Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee?

OBJECTIVE: The present randomized controlled trial compared arthrocentesis of the effusive knee followed by corticosteroid injection performed by the conventional anatomic landmark palpation-guided technique to the same procedure performed with ultrasound (US) needle guidance. METHODS: Sixty-four palpably effusive knees were randomized to (i) palpation-guided arthrocentesis with a conventional 20-mL syringe (22 knees), (ii) US-guided arthrocentesis with a 25-mL reciprocating procedure device (RPD) mechanical aspirating syringe (22 knees), or (iii) US-guided arthrocentesis with a 60-mL automatic aspirating syringe (20 knees). The one-needle two-syringe technique was used. Outcome measures included patient pain by the Visual Analogue Scale (VAS) for pain (0-10 cm), the proportion of diagnostic samples, synovial fluid volume yield, complications, and therapeutic outcome at 2 weeks. RESULTS: Sonographic guidance resulted in 48% less procedural pan (VAS; palpation-guided: 5.8 ± 3.0 cm, US-guided: 3.0 ± 2.8 cm, p < 0.001), 183% increased aspirated synovial fluid volumes (palpation-guided: 12 ± 10 mL, US-guided: 34 ± 25 mL, p < 0.0001), and improved outcomes at 2 weeks (VAS; palpation-guided: 2.8 ± 2.4 cm, US-guided: 1.5 ± 1.9 cm, p = 0.034). Outcomes of sonographic guidance with the mechanical syringe and automatic syringe were comparable in all outcome measures. CONCLUSIONS: US-guided arthrocentesis and injection of the knee are superior to anatomic landmark palpation-guided arthrocentesis, resulting in significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes.

Pressure generated by syringes: implications for hydrodissection and injection of dense connective tissue lesions.

OBJECTIVE: Hydrodissection and high-pressure injection are important for the treatment of dense connective tissue lesions including rheumatoid nodules, Dupuytren's contracture, and trigger finger. The present study determined the optimal syringes for high-pressure injection of dense connective tissue lesions. METHODS: Different sizes (1, 3, 5, 10, 20, and 60 mL) of a mechanical syringe (reciprocating procedure device) with a luer-lock fitting were studied. Twenty operators generated maximum pressure with each mechanical syringe size, and pressure was measured in pounds per square inch (psi). Subsequently, 223 dense connective tissue lesions were injected with different sizes of syringes (1, 3, or 10 mL). Outcomes included (i) successful intralesional injection and (ii) clinical response at 2 weeks. RESULTS: Smaller syringes generated significantly more injection pressure than did larger syringes: 1 mL (363 ± 197 psi), 3 mL (177 ± 96 psi), 5 mL (73 ± 40 psi), 10 mL (53 ± 29 psi), 20 mL (32 ± 18 psi), and 60 mL (19 ± 12 psi). Similarly, smaller syringes were superior to larger syringes for intralesional injection success: 10 mL: 34% (15/44) vs. 1 mL: 100% (70/70) (p < 0.001) and 3 mL: 91% (99/109) (p < 0.001). CONCLUSION: Smaller syringes (≤ 3 mL) are superior to larger syringes (≥ 5 mL) for successful hydrodissection and high-pressure intralesional injection of dense connective tissue lesions.

Surface immunoglobulins on thymus and thymus-derived lymphoid cells.

Lymphoid cells from thymus, thoracic duct lymph (TDL), and thoracic duct lymph in irradiated animals reconstituted with allogeneic thymus cells (TTDL) were labeled with radioiodinated anti-immunoglobulins using radioautographic techniques. Thymus and TTDL were labeled (14.4 and 37.0%, respectively) with anti-light chain protein after prolonged exposures (30-60 days). No labeling was observed on thymus and TTDL with anti-polyheavy chain globulin. In contrast 18.5-19.0% of TDL labeled on short exposure (6 days) with anti-polyheavy chain and anti-light chain materials. It is proposed that the difference between the labeling observed on short exposures versus long exposures can be related to the difference in surface density of immunoglobulins between nonthymus-derived (B) and thymus-derived (T) cells. The distribution of labeled cells in the thymus was preferentially among the larger cells (greater than 10 micro diameter). The TTDL population was mostly composed of a larger, blast-like population and the distribution of label was independent of size. As the thymus and TTDL preparations contain almost exclusively T cells, this represents a direct demonstration of surface immunoglobulin light chains on T lymphoid cells.

