Lessons from Carl M. Pearson 1919 - 1981

Carl M. Pearson was an energetic and exceptional physician-scholar-leader who founded, established, and broadened the Divisions of Rheumatology at University of California in Los Angeles (UCLA) beginning in 1956. His studies to induce myositis by injecting muscle saturated with the heat-killed tubercle bacillus, an emulsifier, and mineral oil (Freund's adjuvant) enabled his report that polyarthritis occurred with Freund's adjuvant alone in certain strains of rat and mice. This model of adjuvant arthritis allowed the next generation of studies to assess therapies for autoimmune diseases.

Targeting inflammatory pathways in axial spondyloarthritis

The triggers and pathogenesis of axial spondyloarthritis (axSpA) are not yet completely understood. However, therapeutic agents targeting tumor necrosis factor-α and interleukin-17 inflammatory pathways have proven successful in suppressing many of the clinical symptoms and signs of axSpA, giving us an indication of which pathways are responsible for initiating and maintaining the inflammation. The mechanisms that eventuate in syndesmophytes and ankyloses are less clear. This review addresses these two critical pathways of inflammation, discussing their nature and these factors that may activate or enhance the pathways in patients with axSpA. In addition, genetic and other markers important to the inflammatory pathways implicated in axSpA are explored, and prognostic biomarkers are discussed. Treatment options available for the management of axSpA and their associated targets are highlighted.

Comparative genomic profiling of synovium versus skin lesions in psoriatic arthritis

Objective

To our knowledge, there is no broad genomic analysis comparing skin and synovium in psoriatic arthritis (PsA). Also, there is little understanding of the relative levels of cytokines and chemokines in skin and synovium. The purpose of this study was to better define inflammatory pathways in paired lesional skin and affected synovial tissue in patients with PsA.

Methods

We conducted a comprehensive analysis of cytokine and chemokine activation and genes representative of the inflammatory processes in PsA. Paired PsA synovial tissue and skin samples were obtained from 12 patients on the same day. Gene expression studies were performed using Affymetrix HGU133 Plus 2.0 arrays. Confirmatory quantitative real-time polymerase chain reaction (PCR) was performed on selected transcripts. Cell populations were assessed by immunohistochemistry and immunofluorescence.

Results

Globally, gene expression in PsA synovium was more closely related to gene expression in PsA skin than to gene expression in synovium in other forms of arthritis. However, PsA gene expression patterns in skin and synovium were clearly distinct, showing a stronger interleukin-17 (IL-17) gene signature in skin than in synovium and more equivalent tumor necrosis factor (TNF) and interferon-γ gene signatures in both tissues. These results were confirmed with real-time PCR.

Conclusion

This is the first comprehensive molecular comparison of paired lesional skin and affected synovial tissue samples in PsA. Our results support clinical trial data showing that PsA skin and joint disease are similarly responsive to TNF antagonists, while IL-17 antagonists have better results in PsA skin than in PsA joints. Genes selectively expressed in PsA synovium might direct future therapies for PsA.

Different tumor necrosis factor α antagonists have different effects on host susceptibility to disseminated and oropharyngeal candidiasis in mice

Tumor necrosis factor α is important for the host defense against intracellular pathogens. We tested the effect of mouse analogs of human TNF-α antagonists, the rat anti-mouse TNF-α monoclonal antibody (XT22) and the soluble mouse 75 kDa TNF-α receptor fused to the Fc portion of mouse IgG1 (p75-Fc), on the susceptibility of mice to hematogenously disseminated candidiasis (HDC) and oropharyngeal candidiasis (OPC). Both XT22 and p75-Fc significantly reduced mice survival, increased kidney fungal burden, and reduced leukocyte recruitment during HDC. However, only XT22 significantly increased the oral fungal burden and reduced leukocyte recruitment during OPC. This result suggests that XT22 and p75-Fc affect host susceptibility to different types of Candida albicans infections by different inhibitory mechanisms.

Significance of sex in achieving sustained remission in the consortium of rheumatology researchers of North America cohort of rheumatoid arthritis patients

OBJECTIVE

To determine whether men with rheumatoid arthritis (RA) are more likely to achieve remission compared to women.

METHODS

RA patients enrolled in the Consortium of Rheumatology Researchers of North America (CORRONA) cohort between October 2001 and January 2010 were selected for the present analyses. Detailed clinical, demographic, and drug utilization data were available at enrollment (baseline) and at subsequent followup visits. We examined the influence of sex on the Clinical Disease Activity Index remission score (≤2.8) using sustained remission or point remission as the primary outcome measure in multivariate stepwise logistic regression models. We stratified the data by RA duration at baseline (≤2 years or >2 years) to investigate whether RA duration had differential effects on remission in men and women.

RESULTS

A total of 10,299 RA patients (2,406 men and 7,893 women) were available for this study. In both early and established RA, women had more severe disease at baseline with worse disease activity measures, modified Health Assessment Questionnaire disability index score, pain on a visual analog scale, and depression. Women were also more likely to have been treated with disease-modifying antirheumatic drugs and anti-tumor necrosis factor therapy compared to men. In the regression models, male sex was associated with sustained remission in early RA (odds ratio [OR] 1.38, 95% confidence interval [95% CI] 1.07-1.78, P = 0.01), but not in established RA. However, for point remission, an inverse association was observed with male sex in established RA (OR 0.65, 95% CI 0.48-0.87, P = 0.005) and not in early RA.

CONCLUSION

Within the large real-life CORRONA cohort of RA patients, men were more likely to achieve sustained remission compared to women in early RA, although not in established RA.

