An open-label pilot study of infliximab therapy in diffuse cutaneous systemic sclerosis.

AIM: The safety and potential efficacy of a chimaeric anti-tumour necrosis factor alpha monoclonal antibody (infliximab) were examined in diffuse cutaneous systemic sclerosis (dcSSc). METHODS: A 26-week open-label pilot study in which 16 cases of dcSSc received five infusions of infliximab (5 mg/kg). Clinical assessment included skin sclerosis score, scleroderma health assessment questionnaire, self-reported functional score and physician global visual analogue scale. Collagen turnover, skin biopsy analysis and full safety evaluation were performed. RESULTS: There was no significant change in skin score at 26 weeks but a trend for lower modified Rodnan skin score at 22 weeks (OR 17, 95% CI 6 to 46) compared with peak value (OR 29, 95% CI 11 to 44; p = 0.10). Serum aminoterminal propeptide of type III collagen level was significantly lower at week 26 compared with baseline (p = 0.03). Secretion of type I collagen by dermal fibroblasts was reduced at 26 weeks compared with baseline (p = 0.02). There were no deaths during the study and no suspected unexpected serious adverse reactions. 21 serious adverse events (AE) occurred in seven subjects, mostly attributable to dcSSc. 127 distinct AE occurred in 16 subjects. Of these, 19 AE (15%) were probably or definitely related to infliximab treatment. Eight (50%) patients prematurely discontinued infliximab. Anti-infliximab antibodies developed during the study in five subjects and were significantly associated with suspected infusion reactions (p = 0.025). CONCLUSION: In dcSSc infliximab did not show clear benefit at 26 weeks but was associated with clinical stabilisation and a fall in two laboratory markers of collagen synthesis. The frequency of suspected infusion reactions may warrant additional immunosuppression in any future studies in systemic sclerosis.

Cardiac Abnormalities in Adult Patients With Polymyositis or Dermatomyositis as Assessed by Noninvasive Modalities.

OBJECTIVE: Cardiac events are a major cause of death in patients with idiopathic inflammatory myopathies. The study objective was in a controlled setting to describe cardiac abnormalities by noninvasive methods in a cohort of patients with polymyositis (PM) or dermatomyositis (DM) and to identify predictors for cardiac dysfunction. METHODS: In a cross-sectional study, 76 patients with PM/DM and 48 matched healthy controls (HCs) were assessed by serum levels of cardiac troponin I, electrocardiography, Holter monitoring, echocardiography with tissue Doppler imaging, and quantitative cardiac (99m) Tc-pyrophosphate ((99m) Tc-PYP) scintigraphy. RESULTS: Compared to HCs, patients with PM/DM more frequently had left ventricular diastolic dysfunction (LVDD) (12% versus 0%; P = 0.02) and longer QRS and QT intervals (P = 0.007 and P < 0.0001, respectively). In multivariate analysis, factors associated with LVDD were age (P = 0.001), disease duration (P = 0.004), presence of myositis-specific or -associated autoantibodies (P = 0.05), and high cardiac (99m) Tc-PYP uptake (P = 0.006). In multivariate analysis of the pooled data for patients and HCs, a diagnosis of PM/DM (P < 0.0001) was associated with LVDD. CONCLUSION: Patients with PM or DM had an increased prevalence of cardiac abnormalities compared to HCs. LVDD was a common occurrence in PM/DM patients and correlated to disease duration. In addition, the association of LVDD with myositis-specific or -associated autoantibodies and high cardiac (99m) Tc-PYP uptake supports the notion of underlying autoimmunity and myocardial inflammation in patients with PM/DM.

Interleukin-2 stimulation of blood mononuclear cells from patients with inflammatory bowel disease.

