Pustular psoriasis: A distinct aetiopathogenic and clinical entity.

Pustular psoriasis is a distinct subset of psoriasis that presents with involvement of the skin in the form of sterile pustules along with systemic manifestations. Though it has been conventionally grouped under the umbrella of psoriasis, recent research has shed light on its pathogenetic mechanisms associated with the IL-36 pathway, which is distinct from conventional psoriasis. Pustular psoriasis in itself is a heterogeneous entity consisting of various subtypes, including generalised, localised, acute, and chronic forms. There is confusion regarding its current classification as entities like deficiency of IL-36 antagonist (DITRA) which are closely related to pustular psoriasis both in their pathogenetic mechanism and its clinical manifestations, are not included under pustular psoriasis. Entities like palmoplantar pustulosis, which presents with similar clinical features but is pathogenetically distinct from other forms of pustular psoriasis, are included under this condition. Management of pustular psoriasis depends upon its severity; while some of the localised variants can be managed with topical therapy alone, the generalised variants like Von Zumbusch disease and impetigo herpetiformis may need intensive care unit admission and tailor-made treatment protocols. The advent of newer biologics and better insight into the pathogenesis of pustular psoriasis has opened the way for newer therapies, including tumour necrosis factor-alpha inhibitors, interleukin-1 inhibitors, interleukin-17 inhibitors, and granulocyte monocyte apheresis. It continues to be an enigma whether pustular psoriasis is actually a variant of psoriasis or an entirely different disease entity, though we feel that it is an entirely different disease process.

Review of the reasons for and effectiveness of switching biologics for psoriasis treatment in Korea.

Background Switching of biologics in patients has become common in clinical practice. Objectives This study investigated the reasons for and effectiveness of switching biologic agents during the treatment of psoriasis. Methods We retrospectively reviewed patients with psoriasis who were treated with biologics at Pusan National University Hospital and Chosun University Hospital from March 2012 to June 2020. We assessed their demographics and treatment characteristics (reasons for switching biologics and efficacy of the first- and second biologic agents). Results Of the 162 psoriatic patients treated with biologic agents for more than 52 weeks, 35 required a switch to another biologic agent. The reasons for switching biologic agents were inefficacy (n = 30), adverse events (n = 2) and others (n = 3). The mean psoriasis area and severity index (PASI) score was 12.1 at the start of the second biologic and 3.4 at 14-16 weeks later. Patients were more likely to switch to another biologic agent when they exhibited a high initial psoriasis area and severity index score and concomitant psoriatic arthritis. Limitations As a retrospective study, there were some limitations such as lack of a placebo control group and the time point of 14-16 weeks being somewhat early to judge the effect of the biologics. Conclusions The most common reason for switching biologic agents in Korea was treatment inefficacy, especially secondary failure. Despite the inefficacy of previous biologic agents, switching to a different agent may be an efficacious approach.

Pattern of use of biologics in psoriasis among Indian dermatologists - A cross sectional survey.

Background and Aims Biologics are a relatively new class of highly effective drugs in the management of psoriasis. They act on specific immune processes, achieve rapid and sustained clearance and do not cause target organ damage unlike conventional systemic therapy. It appears that their use in our country is not as widespread as in developed nations despite these benefits ; their prohibitive cost may be a major factor for the limited usage. This survey aimed to find out the extent of use and factors hindering usage of biologics for the management of psoriasis by Indian dermatologists. Methods It was a cross-sectional questionnaire based study. The questionnaire was designed after a focussed group discussion, followed by validation. The survey was sent in the form of a link to Indian dermatologists. The responses were recorded in excel-sheet and the data was analyzed by SPSS ver 25. Results Of the 310 participants who took part, 287 completed the survey. Two hundred (70%) were users of biologics, while 87 (30%) had never used them. Cost was the major factor which prevented biologic use. Majority of the respondents used biologics in less than 2 cases per month. Secukinumab was the most common biologic used followed by etanercept. The factors which determined choice of biologics were convenience, cost, previous experience, co-morbid conditions and recommendations by an expert. Limitations A small sample size was the limitation of the study. Dermatologists who do not use biologics may be under-represented in the study. Conclusions Biologics are not used optimally by Indian dermatologists for management of psoriasis. The cost, fear of adverse effects, lack of awareness and inadequate felt need are major factors which prevent their regular use.

