Estimation of 10-Year Fracture Risk with and without Bone Mineral Density in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory arthritis affecting 0.5-1.0% of the general population worldwide and although RA is properly considered a disease of the joints, it can cause a variety of extra-articular manifestations. This study was performed to find out any discrepancy in fracture risk estimates with and without bone mineral density (BMD) in rheumatoid arthritis (RA) patients. This observational cross-sectional study was carried out in the Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from July 2013 to July 2015. Total 65 consecutive patients with RA fulfilling ACR/EULAR criteria aged 40-90 year were recruited. Ten year fracture risk of these patients was evaluated by the FRAX score with and without BMD and differences were observed. FRAX score without BMD revealed that major fracture risk was low in 58(89.2%) patients, moderate in 7(10.8%) patients but re-estimation with BMD revealed that 55(84.6%) patients remained in low risk group, 8(12.3%) patients in moderate risk group and 2(3.1%) patients went to the high risk group. In case of hip fracture risk without BMD, risk was low in 58(89.2%) patients, high in 7(10.8%) patients; but with BMD, 50(76.9%) patients remained in low risk group but risk of 15(23.1%) patients became high. Almost all the high risk patients (93.3%) were ≥55 years of age. Increasing age, female sex, disease duration and use of steroid were positively correlated with increased FRAX score where as high BMI and high BMD were associated with low FRAX score. But in multivariate analysis it was found that only relation with age was at statistically significant level. Significant numbers of patients with rheumatoid arthritis have high risk of fracture especially hip fracture. The mean of FRAX score increased in both major & hip osteoporotic fracture risk after adding BMD. More than half of the patients above fifty five years or more had high risk of fracture. So, BMD should be done in patients aged more than fifty five.

AB1090 BIOMARKERS TO DIFFERENTIATE EARLY INDISTINGUISHABLE CASES OF OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS

Background:

Osteoarthritis (OA) and rheumatoid arthritis (RA) are the most frequent inflammatory diseases of the musculoskeletal system, which could not be differentiated in their early stages, and characterized by degradation of articular cartilage and impairment of joint function. Sometimes, criteria and radiography are not insufficient to distinguish early-stages of RA and OA and predict disease course, and therefor biomarkers that help clinicians to early diagnose disease are essential.

Objectives:

The aim of this study is to estimate serum level of Matrix metalloproteinase 3 (MMP3) and hrdroxyproline (HP) in early RA and OA patients to see if they can be used to differentiate both diseases at their early stages

Methods:

The aim of this study is to estimate serum level of Matrix metalloproteinase 3 (MMP3) and hrdroxyproline (HP) in early RA and OA patients to see if they can be used to differentiate both diseases at their early stages

Results:

We found a highly significant elevation of serum MMP3 in OA patients group compared to RA patients and control groups. We also found a highly significant elevation of MMP3 in RA patients than control group,(P < 0.001). Meanwhile, we found a highly significant elevation of HP in OA patients than in RA patients and control groups, (P < 0.001), whereas there was no significant difference between HP in RA patients and control groups (P > 0.05).

Table 1.

Demonstration of serum levels of MMP3 and HP in all groups.

“Enzyme”OA(n=40)RA(n=40)Control(n=40)p-valueMMP3 pg/mL559.92±1112.84153.25±162.0559.79±63.54<0.001HPµg/mL12.87±18.754.81±6.894.52±1.55<0.001HPµg/mL4.81±6.894.52±1.55> 0.05

Conclusion:

Our results suggest that serum levels of Hydroxyproline (HP) rather than MMP3 could be used as a potential biomarker for early differentiation between osteoarthritis (OA) and rheumatoid arthritis (RA) when diagnostic criteria failed to be fulfilled.

References:

[1]Benedetti S, Canino C, Tonti G, Medda V, Calcaterra P, Nappi G, Salaffi F, Canestrari F. (2010): Biomarkers of oxidation, inflammation and cartilage degradation in osteoarthritis patients undergoing sulfur-based spatherapies. ClinBiochem.; 43: 973-8.

[2]Fenton, S. A. M., Veldhuijzen van Zanten, J. J. C. S., Duda, J. L., Metsios, G. S., and Kitas, G. D. (2018). Sedentary behaviour in rheumatoid arthritis: definition, measurement and implications for health. Rheumatology. (Oxford) 57(2), 213-226.

[3]Murphy, G., and Nagase, H. (2008). Progress in matrix metalloproteinase research. Mol. Aspects Med. 29(5), 290-308.

[4]Bonnans, C., Chou, J., and Werb, Z. (2014). Remodelling the extracellular matrix in development and disease. Nat. Rev. Mol. Cell Biol. 15(12), 786-801.

[5]Hofman, K., Hall, B., Cleaver, H., & Marshall, S. (2011): High-throughput quantification of hydroxyproline for determination of collagen. Analytical biochemistry, 417(2), 289-291.

