Distress, symptom distress, and immune function in women with suspected breast cancer.

PURPOSE/OBJECTIVES: To investigate distress and its association with immune function among women with suspected breast cancer. DESIGN: Prospective, descriptive, correlational study. SETTING: An outpatient breast clinic at a tertiary urban hospital. SAMPLE: A convenience sample of women who had either a fine needle aspiration or open breast biopsy for a suspicion of breast cancer. Thirty-five women comprised the study sample, 6 with malignant and 29 with benign tumors. METHODS: Data were collected at three points in time. The first time (T1) was after the physician visit when the need for breast biopsy was ascertained. The second time (T2) was 7-10 days postbiopsy, and the third time (T3) was 7-10 days after T2. At T1, T2, and T3, participants filled out the Brief Symptom Inventory (a measure of psychological distress) and the Adapted Symptom Distress Scale (a measure of symptom distress) and provided a blood sample. Demographic data also were collected at T1. Immune function was measured by serum cytokine levels of transforming growth factor beta (TGF beta) and tumor necrosis factor alpha (TNF alpha). MAIN RESEARCH VARIABLES: Psychological distress, symptom distress, and immune function. FINDINGS: Psychological distress scores were moderate to high. Symptom distress was either nonexistent or slight. Significant correlations between psychological distress and symptom distress were found at T2 and T3. At T2, significant relationships between psychological distress and TNF alpha and between symptom occurrence and TNF alpha were found. Psychological and symptom distress scores were significantly different between women with malignant versus benign tumors at all three times. No differences in cytokine levels were found between the groups. CONCLUSIONS: These results suggest the strong effect that the diagnostic process has on psychological distress and its potential effects on immune functioning. Distress was significantly greater for women with malignant disease; however, women with benign disease continued to have elevated levels of distress. IMPLICATIONS FOR NURSING PRACTICE: Nurses should be aware of the extremely stressful nature of the diagnostic phase and should continue to provide support, knowing that this distress continues throughout this phase, particularly for women diagnosed with malignancy.

Nonspecific and immune-specific up-regulation of cytokines in rabbit dermal tuberculous (BCG) lesions.

To our knowledge, this is the first sequential study of cytokines in tissue sections of developing and healing tuberculous (BCG) lesions. In situ hybridization, immunohistochemical, and RT-PCR techniques were used. Cytokine mRNAs showed a biphasic pattern. The percentage of mononuclear cells (MN) containing IL-1beta, TNF-alpha, MCP-1, and IL-8 mRNAs was highest in 1- to 3-day lesions, apparently because of the nonspecific inflammatory response caused by the tubercle bacilli in the BCG vaccine. At 5 days, this percentage was significantly reduced. With IFN-gamma, the peak and trough were delayed by 2 days. By 9 days, the percentage of MN containing the mRNAs of all five cytokines had again increased and the rabbits had become tuberculin-positive. In general, MCP-1 and TNF-alpha proteins and the vascular adhesion molecules, ICAM, VCAM, and perhaps ELAM, peaked at about 3 days. Many mononuclear cells surrounding the central areas of solid and liquefied caseous necrosis contained chemokine IL-8 mRNA. IL-8 is known to attract PMN, and PMN were present nearby. In contrast, MN containing chemokine MCP-1 mRNA were present more peripherally in areas rich in macrophages and lymphocytes. The early nonspecific cytokine response seems to be an adjuvant effect of the mycobacteria in BCG vaccine in that it causes a rapid entry of macrophages, lymphocytes, granulocytes, and probably dendritic cells into local sites of antigen deposition. This effect should be considered in developing improved vaccines for the prevention of tuberculosis, because BCG vaccines producing a strong early cytokine response should be more immunogenic than BCG vaccines with similar antigens producing a weak response.

Nordihydroguaiaretic acid blocks IL-2-independent lymphocyte proliferation and enhances responses to PPD.