Dermatology practice in the times of the COVID-19 pandemic.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is implicated in the ongoing pandemic across the globe since December 2019. It was first notified by China from Wuhan on 31 December 2020 and transmission to healthcare workers was first reported on 20 January 2020. Human-to-human transmission is mainly by droplet infection. At present no effective vaccine is available. Our speciality needs to collectively address the urgent issue of risk of transmission in dermatology practice. A case series of Coronavirus Disease 2019 (COVID-19) from Wuhan described that 41.3% of their patients may have acquired the infection from the hospital. Of all the infected health care workers, 77.5% worked in general wards and departments. These data highlight the significant risk of nosocomial transmission of COVID-19 and also the higher risk in general wards and departments compared to the emergency room or intensive care unit. Dermatology patients are generally seen in clinics and in outpatient departments in hospitals. Patients wait together in the waiting area, intermingle and then are seen by the physician in their chamber. This can cause transmission of the pathogen among patients and from patient to physician. Social distancing, hand hygiene and the use of personal protective equipment are important for preventing the spread of infection and dermatology practices also have to incorporate these aspects. Telemedicine is becoming an important tool for the management of dermatology patients in these times. At-risk patients in dermatology also need to be given priority care. Protocols for the use of immunosuppressants and biologics in dermatology during the pandemic are being developed.

Nanoencapsulation of triterpene 3ß,6ß,16ß-trihydroxylup-20(29)-ene from Combretum leprosum as strategy to improve its cytotoxicity against cancer cell lines.

The pentacyclic triterpene 3ß,6ß,16ß-tri-hydroxilup-20(29)-ene is a natural product produced by the Brazilian medicinal plant Combretum leprosum. Its cytotoxicity has been previously reported against breast cancer cell lines. The low water solubility of this natural product, that hampers its bioavailability, motivated the investigation of a new nanoparticle formulation containing the triterpene in order to improve its bioactivity. The triterpene was encapsulated in polycaprolactone (PCL) polymer by nanoprecipitation, producing homogenic nanoparticles with nanometer sizes (122.7 ± 2.06 nm), which were characterized by FT-IR, SEM imaging and DSC. The cytotoxicity (MTT method) of the nanoparticle containing the triterpene 1, besides the free natural product and the nanoparticle control (without 1), was assayed against three human tumor cell lines [human colon carcinoma line (HCT116), prostate (PC3) and glioblastoma (SNB19)] and the normal epithelial embryo kidney human cell line (Hek293T). The nanocarrier produced a significative effect in the cytotoxicity of the natural product in the nanoformulation (IC50 0.11-0.26 µg mL-1) when compared with its free form (IC50 1.07-1.44 µg mL-1). Additionally, higher selectivity of the triterpene to the tumor cells was found when it was encapsulated (SI 1.92-4.54) than in its free form (SI 0.42-0.56). In this case, the nanoencapsulated triterpene was more selective to PC3 (SI 3.33) and SNB19 (SI 4.54) tumor cells.

Biologics in Leprosy: A Systematic Review and Case Report.

Tumor necrosis factor (TNF)-α inhibitors increase susceptibility to tuberculosis, but the effect of biologics on susceptibility to leprosy has not been described. Moreover, biologics may play a role in treating erythema nodosum leprosum (ENL). The objectives of this systematic review were to determine whether the development of clinical leprosy is increased in patients being treated with biologics and to assess the use of biologics in treating leprosy reactions. A systematic literature review was completed of patients with leprosy who received treatment with biologics either before or after a diagnosis of leprosy was confirmed. All studies and case reports were included for qualitative evaluation. The search yielded 10 cases (including one duplicate publication) of leprosy diagnosed after initiation of TNF-α inhibitors and four case reports of refractory ENL successfully treated with infliximab or etanercept. An unpublished case of persistent ENL responsive to infliximab is also presented. These data demonstrate that the use of TNF-α inhibitors may be a risk factor for developing leprosy or reactivating subclinical infections. Leprosy can present with skin lesions and arthritis, so leprosy should be considered in patients presenting with these signs before starting treatment with these agents. Leprosy should be considered in patients who develop worsening eruptions and neurologic symptoms during treatment with TNF-α inhibitors. Finally, TNF-α inhibitors appear effective in some cases of refractory ENL.