The functional capacity of biologically active, high-affinity interleukin-2 receptors (IL-2R) was studied by means of interleukin-2 (IL-2) stimulation of blood mononuclear cells (BMC) from 22 patients with inflammatory bowel disease (IBD) and 24 controls. The spontaneous, as well as the IL-2-induced, proliferative responses were significantly decreased in patients with active IBD, whereas the expressions of biologically inactive, low-affinity IL-2R (i.e. TAC antigen or CD25) were significantly increased in the same BMC cultures. In contrast, no significant differences were seen between patients and controls when BMC were stimulated with a nonspecific mitogen (phytohemagglutinin). The results suggest that a downregulation of IL-2 responsiveness may contribute to decreased BMC proliferation in vitro in active IBD.

Cyclosporine-induced renal morphologic and immunohistologic changes in patients with chronic uveitis.

Ten long-term cyclosporine-treated patients with chronic uveitis underwent percutaneous renal biopsy in order to evaluate a) abnormalities of renal morphology and b) the nature of lymphocytic infiltrates by immunohistochemistry. Pretransplant renal biopsies from eleven cadaveric donors served as controls. Eight of the ten patients had lymphocytic infiltrates consisting predominantly of T lymphocytes with a CD4+/CD8+ ratio of 1.46, which is identical to that of peripheral blood in healthy donors. Evidence of immune activation as estimated by the presence of interleukin-2 receptors, transferrin receptors or by the expression of MHC class II antigens was not demonstrated in any of the patients. The severity of morphologic alterations did not correlate with any of the clinical or paraclinical data. Percutaneous renal biopsy should be performed within 18 months of treatment to identify patients susceptible to renal side effects of cyclosporine.

Immune dysfunction in multiple myeloma. Reduced natural killer cell activity and increased levels of soluble interleukin-2 receptors.

Multiple myeloma (MM) is characterized by an increased susceptibility to infections and to other malignancies. Selected related immune functions were studied. Spontaneous and interleukin-2-stimulated natural killer (NK) cell activities were normal in 19 patients with MM compared with 62 controls. In contrast, interferon-stimulated NK cells had a significantly lower increase in activity in MM than in controls. The normal improvement in lytic NK cell activity after addition of indomethacin to the mononuclear cell cultures (to inhibit prostaglandin-mediated suppression) was not observed in cultures from MM patients. As reported for other lymphoproliferative disorders, the levels of soluble interleukin-2 receptors in serum were significantly higher in MM (600 U/ml median value) compared with controls (317 U/ml median value), P less than 0.0001, and the concentration of interleukin-2 receptors was significantly correlated with the concentration of monoclonal immunoglobulin in serum. Blood monocyte chemotactic responsiveness was significantly lower in MM patients with both zymosan-activated serum and f-Met-Leu-Phe as cytotaxins, suggesting reduced ability to accumulate at inflammatory foci. In contrast, release of reactive oxygen radicals, believed to be associated with the killing ability of monocytes, was normal after in vitro stimulation.

Evidence that the effect of physical exercise on NK cell activity is mediated by epinephrine.

The present study was designed to test the hypothesis that the changes in natural killer (NK) cell activity in response to physical exercise were mediated by increased epinephrine concentrations. Eight healthy volunteers 1) exercised on a bicycle ergometer (60 min, 75% of maximal O2 uptake) and 2) on a later day were given epinephrine as an intravenous infusion to obtain plasma epinephrine concentrations comparable with those seen during exercise. Blood samples were collected in the basal state, during the last minutes of exercise or epinephrine infusion, and 2 h later. The NK cell activity (lysis/fixed number of mononuclear cells) increased during exercise and epinephrine infusion and dropped below basal levels 2 h afterward. The increased NK cell activity during exercise and the epinephrine infusion resulted from an increased concentration of NK (CD16+) cells in the peripheral blood. On the other hand, the decreased NK cell activity demonstrated 2 h after exercise and epinephrine infusion did not simply reflect preferential removal of NK cells from the blood, because the proportion of CD16+ cells was normalized. On the basis of the finding that indomethacin abolished the suppressed NK cell activity in vitro and the demonstration of a twofold increase in the proportion of monocytes (CD14+ cells) 2 h after exercise and epinephrine infusion, we suggest that, after stress, prostaglandins released by monocytes are responsible for downregulation of NK cell function. Our findings support the hypothesis that increased plasma epinephrine during physical stress causes a redistribution of mononuclear subpopulations that results in altered function of NK cells.