Gender and ethnicity differences in patients with diffuse systemic sclerosis--analysis from three large randomized clinical trials

OBJECTIVE

Although the incidence of dcSSc is higher in African-American and Hispanic populations compared with European Caucasian patients, it is not clear whether there are differences in subsequent disease course. Also, the potential impact of gender on the disease course of dcSSc is not well defined. Our objective was to assess the course of modified Rodnan skin score (MRSS), HAQ-disability index (HAQ-DI) and forced vital capacity per cent (FVC%) predicted between men vs women and three ethnic groups with dcSSc participating in three randomized clinical trials (RCTs).

METHOD

Data from RCTs (n = 495) were pooled and analysed. Baseline characteristics were compared in men vs women and among ethnic groups. A linear mixed effects model was used to assess the predictors of MRSS, HAQ-DI and FVC%. The primary independent variables were time-in-study and its interaction with gender and ethnicity. The models were adjusted for other covariates that were significant at baseline between gender and ethnicity analyses.

RESULTS

Men had lower HAQI-DI scores compared with women (P < 0.05). Among the three ethnic groups, Caucasians were older, African-Americans had lower FVC% predicted and Hispanics had greater tender joint counts (P < 0.05). The course of MRSS, HAQ-DI and FVC% predicted during the study period was not significantly different between gender and three ethnicities. Time-in-study was an independent predictor of improvement in MRSS and HAQ-DI.

CONCLUSION

Our analysis explores the influence of gender and ethnicity on disease course in RCTs. These findings are relevant to issues of future trial design.

Differences in binding and effector functions between classes of TNF antagonists

There are currently two Food and Drug Administration-approved classes of biologic agents that target tumor necrosis factor-alpha (TNF-alpha): anti-TNF monoclonal antibodies (mAbs) (adalimumab and infliximab), and soluble TNF receptors (etanercept). This study examined the ability of the TNF antagonists to: (1) bind various polymorphic variants of cell surface-expressed Fc receptors (FcgammaRs) and the complement component C1q, and (2) mediate Ab-dependent cellular cytotoxicity (ADCC) and complement-mediated cytotoxicity (CDC) killing of cells expressing membrane-bound TNF (mTNF) in vitro. Both mAbs and the soluble TNF receptor demonstrated low-level binding to the activating receptors FcgammaRI, FcgammaRIIa, and FcgammaRIIIa, and the inhibitory receptor FcgammaRIIb, in the absence of exogenous TNF. However, upon addition of TNF, the mAbs, but not etanercept, showed significantly increased binding, in particular to the FcgammaRII and FcgammaRIII receptors. Infliximab and adalimumab induced ADCC much more potently than etanercept. In the presence of TNF, both mAbs bound C1q in in vitro assays, but etanercept did not bind C1q under any conditions. Infliximab and adalimumab also induced CDC in cells expressing mTNF more potently than etanercept. Differences in the ability to bind ligand and mediate cell death may account for the differences in efficacy and safety of TNF antagonists.

Structural-functional relationships of TNF-alpha antagonists: next steps

The balance between effective tumor necrosis factor (TNF) blockade to control aggressive autoimmune disease states and adequate remaining TNF activity to confer immunoprotection against infections such as tuberculosis is an important and complex issue. An increased scientific understanding of how each of the TNF antagonist agents affects the complex interactions of the inflammation cascade and apoptosis, and whether the effects are modulatory or destructive, is needed. The data presented in this supplement highlight the need for further research into these key areas, and illustrate our current understanding of the mode of action of TNF blockers as only the tip of the iceberg.

Neutralization of Tumor Necrosis Factor (TNF) by Antibody but not TNF Receptor Fusion Molecule Exacerbates Chronic Murine Tuberculosis

Tumor necrosis factor (TNF) plays an essential role in the immunologic maintenance of Mycobacterium tuberculosis infection. Although an increased rate of tuberculosis has been reported in humans treated with anti-TNF biological agents, disparate rates of disease have been observed between those treated with infliximab, an anti-TNF antibody, and etanercept, a TNF-neutralizing TNF receptor (TNFR) fusion molecule. We compared the effects of anti-TNF antibody and soluble TNFR fusion molecule in the murine model of tuberculosis. Systemic TNF neutralization was equivalent between these molecules, and both resulted in rapid morbidity at the initiation of infection. During chronic infection, administration of the receptor fusion molecule allowed the control of infection, whereas antibody treatment caused mice to die within a month. We provide evidence of decreased penetration into the granulomas by the receptor fusion molecule, compared with antibody. These findings begin to clarify the mechanistic difference between anti-TNF agents and their role in the exacerbation of tuberculosis.

Binding characteristics of tumor necrosis factor receptor-Fc fusion proteins vs anti-tumor necrosis factor mAbs

Tumor necrosis factor (TNF) antagonists are efficacious in the treatment of various autoimmune diseases. Two classes of TNF antagonists are currently commercially available: soluble TNF receptor-Fc fusion proteins (etanercept) and anti-TNF mAbs (adalimumab and infliximab). The classes differ in molecular structures and mechanisms of action. The interactions between TNF antagonists with TNF molecules were characterized. The anti-TNF mAbs, but not the soluble TNF receptor, formed visible lines of precipitation in Ouchterlony assays. The molecular weights of complexes formed by TNF (52 kDa) with either etanercept (130 kDa), adalimumab (150 kDa), or infliximab (average 165 kDa) were determined by size exclusion chromatography-light-scattering assays. Etanercept and TNF formed complexes of 180 and 300 kDa, representing one and two etanercept monomers bound to a TNF trimer, respectively. Adalimumab and infliximab formed a variety of complexes with TNF with molecular weights as high as 4,000 and 14,000 kDa, respectively, suggesting the presence of complexes with a wide range of sizes and stoichiometries. The absence of large complex formation with the binding of soluble receptor-fusion proteins to TNF may account for the different clinical efficacy and safety profiles of the two classes of TNF antagonists.