[6]Barranco, C. (2015): Osteoarthritis: activate autophagy to prevent cartilage degeneration? Nat. Rev. Rheumatol. 11, 127.

[7]M.S. Radha and Dr. M.R. Gangadhar (2015), Serum enzyme of matrix metalloproteinase-3 in patients with knee osteoarthritis, International Journal of Recent Scientific Research Vol. 6, Issue, 6, pp.4457-4460, June, 2015.

[8]Bassiouni, H. M., El-Deeb, M., Kenawy, N., Abdul-Azim, E., & Khairy, M. (2011). Phonoarthrography, musculoskeletal ultrasonography, and biochemical biomarkers for the evaluation of knee cartilage in osteoarthritis. Modern rheumatology, 21(5), 500-508.

[9]Ahmed, U., Anwar, A., Savage, R. S., Costa, M. L., Mackay, N., Filer, A., Raza, K., Watts, R. A., Winyard, P. G., Tarr, J., Haigh, R. C., Thornalley, P. J., and Rabbani, N. (2015). Biomarkers of early stage osteoarthritis, rheumatoid arthritis and musculoskeletal health. Sci. Rep. 5, 9259.

Acknowledgments:

We are indebted to Dr El Shaimaa Abdel Hakim, and Dr Asmaa Fouaad for their great help in this study

Disclosure of Interests:

None declared

Cracking in drying films of polymer solutions

Thin films of polymer coatings have important industrial applications ranging from paints and coatings to pharmaceuticals. In many applications, the coatings are obtained by applying thin films of dilute polymer solutions, wherein the solvent evaporates to leave behind a thin polymer film. In some cases, the thin films may crack due to shrinkage stresses developed during drying. While a number of studies have focused on the stress development, the phenomenon of cracking in polymer films is not fully investigated. In the present work, thin films of a silicone polymer solution were cast on substrates of varying Young's moduli and investigated for cracking as a function of film thickness and substrate modulus. Micro-Raman spectroscopy measurements show that thin films dry uniformly while thick films form a skin at the top surface leading to slow drying rates. Transverse stresses were measured using the cantilever technique and related to the extent of cracking in the film. We investigated the influence of substrate rigidity on the cracking behavior and found that decreasing the stiffness of the substrate increases the extent of cracking.

Oral Cancer Early Detection--a Pressing Need for Continuing Education in Jordan

AIMS

To identify deficiencies in the knowledge of general medical (GMPs) and dental practitioners (GDPs) regarding early detection of oral cancer, to compare differences between subgroups, and to identify educational needs for continuing education courses on this subject.

MATERIALS AND METHODS

165 GDPs and 165 GMPs were directly interviewed to assess their knowledge about oral cancer using a pre-tested survey. Knowledge scores were generated from correct responses of participants to factual questions about oral cancer.

RESULTS

Few participants (15.2% of GDPs and 12.8% of GMPs) reported that they attended any continuing education courses on oral cancer during their professional career. Most participants (81.6% of GDPs and 86.3% of GMPs) admitted that their knowledge about oral cancer was not up to date and that they would need to attend continuing education courses on oral cancer if available. A few significant differences were identified between groups regarding knowledge about risk factors, clinical presentations and diagnostic techniques but the overall knowledge scores showed no significant difference between GMPs and GDPs.

CONCLUSIONS

The present study identified several deficiencies in the knowledge of GMPs and GDPs regarding risk factors, clinical presentations, and diagnostic techniques of oral cancer. Interventions to correct these defects through properly designed continuing education courses are required.

Factors Influencing Early Detection of Oral Cancer by Primary Health-Care Professionals

The purposes of this study are to determine early detection practices performed by primary healthcare professionals, to compare medical and dental sub-groups, and to identify factors that influence the ability of medical and dental practitioners to recognize precancerous changes and clinical signs of oral cancer. A 28-item survey instrument was used to interview a total of 330 Jordanian primary health-care professionals (165 dental and 165 medical). An oral cancer knowledge scale (0 to 31) was generated from correct responses on oral cancer general knowledge. An early detection practice scale (0 to 24) was generated from the reported usage and frequency of procedures in oral cancer examination. Also, a diagnostic ability scale (0 to 100) was generated from correct selections of suspicious oral lesions. Only 17.8 % of the participants reported that they routinely performed oral cancer screening in practices. Their oral cancer knowledge scores ranged from 3 to 31 with a mean of 15.6. The early detection practice scores ranged from 2 to 21 with a mean of 11.6. A significant positive correlation was found between knowledge scores and early detection practice scores (r = 0.22; p < 0.001). The diagnostic ability scores ranged from 11.5 to 96 with a mean of 43.6. The diagnostic ability score was significantly correlated with knowledge scores (r = 0.39; p < 0.001), but not with early detection practice scores (r = 0.01; p = 0.92). Few significant differences were found between medical and dental primary care professionals. Continuous education courses on early diagnosis of oral cancer and oral mucosal lesions are needed for primary health-care professionals.