Immune parameters in male atheletes after a lacto-ovo vegetarian diet and a mixed Western diet.

The influence of a lacto-ovo vegetarian diet versus a meat-rich Western diet on in vitro measures of immune function was studied in eight male endurance athletes. Subjects consumed two different diets for 2 x 6 wk, separated by 4 wk on an ad libitum diet, in a cross-over design. Both diets consisted of 57 energy % (E%) carbohydrates, 14 E% protein and 29 E% fat. One diet was a mixed meat-rich diet (M) prepared with 69% animal protein sources, whereas the other diet (V) was a lacto-ovo vegetarian diet prepared with 82% vegetable protein sources. Blood for determination of leukocyte subpopulations and in vitro function was collected at the end of each diet period 36 h after the last training bout. Fiber content and P/S ratio of fatty acids were twice as high on the V diet as on the M diet. Training volume was similar on the two diets, and maximal aerobic capacity did not change during diet periods. The number of CD3+ (pan T-cells), CD8+ (mainly T suppressor cells), CD4+ (mainly T helper cells), CD16+ (natural killer cells), and CD14+ (monocytes) was similar after the two different diets. Similarly, proliferations of mononuclear cells after stimulation with interleukin-2 (IL-2), phytohemagglutinin, and purified derivative of tuberculin (PPD), as well as activity of natural killer cells in the unstimulated state and after stimulation with IL-2, indomethacin, and interferon-alpha (IFN-alpha), were identical after the two diet periods.(ABSTRACT TRUNCATED AT 250 WORDS)

Double blind placebo controlled trial of pulse treatment with methylprednisolone combined with disease modifying drugs in rheumatoid arthritis.

OBJECTIVE: To assess whether monthly treatment with intravenous methylprednisolone enhances or accelerates the effect of disease modifying drugs in patients with rheumatoid arthritis. DESIGN: A 12 month double blind, placebo controlled, multicentre trial in which patients with active rheumatoid arthritis were randomly allocated to receive pulses of either methylprednisolone or saline every four weeks for six months. At the start of the pulse treatment all patients were started on penicillamine or azathioprine. SETTING: Four rheumatology departments in Denmark. PATIENTS: 97 Patients (71 women, 26 men) aged 23-84 (mean 60) who had active rheumatoid arthritis of at least four weeks' duration despite treatment with non-steroidal anti-inflammatory drugs. MAIN OUTCOME MEASURES: Monthly clinical recording of morning stiffness, number of tender and swollen joints, blinded observers' evaluation of therapeutic effect, and patients' self assessed condition. Concomitant laboratory measurements of erythrocyte sedimentation rate and concentrations of C reactive protein and haemoglobin. Radiography to determine the number of erosions at the start of treatment and after 12 months. RESULTS: 57 Patients completed the trial, taking the same disease modifying drug throughout. Evaluation four weeks after each pulse treatment and at 12 month follow up showed no significant differences between the methylprednisolone and placebo groups in any of the clinical or laboratory variables. Radiography showed the same degree of progression of erosions in both groups. Evaluation of the total data on 97 patients and on the 57 who completed the trial showed the same lack of significance between the treatment groups. CONCLUSIONS: Intravenous pulse treatment with steroids can be recommended only for rapid temporary relief of flares of disease in patients with rheumatoid arthritis. The response is short lived. Repeated pulses of methylprednisolone at four week intervals do not improve the results of treatment with drugs that induce remission such as penicillamine and azathioprine.

[The immune system and physical training]. / Immunsystemet og fysisk traening.