Patient's ethnicity does not influence utilization of effective therapies in rheumatoid arthritis

OBJECTIVE

Biological agents have revolutionized the treatment of rheumatoid arthritis (RA). Given the previously documented ethnic disparity in the health service literature, we sought to determine if ethnic difference exists in the lag time between the diagnosis of RA and use of first biological agent.

METHODS

RADIUS 1 and 2 are observational studies designed to document how rheumatologists treat RA across the United States. The sample analyzed here included early patients with RA who entered RADIUS with the initiation of the first biological agent. Ethnic status was categorized as White (W), African American (AA), and Hispanic (H). Lag time (months from RA diagnosis to initiation of the first biological agent) was the principal outcome variable.

RESULTS

Compared to W (n=1616), AA (n=147) and H (n=116) were more likely to be female, younger, and have less than a high school education. Despite similar swollen and tender joint counts, AA and H had more active disease on the basis of Health Assessment Questionnaire and patient global assessments. Almost 97% of patients had some type of insurance coverage. On multivariable analysis, ethnic affiliation was not associated with lag time (14.5 months W vs 14.9 AA vs 14.3 H; p=NS). Similarly, there were also no significant ethnic differences in time to first DMARD (e.g., methotrexate) initiation.

CONCLUSION

In a national sample of patients with RA, most of whom were insured, the length of time from diagnosis of RA to initiation of the first biological agent was not significantly different among Whites, African Americans, and Hispanics.

Blockade of plasmid replication mediated by peptide nucleic acids

Because peptide nucleic acids (PNAs) are capable of blocking amplification of deoxyribonucleic acid (DNA) by Taq DNA polymerase in vitro, we postulated that PNAs might be able to block replication in vivo. To explore this possibility, we assessed the ability of PNA to specifically block the replication of pUC19 plasmids by allowing a PNA, directed against segments of the Ampr sequence to bind to pUC19 prior to electroporation into Escherichia coli, strain DH10B. Colonies produced by this maneuver not only remained sensitive to ampicillin but were also incapable of blue color production on X-gal-containing media, thus demonstrating true blockade of pUC19 replication, rather than antisense activity. The ability of the PNA to prevent pUC19 replication in these experiments was shown to be dose related. Attempts to prevent the replication of E. coli using a PNA directed against a portion of the lac Z sequence found within the bacterial genome were not uniformly successful. Subsequent experiments showed that the electroporated PNA did not consistently enter a sufficient number of cells for an effect to be demonstrated in the assays used. Nonetheless, this is the first demonstration of in vivo complete replication blockade by a PNA and opens up the potential for new forms of specific antibiosis in both prokaryotic and eukaryotic cells.

Etanercept ameliorates sarcoidosis arthritis and skin disease

Sarcoidosis is a systemic disorder of unknown etiology characterized by its pathological hallmark, the noncaseating granuloma. In granulomatous diseases, the proinflammatory peptide mediators, including tumor necrosis factor-alpha (TNF-alpha), are increased in the blood and fluids surrounding the activated macrophages. We describe a patient with chronic sarcoidosis arthropathy and lupus pernio resistant to corticosteroids and disease modifying antirheumatic agents, who responded to the addition of etanercept. We discuss the possible mechanisms of action of anti-TNF agents in granulomatous diseases and suggest that chronic, resistant sarcoidosis requires combination immunosuppressive therapy.

Effects of disease management programs on functional status of patients with rheumatoid arthritis

OBJECTIVE

To perform a systematic review of the published literature on disease management of rheumatoid arthritis (RA) and to use meta-analysis to estimate the magnitude of benefit these programs have on functional status in patients with RA.

METHODS

Computerized databases for English articles from 1966 to September 2001 were searched. Two reviewers evaluated 1,029 published titles, identified 11 studies meeting explicit inclusion criteria, and extracted data about study characteristics, interventions used, and outcomes measured. Pooled effect sizes for functional status were calculated using a random-effects model.

RESULTS

Four out of 8 disease management programs showed significant improvements in functional status; however, the pooled effect size (ES) was small and statistically non-significant (ES 0.27; 95% confidence interval [95% CI] -0.01, 0.54). Studies with longer intervention durations (>5 weeks) had significantly improved patient functional status (ES 0.49; 95% CI 0.12, 0.86), compared with studies with shorter intervention durations (</=5 weeks, ES 0.13; 95% CI -0.25, 0.52).

CONCLUSIONS

There were limited data to support or refute the effectiveness of disease management programs in improving functional status in patients with RA. Additional studies are needed to confirm if a more intensive intervention may be of benefit to patients with RA, as suggested by our study.

Guidelines for the use of immunosuppressive drugs in patients with ocular inflammatory disorders: recommendations of an expert panel

PURPOSE

To provide recommendations for the use of immunosuppressive drugs in the treatment of patients with ocular inflammatory disorders.

PARTICIPANTS

A 12-person panel of physicians with expertise in ophthalmologic, pediatric, and rheumatologic disease, in research, and in the use of immunosuppressive drugs in patient care.

EVIDENCE

Published clinical study results. Recommendations were rated according to the quality and strength of available evidence.

PROCESS

The panel was convened in September of 1999 and met regularly through May 2000. Subgroups of the panel summarized and presented available information on specific topics to the full panel; recommendations and ratings were determined by group consensus.

CONCLUSIONS

Although corticosteroids represent one of the mainstays in the management of patients with ocular inflammation, in many patients, the severity of the disease, the presence of corticosteroid side effects, or the requirement for doses of systemic corticosteroids highly likely to result in corticosteroid complications supports the rationale for immunosuppressive drugs (for example, antimetabolites, T-cell inhibitors, and alkylating agents) being used in the management of these patients. Because of the potential for side effects, treatment must be individualized and regular monitoring performed. With careful use of immunosuppressive drugs for treatment of ocular inflammatory disorders, many patients will benefit from them either with better control of the ocular inflammation or with a decrease in corticosteroid side effects.