Physicochemical effects in aging aqueous Laponite suspensions

We study aging behavior of an aqueous suspension of Laponite as a function of concentration of Laponite, concentration of salt, time elapsed since preparation of suspension (idle time), and temperature by carrying extensive rheological and conductivity experiments. We observe that temporal evolution of elastic moduli, which describes structural build-up and aging, shifts to low times for experiments carried out for higher concentration of Laponite, higher concentration of salt, greater temperature, and longer idle time while preserving the curvature of evolution in the solid regime (elastic modulus greater than viscous modulus). Consequently appropriate shifting of evolution of elastic modulus in the solid regime leads to aging time-idle time-salt concentration-Laponite concentration-temperature superposition. The existence of such a superposition suggests the generic nature of microstructure buildup irrespective of mentioned variables in the explored range. The behavior of shift factors needed to obtain the superposition indicate that the energy barrier associated with structural buildup decreases with an increase in idle time and temperature and decreases linearly with an increase in concentration of Laponite and that of salt. The conductivity experiments show that ionic conductivity of the suspension increases with increasing Laponite concentration, salt concentration, temperature, and very importantly the idle time. We also analyze the interparticle interactions using DLVO theory that suggests an increase in idle time, temperature, and salt concentration increases the height of the repulsive energy barrier while it decreases the width of the same when particles approach each other in a parallel fashion. However when particles approach each other in a perpendicular fashion, owing to dissimilar charges on edge and face, the energy barrier for the attractive interaction is expected to decrease with an increase in idle time, temperature, and salt concentration. Analysis of rheological and conductivity experiments suggests a strong influence of attractive interactions on the low energy structures in an aqueous suspension of Laponite.

Hyper-aging dynamics of nanoclay suspension

Aqueous suspension of nanoclay Laponite undergoes structural evolution as a function of time, which enhances its elasticity and relaxation time. In this work, we employ an effective time approach to investigate long-term relaxation dynamics by carrying out creep experiments. Typically, we observe that the monotonic evolution of elastic modulus shifts to lower aging times, while maxima in viscous moduli get progressively broader for experiments carried out on a later date after preparation (idle time) of the nanoclay suspension. Application of effective time theory produces a superposition of all the creep curves irrespective of their initial state. The resulting dependence of the relaxation time on aging time shows very strong hyper-aging dynamics at short idle times, which progressively weakens to demonstrate a linear dependence in the limit of very long idle times. Remarkably, this behavior of nanoclay suspensions is akin to that observed for polymeric glasses. Consideration of aging as a first-order process suggests that continued hyper-aging dynamics causes cessation of aging. The dependence of relaxation time on aging time, therefore, must attenuate eventually producing linear or weaker dependence on time in order to approach a progressively low-energy state in the limit of very long times as observed experimentally. We also develop a simple scaling model based on a concept of aging of an energy well, which qualitatively captures various experimental observations very well, leading to profound insight into the hyper-aging dynamics of nanoclay suspensions.

Interface-induced anisotropy and the nematic glass/gel state in jammed aqueous Laponite suspensions

Aqueous suspensions of Laponite, a system composed of disklike nanoparticles, are found to develop optical birefringence over several days, well after the suspensions solidified because of jamming. The optical anisotropy is particularly enhanced near the air-Laponite suspension interface over length scales of several millimeters, which is beyond 5 orders of magnitude larger than the particle length scale, suggestive of large-scale ordering influenced by the interface. The orientational order increases with time and is always greater for higher concentration of salt, higher concentration of Laponite, and higher temperatures of the suspension. Although weakly birefringent, Laponite suspensions covered by paraffin oil do not show any enhancement in optical anisotropy near the interface compared to that in the bulk. We suggest that the expedited structure formation near the air interface propagating progressively inside the sample is responsible for the observed behavior. We discuss the observed nematic ordering in the context of glass-like and gel-like microstructure associated with aqueous Laponite suspensions.

Prediction of long and short time rheological behavior in soft glassy materials

We present an effective time approach to predict long and short time rheological behavior of soft glassy materials from experiments carried out over practical time scales. Effective time approach takes advantage of relaxation time dependence on aging time that allows time-aging time superposition even when aging occurs over the experimental time scales. Interestingly, experiments on a variety of soft materials demonstrate that the effective time approach successfully predicts superposition for diverse aging regimes ranging from subaging to hyperaging behaviors. This approach can also be used to predict behavior of any response function in molecular as well as spin glasses.

Irreversible aging dynamics and generic phase behavior of aqueous suspensions of Laponite

We study the aging behavior of aqueous suspension of Laponite having 2.8 wt % concentration using rheological tools. At various salt concentration all the samples demonstrate orientational order when observed using crossed polarizers. In rheological experiments we observe inherent irreversibility in the aging dynamics which forces the system not to rejuvenate to the same state in the shear melting experiment carried out at a later date since preparation. The extensive rheological experiments carried out as a function of time elapsed since preparation demonstrate the self-similar trend in the aging behavior irrespective of the concentration of salt. We observe that the exploration of the low-energy states as a function of aging time is only kinetically affected by the presence of salt. We estimate that the energy barrier to attain the low-energy states decreases linearly with increase in the concentration of salt. The observed superposition of all the elapsed time and the salt-concentration-dependent data suggests that the aging that occurs in low salt concentration systems over a very long period is qualitatively similar to the aging behavior observed in systems with high salt concentration over a shorter period.