The effects on the immune system of sudden physical exercise and degree of training are reviewed. During moderate as well as strenuous physical exercise natural killer (NK) cells especially, but also T and B cells are released into the blood. A few hours after moderate physical exercise the immune system is back to the pre-exercise state, but following strenuous exercise the lymphocyte concentration and the NK and B cell functions are suppressed. The immune suppression following strenuous exercise is at least partly due to release of prostaglandins from an elevated number of monocytes in the circulation. The importance of stress hormones for mediating the immune modulation is discussed. Examination of trained persons at rest show that these have elevated NK cell activity when compared to matched controls. There are sporadic reports in the literature, showing that persons who train moderately have fewer infections, while persons who train very hard have increased risk of upper respiratory diseases. These findings are in accordance with the observed immune modulation on moderate versus strenuous exercise. The effects of physical training in relation to acute and chronic diseases are evaluated.

Plasma interleukin-2 and a soluble/shed interleukin-2 receptor in serum of patients with Crohn's disease. Effect of cyclosporin.

Circulating concentrations of interleukin-2 (IL-2) and a soluble or shed form of the IL-2 receptor (sIL-2R) were determined by enzyme-linked immunosorbent assays (ELISA) in 61 patients with chronic active Crohn's disease (CD) initially and during a three month placebo controlled trial of cyclosporin 5-7.5 mg/kg/day. The baseline median (25-75% range) plasma IL-2 concentration was 0.6 ng/ml (0.3-2.85 ng/ml) in patients who did not receive prednisolone, 0.5 ng/ml (0.23-3.4 ng/ml) in patients who did (not significant), and 0 ng/ml (0-0.07 ng/ml) in control subjects (p less than 0.00001). The corresponding median serum sIL-2R concentrations were 747 U/ml (580-1287 U/ml), 540 U/ml (422-616 U/ml) respectively in CD patients (p = 0.006) and 320 U/ml (268-406 U/ml) in control subjects (p less than 0.00001). Increased concentrations of plasma IL-2 and serum sIL-2R were seen in 66% and 81% of the patients, respectively. A fall in serum sIL-2R was only seen in patients who improved with cyclosporin treatment (p = 0.006). At month 3 the median serum sIL-2R concentration was 440 U/ml (400-668 U/ml) v 801 U/ml (534-1067 U/ml) in patients not responding to cyclosporin (p = 0.003). No changes occurred in the placebo group. These results suggest that the IL-2 dependent pathway of immune activation is upregulated in vivo in CD and that cyclosporin may interfere with this process.

Bradycardia after high-dose intravenous methylprednisolone therapy.

In 5 consecutive patients with rheumatoid arthritis who received intravenous high-dose methylprednisolone (MP) therapy (1 g daily for 2 or 3 consecutive days), a decline in pulse rate was observed, most pronounced on day 4. In one of the 5 patients the bradycardia was associated with complaints of substernal pressure. Reversal to normal heart rate was found on day 7. Electrocardiographic registrations showed sinus bradycardia in all cases. No significant changes in plasma concentrations of electrolytes were found. Careful observation of patients receiving high-dose MP is recommended. High-dose MP may be contraindicated in patients with known heart disease.

Increased concentrations of interleukin 1 beta, interleukin-2, and soluble interleukin-2 receptors in endoscopical mucosal biopsy specimens with active inflammatory bowel disease.

Concentrations of interleukin-1 beta (IL-1 beta), interleukin-2 (IL-2), and soluble IL-2 receptors (sIL-2R) were determined by enzyme linked immunosorbent assays (ELISA) in supernatants of sonicated endoscopical mucosal biopsy specimens from 31 patients with inflammatory bowel disease and 19 controls. IL-1 beta was detected in 53% of the patient supernatants (p = 0.0001), IL-2 in 35% (p = 0.0031), compared with none of the controls. Soluble IL-2R was present in 55% and 26% of the specimens, respectively (p = 0.07). The concentrations of IL-1 beta (p = 0.00015), IL-2 (p = 0.0019), and sIL-2R (p = 0.0073) were highest in the most inflamed biopsy specimens, compared with less inflamed specimens and controls. There were no significant differences in IL-1 beta, IL-2, and sIL-2R concentrations between ulcerative colitis (16) and Crohn's disease patients (15). The results suggest that enhanced cellular immunity operates in vivo at the mucosal level in active inflammatory bowel disease.