The authors examined the mechanism by which the non-specific lipoxygenase inhibitor nordihydroguaiaretic acid (NDGA) inhibits human lymphocyte proliferative responses and compared its effects with those of cyclosporine (CsA). It was found that CsA-resistant proliferative responses induced by direct PK-C activators such as mitogenic concentrations of the phorbol ester TPA or the putative antitumour agent bryostatin 1 (bryo 1) were inhibited in a concentration-dependent manner by NDGA (IC50 = 2 microM). In contrast, CsA-sensitive IL-2-dependent proliferative responses induced by PHA, anti-CD3 or the purified protein derivative (PPD) of M. tuberculosis were not significantly inhibited by NDGA concentrations as high as 8 microM. The expression of the IL-2R by lymphocytes was also resistant to NDGA concentrations that effectively blocked the mitogenic effects of TPA or bryostatin, but could be inhibited by higher concentrations of NDGA (IC50 = 8 microM). In addition, NDGA, but not CsA, blocked the production of IL-6 by human mononuclear cells. Furthermore, PPD-induced proliferation was significantly enhanced by NDGA. These data would suggest that NDGA at concentrations below 8 microM selectively inhibits IL-2-independent proliferation. NDGA's ability to inhibit IL-6 while enhancing the proliferative response to PPD may indicate an anti-inflammatory therapeutic potential of antioxidants in mycobacterial infections.

Infection of SCID mice with Mycobacterium leprae and control with antigen-activated "immune" human peripheral blood mononuclear cells.

The SCID (severe combined immunodeficient) mouse lacks both B and T cells and tolerates injected mononuclear cells from humans, the principal hosts of Mycobacterium leprae. A SCID mouse model of leprosy could be useful to investigate potential vaccine strategies using human cells in a context in which the growth of the organism is monitored. Initial experiments determined that SCID mice are more susceptible than normal mice to infection and dissemination of M. leprae. Cells from humans, either BCG vaccinated or from countries where leprosy is endemic, were stimulated in vitro with a number of mycobacterial antigens--whole M. leprae, M. leprae cell walls, purified protein derivative of M. tuberculosis, and Mycobacterium bovis BCG--and tested for proliferation and production of interleukin-6, tumor necrosis factor alpha, and gamma interferon. Cell walls were the most efficient and consistent in inducing all of these activities. In vitro-activated human cells retain function better after injection into SCID mice than nonactivated cells. To test the ability of cells to affect the growth of M. leprae in the footpads of SCID mice, cells from a known responder to mycobacterial antigens and from a nonresponder were activated by M. leprae cell wall antigens. The cells were harvested and coinjected with fresh M. leprae into the right hind footpads of SCID mice. After 3 months, there was no growth of M. leprae in the footpads of mice coinjected with cells from the mycobacterial antigen responder, while growth was uninhibited in mice receiving cells from the nonresponder. Future experiments will determine requirements for antigen specificity in inhibiting M. leprae multiplication.

Immune responses to fractionated cytomegalovirus (CMV) antigens after HIV infection. Loss of cellular and humoral reactivity to antigens recognized by HIV-, CMV+ individuals.

In order to delineate the molecular pathogenesis of the increased susceptibility to CMV disease in HIV infection, the patterns of antigen responsiveness in HIV-infected and non-infected individuals were investigated. CMV was fractionated by SDS-PAGE and electroblotted onto nitrocellulose. Lymphoproliferative responses of healthy HIV-, CMV+ individuals and HIV+, CMV+ asymptomatic patients to a whole CMV antigen preparation and to 20 fractions of nitrocellulose-bound CMV were then compared. Three fractions of approximate molecular weight of 130-165, 65-75, and 55-65 kD appeared to contain the major T cell stimulating antigens for HIV-, CMV+ individuals. A statistically significant depression of responses to fractions containing antigens in the ranges of 130-165 kD and 55-65 kD but not to whole CMV was seen in HIV+ individuals compared with controls. In healthy controls, the sum of the proliferative responses as measured by 3H-thymidine uptake to these three major fractions was approximately equal to the response to a whole CMV antigen preparation, whereas it was less than half of this response in five out of six HIV+ subjects. When antibody activities to CMV antigens were analysed by immunoblotting of sera from the two subject groups and also sera of ARC and AIDS patients, a selective loss of reactivity was revealed in 10 out of 19 HIV+ subjects to a band of 26-28 kD whereas all 15 HIV-, CMV+ controls recognized this band. Serum IgG and IgM values were both significantly higher in HIV+ individuals than in controls. These findings suggest that specific lesions in the repertoire of immune responsiveness to CMV antigens occur in HIV+ individuals.