Functional capacity of macrophages determines the induction of type 1 diabetes

Macrophages are potent immune regulators and are critical in the development and pathogenesis of autoimmune diabetes. They are said to be the first cell type to infiltrate the pancreatic islet, serve as antigen-presenting cells, and are important as effector cells during diabetogenesis. The article examines the role of macrophages in autoimmune diabetes with particular emphasis on the role of galectin-3, a beta-galactoside-binding lectin, and T1/ST2, an IL-1 receptor-like protein, both of which play significant roles in the immunomodulatory functions of macrophages. Multiple low-dose streptozotocin (MLD-STZ) induces infiltration of mononuclear cells in the islets of susceptible strains leading to insulitis. Deletion of the galectin-3 gene from C57BL/6 mice significantly attenuates this effect as evaluated by quantitative histology of mononuclear cells and loss of insulin-producing beta cells. In contrast, deletion of the ST2 gene enhanced insulitis after MLD-STZ treatment when compared with relatively resistant wild-type BALB/c mice. Thus, it appears that functional capacity of macrophages influences their participation in T helper (Th) 1-mediated autoimmunity and the development of autoimmune diabetogenesis.

New members of the interleukin-12 family of cytokines: IL-23 and IL-27 modulate autoimmune diabetes

Multiple low doses of streptozotocin (5 x 40 mg/kg) given to susceptible male C57BL6 mice induced delayed and sustained hyperglycemia accompanied by body weight loss, mononuclear cell infiltration in the islet, and apoptosis of beta cells. Shorter regimes (4 x 40 mg/kg) did not have such effect. Administration of IL-23 at a dose of 400 ng/mL for 10 consecutive days concomitantly with this subdiabetogenic regimen of STZ, however, induced significant hyperglycemia, weight loss, and mononuclear cellular infiltration. The same regimen of IL-27 induced milder effect on glycemia and no weight loss inspite of a massive peri-islet and intra-islet infiltration of mononuclear cells. The molecular mechanisms underlying the actions of these cytokines on diabetogenesis is under study.

Streptozotocin-induced diabetic nephropathy in rats: the role of inflammatory cytokines

The role of inflammatory cytokines in the pathogenesis of diabetic nephropathy has been studied in streptozotocin-induced diabetic rats. Rat kidneys were examined by light and electron microscopy and kidney homogenates were also analyzed by Western blot and flow cytometry for the expression of markers of inflammation namely, CD4+ and CD8+ T cells, macrophages, MHC classes I and II, the proinflammatory cytokines tumor necrosis factor-alpha, interferon-gamma and nitric oxide (NO). Light and electron microscope examination revealed infiltration of mononuclear cells throughout the renal parenchyma, with the glomeruli being more severely affected especially at 8 months after disease induction. Western blot and flow cytometric analyses revealed the infiltrating cells to be CD4+ T cells, CD8+ T cells and macrophages. Western blot analyses also revealed increased expression of the proinflammatory and Th1 cytokines tumor necrosis factor-alpha, interferon-gamma as well as nitric oxide. Using flow cytometry, we have shown that the difference in expression of CD4+ T cells in control and diabetic kidneys is more significant at 1 month than at 8 months, while expression of CD8+ T cells is more significant at 8 months. We speculate therefore that diabetic nephropathy is probably initiated and driven by a Th1 process. CD8+ T cells, however, become more significant at later stages of the disease when tissue loss is evident. Since NO induction also occurs only after 8 months, we hypothesize that NO might be significant for the later stages of the disease. Our data implicate inflammation in the pathogenesis of diabetic nephropathy in view of the overexpression of the proinflammatory cytokines TNF-alpha and IFN-gamma and the cells that secrete them in the early and late phases of the disease.

Effects of single high-dose and multiple low-dose streptozotocin on contraction and intracellular Ca2+ in ventricular myocytes from diabetes resistant and susceptible rats