A prospective study of vasculitis patients collected in a five year period: evaluation of the Chapel Hill nomenclature.

OBJECTIVE: To test the usefulness of the Chapel Hill nomenclature, supplemented with surrogate parameters, as diagnostic criteria for primary vasculitides. METHODS: To prospectively evaluate vasculitis patients according to a standardised clinical and para-clinical programme. In accordance with the Chapel Hill publication surrogate parameters were used: proteinuria, haematuria and red blood cell casts (glomerulonephritis), angiographic or ultrasonic demonstration of aneurysms or stenoses (arteritis), radiological lung infiltrates or cavitations of more than one month's duration (granuloma in the lungs), bloody nasal discharge or crusts, chronic sinusitis, otitis and/or mastoiditis, bone and/or cartilage destruction, and acute hearing loss (granuloma in upper airways). RESULTS: The following entities were diagnosed: giant cell arteritis (n=14), Takayasu arteritis (n=1), polyarteritis nodosa (n=2), Wegener's granulomatosis (n=27), Churg-Strauss syndrome (n=2), microscopic polyangiitis (n=12), Henoch-Schönlein purpura (n=2), cutaneous leucocytoclastic angiitis (n=37), and secondary vasculitis (n=21). Giant cell arteritis and cutaneous leucocytoclastic angiitis were in all cases diagnosed by biopsy. Using the Chapel Hill nomenclature supplemented with surrogate parameters, only 8 of 27 patients were diagnosed with Wegener's granulomatosis, and 3 of 12 cases with microscopic polyangiitis. The number of patients in the remaining diagnostic entities were considered to few to evaluate. CONCLUSIONS: The Chapel Hill nomenclature, supplemented with surrogate parameters, failed to act as diagnostic criteria in Wegener's granulomatosis and microscopic polyangiitis. The following diagnostic criteria are proposed for Wegener's granulomatosis: (1) Biopsy or surrogate parameter for granulomatous inflammation in the respiratory system and (2) Biopsy verified necrotising vasculitis in small to medium sized vessels or biopsy/surrogate parameter for glomerulonephritis or positive PR3-ANCA test and (3) Lack of eosinophilia in blood and biopsy samples. The following diagnostic criteria are proposed for microscopic polyangiitis: (1) Biopsy verified necrotising vasculitis in small vessels and/or glomerulonephritis with few or no immune deposits and (2) Involvement of more than one organ system as indicated by biopsy verified vasculitis in small to medium sized vessels or surrogate parameter for glomerulonephritis and (3) Lack of biopsy and surrogate parameter for granulomatous inflammation in the respiratory system. Using these criteria all Wegener's patients and 9 of 12 patients with microscopic polyangiitis could be diagnosed.

Interleukin 2 receptor expression by human blood lymphocytes after vaccination with pneumococcal polysaccharides.