The polymerase chain reaction in infectious and post-infectious arthritis. A review

Polymerase chain reaction and other DNA amplification techniques to identify elusive infections should prove to be an effective tool for the clinical and investigative rheumatologist. The capability to identify and characterize infectious organisms in fluids and tissue will enable early, specific, and potentially curative treatment. Similarly, the capability to exclude infection and differentiate postinfectious diseases will enable other therapies to control the inflammation. Understanding these molecular techniques will most certainly improve clinicians' effectiveness for diagnosis and care.

Single-tube, nested, reverse transcriptase PCR for detection of viable Mycobacterium tuberculosis

Several problems remain before molecular biology-based techniques, such as PCR, are widely accepted for the detection of infectious agents. Among the most formidable of these problems are the inability of the tests to distinguish between viable and nonviable organisms. We approached this problem by using the fact that bacterial mRNA has an extremely short half-life, averaging only a few minutes. We reasoned that by targeting bacterial mRNA by a reverse transcriptase PCR (RT-PCR), a positive signal would indicate the presence of a recently viable organism. To test our hypothesis, we chose to target the mRNA coding for the ubiquitous 85B antigen of mycobacteria. After partially sequencing the gene coding for 85B, we developed primers that were specific for Mycobacterium tuberculosis. In a single-tube, nested, RT-PCR (STN RT-PCR), these primers detected fewer than 40 CFU in spiked sputum samples and as few as 12 CFU in clinical sputum specimens. The sensitivity of STN RT-PCR with smear-negative samples was as good as that of culture. The specificity was 100%. More importantly, when M. tuberculosis was cultured with and without 1 microgram of isoniazid per ml, this assay could distinguish between those cultures which contained the antibiotic and those which did not. Subcultures on Lowenstein-Jensen agar confirmed the viability assessments of the STN RT-PCR. Control experiments demonstrated that isoniazid did not inhibit the RT-PCR. In addition, when an IS6110-targeted, DNA PCR was used to examine the same samples, all samples though 13 days (the last sample) continued to be positive, irrespective of whether isoniazid was present, thereby demonstrating the superiority of an mRNA target in the detection of mycobacterial viability.

Imaging rheumatic joint diseases with anti-T lymphocyte antibody OKT-3

T lymphocytes play an important role in the pathogenesis of rheumatoid arthritis (RA). Murine monoclonal antibody OKT-3 (IgG2a), known to be specific for T lymphocyte 20 kD glycoprotein CD3 receptor was labelled with 5 mCi 99Tcm and given intravenously (i.v.) to seven RA and two psoriatic arthritis patients following informed consent to identify inflamed synovium. Anterior and posterior whole body scans and specific regional imaging was commenced 20 min later. At 1 h, approximately 20% of 99Tcm was associated with the lymphocytes. In these patients, all 41 asymptomatic joints and 43 joints with mild pain or minimal tenderness had normal scans. All 34 joints with moderate to severe pain had moderate to marked uptake of radioactivity. Two patients experienced shaking chills for 20-30 min within an hour of 99Tcm-OKT-3 infusion. These results suggest that 99Tcm-OKT-3 imaging serves as an objective surrogate for joint inflammation and could be useful as a measurement of therapeutic effectiveness in RA and other diseases with inflamed synovium. The side effect profile may limit the utility of 99Tcm-OKT-3 but other forms of antibodies directed toward lymphocyte subsets may be useful.

Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction

OBJECTIVE

To analyze synovial fluid (SF) for the presence of Neisseria gonorrhoeae DNA using the polymerase chain reaction (PCR).

METHODS

We used a modified, nested PCR to detect the presence of N gonorrhoeae DNA in 41 samples of SF obtained from 10 patients with clinical gonococcal arthritis whose SF samples were sterile by culture and from 27 controls, including 11 patients with Reiter's syndrome. Results obtained using this method were compared with those obtained using the GEN-PROBE system, an RNA-DNA hybridization technique.

RESULTS

With nested PCR, N gonorrhoeae DNA was detected in 11 of 14 SF samples obtained from patients with culture-negative clinical gonococcal arthritis but in none of the 11 SF samples from Reiter's syndrome patients. The specificity of this technique was 96.4%, with a sensitivity of 78.6%. The rate of false-positive results was 3.6%. The GEN-PROBE technique was unable to detect N gonorrhoeae ribosomal RNA in any of the samples.

CONCLUSION

These findings demonstrate the potential utility of the PCR in confirming the clinical diagnosis of gonococcal arthritis as well as providing insight into the pathogenesis of this disorder in patients whose SF are sterile by standard culture techniques. PCR may also prove helpful in differentiating N gonorrhoeae arthritis from acute Reiter's syndrome.

The polymerase chain reaction for the detection of Borrelia burgdorferi in human body fluids

OBJECTIVE

To analyze clinical fluids for the presence of Borrelia burgdorferi DNA using the polymerase chain reaction (PCR).

METHODS

We utilized a modified, nested PCR to detect the presence of Borrelia DNA in 99 samples of serum, urine, cerebrospinal fluid (CSF), or synovial fluid obtained from 44 patients with various stages of Lyme disease and 47 control subjects. Primer specificity was corroborated by examining 2 DNA data banks, testing against DNA from other organisms, and confirming results with a second set of nested primers.

RESULTS

Nested PCR was capable of detecting DNA from fewer than 10 organisms in 1 ml of fluid. The specificity of this technique was 96.4%, with a sensitivity of 76.7%. Although the specificity was uniformly high, the sensitivity was dependent upon the body fluid being tested: CSF 100%, urine 100%, synovial fluid 80%, and serum 59%. The rate of false-positive results was 3.6%.

CONCLUSION

These data demonstrate the potential utility of PCR in confirming the clinical diagnosis of Lyme disease as well as providing insight into the pathogenesis of various stages of this disorder.