Administration of a single high-dose (SHD) of streptozotocin (STZ) to young adult rats causes a diabetic cardiomyopathy. Albino Oxford (AO) and Dark Agouti (DA) inbred strains of rats are susceptible to developing diabetes when administered a SHD of STZ but differ in susceptibility to multiple low-dose (MLD) STZ. We have investigated the effects of SHD and MLD-STZ on contraction and intracellular Ca2+, measured with fura-2, in ventricular myocytes from AO and DA rats at 18-20 weeks after treatment. Time to peak shortening was significantly prolonged in myocytes from DA rats after SHD-STZ but was not altered in DA rats after MLD-STZ or in AO rats by either MLD or SHZ-STZ treatment. Time to peak shortening in myocytes from DA control and DA rats after SHD-STZ were 88+/-2 ms and 107+/-4 ms, respectively. Time to half relaxation and the amplitude of myocyte shortening were not altered in AO or DA rats by either MLD or SHD-STZ treatment. Amplitude, time to peak fura-2 transient and time to half relaxation of the fura-2 transient were not significantly altered in AO or DA rats by either MLD or SHD-STZ treatment. Contractile defects reported in myocytes from SHD-STZ treated DA rats may be a consequence of altered myofilament sensitivity to Ca2+. The hyperglycaemic effects of MLD-STZ and SHD-STZ induced diabetes was much greater in DA compared to AO rats and the effects of the hyperglycaemia on the time-course of ventricular myocyte contraction was most profound in DA rats after SHD-STZ.

Neuroglial response after induction of experimental allergic encephalomyelitis in susceptible and resistant rat strains

Experimental allergic encephalomyelitis (EAE), the animal model for multiple sclerosis in humans, a T-cell mediated disease of the central nervous system is characterized by inflammatory infiltrates of myelin antigen(s)-specific T cells and consecutive demyelination. Spinal cord tissue emulsified in complete Freund's adjuvant clinical disease in the genetically susceptible Dark Agouti rats (DA) but not in Albino Oxford (AO) rats although similar inflammatory infiltrates in the CNS are observed in both strains 10-12 days after induction. We have shown that the resistance to clinical disease of AO rats is associated with rapid clearance of infiltrating mononuclear cells by a mechanism of apoptosis. Here, we demonstrate by immunohistochemical and FACS analyses of the expression of CD11b/c that microglial cells respond differently to disease induction in the two strains. Whereas microglial cells are activated throughout the period of day 10-28 days after EAE induction in AO rats they are only activated at the inception and resolution phases but not at the peak of clinical disease in DA rats when there is the highest level of CD4+ T cell infiltration. Our findings are compatible with the notion that microglia terminate effector T cells by apoptosis and that lack of this mechanism as evidenced by the lack of CD11b/c expression, support T cell survival and clinical expression of disease.

Lack of the mediators of innate immunity attenuate the development of autoimmune diabetes in mice

Interleukin 15 (IL-15) and Interleukin 18 (IL-18) are key cytokines produced by macrophages during innate immune response. These cytokines can profoundly affect subsequent adaptive immune responses including autoimmunity. We have investigated the role of IL-15 and IL-18 in the development of autoimmune diabetes in mice induced by multiple low dose streptozotocin (MLD-STZ). To analyze the role of IL-15, we tested the effects of a soluble murine IL-15 receptor alpha-chain (smIL-15Ralpha), on the development of MLD-STZ in C57BL/6 mice. Animals were treated with 10 daily injections of 32 microg of smIL-15Ralpha starting on the first day of diabetes induction. This treatment significantly attenuated the development of diabetes as evaluated by significantly lower glycemia compared with control mice treated with an inactive mutant form of sIL-15Ra. To directly address the role of IL-18 in MLD-STZ we used IL-18 knockout (KO) mice on DBA/1 background. IL-18 deficient mice were significantly more resistant to the induction of diabetes compared with the wild-type controls and did not develop the typical mononuclear cell infiltrates in the islets. Taken together our data suggest that the innate mediators, IL-15 and IL-18, are essential for the development of diabetes and may be important targets in prevention and early treatment of autoimmune diabetes.

Paraoxon induces apoptosis in EL4 cells via activation of mitochondrial pathways

The toxicity of organophosphorus compounds, such as paraoxon (POX), is due to their anticholinesterase action. Recently, we have shown that, at noncholinergic doses (1 to 10 nM), POX (the bioactive metabolite of parathion) causes apoptotic cell death in murine EL4 T-lymphocytic leukemia cell line through activation of caspase-3. In this study, by employing caspase-specific inhibitors, we extend our observations to elucidate the sequence of events involved in POX-stimulated apoptosis. Pretreatment of EL4 cells with the caspase-9-specific inhibitor zLEHD-fmk attenuated POX-induced apoptosis in a dose-dependent manner, whereas the caspase-8 inhibitor zIETD-fmk had no effect. Furthermore, the activation of caspase-9, -8, and -3 in response to POX treatment was completely inhibited in the presence of zLEHD-fmk, implicating the involvement of caspase 9-dependent mitochondrial pathways in POX-stimulated apoptosis. Indeed, under both in vitro and in vivo conditions, POX triggered a dose- and time-dependent translocation of cytochrome c from mitochondria into the cytosol, as assessed by Western blot analysis. Investigation of the mechanism of cytochrome c release revealed that POX disrupted mitochondrial transmembrane potential. Neither this effect nor cytchrome c release was dependent on caspase activation, since the general inhibitor of the caspase family zVAD-fmk did not influence both processes. Finally, POX treatment also resulted in a time-dependent up-regulation and translocation of the proapoptotic molecule Bax to mitochondria. Inhibition of this event by zVAD-fmk suggests that the activation and translocation of Bax to mitochondria is subsequent to activation of the caspase cascades. The results indicate that POX induces apoptosis in EL4 cells through a direct effect on mitochondria by disrupting its transmembrane potential, causing the release of cytochrome c into the cytosol and subsequent activation of caspase-9. Inhibition of this specific pathway might provide a useful strategy to minimize organophosphate-induced poisoning.