Prostaglandins from human T suppressor/cytotoxic cells modulate natural killer antibacterial activity.

We have recently described potent antibacterial activity of purified human NK cells. Here we show that this function is regulated by T cytotoxic/suppressor CD8+ cells. Thus, coculture of NK and CD8+ cells for 3 h or longer times abrogated the expression of the NK antibacterial activity, and of two activation markers IL-2R and transferrin receptor (Tf-R). The suppressive activity was mediated by PGE2 as demonstrated by direct PGE2 determination in CD8+ cell free supernatants, and by inhibition of CD8+ cell suppression with indomethacin or piroxicam in vitro. We also found that resting T cytotoxic/suppressor cells purified by negative selection produce higher amounts of PGE2 than adherent cells like monocytes and macrophages, and that these concentration levels are in the range of concentrations known to suppress a significant number of in vitro immunologic functions.

Suppression of human T-cell mitogenesis by prostaglandin. Existence of a prostaglandin-producing suppressor cell.

Small amounts of PGE inhibit mitogen-induced [3H]thymidine incorporation in human peripheral lymphocytes. The 50% inhibitory concentration is approximately 10(-7) M, and this is reduced to approximately 10(-8) M when endogenous PGE production is blocked. PGE inhibits PHA- and Con A-stimulated cultures much better than PWM cultures, suggesting a differential effect of PGE on T-cell vs. B-cell function. In vitro blockade of PG synthesis results in approximately 50% increase in [3H]thymidine incorporation in PHA cultures. PGE is produced endogenously in PHA cultures by glass adherent suppressor cells.

Antibacterial activity of human natural killer cells.

The in vitro effects of human NK cells on viability of Gram-negative and Gram-positive bacteria was investigated. PBLs depleted of glass-adherent cells showed a significant antibacterial activity that was increased as the concentration of NK cells became higher. Leu-11-enriched cells exhibited the most efficient bactericidal activity. Stimulation of NK cells with staphylococcal enterotoxin B for 16 h produced a significant increase in the antibacterial activity of all NK cells tested. The antibacterial activity of monocyte-depleted cells and Leu-11-enriched cells was also enhanced after culturing in vitro for 16-24 h without exogenous cytokines. Dependence of the antibacterial activity on the presence of serum in the culture medium was not found. Ultrastructural studies revealed close contact between NK cell membranes and bacteria, no evidence of phagocytosis, and extracellular bacterial ghosts, after incubation at 37 degrees C. Supernatants from purified NK cells exhibited potent bactericidal activity with kinetics and target specificity similar to that of effector cells. These results document the potent antibacterial activity of purified NK cells and suggest an extracellular mechanism of killing.

Identification of DNA-binding lymphocytes in patients with systemic lupus erythematosus.

Antigen-ginding lymphocytes capable of binding native DNA (DNA-ABC) were identified in the peripheral blood of normal controls and patients with systemic lupus erythematosus (SLE) by autoradiography with 125I-nDNA. 12 patients with active SLE had 404 +/- 273 (mean +/- SD) DNA-ABC/105 lymphocytes, while 7 inactive SLE patients and 13 normals had 120 +/- 48 and 48 +/- 36, respectively. All three groups were significantly different from one another (p less than 0.01). No significant correlation was detected between the quantity of anti-native DNA (nDNA) antibody and number of DNA-ABC; however, most patients with large amounts of anti-nDNA antibody had both active disease and large numbers of DNA-ABC. Numbers of DNA-ABC and lymphocytes with surface immunoglobulin (Ig) did not change significantly after an 18-h incubation at 37degreeC. After depletion of B-lymphocytes by passage over bead columns coated with a complex of IgG and anti-IgG, the great majority of DNA-ABC were removed in both normal subjects and SLE patients. Labeling lymphocytes sequentially with 125I-nDNA, followed by an indirect fluorescence technique for identification of surface Ig, indicated that the great mahority of radiolabeled cells had surface Ig by fluorescence microscopy in four normals (average 93%) and five patients with active SLF (average 82%). The predominance of nDNA-sensitive B-lymphocytes in the peripheral blood of both normals and SLE patients is consistent with the concept that the induction of the anti-nDNA antibody response is due to the stimulation of preexisting nDNA-specific B lymphocytes by mechanisms other than those necessarily involving participation of nDNA-specific T lymphocytes.

