed no cross-resistance to gemcitabine and only 3.3- and 2.7-fold resistance to cytarabine, respectively. Characterization of both clones revealed stably elevated levels of purine-specific "high-Michaelis constant (Km)" 5'-nucleotidase (5'-NT) messenger RNA expression and specific activity, whereas pyrimidine-specific "low-Km" 5'-NT activity was undetectable, and dCK activity was only marginally decreased in R13. Thus, the ratio of dCK (specific for cladribine) to high-Km 5'-NT activity in R13 and R23 was reduced to 65.3% and 63.7%, respectively. These results show that changes of high-Km 5'-NT activity can induce cladribine resistance, without cross-resistance to gemcitabine.
Abstract: Changes in T cell populations and concomitant perturbation of T cell effector functions have been postulated to account for many aging-related immune dysfunctions. Here, we report that high frequencies of CD28(null) CD4+ T cells were found in elderly individuals. Because deviations in the function of these unusual CD4+ T cells might be directly related to CD28 deficiency, we examined the molecular basis for the loss of CD28 expression in CD4+ T cells. In reporter gene bioassays, the minimal promoter of the CD28 gene was mapped to the proximal 400 base pairs (bp) of the 5' untranslated region. CD28 deficiency was associated with the loss of two noncompeting binding activities within a 67-bp segment of the minimal promoter. These binding activities were not competed by consensus Ets, Elk, or AP3 motifs that were found within the sequence stretch. The DNA-protein complexes were also not recognized by antibodies to Ets-related transcription factors. Furthermore, introduction of mutations into the 67-bp segment at positions corresponding to the two DNA-protein interaction sites, i.e. nucleotides spanning -206 to -179 and -171 to -148, resulted in the loss of specific nuclear factor binding activities and the abrogation of promoter activity. These observations implicate at least two regulatory motifs in the constitutive expression of CD28. The loss of binding activity of trans-acting factors specific for these sequences may contribute to the accumulation CD4+CD28(null) T cells during aging.
Abstract: BACKGROUND/AIMS: Hepatocellular carcinoma is one of the most malignant tumors in the world. Although a wide range of therapeutic options is available, the efficacy of these methods and the prognosis of hepatocellular carcinoma are still very poor. The nucleoside analogs 2-chlorodeoxyadenosine (Cladribine, 2-CdA) and 2',2'-difluorodeoxycytidine (Gemcitabine, dFdC) have shown potent cytotoxic effects on various human tumor cell lines in vitro and marked therapeutic efficacy in the treatment of lymphoproliferative disorders and several solid tumors in vivo. In the present study we evaluated the antitumor effect of 2-CdA and dFdC on human hepatoma HepG2 cells. METHODS: HepG2 cells were grown in the absence and presence of increasing concentrations of 2-CdA and dFdC. Antitumor activity was assessed by inhibition of cell growth, evaluated by counting cell numbers in a hemocytometer and by 3H-thymidine uptake, and by reduction of cell viability as determined by exclusion of 0.1% trypan blue. For rescue experiments, the natural pyrimidine deoxycytidine (dCyd) was added simultaneously or delayed. RESULTS: A strong antitumor activity was observed for both compounds. dFdC showed a more pronounced effect with an inhibition constant (IC50) of 3.98+/-0.03 nM in comparison to 2-CdA with an IC50 of 16.66+/-0.40 nM. Both drugs achieved their half-maximal antitumor activity after 31 h. With respect to dFdC, fractionated daily administrations showed a distinctly greater antitumor activity than a single transient administration. The cytotoxic effects of 2-CdA and dFdC were completely reversed by simultaneous addition of dCyd. CONCLUSION: In this paper we show strong antitumor effects of the nucleoside analogs 2-CdA and dFdC on the human hepatoma cell line HepG2. These findings suggest that both compounds, but in particular dFdC, are promising substances for further evaluations in the treatment of hepatocellular carcinoma.