Oxygen uptake during exercise in patients with primary fibromyalgia syndrome

OBJECTIVE

Muscle ischemia has been postulated as a causative factor in pain and disability in patients with primary fibromyalgia syndrome (PFS) and previous studies have demonstrated that patients with PFS have reduced maximum oxygen uptake (VO2). Our objective was to examine the level and pattern of VO2 in response to graded exercise and defined levels of constant work rate exercise in patients with PFS.

METHODS

Unmedicated patients fulfilling modified Yunus' criteria for the diagnosis of PFS and healthy control subjects performed upright cycle ergometry exercise with measurements of respiratory gas exchange and grading of pain using visual analog scores.

RESULTS

Patients, but not controls, had significantly higher levels of pain after graded exercise than before exercise. Although peak VO2 did not differ between the 2 groups, effort dependent variables of exercise function were more variable in the patients than in control subjects. The onset of muscle anaerobiosis as reflected in respiratory gas exchange, the relationship between VO2 and work rate throughout the range of exercise work rates, and the mean response time for the increase in VO2 to the exercise level in response to a constant work rate of exercise were not different for patients compared to controls.

CONCLUSION

Despite the subjective reports of pain, our studies demonstrate no abnormality in the overall rate and pattern of utilization of oxygen during muscular exercise in patients with PFS.

Idiotypic characteristics of immunoglobulins associated with human systemic lupus erythematosus. Association of high serum levels of IdGN2 with nephritis but not with HLA class II genes predisposing to nephritis

Serum levels of IdGN2 (an idiotype enriched in nephritogenic antibodies), IdX (an idiotype not enriched in nephritogenic antibodies), IgG, and anti-DNA were measured in 23 Caucasian patients with lupus nephritis, in age- and sex-matched lupus patients without nephritis, and in similarly matched healthy individuals. Serum levels of IdGN2 were significantly higher in the patients with lupus nephritis than in those without, and they were higher in all lupus patients compared with the healthy control subjects. However, the same observations were true for serum levels of IdX. There were significant positive correlations between the serum levels of IgG, IdGN2, IdX, and anti-DNA. HLA typing at the DR and DQ loci was performed in 105 lupus patients of different races (Caucasian, black, and Asian/Polynesian/Filipino). Serum levels of IdGN2 in 83 of these individuals did not correlate with any of the HLA class II haplotypes currently known to predispose to lupus nephritis. We conclude that the high serum levels of IdGN2, which are characteristic of some patients with lupus nephritis, may often result from polyclonal B cell activation rather than from idiotype-specific upregulation associated with one or more of the class II genes that predispose to nephritis in this disease.

Lupus membranous glomerulonephritis: different prognostic subgroups obscured by imprecise histologic classifications

Eighteen patients with lupus membranous nephritis were retrospective identified by reviewing the renal biopsy records of an active renal pathology service. Seven had minimally proliferative membranous nephropathy (World Health Organization (WHO) classes Va and b). Eleven had membranous nephropathy with superimposed changes of focal or diffuse proliferative glomerulonephritis (WHO Vc and d). After mean follow-up periods of 73 +/- 6 and 74 +/- 15 mo, respectively, one patient of seven from WHO Va and b and seven of 11 from WHO Vc and d reached end stage renal disease. The latter patients were distinguishable from the former only by the degree of superimposed proliferation on renal biopsy and not by blood pressure, antinuclear antibody, anti-double stranded DNA, or complement levels. These data stand in contrast to the widely held belief that lupus membranous nephropathy is relatively benign. The belatedness of this observation is partially due to imprecision in nosology for patients with lupus who have renal biopsies with "overlap" characteristics.

Idiotypic characteristics of immunoglobulins associated with systemic lupus erythematosus. Studies of antibodies deposited in glomeruli of humans

Indirect immunofluorescence with monoclonal antibodies to 6 different idiotypes was used to characterize immunoglobulins deposited in the glomeruli of renal biopsy samples from 32 patients with systemic lupus erythematosus (SLE) and 19 patients with nonlupus immune glomerulonephritis. IdGN2 was present in 75% of the biopsy specimens from SLE patients and in 6% of those from patients with non-lupus nephritis; IdGN1 occurred in 38% and 6%, respectively. The other idiotypes were not increased in biopsy samples from patients with SLE. Deposition of IdGN2 was associated with a subendothelial location of Ig and proliferative changes in the glomeruli. In studies of glomerular eluates from 4 immunosuppressed SLE patients, an average of 26% of total Ig and 37% of anti-DNA was composed of IdGN2. Compared with IdGN2- immunoglobulin, IdGN2+ immunoglobulin was enriched in IgG1 in all 4 eluates, and was enriched in high-avidity anti-DNA in 2 eluates. IdGN2 is a marker of antibody subsets that are characteristic of SLE and are associated with severe lupus nephritis.

Poor prognosis in end-stage lupus nephritis due to nonautologous vascular access site associated septicemia and lupus flares

A poor prognosis was observed in patients who had end-stage renal disease (ESRD) as a result of systemic lupus erythematosus (SLE). This was true even in patients in whom SLE disease activity was transiently quiescent during the period of hemodialysis. Six of 9 patients with ESRD and SLE died with active SLE and/or sepsis 1-28 months following the onset of dialysis. In 5 of the 6 patients, acute inflammatory activity of SLE flared within 1 month of the patient's death. Four patients died with superimposed sepsis, but only 2 of the 4 were receiving high-dose concomitant immunosuppressives for more than 1 week prior to death. Infected hemodialysis vascular access sites were implicated as the source of septicemia in 3 of 4 infectious deaths. The 3 surviving patients had minimal lupus activity prior to the development of ESRD, a possible marker for stability in SLE patients who require hemodialysis. Our results suggest that hemodialyzed lupus patients with nonautologous vascular access sites may be at continued increased risk for life-threatening inflammatory and septic complications.