Studies of human cord blood and adult lymphocyte interactions with in vitro immunoglobulin production.

Newborns are unable to produce normal amounts of immunoglobulin despite the presence of circulating lymphocytes with surface immunoglobin (Ig). This study was designed to examine the cellular basis of such impaired Ig synthesis in the newborn infant. An in vitro assay for IgG and IgM synthesis was employed which measured the Ig present in the supernates of pokeweed mitogen-stimulated cord blood and/or adult peripheral mononuclear cells (MNC). Results were as follows: (a) the addition of cord blood MNC to adult MNC suppressed both normal IgG and IgM production; (b) addition of a suspension of adult thymus-derived (T) cells to cord bone marrow-derived (B) cells did not enhance the production of Ig; (c) the addition of cord T cells to adult B cells did not enhance normal Ig production but did significantly depress IgM and IgG synthesis; and (d) irradiation of cord T cells with 2,000 rads removed the suppressive effect of cord T cells on adult MNC. A similar reversal of the suppressive effect exerted by cord MNC was also seen in the presence of 10 microM of hydrocortisone. It appears that the inability of newborn infants to make normal amounts of Ig is a result of a combined B-cell defect and the presence of a steroid-sensitive and radiosensitive suppressor cord T cell.

Studies of cell subpopulations mediating mitogen hyporesponsiveness in patients with Hodgkin's disease.

Hodgkin's disease (HD) is associated with a deficit in T-cell immunity characterized by skin test anergy and decreased lymphocyte responses to phytohemagglutinin (PHA). To investigate this mitogen hyporesponsiveness in HD, we separated peripheral blood mononuclear cells on Ficoll-Hypaque gradients and determined their response to various suboptimal concentrations of PHA. As was expected, patients with HD demonstrated marked mitogen hyporesponsiveness relative to normal controls; however, if the cell suspensions were first passed through glass wool columns to remove adherent cells, the PHA responsiveness of the hyporesponsive HD cells was markedly increased. In contrast, the responsiveness of normal controls was decreased so that the responses of nonadherent normal and HD cells were statistically indistinguishable. Evidently, a glass wool-adherent suppressor cell had been removed from patients with HD, while a glass wool-adherent cell which enhanced mitogenic responses had been removed from normal controls during column passage. Previous to column depletion, patients with HD had decreased proportions of E-rosettes and increased proportions of cells with surface alpha-fetoprotein; however, the proportion of these cells was not changed after column passage. Significant changes with column depletion of glass wool-adherent cells in HD were recorded in the proportions of monocytes (13.2 vs 5.8%) and lymphocytes with C-3 receptors (12.6 vs. 7.8%). The only significant change in normal controls was a decrease in the proportion of monocytes (10 vs. 1.7%). To determine if glass-adherent cells would have a suppressor effect, HD-adherent cells were added in progressively increasing numbers to mononuclear cell suspensions depleted of glass wool-adherent cells. PHA responsiveness returned toward predepletion levels. In summary, patients with HD possess a glass wool-adherent suppressor cell which is responsible at least in part for in vitro mitogen hyporesponsiveness.

Natural killer cell in systemic lupus erythematosus. Defects in effector lytic activity and response to interferon and interferon inducers.