Downregulation of apoptosis in the target tissue prevents low-dose streptozotocin-induced autoimmune diabetes

3,7-dimethyl-1-(5-oxohexyl) xanthine, pentoxifylline (PTX) is shown to affect cytokine-induced apoptosis in several experimental models and clinical conditions. It had been also shown to prevent insulitis and hyperglycemia in non-obese diabetic (NOD) mice, and mice and rats susceptible to diabetes induction with multiple low-doses of streptozotocin (MLD-STZ). We therefore analysed the development of diabetes and apoptosis of pancreatic beta islet cells in CBA/mice after diabetes induction with MLD-STZ. We have evaluated the effect of PTX on the level of apoptosis in the islet at different time intervals after diabetes induction. Complementary histological and immunohistochemical studies and analyses of the expression of cytokines and nitric oxide have also been done. It was concluded that PTX significantly attenuated apoptosis of the beta-cells in the islet and suppressed the induction of diabetes. Our data are compatible with the notion that interferon-gamma (IFN-gamma)/tumor necrosis factor (TNF)/nitric oxide (NO)-induced apoptosis of beta-cells in experimental diabetes is attenuated by PTX.

Lack of apoptosis of infiltrating cells as the mechanism of high susceptibility to EAE in DA rats

Dark Agouti (DA) rats are highly susceptible to induction of Th-1-mediated autoimmunity disease, including experimental allergic encephalomyelitis (EAE). In contrast to other susceptible rat strains in which disease is induced only with encephalitogen emulsified in complete Freund's adjuvants (CFA), in DA rats EAE develops after injection of encephalitogen in incomplete Freund's adjuvants (IFA) or Titermax, putative Th-2 directed adjuvant. Lymph node cells derived from immunized DA rats and stimulated in vitro produce significantly more Interferon-gamma (IFN-gamma) than resistant Albino Oxford (AO) rats. However, cells derived from both strains produce large amounts of IL-10 but not IL-4. Immunized lymph node cells derived from EAE susceptible (AO x DA) F1 rats induce clinical signs of disease in sublethally irradiated parental DA but not AO rats. The pathohistology of the target tissue in these recipients clearly demonstrated infiltration of mononuclear cells in both parental strains. However, the number of CD4+ cells was significantly higher and number of apoptotic cells significantly lower in DA rats sacrificed 8 days after passive transfer. We postulate that in addition to higher IFN-gamma and TNF-alpha production, resistance to early apoptosis of the invading cells in the target tissue possibly due to lack of downregulation by TGF-beta leads to exceptional susceptibility to EAE in DA rats.

Cooperation of fuzzy segmentation operators for correction aliasing phenomenon in 3D color Doppler imaging

The study described in this paper concerns natural object modeling in the context of uncertain, imprecise and inconsistent representation. We propose a fuzzy system which offers a global modeling of object properties such as color, shape, velocity, etc. This modeling makes a transition from a low level reasoning (pixel level), which implies a local precise but uncertain representation, to a high level reasoning (region level), inducing a certain assignment. So, we use fuzzy structured partitions characterizing these properties. At this level. each property will have its own global modeling. Then, these different models are merged for decision making. Our approach was tested with several applications. In particular, we show here its performance in the area of blood flow analysis from 3D color Doppler images in order to quantify and study the development of this flow. We present methods that detect and correct aliasing phenomenon, i.e. inconsistent information. At first, the flow space is partitioned into fuzzy sectors where each sector is defined by a center, an angle and a direction. In parallel, the velocity information carried by the pixels is classified into fuzzy classes. Then, by combining these two partitions, we obtain the velocity distribution into sectors. Moreover, for each found path (from the first sector to the last one), we locate and correct inconsistent velocities by applying global rules. After extracting some meaningful sector features, the fuzzy modeling, applied to the aliasing correction, makes it possible to simplify and synthesize the blood flow direction.

Effector mechanisms in low-dose streptozotocin-induced diabetes

The cellular and molecular requirements for beta-cell damages in an immune-mediated toxin-induced insulin-dependent diabetes mellitus have been studied in the model of multiple low-dose streptozotocin-induced diabetes in rats and mice. It was found that strain-related susceptibility to diabetes induction correlated with a higher level of IL-2, IFN-gamma, and TNF-alpha production, whereas such differences were not observed when IL-1 and NO production by macrophages were analyzed; elimination of immunoregulatory RT6+T cells that increases IFN-gamma production, enhances susceptibility to MLD-STZ-induced diabetes; mercury-induced Th-2 cells down-regulated the disease; IFN-gamma-mediated macrophage activation to produce proinflammatory cytokines rather than NO is an important event in early diabetogenic effects of invading macrophages; inhibition of IL-1 activity downregulates diabetes induction; and generation of NO in beta cells appears to be important for diabetogenic effects. Taken together, data indicate that MLD-STZ diabetes induced by Th-1 lymphocytes that secrete soluble effector molecules that activate macrophages and promote destruction of beta cells possibly by both nitric oxide and nonnitric oxide-mediated mechanisms.