Abstract: Patients with rheumatoid arthritis have a subset of CD4+ T lymphocytes that are characterized by a defect in CD28 expression. CD4+CD28- T cells frequently undergo clonal expansion in vivo. These clonotypes include autoreactive cells and persist over many years. The clonogenic potential and longevity of these T cells could be related to an altered response to apoptosis-inducing signals. To explore this possibility, CD4+CD28- T cell lines and clones were examined for their response pattern to stimuli inducing physiologic cell death. CD4+CD28- T cells were found to be resistant to apoptosis upon withdrawal of the growth factor, IL-2. To examine whether the altered sensitivity to this apoptotic signal was correlated with the expression of proteins of the bcl-2 family, the expression of bcl-2, bcl-x, and bax proteins was determined. CD28+ and CD28-CD4+ T cells could not be distinguished by the levels of bax or bcl-xL protein; however, CD4+CD28- T cells expressed higher amounts of bcl-2 protein than did CD4+CD28+ T cells. The increased bcl-2 expression in CD4+CD28- T cells was relatively independent of signals provided by exogenous IL-2. In CD28-deficient CD4+ T cells, bcl-2 was not significantly up-regulated by the addition of exogenous IL-2 and was maintained despite IL-2 withdrawal, as opposed to CD28-expressing CD4+ T cells. We propose that CD4+CD28- T cells are characterized by a dysregulation of the survival protein, bcl-2, which may favor the clonal outgrowth of autoreactive T cells and thus contribute to the pathogenesis of rheumatoid arthritis.
Abstract: We report that continuous suppression of CD4+ lymphocyte subsets does not necessarily lead to an increased rate of infections more than 6 months after treatment of hairy cell leukemia (HCL) with 2-chlorodeoxyadenosine (cladribine; 2-CdA). In a retrospective analysis of 17 consecutive patients with HCL treated with 2-CdA and followed thereafter for an average of 440 days (ranging from 71 to 1,046 days), all lymphocyte subsets significantly decreased after therapy. However, natural killer (NK) cells increased to 203 cells/microliter during the following 4 months, whereas CD3+ and CD4+ T cell subsets did not reach pretreatment values even more than 1 year after 2-CdA therapy. In our study group, 5 opportunistic infections occurred during the first 2 weeks after treatment with 2-CdA, and no severe infections were registered after this early leukopenic phase. A review of the current literature revealed that at least 56 infections occurred in 158 patients repeatedly treated with 2CdA for low-grade lymphoproliferative diseases other than HCL (= 35%). In patients with HCL, the rapid increase of NK cell counts after 6 months might be responsible for reducing the risk of severe infections after the early leukopenic phase despite CD4+ cell suppression.
Abstract: Cladribine (2-chlorodeoxyadenosine, 2-CdA) is a newer purine analog with specific toxicity to lymphocytes. As lymphocytes play a major role in rheumatoid arthritis (RA), we assessed the safety profile of low-dose 2-CdA in patients who were refractory to more than three disease-modifying drugs. Five patients were given a subcutaneous dosage of 0.05 mg/kg 2-CdA weekly over a period of 8 weeks. Of the lymphocyte subsets, both T and B cells decreased below the normal range, whereas natural killer cells remained stable. These changes were the only side-effects noted during treatment and 4 weeks afterwards. In one patient a pacemaker was implanted for reasons unlikely to be related to 2-CdA administration. We conclude that even low-dose 2-CdA (0.05 mg/kg) can decrease T and B cell populations in patients with refractory RA, but other side-effects are unlikely. For assessing the possible clinical efficacy of low-dose 2-CdA further studies are warranted.
Abstract: We compared the antiproliferative effects in vitro of recombinant preparations of interferon-alpha 2c (IFN-alpha 2) and IFN-omega on the formation of colonies from bone marrow progenitor cells. Both IFNs led to statistically indistinguishable dose-dependent inhibitory effects when tested on bone marrow cells derived from 8 normal donors or from 7 patients with chronic myelogenous leukemia (CML). With both IFNs, the cells from CML patients appeared slightly but not significantly more sensitive to inhibition than the cells from normal donors. These results suggest that under some circumstances, IFN-omega may prove an effective treatment for CML, for example, in those becoming resistant to IFN-alpha 2 because of the formation of neutralizing antibodies.
Abstract: Active compression-decompression cardiopulmonary resuscitation (ACD-CPR) has been introduced to improve outcome of CPR after cardiac arrest. Usually, ACD-CPR is performed with the rescuer kneeling beside the patient (ACD-B), but ACD-CPR with the rescuer in standing position (ACD-S) has been taught and applied in some centres in addition to conventional ACD-CPR (ACD-B). The aim of this randomised and cross-over study was to evaluate the new technique of ACD-S and to compare it with conventional ACD-B. Twelve professional rescuers (aged 30.8 +/- 7.9 years) applied both methods of ACD-CPR on a manikin. We obtained the following results. (1) Duration of CPR performance was comparable for ACD-S (13.2 +/- 7.1 min) and ACD-B (15.5 +/- 10.2 min, P = 0.48). (2) Pain in the upper extremity and pain in the vertebral column were the main reasons for break-off by the rescuers. Exhaustion was judged to be similar during ACD-S (5.3 +/- 2.3) and ACD-B (6.2 +/- 2.1; on a rating scale with 1 = no and 9 = complete exhaustion). (3) Oxygen consumption was significantly higher during ACD-S (P < 0.005), whereas heart rate and lactate levels did not differ. (4) Decompression forces were lower than compression forces. The averaged decompression forces in both methods were similar during the first 2 min and the last min. Compression forces decreased in ACD-S from 55.1 to 48.9 kp (P = 0.002) and in ACD-B from 52.8 to 47.0 kp (P = 0.069). We conclude that ACD-CPR in standing position can be considered equal to ACD-B in view of maximal duration of CPR, exhaustion of the rescuers and decompression forces. The decrease of compression forces in ACD-S and ACD-B as well as the difference between compression forces in ACD-S and ACD-B seem to be of no clinical relevance, and exhaustion was judged to be similar despite oxygen consumption being higher in ACD-S than in ACD-B.