Spontaneous cytotoxicity mediated by natural killer (NK) cells is impaired in several human diseases including systemic lupus erythematosus (SLE). The precise mechanism(s) by which NK activity is suppressed in patients with SLE is generally unknown. The present study was designed to focus on cellular defects per se in NK cells from patients with SLE. It was observed that the usual enhancing effect of interferon (IF) and IF inducers was markedly impaired in SLE patients. Of 24 SLE patients studied, 17 had significantly decreased NK activity relative to controls. NK activity had a significant negative correlation with clinical activity score (r = -0.56, P less than 0.005) but was not correlated with corticosteroid dose, antinuclear antibody titers, total hemolytic complement (CH50), or sedimentation rate. Furthermore, significant depressions in NK activity correlated with variations in disease activity in six patients followed serially. Depressed NK function could not be reversed by prolonged in vitro incubation at 37 degrees C or with protease treatment. Furthermore, depressed NK activity was not altered by removal of glass adherent cells nor was a suppression of NK activity in normal controls seen by the addition of SLE peripheral mononuclear cells. No reversal of depressed activity to normal levels was seen by the addition of indomethacin nor did the supernatants from SLE cell cultures cause a suppression of normal NK function. NK activity in SLE patients did not respond normally to IF inducers (poly-I:C and concanavalin A) even if the SLE patients had normal NK function. The response of SLE cells to exogenous IF was also impaired. The number of effector-target conjugates was quantitated with several target cells (K562, Yac-1, Fravel) in SLE patients and controls. A significant correlation between the proportion of glass nonadherent mononuclear cells that formed effector-target conjugates with these various targets and the magnitude of NK lysis was observed. However, SLE and normal subjects had equal numbers of effector-target conjugates independent of NK function. Release of a soluble cytotoxic factor was induced with concanavalin A, and was markedly impaired in SLE patients relative to normal controls. Thus, impaired NK cell function in SLE does not appear to be related to cell-mediated suppressive mechanisms or to the deletion of effector cells; rather, the decreased NK activity may be related to an impaired release of a soluble cytotoxic factor.

Studies of T- and B-cell interactions in adult patients with combined immunodeficiency.

Cellular interactions involved in the pathogenesis of hypogammaglobulinemia were studied in six patients with common variable immunodeficiency. Amounts of immunoglobulin (Ig)G and IgM in the supernate of pokeweed mitogen-stimulated cocultures of normal and immunodeficient mononuclear cells were measured by radioimmunoassays. Mononuclear cells from three of six patients inhibited Ig production of normal B cells (P < 0.005). When purified patient and normal T cells were added to B cells in various autologous or allogeneic combinations, it was observed that immunodeficient T cells (AT) from four patients suppressed normal IgM synthesis. Allogeneic normal T cells did not provide help for B cells from these same immunodeficient patients. In two patients, autologous T cells were able to help autologous B-cell IgM synthesis in vitro. In five patients, AT cells inhibited normal B-cell IgG synthesis. Removal of T cells bearing Ia determinants or T cells with Fc-IgG receptors did not diminish the suppressive effect of AT cells on normal B-cell Ig synthesis. Addition of indomethacin, a prostaglandin synthetase inhibitor, did not abrogate the suppressive effect of immunodeficient mononuclear cells. Addition of hydrocortisone succinate (10 muM) did reverse the suppressive effect of AT cells on IgM production in one patient; however, no in vitro reversal of suppressor cell effect was recorded in five. Suppression by immune-deficient T cells was eliminated by 2,000 rad of x-ray irradiation in three patients. After x-ray irradiation immunedeficient T cells could function as helpers of normal B cells.

Characterization of the suppressor cell activity in human cord blood lymphocytes.

Newborn mononuclear cells are known to have increased suppressor activity when compared with adult cells. However, the precise phenotypic description of the suppressor cell subpopulation has not yet been reported. This study was designed to examine the surface markers on human cord blood cells as defined by monoclonal antibodies and to characterize cord blood mononuclear cells that suppress in vitro pokeweed mitogen-driven immunoglobulin production. The pattern of fluorescence with the 9,6-monoclonal antibody suggested either a decreased density or a partial blocking of E-receptors on cord blood lymphocytes. Otherwise, human cord and adult cells had similar proportions of T cell subpopulations. Different subsets of newborn cells isolated by a monoclonal antibody rosetting technique were tested for suppressor activity. Cord blood lymphocytes recognized by the OKT8 monoclonal antibody constituted the major functional suppressor cell subpopulation. These cells were present in both E-rosetting and non-E-rosetting populations. Removal of OKT8+ mononuclear cord blood cells abrogated most of the suppressor activity. Thus the major suppressor cell present in cord blood is an OKT8 positive lymphocyte.

Defects in natural killer cell activity and interferon response in human lung carcinoma and malignant melanoma.