Proliferative responses of unseparated peripheral blood mononuclear cells (PBMC) and blood T cells to recombinant interleukin 2 (rIL-2) were significantly increased 7-21 days after the vaccination with pneumococcal polysaccharides (PPS). In contrast, non-T cells expressed increased responsiveness to rIL-2 only on post-vaccination day 7. Analysis of the proliferative response to rIL-2 among lymphocyte subsets (CD4+Leu8+, CD4+Leu8-, CD8+Leu8+, CD8+Leu8-, CD20+) in cultures of unseparated PBMC revealed that the CD8+Leu8- T cells expressed increased responsiveness 7-14 days after vaccination, whereas neither CD4+ (Leu8+ and Leu8-) nor CD8+Leu8+ T cells showed significantly increased responsiveness after vaccination. The CD20+ B cells, like non-T cells, expressed increased responsiveness to rIL-27 days after the vaccination only. Expression of the 55 kD low-affinity interleukin 2 receptor (IL-2R, CD 25) on freshly isolated PBMC, as judged by direct fluorescence staining with a MoAb anti-55 kD chain, was low (less than 3%) and an increased expression of this receptor was not detected following vaccination. In contrast, binding of 125I-labelled IL-2 to freshly isolated PBMC increased following vaccination (day 7). Scatchard plot analysis revealed a modest increase in the expression of high-affinity IL-2R (Kd = 1-2 pM), whereas the increase in expression of the 75-kD, intermediate-affinity IL-2R (Kd = 300 pM) was more pronounced (from 195 to 295 (means) receptors per PBMC). It is concluded that, following vaccination with PPS increased IL-2R expression is induced on blood lymphocytes. These investigations suggest a role for T cells in the human immune response against PPS.

Occupational capacity after hip replacement.

Working capacity and dependence on the social welfare system were analyzed in 387 patients 5 years after hip replacement. Significant pre-operative factors were age, etiology of the hip disease and walking ability, and at the follow-up age, walking ability, pain and subjective experience of satisfaction with the operation. Among patients working pre-operatively, 92 per cent kept on working, and 70 per cent of patients on sick-leave went back to work. Only 9 per cent of patients working or sick-listed pre-operatively became invalidity pensioners, but none who were pensioners pre-operatively went back to work.

Blood mononuclear cells in patients with primary Sjögren's syndrome: production of interleukins, enumeration of interleukin-2 receptors, and DNA synthesis.

Disturbed immunoregulation is considered an essential feature of the pathogenesis in primary Sjögren's syndrome (primary SS). After in vitro stimulation we investigated the interleukin-1 production by blood monocytes, interleukin-2 production by blood T-lymphocytes, the number of IL-2 receptor-bearing blood T-lymphocytes and the blood lymphocyte DNA synthesis in 6 consecutive female patients with primary SS and in 6 female controls. In the patient group we found all the parameters examined within a wider range as compared to the controls. The three patients with reduced interleukin-2 production and low proliferative responses were exclusively characterized by elevated plasma-IgG concentration, positive antinuclear antibodies and rheumatoid factor, and by having circulating immune complexes.

Effects of in vivo hyperthermia on natural killer cell activity, in vitro proliferative responses and blood mononuclear cell subpopulations.

This work was designed to test the hypothesis that elevations in body temperature of humans induce immunostimulation. Eight healthy volunteers were immersed in a water bath (water temperature 39.5 degrees C) for 2 h, during which their rectal temperature rose to 39.5 degrees C. On a later day they served as their own controls, being immersed into thermoneutral water (34.5 degrees C) for 2 h. Blood samples were collected before immersion, at body temperatures of 38 degree C, 39 degree C and 39.5 degree C, and 2 h after water immersion. The interleukin-2 (IL-2) enhanced natural killer (NK) cell activity (lysis per fixed number of mononuclear cells), as well as the proportion and total number of NK cells (CD16+ cells), increased significantly during hyperthermia compared with control values. The lymphocyte proliferative responses did not differ significantly between hyperthermia and thermoneutral conditions. The proportion of pan-T (CD3+) cells was maximally depressed 2 h after water immersion. The decreased proportion of CD3+ cells was mainly due to a decreased percentage of CD4+ cells (not significant). The proportion of B cells (CD19+ cells) did not fluctuate significantly, while a marked and significant increase in monocyte proportion (CD14+ cells) was found 2 h after hyperthermia. Two hours after hot water immersion the lymphocyte concentration declined while the neutrophil and monocyte concentrations were augmented. Induced hyperthermia causes significantly increased serum cortisol, plasma norepinephrine and plasma epinephrine concentrations compared to controls. It is possible that the altered immune functions induced by elevated body temperature can be ascribed to altered composition and function of blood mononuclear cells induced by elevated levels of stress hormones.