Abstract: A 65 year old man was found to have mucormycosis cerebri during immunosuppression after treatment of hairy cell leukaemia with 2-chlorodeoxyadenosine. Although mucormycosis cerebri has a poor prognosis, the patient survived after systemic administration of high dose amphotericin B, extensive excision of the abscess, and additional local application of amphotericin B with the help of an absorbable gelatin sponge.
Abstract: Specific training in the techniques of cardiopulmonary resuscitation (CPR) has been the major aim of CPR education for both health care professionals and lay people over the past few decades. We performed a randomized trial to evaluate individual physiological parameters of 12 professional rescuers influencing duration and quality of standard CPR and active compression-decompression CPR. CPR duration was assessed according to individual work capacity after grouping rescuers as untrained and trained individuals, according to their work capacity of up to and including 100% and over 100%. The average work capacity of all the rescuers was determined by incremental exercise testing, resulting in 110.0 +/- 26.5% compared with data for the normal population. With 29.3 +/- 12.8 min duration, standard CPR was significantly longer than active compression-decompression CPR with 15.5 +/- 10.2 min duration (P = 0.009). No changes in the forces of compression and decompression were measured during active compression-decompression CPR, thus demonstrating maintenance of constant CPR quality. Duration of resuscitation was influenced by the CPR method performed and by the individual work capacity (P = 0.004 and P = 0.027, respectively). We conclude that the duration of CPR depends both on the method applied and the rescuers' individual work capacity and recommend improvement of work capacity by aerobic training especially for professional rescuers.
Abstract: Gemcitabine (2',2'difluoro-2'deoxycytidine, dFdC) is a synthetic antimetabolite of the cellular pyrimidine nucleotide metabolism. In a first series of in vitro experiments, the drug showed a strong effect on the proliferation and colony formation of the human androgen-sensitive tumor cell line LNCaP and the androgen-insensitive cell lines PC-3 and DU-145. Maximal inhibition occurred at a dFdC concentration as low as 30 nM. In contrast to the cell lines which were derived from metastatic lesions of prostate cancer patients, no inhibitory effects were found in normal primary prostatic epithelial cells at concentrations up to 100 nM. The effect of gemcitabine was reversed by co-administration of 10-100 microM of its natural analogue deoxycytidine. In view of a future clinical application of this anti-tumor drug in advanced prostatic carcinoma, we have compared the effect of gemcitabine on prostatic tumor cells with that on bone marrow granulopoietic-macrophage progenitor cells, because neutropenia is a common side effect of gemcitabine treatment. The time course of action on the two kinds of cells was markedly different. Colony formation of tumor cells was inhibited by two thirds at a gemcitabine concentration of about 3.5 nM. The same effect on granulopoietic-macrophagic progenitor cells required a concentration of 9 nM. Co-administration of deoxycytidine to gemcitabine-treated tumor cell cultures completely antagonized the effect of gemcitabine whereas addition of deoxycytidine after 48 hr of gemcitabine treatment could not prevent gemcitabine action on the tumor cells. In contrast, more than half of the granulopoietic-macrophagic progenitor cells could still be rescued by deoxycytidine administration after 48 hr. These findings and the marked difference in the susceptibility of neoplastic and normal prostatic cells suggest that gemcitabine is a promising substance which should be further evaluated as to its efficacy in the treatment of advanced prostatic carcinoma.