Serious Adverse Drug Events Reported to the FDA: Analysis of the FDA Adverse Event Reporting System 2006-2014 Database.

BACKGROUND: Data on adverse drug events (ADEs) observed at the population level provide important evidence regarding the safety of a pharmaceutical product in real-world settings. Recent patterns in serious and fatal ADE reporting have not been documented. OBJECTIVE: To assess recent patterns in serious and fatal ADE reports in the United States. METHODS: We conducted a retrospective analysis of the publicly available 2006-2014 FDA Adverse Event Reporting System database. Non-U.S. reports, reports from clinical trials, and reports with missing outcome data were excluded. The annual numbers of ADEs with reported outcome of death, disability, and other serious outcomes were determined. Types (direct, manufacturer expedited, or manufacturer periodic) and sources (consumer, health professional, or other) of these serious ADE reports were also identified. The distribution of serious ADE reports by patient age groups (< 18, 18-44, 45-64, and ≥ 65 years) was determined. Drugs listed as primary suspects in serious ADEs (death, disability, and other serious outcomes) were identified and ranked. Descriptive statistics were used to characterize the patterns in serious or fatal ADE reporting. RESULTS: From 2006 to 2014, the number of serious ADEs reported to the FDA increased 2-fold. A total of 902,323 serious outcomes were reported over the 9-year study period: 244,408 deaths, 72,141 disabilities, and 585,774 other serious outcomes. The relative percentage of reports of deaths was highest during 2012 (32.4%). The percentage of reports of disability was highest during 2006 (12.1%). Overall, the "other serious outcomes" category accounted for almost 65% of serious ADEs reports. Expedited reports from drug manufacturers were most common (about 72%) of the serious ADEs with available data on report type. Health professionals (47.3%) were the most common source of report followed by consumers (36.1%) and other sources (16.6%). A disproportionately high number of reported ADEs was among patients aged 45-64 years (40%) and ≥ 65 years (32.6%). Antineoplastic drugs were more frequently reported with deaths. Three antidepressant drugs were among the top 10 drugs reported with disability. During 2006-2014, there were 38 drugs with more than 1,000 reports of serious ADEs in a given year: 2 drugs currently withdrawn from the market (rofecoxib and parecoxib), 10 drugs with an FDA risk evaluation and mitigation strategies (REMS) program, 13 biologic or specialty drugs, and 14 others. CONCLUSIONS: An overall increase in the trend of the number of serious ADE reports was observed from 2006 to 2014. Drugs with a REMS program and biologic and specialty drugs were involved in a significant number of reported serious ADEs. Data on reporting patterns can guide surveillance and pharmacoepidemiological studies to understand the public health burden of serious ADEs. DISCLOSURES: No outside funding supported this study. Hansen has received consulting fees from and has provided expert testimony for Daichii Sankyo and Takeda. The other authors have nothing to disclose.

[Some case reports which suggest correlation between biologics and leprosy, Mini-symposium on problems on leprosy].

Biologics are relatively new drugs developed through modern monoclonal antibody techniques and became more familiar to some disease treatments such as Rheumatoid arthritis, psoriasis, ankylosing spondylitis, ulcerative colitis, malignant lymphoma, SLE and lupus nephritis. Some case reports shows development of leprosy during/after biolo- gics treatment and success treatment of ENL with biologics. Collection of reports was done through web search by using document retrieval engine such as Pub-med and ProQuest. 7 cases of development of leprosy with biologics and 2 cases of ENL treatment with biologics and they were reported in the mini-symposium of Annual academic meeting of Japan Leprosy association. The widespread use of biologics reminds us of development of some infectious diseases as a side-effect and leprosy might be one of them. Because number of the reports was still very limited, we cannot go to further discussion at this moment. Accu- mulation of reported cases will lead the detailed information about correlation between biologics and leprosy, either on effectiveness or on adverse ones.

Non-stabilized nucleophiles in Cu-catalysed dynamic kinetic asymmetric allylic alkylation.