Cellular, humoral, and gamma interferon responses to Mycobacterium leprae and BCG antigens in healthy individuals exposed to leprosy.

Protective immunity against mycobacteria is dependent on antigen-specific T cells. The antibodies induced upon immunization with mycobacteria have no apparent role in host protection. Serological techniques have detected some antigens that are also recognized by human T cells but may fail to recognize others. Potentially, there may be differences in the epitopes seen by the T and B cell anti-mycobacterial antigen repertoires. We have screened the different components of sonicated BCG or Mycobacterium leprae that were separated according to their molecular weight (MW) by SDS-PAGE and then electroblotted on nitrocellulose paper. The blots were cut into squares and tested directly in a T cell proliferation assay. Our results indicate that peripheral T cells of healthy leprosy patient contacts respond preferentially to the lower MW (less than 70,000) and not the higher MW fractions of M. leprae and BCG, in contrast to the humoral response of these same individuals. The most important fractions in inducing a lymphoproliferative response were in the regions of 11-16 kDa of BCG and M. leprae and to the 22-26 kDa region of M. leprae. These fractions appeared to represent molecular weight regions that were in some instances clearly distinct from previously defined antigens. It was further shown that lymphoproliferation in response to mycobacterial fractions correlated with the production of gamma interferon, a lymphokine required for macrophage activation and elimination of mycobacteria. These studies allow the direct assessment of antigens involved in protective T cell-mediated immunity, and should be helpful in selecting relevant antigens for skin testing and immunization.

Natural killer (NK) cell activity and reversal reaction in leprosy.

Two studies were conducted to assess natural killer (NK) cell activity in leprosy patients and healthy Ethiopian controls. The first study tested 26 untreated leprosy patients across the spectrum of the disease. It was found that lepromatous leprosy and all untreated, nonreactional patients had lower NK activity than healthy controls. However, patients presenting with reversal reaction (RR) had NK activity within the normal range. Heterogeneity was particularly marked in the NK activity of borderline patients. In the second study, NK cell activity was assessed in treated borderline tuberculoid leprosy (BT) patients. There were 30 patients with a history of RR and 27 BT patients without such a history (NR). All patients had had at least 3 years of dapsone treatment and 6 months of multidrug therapy. There were 26 control subjects. NK activity was higher in controls than in patients only at one effector:target (E:T) ratio tested, but NK cells from the BT patient group appeared to be more "aggressive" in that there was significantly (p less than 0.001) less reduction of activity with dilution of effector cells. There were no significant differences in NK activity between RR and NR patients. The NK activity of NR patients was positively correlated with the size of induration of the lepromin response. We conclude that higher NK activity in acute RR would appear to be a consequence rather than a cause of reversal reactions.

An in vitro predictive test for graft versus host disease in patients with genotypic HLA-identical bone marrow transplants.