[Renal tubular dysgenesis]

Renal tubular dysgenesis (RTD) is a very rare malformation, only 24 cases having been described. We present the case of twins born after 28 weeks gestation to a newly-arrived Ethiopian immigrant in whom oligohydramnios was diagnosed when she was admitted. 1 twin had developed polyhydramnios, died before birth and was born with hydrops fetalis. The other newborn suffered from pulmonary distress and anuria, and died 2 days after birth. At autopsy there were no apparent changes in the kidneys or urinary tract, but histological examination showed absence of proximal convoluted tubules. This was attributed to RTD and confirmed by histochemical examination.

Renal tubular dysgenesis present in a newborn with meconium ileus

The combination of renal tubular dysgenesis (RTD) and meconium ileus in a native Israeli is presented for the first time. The clinical diagnosis was oligohydramnios and abruptio placentae, respiratory failure, and anuria refractory to treatment. The autopsy revealed meconium ileus and meconium peritonitis. RTD was established by the detection of a monomorphous undifferentiated population of tubules, absence of proximal tubules, and dense epithelial membrane antigen immunoreactivity of all tubules. The lack of alpha 1-antitrypsin- and lysozyme-immunoreactive tubules was first revealed in the kidney with RTD. These findings extend the possibilities of RTD detection.

Improved immunotherapy for pulmonary tuberculosis with Mycobacterium vaccae

We previously demonstrated that a single intradermal injection of 10(9) irradiation-killed M. vaccae, given 1 month after starting chemotherapy, caused significant changes in responses to mycobacterial antigens. Amongst 38 patients with pulmonary tuberculosis, 29% had lymphocytes responding to common myocobacterial antigens after the injection, compared with only 11% of 49 similar patients after an injection of saline (p less than 0.03). To increase the proportion of responders to these antigens, six modifications of the potentially immunotherapeutic injection, randomized with injections of saline, have been assessed by biochemical, clinical, haematological, immunological and radiological criteria. Subsequent lymphocyte proliferation to mycobacterial antigens enabled the modifications to be ranked in order of efficacy. Tuberculin plus murabutide plus 10(9) irradiated M. vaccae (36% of 25), an autoclaved preparation of 10(9) M. vaccae (45% of 22), and 2 x 10(9) irradiated M. vaccae (75% of 12) were the most effective. Antibody responses in several IgG subclasses to mycobacteria, but not streptococci, were also significantly increased by the most effective modifications over the 8 weeks following injection. Detailed radiological study showed that use of the autoclaved bacilli was followed by a delay in clearing of consolidation, but by better closing of cavities than was found in the control group, suggesting enhanced, or altered, immunological activity around the lesions.

An investigation of patients with pulmonary tuberculosis in Kuwait in preparation for studies of immunotherapy with Mycobacterium vaccae

Sixty-five patients, many of them immigrant to Kuwait, with bacteriologically proven, adult type, pulmonary tuberculosis were studied by many parameters over the 4 months following diagnosis. Twelve were infected with tubercle bacilli resistant to at least one anti-tuberculosis drug. Preliminary evidence suggested that this was frequently primary resistance in patients infected in their countries of origin. The Kuwaiti environment results in very high skin test and lymphocyte proliferative responses (LTT) to shared and species specific antigens of mycobacteria in healthy persons. In comparison, patients with tuberculosis lacked cellular responses to group i and group ii antigens, but had increased IgG and IgA binding to mycobacterial antigens in general. LTT responses to added interleukin 2, and production of alpha interferon, were normal in our patients, but induction of gamma interferon in response to phytohaemagglutinin was reduced initially, rising towards normal during treatment. Biochemical and haematological abnormalities present at the time of diagnosis rapidly corrected. The disease differed from that reported in most previous studies in that fever was uncommon, the disease was never fatal, and most tuberculin tests were not necrotising. This implied that a detrimental immunopathological component is less pronounced in those exposed to the Kuwaiti environment, and a hypothesis is put forward to explain this.