The development of new reactions forming asymmetric carbon-carbon bonds has enabled chemists to synthesize a broad range of important carbon-containing molecules, including pharmaceutical agents, fragrances and polymers. Most strategies to obtain enantiomerically enriched molecules rely on either generating new stereogenic centres from prochiral substrates or resolving racemic mixtures of enantiomers. An alternative strategy--dynamic kinetic asymmetric transformation--involves the transformation of a racemic starting material into a single enantiomer product, with greater than 50 per cent maximum yield. The use of stabilized nucleophiles (pKa < 25, where Ka is the acid dissociation constant) in palladium-catalysed asymmetric allylic alkylation reactions has proved to be extremely versatile in these processes. Conversely, the use of non-stabilized nucleophiles in such reactions is difficult and remains a key challenge. Here we report a copper-catalysed dynamic kinetic asymmetric transformation using racemic substrates and alkyl nucleophiles. These nucleophiles have a pKa of ≥50, more than 25 orders of magnitude more basic than the nucleophiles that are typically used in such transformations. Organometallic reagents are generated in situ from alkenes by hydrometallation and give highly enantioenriched products under mild reaction conditions. The method is used to synthesize natural products that possess activity against tuberculosis and leprosy, and an inhibitor of para-aminobenzoate biosynthesis. Mechanistic studies indicate that the reaction proceeds through a rapidly isomerizing intermediate. We anticipate that this approach will be a valuable complement to existing asymmetric catalytic methods.

Platelet-rich plasma in dermatology: boon or a bane?

There has been a recent spurt in application of platelet-rich plasma (PRP) in dermatology and aesthetic medicine. However, the details regarding use of PRP in various dermatological indications ranging from hair restoration to chronic ulcers are dispersed in literature, herein we have tried to focus all under one heading. Overall, PRP seems to be a promising therapeutic modality but the level of evidence as of now, from the available published data is low. This review will also stimulate readers to carry out well designed, larger population based trials, so as to validate its use in dermatology practice.

Bioprocess design for the microbial production of natural phenolic compounds by Debaryomyces hansenii.

Debaryomyces hansenii NRRL Y-7426 metabolised ferulic acid into different phenolic compounds using a factorial design where glucose concentration (in the range of 1-20 g/L), peptone concentration (2-20 g/L) and yeast extract concentration (0.2-10 g/L) were the independent variables. The interrelationship between dependent and operational variables was well fitted (R (2) > 0.95) to models including linear, interaction and quadratic terms. Depending on the glucose and nitrogen concentrations, which redirected the metabolism, the major degradation products were 1,226.2 mg 4-vinyl guaiacol/L after 72 h (molar yield of 86.0 %), 1,077.8 mg vanillic acid/L after 360 h (molar yield of 91.1 %) or 1,682.6 mg acetovanillone/L after 408 h (molar yield of 98.8 %) in fermentations carried out with 2,000 mg ferulic acid/L. Other metabolites such as vanillin, vanillyl alcohol or 4-ethylguaiacol were present in lower amounts.

Biocontrol of Penicillium nordicum growth and ochratoxin A production by native yeasts of dry cured ham.

Twelve yeast strains isolated from the surface of Italian typical dry-cured hams, belonging to D. hansenii, D. maramus, C. famata, C. zeylanoides and H. burtonii species, and previously selected for their ability to grow in dry-cured ham-like substrates, were screened for antagonistic activity against a toxigenic strain of P. nordicum and inhibition of ochratoxin A (OTA) biosynthesis. On average, yeast inhibitory activity was lowered by increasing fungal inoculum and enhanced by NaCl presence. In the assay conditions, H. burtonii and C. zeylanoides were the most effective, both in inhibiting P. nordicum growth and OTA production. D. hansenii was the species with the lowest inhibitory activity, especially in the absence of salt. OTA production dropped from the range < LOD - 5000 ppb in P. nordicum control plates to the range < LOD - 200 ppb in yeast-added plates. OTA production increased in the presence of NaCl in P. nordicum control plates, while salt enhanced inhibition against OTA production in yeast-added plates.

Psoriasis: what is new in nonbiologic systemic therapy in the era of biologics?

Psoriasis is a common debilitating disease significantly affecting the quality of life of the patients. Majority of the psoriasis patients have mild disease which can be managed by topical therapies. Around 30% of the psoriasis patients require systemic therapy during the course of their disease. There is a vast array of drugs for the treatment. Methotrexate, cyclosporine and retinoids are the most commonly used conventional systemic drugs. Newer studies provide insight into their more effective and safer use and as combination therapy with biologics. In recent times, many new drugs with novel mechanisms of action other than biologics have been tried in psoriasis. In this article, we have reviewed the current developments and new found role of the conventional drugs as well as the newer nonbiologic systemic drugs in the treatment of psoriasis.