Specific suppression of anti-DNA production in vitro

To investigate the regulation of anti-DNA antibody production, we generated anti-DNA-specific suppressor cells by exposing normal human T cells and a small percentage of adherent cells to high concentrations of DNA. These cells suppressed the production of anti-DNA by both autologous peripheral blood mononuclear cells (PBMC) and allogeneic PBMC derived from systemic lupus erythematosus (SLE) patients. Anti-DNA production was suppressed significantly more than anti-RNA, antitetanus, or total immunoglobulin production. Specific suppression was enhanced by increasing the numbers of DNA-primed CD8+ cells and was obliterated by irradiation of the DNA-primed cells. In contrast to T cells from normal individuals, T cells obtained from two intensively studied SLE patients were unable to generate specific suppressor cells for anti-DNA production in both autologous and allogeneic test systems. Despite this defect, these patients were still capable of generating specific suppressor cells for antibody production directed against an exogenous antigen, tetanus toxoid.

Retinoid modulation of collagenase production by adherent human mononuclear cells in culture

Previous observations have suggested that retinoids might be useful for the treatment of rheumatoid arthritis. In this study we examined the effects of various retinoids on collagenase production by adherent human peripheral blood mononuclear cells in culture. We have previously shown that these cells, consisting predominantly of monocyte-macrophages, actively synthesize and secrete collagenase upon stimulation with concanavalin A. The cells were incubated in serum free medium with all-trans-retinoic acid, 13-cis-retinoic acid, all-trans-retinal, or Ro 10-9359 (trimethylmethoxyphenyl retinoic acid ethyl ester) for up to 72 hours, and the collagenase activity was determined with [3H]proline labelled type I collagen as substrate. The incubation of mononuclear cells with all-trans-retinoic acid in the concentration range 10(-7)-10(-5) mol/l resulted in a dose dependent inhibition of the collagenase production. All-trans-retinal was also a potent inhibitor, whereas 13-cis-retinoic acid and Ro 10-9359 in a concentration of 10(-5) mol/l had a lesser effect. Control experiments indicated that the inhibition of collagenase production by all-trans-retinoic acid did not result from inhibition of total protein synthesis nor could it be explained by induction of an inhibitory molecule. These results indicate that retinoids with distinct structural features can inhibit collagenase production by monocyte-macrophages, and suggest a role for retinoids in the treatment of rheumatoid arthritis.

Collagenase production by human mononuclear cells in culture: inhibition by gold containing compounds and other antirheumatic agents

Human peripheral blood mononuclear cells in adherent cultures have been shown to synthesise and secrete collagenase. In the present study we have examined the modulation of collagenase production in these cultures by several antirheumatic agents. Incubation of monocytes in serum free medium with sodium aurothiomalate in concentrations varying from 7.7 X 10(-7) to 7.7 X 10(-3) mol/l resulted in marked dose dependent inhibition of the collagenase production. This inhibition was apparently selective in that total protein synthesis or the viability of the cells were not affected. Similar inhibition of the collagenase production was also noted with auranofin, aurothioglucose, and chloroauric acid. The inhibition with auranofin was achieved with a concentration as low as 7.4 X 10(-8) mol/l. To examine the mechanisms of the inhibition of the collagenase activity induced by sodium aurothiomalate the production of prostaglandin E2 was also measured in the same cell cultures. Sodium aurothiomalate in concentrations greater than 7.7 X 10(-4) mol/l significantly inhibited the prostaglandin E2 production; the prostaglandin E2 production was not inhibited, however, in 7.7 X 10(-5) mol/l concentration, while the collagenase production was reduced by 51.0%. Also, exogenous prostaglandin E2 added to the cultures only slightly reversed the inhibition of the collagenase production by sodium aurothiomalate. Thus the inhibition of collagenase production by sodium aurothiomalate in human adherent mononuclear cell cultures appears to be independent of the inhibition of prostaglandin E2 production. The inhibition of collagenase produced by monocyte-macrophages, as shown here in vitro, may contribute to the clinical efficacy of the compounds tested in the treatment of rheumatoid arthritis.

The production of collagenase by adherent mononuclear cells cultured from human peripheral blood

Mononuclear cells were isolated from human peripheral blood by Ficoll-Hypaque centrifugation, and the cells adherent to plastic substrata were cultured in serum-free media supplemented with lactalbumin hydrolysate. These cell cultures, which consisted predominantly of monocyte-macrophages as judged by nonspecific esterase staining, accumulated collagenase in the medium. This collagenase resembled other vertebrate collagenases in that it cleaved native triple-helical type I collagen at a locus 3/4-length away from the amino-terminal end of the molecule. The collagenase activity was inhibited by Na2EDTA, dithiothreitol, and fetal calf serum, while the addition of Ca++ or N-ethylmaleimide enhanced the enzyme activity. The accumulation of collagenase in the culture media was markedly enhanced by the incubation of cells with concanavalin A or phorbol myristic acetate. In the presence of cycloheximide, the levels of collagenase activity were markedly reduced, suggesting that active protein synthesis was required to express the enzyme activity. In additional experiments, monocytes were further purified by counterflow centrifugation-elutriation. The collagenase production was markedly increased in cultures enriched in monocyte-macrophages and devoid of polymorphonuclear leukocytes. The accumulation of collagenase in monocyte cultures incubated for 48 hours in the presence of concanavalin A or phorbol myristic acetate was of the same order of magnitude as in parallel cultures containing the same number of polymorphonuclear leukocytes purified by Ficoll-Hypaque centrifugation and Plasmagel sedimentation.(ABSTRACT TRUNCATED AT 250 WORDS)