Abstract: Some patients in apparent complete remission of hairy cell leukemia (HCL) after 2-chlorodeoxyadenosine (2-CdA) treatment may have minimal residual disease (MRD). This study examines detection of minimal residual disease by immunohistological staining using the monoclonal antibody (MoAb) B-ly 7 in 11 patients with complete remission of hairy cell leukemia (HCL) after 2-CdA therapy administered between 1990 and 1993. In all 11 cases, residual hairy cells could be detected by MoAb B-ly 7 (0.1 to 7.5%, median 0.65%). At a follow-up period of 7 - 29 months (median 19.3), 9 of these patients remained in complete remission, whereas 2 patients relapsed 22 and 27 months after 2-CdA therapy. To determine whether flow-cytometric analysis of hairy-cells in bone marrow aspirates and peripheral blood cells are comparable with results obtained by immunostaining with B-ly 7 in bone marrow biopsies, available data using CD-19/CD-11c double-staining were analyzed. In 5 of 10 cases no hairy-cells could be detected in bone marrow aspirates, and in 6 partly different cases no hairy-cells were detectable in peripheral blood using flow-cytometry, although immunostaining of bone marrow biopsies using B-ly 7 revealed hairy-cells (ranging form 0.1 to 7.5%) in these cases. These results indicate that therapy with 2-CdA does not eradicate hairy cell leukemia despite complete remission according to conventional criteria. Minimal residual disease might be responsible for subsequent relapse. We conclude that routine immunohistological examination of bone marrow biopsies with B-ly 7 should be performed for assessment of MRD. Flow cytometric investigations of mononuclear cells of bone marrow aspirate or peripheral blood seem valuable for regular long term monitoring of MRD, but does not substitute for immunostaining of bone marrow biopsies.
Abstract: A recently developed immunosuppressive substance, 2-chloro-2-deoxyadenosine (2-CdA), was reported to inhibit monocyte functions at low concentration. Because macrophages play a key role in the formation of atherosclerotic plaques, it was of interest to study the effect of 2-CdA on cellular lipid metabolism. For this purpose we have used a macrophage cell line (P388) to perform incubation studies in the presence of acetylated low density lipoprotein (Ac-LDL) and 2-CdA. The addition of 2-CdA, in concentrations ranging from 5-20 nM, induced a dose-dependent decrease in cellular cholesterol content and in the amount of extracellular [14C]oleic acid (OA) incorporated into the cholesteryl ester (CE) fraction. The effect was maximized at 20 nM 2-CdA with an 86% reduction in cholesterol esterification compared to controls (P < 0.008). To evaluate the mechanism of interaction of 2-CdA with cellular lipid metabolism, deoxycytidine (dCyt) and 3-methoxybenzamide (3-MOB), substances known to antagonize the effect of 2-CdA in different ways, were co-administered with 2-CdA. dCyt, a competitive inhibitor of dCyt kinase, which catalyzes phosphorylation to the active metabolite, antagonized the effects of 20 nM 2-CdA, producing significantly greater incorporation of extracellular [14C]OA into the CE fraction than in the presence of 2-CdA alone (P < 0.0086). Co-incubation with 2-CdA and the poly-ADP-ribose synthetase inhibitor 3-MOB, which is known to render cells resistant to 2-CdA toxicity by preventing cellular nicotinamide adenine dinucleotide (NAD)- and adenosine triphosphase-depletion, also reversed the effect of 2-CdA on lipid accumulation.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: The cytotoxic effect of chlorodeoxyadenosine (CdA) on lymphocytes and monocytes requires phosphorylation by the enzyme deoxycytidine kinase and can be antagonized by coadministration of deoxycytidine (dCyt), a competitive substrate of deoxycytidine kinase. It has also been shown for lymphocytes that coadministration of 3-aminobenzamide (3-ABA), an inhibitor of the enzyme poly-(ADP ribose) synthetase, is activated by CdA-mediated DNA strand breaks, consumes intracellular nicotinamide-dinucleotide (NAD) and can antagonize the lethal effect of CdA. Recent in vitro studies have shown that not only growth of lymphocytes and monocytes, but also colony formation by erythroid and myeloid progenitors derived from normal human bone marrow, is inhibited by CdA in a dose-dependent manner. In this study we examined the effect of various doses of dCyt (10(-6) to 10(-3) M) on CdA-mediated growth inhibition of erythroid and myeloid progenitor cells in vitro. Our results show that colony formation by human bone marrow-derived progenitor cells--CFU-E (colony-forming unit erythroid), BFU-E (burst-forming unit erythroid) and CFU-GM (colony-forming unit granulocyte/macrophage)-in semisolid medium is protected by a high, but clinically achievable and non-toxic, concentration of dCyt (> 10(-4) M) against the inhibitory effects of coadministered high concentrations of CdA. The protective effect of dCyt was markedly different on the various subclasses of progenitor cells, however. Thus, with coadministration of 10(-4) M dCyt, the CFU-E colony formation could be restored to almost 100% despite the presence of high concentrations of CdA (160 nM) compared to control cultures, whereas the colony formation of BFU-E and CFU-GM was restored to only 50%. At a concentration of 10(-3) M dCyt, colony formation of BFU-E and CFU-GM was raised to 80% of control cultures even in the presence of high concentrations of CdA (160 nM). Further experiments in which 3-ABA was coadministered to CdA-treated cultures showed that in all concentrations tested (0.3 to 5 mM) 3-ABA was not able to prevent CdA-mediated cytotoxicity on bone marrow progenitors. Based on these studies, we suggest that the CdA toxicity on CFU-E is mainly mediated by phosphorylation by deoxycytidine kinase, whereas additional mechanisms may be operative in BFU-E and CFU-GM. Considerable biochemical differences seem to exist between hematopoietic stem cells on the one hand and lymphocytes and monocytes from peripheral blood on the other.