Management of psoriatic arthritis.

Psoriatic arthritis (PsA) is a chronic inflammatory disease that can be progressive and may be associated with permanent joint damage and disability. Early identification of PsA will enable these patients with progressive disease to be treated early and aggressively. Due to lack of consistent diagnostic or classification criteria in the past, PsA was considered as uncommon. Overall it affects 6-10% of all psoriasis patients during the course of their disease. Both dermatologists and rheumatologists should be involved in the diagnosis and management of this disorder. Interest in PsA has greatly enhanced over the past several years due to many factors including a better understanding of disease mechanisms, improved investigational tools, better clinical trial design and perhaps most importantly, the availability of newer therapeutic agents. Mild forms of PsA can initially be treated with nonsteroidal antiinflammatory drugs (NSAID). In acute as well as oligo- to polyarticular joint involvement, disease-modifying anti-rheumatic drugs (DMARD) are indicated for PsA. The biologics particularly tumor necrosis factor alpha (TNF-α) antagonists are gaining increasing significance as second-line therapy. Treatment choice should also take into consideration the extent of skin involvement.

[Psoriasis]. / Psoriasis.

Psoriasis is a skin disease typically presenting with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. The name derives from pisigmaomicronrhoalpha (mange or scabies), and in ancient times the disease was confused with leprosy resulting in expulsion from society. Hence, both itching and social stigmatization are major problems affecting patients with psoriasis. Today, psoriasis is recognized as a genetically determined, autoimmune, T cell mediated systemic disease manifesting on the skin, nails and joints and associated with a number of co-morbidities. Accordingly, therapeutic strategies are antiinflammatory, antiproliferative and keratolytic. The extent and severity of disease (PASI), impairment of life quality (DLQI), and affected anatomic regions (inverse, palmoplantar, nails) as well as co-morbidities (arthritis, metabolic syndrome, cardiovascular disease, depression) determine the therapy. In 80 % of cases psoriasis is mild or moderate and sufficiently treated with topical corticosteroids, vitamin D-analogues, and phototherapy. 20 % of patients suffer from severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, ciclosporin A or the newer biologic agents. Especially in severe psoriasis, psychological strain, co-morbidities, and medico-economic aspects must be taken into account.

Natural products with antileprotic activity

Leprosy is a chronic infectious disease caused by Mycobacterium leprae bacillus. It was considered to be an incurable disease for ages. Nowadays leprosy is a vanishing disease although we can meet it principally in the tropical zone countries. Brazil has the second greatest number of leprosy cases around the world with almost 30,000 new cases diagnosed in 2005. The present work constitutes a literature review on plant extracts and chemically defined molecules of natural origin showing antileprotic activity. The review refers to 11 plants, their families, and geographical distribution, the utilized parts, the type of extract and the tested organism. It also includes 17 compounds isolated from higher plants and microorganisms, classified into appropriate chemical groups. Some aspects of recent antileprotic-activity-directed research on natural products are discussed. For this purpose 63 references were consulted.

A hanseníase é uma doença crônica infecciosa ocasionada pelo Mycobacterium leprae. Foi considerada incurável por muitos anos. Atualmente a lepra é uma doença em desaparecimento, apesar de podermos encontrá-la principalmente nos países da zona tropical. O Brasil é o país que tem o segundo maior número de casos de lepra ao redor do mundo com quase 30.000 novos casos diagnosticados em 2005. Este trabalho teve como objetivo revisar a literatura dos vegetais e substâncias de origem natural com atividade antileprótica. Foram encontradas 11 plantas e 17 substâncias isoladas de plantas e microrganismos que foram classificados em grupos químicos adequados. Alguns aspectos de pesquisa recente com produtos naturais direcionados à produção de drogas contra a lepra também são discutidos. Foram consultadas 63 referências.

Defective production of monocyte-activating cytokines in lepromatous leprosy.