Clonally restricted anti-IgG antibodies in rheumatoid arthritis

Clonally restricted anti-IgG antibodies were detected, by isoelectric focusing (IEF) and chromatofocusing techniques, in the sera of patients with rheumatoid arthritis (RA). Anti-Fab antibodies were predominantly acidic proteins with isoelectric points of 4.5-6.5 and displayed restricted spectrotype patterns. Proteins reactive with the Fc portion of IgG showed polyclonal spectrotype patterns with alkaline pI of 7.5-9.0. A limited array of anti-Fab spectrotypes was consistently detected in RA sera when analyzed by IEF on 6M urea gels. Additional anti-Fab antibody bands were detected when the RA sera were dialyzed against 4-6M urea prior to IEF analysis, indicating that some anti-Fab antibodies exist in a complexed form in serum. Under these dissociating conditions, anti-Fab antibodies could also be detected in normal subjects, but the spectrotype patterns were more restricted than those in RA sera. Because anti-Fab antibodies may regulate normal immune responses, the increased quantity of clonally restricted anti-Fab antibodies in RA may indicate an abnormality of this immunoregulation.

12-O-Tetradecanoylphorbol-13-acetate (TPA) directly inhibits spontaneous immunoglobulin secretion by in vivo antigen-induced human lymphoblastoid B cells

Tetanus toxoid (Tet) booster immunization induces the transient appearance in the circulation of lymphoblastoid (LB) B cells which spontaneously produce anti-tetanus toxoid IgG antibody (IgG-Tet) during a 3-day in vitro culture. In this study we have examined the effects of TPA on the ability of LB cells to secrete antibody and have found that as little as 10 ng/ml of TPA provoked a marked inhibition of the induced LB cells' IgG-Tet production. This inhibitory effect was observed only when TPA was added early in the culture and could be achieved by pretreating the B cells with TPA for as little as 1 hr. Only marginal inhibition of IgG-Tet production was observed if the addition of TPA was delayed 14-24 hr. The TPA inhibition was not mediated by contaminant T cells as the addition of increasing numbers of T cells to LB cell cultures proportionally reversed the TPA inhibitory effect. Likewise, the inhibition of antibody synthesis was not due to a monocyte-dependent mechanism since (1) substantial depletion of adherent cells did not reverse the inhibition of antibody synthesis, (2) the addition of a monocyte-enriched population to monocyte-depleted B cells did not enhance, but in fact partially reversed, the inhibition caused by TPA, and (3) the addition of monocyte populations pretreated with TPA to monocyte-depleted B-cell fractions did not inhibit subsequent IgG-Tet production by the LB cells.

Pharmacology of human spontaneous monocyte-mediated cytotoxicity. I. Enhancement by salicylates and steroids

The effect of various antiinflammatory agents on the spontaneous cytotoxicity of human mononuclear cells in vitro was assessed. Acetylsalicylic acid (ASA) and hydrocortisone enhanced spontaneous monocyte-mediated cytotoxicity compared to control values. This enhancement could not be mediated through inhibition of prostaglandin biosynthesis since indomethacin had no effect on cytotoxic function and since the direct addition of PGE2 to the cell cultures did not inhibit the expression of cytotoxicity. Likewise, salicylic acid (SA), which had no effect on prostaglandin biosynthesis, also enhanced monocyte cytotoxicity. Stimulation of monocyte-mediated cytotoxicity resulting in more efficient antigen removal and thus decreasing antigen persistence may be an additional mechanism by which ASA, SA, and hydrocortisone modulate the destructive inflammatory response in rheumatoid arthritis.

Immunoperoxidase staining of the choroid plexus in systemic lupus erythematosus

Immune deposits in the choroid of patients with systemic lupus erythematosus (SLE) are thought to relate to the pathogenesis of central nervous system (CNS) SLE. Using an immunoperoxidase technique, we found the presence of immunoglobulin heavy and light chains in the choroid stroma and/or in the ependymal cells in all of 7 patients with SLE, 2 of 4 with rheumatoid arthritis, but not in 3 subjects without autoimmune disease. The occurrence, pattern or intensity of the immunoglobulin deposits did not distinguish the patients with or without clinical neuropsychiatric manifestations. Thus, the presence of immune deposits in the choroid plexus is not specific for CNS involvement in SLE.

Normal T cell regulation of IgG synthesis in systemic lupus erythematosus

The regulation of pokeweed mitogen (PWM) stimulated IgG synthesis by peripheral blood mononuclear cells (PBL) was studied in patients with systemic lupus erythematosus (SLE) and controls. The helper-T, suppressor-T and B cell functions of SLE-PBL were separately evaluated and compared to the functions of control lymphocyte populations. SLE-T cells function normally both in helper and suppressor modulation of PWM-stimulated IgG secretion by control or autologous B cells. The SLE-B cell, however, fails to synthesize normal quantities of IgG when cultured under conditions that induce maximal stimulation. While other studies document abnormal Con A induced suppressor cell function in SLE, this study shows that normal functioning populations of SLE-suppressor T cells exist in the peripheral blood.

Acute monoarticular arthritis. A diagnostic approach

A group of adult patients with acute nontraumatic monoarticular arthritis was studied. Using only the traditional clinical tools of history, physical examination, joint x-ray films, and synovial fluid culture, Gram's stain, and examination for crystals, 74% of the diagnoses made were achieved either immediately or within two to three days. Overall, 64% of the cases were diagnosed during follow-up. Other tests were not found to be helpful in the acute situation and should be utilized only if the tests already mentioned fail to yield a diagnosis. The prognosis of patients with acute monoarthritis that remains undiagnosed after thorough evaluation is generally good.