Immunotherapy with Mycobacterium vaccae as an adjunct to chemotherapy in the treatment of pulmonary tuberculosis

47 patients with adult-type pulmonary tuberculosis attending the Chest Diseases Hospital in Kuwait were given a single injection of 10(9) irradiation-killed M. vaccae after 1 month of a 9-month course of chemotherapy. The patients were followed-up for 3 more months in double blind comparison with 65 patients given an injection of saline (placebo). The immunotherapeutic injection produced a small local lesion in 44/47 patients, 18 of which ulcerated and produced small scars. Immunotherapy made no measurable difference to the bacteriological, biochemical, haematological, or radiological parameters measured. However it was associated with significantly improved weight gain, reduced size of skin test response to Tuberculin, increased lymphocyte proliferation to common mycobacterial antigens, and increased antibody levels to mycobacterial antigens. The changes in skin test and LTT responses were related and occurred in 29% of patients whose recognition of common mycobacterial antigens returned to normal. The remaining patients did not differ in these respects from those receiving placebo. The proportion of patients whose responses were improved was very similar to that achieved using the same immunotherapeutic agent in a group of treated multibacillary leprosy patients.

HLA-DR and tuberculin tests in rheumatoid arthritis and tuberculosis

Responses to four new tuberculins were found to be significantly reduced in 46 patients with rheumatoid arthritis in comparison with a control group of 79. Except for tuberculin itself, the same was found in 111 patients with tuberculosis. In common with patients with tuberculosis and leprosy, those with rheumatoid arthritis did not respond to common mycobacterial (group i) antigen. Three DR haplotypes were found to have significant effects on skin test responsiveness of the rheumatoid patients but had little or no effect on that of the patients with tuberculosis and none on that of the healthy control group. Rheumatoid patients with the HLA-DR4 haplotype had significantly greater responses to all four reagents than did non-DR4 patients, but their responses to leprosin A and scrofulin remained significantly lower than those of the control group. Possession of HLA-DR3 haplotype was associated with skin test positivity approaching normal, but the sizes of responses were reduced. Possession of DR7 was associated with an unexpected reduction in skin test positivity, especially in the case of tuberculin. These results support the hypothesis that mycobacteria, or autoantigens cross reactive with mycobacteria, may be involved in the aetiology of rheumatoid arthritis. The results also show that the regulation and specificity of responsiveness to mycobacterial antigens are different in patients with rheumatoid arthritis with different HLA-DR haplotypes.

HLA-DR-associated isotype-specific regulation of antibody levels to mycobacteria in rheumatoid arthritis

Using sera from 75 healthy donors, 68 rheumatoid arthritis (RA) patients, and 85 tuberculosis (TB) patients, we have examined the level of antibody of the three major classes binding to seven mycobacterial species, and to three control antigens. The major findings are that IgM binding to mycobacteria is reduced in RA patients who have HLA-DR7 (P = 0.008 for M. tuberculosis antigen), and that IgA binding to mycobacteria is reduced in RA patients who have HLA-DR2 (P = 0.007 for M. tuberculosis; P = 0.0004 for M. nonchromogenicum). These associations were not seen in TB, and were restricted to these antibody isotypes. We believe this is the first report of isotype specific Class II MHC-associated regulation of antibody levels in man. A possible interpretation of our data is that patients bearing these haplotypes are recognizing suppressor epitopes common to all the mycobacterial species tested. Since DR2 and DR7 have recently been shown to be associated with a significantly reduced risk of RA, our findings are compatible with the view that changes in immune responsiveness to mycobacterial antigens, or to autoantigens which cross-react with them, are relevant to RA.

Ultrastructural abnormalities of the liver in total lipodystrophy

We present the results of light and electron microscopy studies of the liver in an 8-year-old girl with congenital total lipodystrophy. Liver histology revealed cirrhosis, and ultrastructural study showed mitochondrial abnormalities and an increase in the number of peroxisomes. A potential relationship between the high fatty acid concentration in the serum and the peroxisomal proliferation is considered.

Lead poisoning in a West Bank Arab Village

Eleven patients from the West Bank village of Es-Sawiyeh were admitted with lead poisoning to two Jerusalem hospitals between November 1982 and January 1983. They all belonged to several households of a single large family. Colicky abdominal pains were present in five patients, weakness in four, behavioral changes ranging from irritability to frank psychosis in four, and paralysis in one. Anemia of various degrees was seen in all patients. Basophilic stippling and reticulocytosis were encountered in all patients with moderate to severe anemia. Therapy with edetate disodium calcium and penicillamine resulted in clinical improvement in all patients. A preliminary survey of 270 subjects in the same village disclosed 84 subjects with abnormally elevated blood lead levels, 17 of whom had grade IV lead burden according to the Centers for Disease Control risk classification. Contamination of homemade flour by lead used for stabilizing the metal parts of stone mills was the source of poisoning. As the method of milling in many West Bank villages is similar, these findings may have important implications to the well being of a large section of the rural West Bank population.

[Infectious endocarditis in idiopathic hypertrophic subaortic stenosis. Report of a case (author's transl)]

A case is reported of aortic valve endocarditis in a 53 year-old female patient with idiopathic hypertrophic subaortic stenosis. Emphasis is made on the value of ultrasonography in the diagnosis of both conditions. Ecography has also prognostic interest when big vegetations are found. A comment is made on the need for early surgical replacement of the aortic valve when valvular insufficiency is present.