We have examined the capacity of monocytes from patients with leprosy to undergo activation and the capacity of mononuclear cells from these patients to incorporate [3H]thymidine and produce monocyte-activating cytokines. Monocytes from patients with either lepromatous or tuberculoid leprosy were activated by concanavalin A (Con A)-induced mononuclear cell supernatants generated from the leukocytes of a normal person. Monocytes activated by these supernatants strongly inhibited L. pneumophila multiplication, and the degree of inhibition was comparable in both groups of patients. Mononuclear cells from patients with either form of leprosy responded comparably to Con A with vigorous [3H]thymidine incorporation. Mononuclear cells from patients with tuberculoid leprosy also vigorously incorporated [3H]thymidine in response to M. leprae antigens. In contrast, mononuclear cells from patients with lepromatous leprosy did not exhibit significant [3H]thymidine incorporation in response to M. leprae antigens. The capacity of mononuclear cells to generate monocyte-activating cytokines generally paralleled their capacity to incorporate [3H]thymidine in response to Con A and M. leprae. Mononuclear cells from patients with either form of leprosy responded to Con A with the production of cytokines (supernatants) able to activate normal monocytes, expressed by inhibition of L. pneumophila multiplication. However Con A-induced supernatants from patients with lepromatous leprosy were less potent than Con A-induced supernatants from patients with tuberculoid leprosy. Mononuclear cells from patients with tuberculoid leprosy responded to M. leprae antigens with the production of potent monocyte-activating supernatants. In contrast, mononuclear cells from patients with lepromatous leprosy did not produce monocyte-activating cytokines in response to M. leprae antigens. These studies support the hypothesis that the immunological defect in lepromatous leprosy results from a failure to activate mononuclear phagocytes rather than from an intrinsic inability of these cells to be activated. We suggest that the failure to activate mononuclear phagocytes stems from defective production of monocyte-activating cytokines in response to M. leprae antigens.

Cell-mediated immunity in Legionnaires' disease.

Previous studies from this laboratory have suggested a role for cell-mediated immunity in host defense against Legionella pneumophila. In this paper, cell-mediated immunity to L. pneumophila in patients recovered from Legionnaires' disease was studied by examining patient mononuclear cell responses to L. pneumophila antigens. Patient mononuclear cells were assayed both for their capacity to respond to L. pneumophila antigens with the production of cytokines that activate monocytes, as measured by monocyte inhibition of L. pneumophila multiplication, and for their capacity to respond with proliferation, as measured by [(3)H]thymidine incorporation. Patient mononuclear cells incubated with formalin-killed L. pneumophila generated cytokines (supernatants) that were capable of activating in vitro freshly explanted monocytes from a person without historical or serological evidence of L. pneumophila infection (nonpatient). Such activated nonpatient monocytes inhibited the intracellular multiplication of L. pneumophila, and the degree of inhibition was proportional to the concentration of supernatant added. Patient mononuclear cells incubated with 5 x 10(6) - 5 x 10(8) formalin-killed L. pneumophila/ml for 4 d produced maximally potent supernatants; supernatants generated in flat-bottomed wells were equivalent in potency to supernatants generated in cone-shaped wells. Patient L. pneumophila-induced mononuclear cell supernatants were less potent than patient concanavalin A-induced mononuclear cell supernatants. Patient mononuclear cells also responded to formalin-killed L. pneumophila with proliferation (lymphoproliferation). Patient mononuclear cells responded more strongly to L. pneumophila antigens than mononuclear cells of age- and sex-matched nonpatients, as measured by both assays; responses to concanavalin A were comparable. Mononuclear cells from patients recovered from Legionnaires' disease responded more strongly to L. pneumophila than to Mycobacterium leprae antigens, whereas mononuclear cells from patients with tuberculoid leprosy responded more strongly to M. leprae antigens. These findings indicate that cell-mediated immunity to L. pneumophila develops in patients with Legionnaires' disease and, taken together with previously reported findings, that cell-mediated immunity plays a major role in host defense against L. pneumophila. The monocyte activation assay described in this paper has general applicability for the study of monocyte and mononuclear cell effector functions in selected patients. The assay may be used to study (a) the capacity of a patient's monocytes to be activated to an antimicrobial potential by a standard preparation of cytokines and (b) the capacity of a patient's mononuclear cells to generate such monocyte-activating cytokines in response to a mitogen or antigen.