Abstract: The purified dihydropyridine-sensitive calcium channel from skeletal muscle transverse tubules consists of several subunits, termed alpha 1, alpha 2, beta, gamma and delta. From its associated drug receptors, those for 1,4-dihydropyridines and phenylalkylamines have been shown previously by photoaffinity labeling to reside on the alpha 1 subunit. In the present study the arylazide photo-affinity ligand, (+)-cis-azidodiltiazem ((+)-cis-(2S,3S)-5-[2-(4- azidobenzoyl)aminoethyl]-2,3,4,5-tetrahydro-3-hydroxy-2-(4-methoxyphenyl )-4- oxo-1,5-benzothiazepine), and the respective tritiated derivative, (+)-cis-[3H]azidodiltiazem (45 Ci/mmol), were developed to identify directly the benzothiazepine binding subunit. (+)-cis-Azidodiltiazem binds competitively to the benzothiazepine receptor in rabbit skeletal muscle transverse tubule membranes. Upon ultraviolet irradiation of the (+)-cis-[3H]azidodiltiazem-purified calcium channel complex, the ligand photoincorporates exclusively into the alpha 1 subunit. Photoincorporation is protected by 100 microM (-)-desmethoxyverapamil and 100 microM (+)-cis-diltiazem. A polyclonal antiserum directed against (+)-cis-azidodiltiazem was employed to detect (+)-cis-azidodiltiazem immunoreactivity photoincorporated into the purified calcium channel complex, confirming the exclusive labeling of the alpha 1 subunit. Our data provide direct evidence that, together with the drug receptors for 1,4-dihydropyridines and phenylalkylamines, the benzothiazepine binding domain of skeletal muscle calcium channels is located on the alpha 1 subunit. We conclude that our anti-ligand antibodies could be used successfully to affinity purify the photolabeled proteolytic fragments of the alpha 1 subunit which are expected to form part of the benzothiazepine binding domain.
Abstract: Selenium content was investigated by atomic absorbtion spectroscopy in 32 normal pregnant women in the 38th-42, week of pregnancy. In congruence with other investigations from middle and northern Europe, selenium deficiency was stated in all of the patients.
Abstract: Distinct drug receptors for 1,4-dihydropyridines, phenylalkylamines, and the benzothiazepine d-cis-diltiazem exist on voltage-dependent calcium channels. The drug receptors show reciprocal allosteric communication and are linked to calcium binding sites. The 1,4-dihydropyridine-selective receptor (probed with [3H]nimodipine) has a size (measured by radiation inactivation) identical in heart, skeletal muscle, and brain (180 kDa). To compare the sizes of 1,4-dihydropyridine receptors in different tissues, pure tritiated enantiomers of the arylazido photoaffinity probe [3H]azidopine were used to irreversibly label the purified 1,4-dihydropyridine receptor (155, 65, and 32 kDa) from guinea pig skeletal muscle transverse tubules and the membrane-bound cardiac receptor. The 155 kDa polypeptide region, but not the 65 or 32 kDa bands, was specifically labelled by (-)-[3H]azidopine. (+)-[3H]Azidopine did not label any of the polypeptides in the purified receptor preparation. In contrast with the results from other investigators, a 155 kDa polypeptide was also specifically labelled in cardiac membranes by (-)-[3H]azidopine. A 34 kDa photolabelled band carries a low-affinity 1,4-dihydropyridine binding site that has no obvious relation to the channel but is abundant in heart membranes and has apparently led to erroneous results in previous affinity or photoaffinity labelling experiments. Antibodies raised against the purified skeletal muscle channel precipitate the 125I-labelled 155 kDa channel polypeptide from skeletal muscle and precipitate the three drug receptor sites from both crude and purified channel preparations. We conclude that all three drug receptor sites are localized on this polypeptide.