Acute graft versus host disease remains a major cause of morbidity and mortality in allogeneic bone marrow transplantation. To date, no clinically useful test has been reported that will predict the occurrence of graft versus host disease in genotypic HLA-identical donor-recipient pairs. We have developed a skin-explant model using donor lymphocytes that have been sensitized against recipient lymphocytes in vitro and cocultured with the recipient's skin. Histologic changes compatible with acute graft versus host disease are found in the positive explants. To date 32 patients have been tested in a prospective manner. Among the 18 recipient-donor pairs that were positive, 16 patients were found to have histologic Grade 2 or higher graft versus host disease of the skin on biopsy. Among the 14 negative pairs, only 3 patients had histologic Grade 2 or higher graft versus host disease of the skin on biopsy. Thus, the model has a sensitivity of 84 per cent and a specificity of 85 per cent, and is a significant predictor of the histologic occurrence of graft versus host disease (P less than 0.0005 by chi-square test). The test may be useful in the selection of donors for bone marrow transplantation and in the planning of prophylaxis against graft versus host disease.

Effect of cyclosporin and interleukin-2 on the restoration of in vitro immune responses to cytomegalovirus.

Previous studies have shown that cyclosporin (CSA) inhibits lymphoproliferation to cytomegalovirus (CMV)-infected, glutaraldehyde-fixed, and irradiated fibroblasts (CMVFFx) in vitro. Generation of cytotoxic cell activity is impaired in cultures with CSA, but the induction of suppressor cells is not. In the present studies we tested the ability of interleukin-2 (IL-2) and supernatants of lymphocytes stimulated by CMVFFx with or without CSA (1 microgram/ml) to restore functional activities of lymphocytes from primary cultures treated or not treated with CSA. IL-2 significantly enhanced lymphoproliferation, cell-mediated cytotoxicity to CMV-infected fibroblasts (CMVF), natural killer cell activity, and the activity of cells capable of suppressing the response of fresh autologous cells to CMVFFx of cells derived from control and CSA-treated primary cultures. IL-2 was found in day-2 supernatants of control cultures but not CSA-treated cultures. Day-2 control supernatants were capable of significantly enhancing proliferation and suppressor cell activity but were less efficient at restoring cytotoxic cell function. Day-2 supernatants from CSA-treated cultures were not able to enhance lymphoproliferation or cytotoxic cell function but did induce significant levels of suppressor cell activity. The results indicate the presence of different functional mediators in the culture supernatants. The ability of IL-2 to restore lymphocyte effector functions against a clinically important virus may have important therapeutic implications in the treatment of this viral infection in immunodeficiency diseases and in the restoration of immune competence after transplantation.

Effect of cyclosporine on the response of normal human lymphocytes to cytomegalovirus in vitro.

Lymphocytes from healthy volunteers seropositive for cytomegalovirus (CMV) demonstrated strong lymphoproliferative responses to CMV-infected and glutaraldehyde-fixed foreskin fibroblasts (CMVFFx) when cocultured for 6 days. Addition of the immunosuppressive drug cyclosporine (CsA) to the cultures resulted in a 10-fold reduction (P less than 0.001) in counts per minute of [3H]thymidine uptake. The proliferative response to noninfected fixed fibroblasts was also reduced 10-fold. Kinetic studies showed an inhibition of the lymphoproliferative response and not an alteration in the time course kinetics in CsA-treated cultures. Cytotoxicity to CMV-infected and unfixed fibroblasts by lymphocytes primed by CMVFFx in the presence of 0.5 micrograms of CsA per ml was significantly reduced (P less than 0.01) as compared with untreated cultures but remained significantly above background level (P less than 0.01). The cytotoxic response was still present but reduced at concentrations of greater than or equal to 1.0 micrograms/ml. Cytotoxicity to noninfected fibroblasts by CMVFFx-primed lymphocytes could be eliminated by as little as 0.5 micrograms of CsA per ml. Stimulation of lymphocytes by CMVFFx but not by noninfected fixed fibroblasts resulted in the in vitro generation of suppressor cells. CsA at a final concentration of 1.0 or 2.5 micrograms/ml did not significantly impair the induction of cells capable of suppressing the lymphoproliferative response of fresh autologous mononuclear cells to CMVFFx. The findings described above may have important clinical implications in that a degree of protective immunity to CMV-infected cells is maintained even in the presence of CsA.