Correlation and predictive accuracy of circulating immune complexes with disease activity in patients with systemic lupus erythematosus

Serial serum samples from 48 patients with systemic lupus erythematosus (SLE) were assayed for C3, anti-DNA antibody, and circulating immune complexes (CIC). CIC were measured by the fluid phase (FClq) and solid phase (SClq) Clq binding assays. Elevations of the SClq results were associated with the presence of manifestations of SLE (P less than 0.001), including active renal disease (P less than 0.005) and arthritis (P less than 0.001), as well as changes in degree of disease activity which prompted physician action. A change in the SClq results correctly predicted a change in disease activity 82% of the time (P less than 0.005). Abnormalities of FClq, anti-DNA antibody, and C3 were neither associated with nor predictive of changes in disease activity of SLE. These data suggest that the SClq method of determining CIC is the most reliable laboratory indicator of clinical activity in SLE.

Regional migratory osteoporosis. A denervation disease

Regional migratory osteoporosis is an uncommon entity charcterized by sudden attacks of migrating lower extremity paraarticular pain, local edema, and muscle atrophy; the disease is verified by radiologic demineralization and bone scan uptake. The etiology and pathogenesis are unknown. We describe a case of regional migratory osteoporosis followed over nine years by serial electromyographic studies documenting denervation patterns coincident in time and location of each acute attack. The substantiation of denervation in regional migratory osteoporosis is of both diagnostic and pathogenetic significance.

Clinical and antibody responses after influenza immunization in systemic lupus erythematosus

After immunization with A/New Jersey/76 and A/Victoria/75 influenza vaccines, 11 patients with systemic lupud erythematosus were serially evaluated for changes in disease activity, serologic abnormalities, and their capability to generate specific antibodies. One patient, with active disease, developed a diffuse, proliferative glomerulonephritis. None of the other patients or control subjects had significant local or systemic side effects. Significant levels of antibodies were generated to A/New Jersey/76 in eight of the 11 patients and in seven of eight control subjects and to A/Victoria/75 in seven of 11 patients and five of eight control subjects. The geometric mean responses of both total and IgG antibodies to each viral antigen were no different in patients with systemic lupus erythematosus than in control subjects. In patients with stable systemic lupus erythematosus, immunization with killed influenza viral vaccine appears to be safe and effective.

Impaired immunoglobulin synthesis by peripheral blood lymphocytes in systemic lupus erythematosus

Pokeweed mitogen (PWM)-induced immunoglobulin (Ig) synthesis by peripheral blood mononuclear cells (PBL) from 33 patients with systemic lupus erythematosus (SLE) was compared to that synthesized by PBL from 22 normal individuals. Short-term unstimulated culture of SLE-PBL immediately after separation from PB revealed Ig synthesis 4 times that of normal PBL. However, SLE-PBL had a depressed PWM-induced Ig synthetic response that was partially, but not totally, related to active disease and was not correctable by co-culture with normal lymphocyte populations. In both the short-term-unstimulated and the PWM-stimulated cultures, IgM was the major Ig class synthesized by normal PBL, while IgM synthesis by SLE-PBL was depressed more than the other Ig classes. These results can best be explained by a preactivated PBL population in SLE.

Synovectomy and total joint arthroplasty for recurrent hemarthroses in the arthropathic joint in hemophilia

Severe hemophiliacs with intractable bleeding into one or more joints despite adequate clotting factor replacement therapy are difficult management problems. Synovectomy has controlled bleeding only in joints without significant arthritis destruction. Total joint replacements have been performed in arthropathic joints, but not when uncontrolled bleeding was a concurrent problem. This report describes a hemophiliac with uncontrolled bleeding into an arthritic knee who was successfully managed by combining synvectomy with total knee replacement.

Sternoarticualr pyoarthrosis due to gram-negative bacilli. Report of eight cases

Of eight patients with Gram-negative bacillary sternoarticular pyoarthrosis, seven were long-term intravenous heroin abusers. Clinical onset was insidious and a long delay (one month or more) in seeking hospitalization was usually noted. Anterior chest discomfort and painful, restricted homolateral shoulder motion were the chief complaints. Fever and monoarticular arthritis were universally present, Open synovial biopsy examination was frequently required for etiologic diagnosis. Pseudomonas aeruginosa was the most common pathogen isolated. Roentgenographic evidence of associated osteomyelitis was usually seen, but tomography was often necessary to delineate this lesion. Intraoperatively, associated osteomyelitis of the clavicular head and/or sternum was present in all eight cases and a perisynovial and/or retrosternal abscess was found in five patients. Early surgical exploration and prolonged antimicrobial therapy yielded excellent results.

Acute venereal arthritis. Comparative study of acute Reiter syndrome and acute gonococcal arthritis

Acute venereal arthritis, a syndrome of fever and inflammatory arthritis following recent sexual intercourse, is a frequently misdiagnosed arthritic presentation. Nearly half of 39 patients admitted with a diagnosis of acute gonococcal arthritis were subsequently recognized as having acute Reiter syndrome. A retrospective study of both diseases revealed differentiating features that, when prospectively applied to 21 consecutive patients, permitted a correct and prompt bedside diagnosis. Acute Reiter syndrome could be differentiated by characteristic mucucutaneous lesions, arthritis/tenosynovitis confined to lower extremities, massive recurrent knee effusions, low back pain, conjunctivitis, and genitourinary inflammation. Gonococcal arthritis could be differentiated by migratory arthralgias, high fevers, arthritis/tenosynovitis initially confined to upper extremities, typical cutaneous lesions, and dramatic defervescence to penicillin therapy. Laboratory data provided support for each diagnosis.

Ultrasonic diagnosis of a popliteal artery aneurysm

Ultrasound techniques are very effective in screening painful masses of the popliteal space. These techniques easily differentiate popliteal cysts from thrombophlebitis, and in addition permit sequential evaluation without patient discomfort or invasion. We report its use in diagnosing a popliteal artery aneurysm, another cause of a painful popliteal mass.