The natural killer (NK) activity of peripheral blood mononuclear cells from 25 patients with squamous cell carcinoma of the lung, malignant melanoma, or epitheloid cancers of the gastrointestinal tract was measured by the lysis of 51Cr-labeled K562 target cells. NK activities of many patients with lung cancer or malignant melanoma were decreased relative to normal controls. This abnormality was significantly correlated with advancing stage of disease and the percentage of monocytes in the cell suspensions. Addition of indomethacin or removal of monocytes did not restore depressed NK function to normal levels. Abnormalities of NK function did not appear to be secondary to the presence of mononuclear suppressor cells. The response to interferon was also impaired in patients with advanced disease. The number of effector:target conjugates was normal even in patients with depressed NK function; however, the number of active lytic effectors was decreased. These results imply that the cells which bind tumor targets are present in patients with advanced cancers, but these cells are either immature or functionally inactive.

Quantitation of effector-target affinity in the human NK cell and K562 tumor cell system.

A quantitative procedure to characterize the affinity of human natural killer (NK) cells for K562 tumor is described. Using highly purified (greater than or equal to 98%) NK cells, measurements of the conjugate frequencies permit the determination of the apparent Michaelis constants (KappM) for the conjugation process. Because no intermediate steps for the lytic process are involved the interpretation of the values of KappM is the simplest one that can be achieved. Thus, we found that a plot of KappM against the number of effector cells allows us to determine the dissociation constant, KS, that characterizes the effector-target affinity. KS is independent of the donor cell source and this value was (1.0 +/- 0.1) x 10(5) cell/tube. In contrast, the KappM values vary among donors, and this could be used to compare the relative activity of different donors in relation to their binding capacity.

The maximum conjugate frequency (alpha max) characterizes killer cell populations.

A quantitative procedure to characterize NK cell populations based on the dependence of the frequency of conjugation (alpha) on the effector-to-target ratio (R) is shown. To this end, a detailed study of the influence exerted by: (a) the value of R; (b) the number of effector and target cells (N, T); and (c) the source (donor) and enrichment of the effector cell population on the frequency of conjugation between NK effector and K562 target cells has been performed. This has demonstrated that for a given value of R large differences in the values of alpha can be obtained for different donors and/or N values. Hence, the usual practice of reporting the frequency of conjugation at a given value of R cannot be used as a valid criterion for comparison, and this could explain the differences in the alpha values reported in the literature for the same effector-target system. Moreover, the frequency of conjugation depends on the enrichment of the effector cell populations, although it has been shown that in all cases a plot of 1/alpha vs. R for N = constant is always linear with intercept 1/alpha max.alpha max represents the maximum frequency of conjugation for an effector-target system and remains constant for all values of R and N, and is also independent on the donor of the cell source. These characteristics make that the values of alpha max can be used as an easy criterion to determine with accuracy conjugate frequencies in an effector-target system, and could also be applied to characterize the activation or inhibition of effector cell populations by monoclonal antibodies or other agents. This criterion was applied to characterize the enrichment of NK cell populations and so, a value of alpha max = 58 +/- 3% has been obtained when highly purified (greater than or equal to 99%) NK effector cells obtained by panning with the monoclonal antibodies Leu-2, Leu-3 and Leu-4 are used. However, the corresponding value for MDC (14% NK cells) was lowered to 26 +/- 1%.

Crossed radioimmunoelectrophoresis for the analysis of lymphocyte surface antigens.

A sensitive crossed radioimmunoelectrophoreses technique is described as a model tool for studying lymphocyte surface antigens, using Triton X-100 solubilized sufface radiolabeled human peripheral blood lymphocytes as the antigen source and experimental antiserum produced by hyperimmunization of rabbits as the antibody source. The technique seems to have potential for qualitative as well as quantitative analyses of lymphocyte surface antigens.

Enrichment of natural killer cells by negative selection: comparison to Percoll gradient separation method.

A method is described for the preparation of human peripheral blood mononuclear cell (PBMC) suspensions containing highly enriched natural killer (NK) cell cytotoxicity. The technique involved the negative selection of OKM1+ cells by the selective removal of nylon wool nonadherent PBMC which are reactive with the Leu-1 monoclonal antibody. The Leu-1+ cells are removed by subsequent rosette formation with anti-mouse IgG coated bovine erythrocytes. The resultant OKM1+ cell suspension had a greater number of large granular lymphocytes, K562 target binding effector cells, and lytic activity than concomitantly prepared fractions of Percoll gradients.

Long-term treatment of rheumatoid arthritis comparing nabumetone with aspirin.

This report summarizes the results of a 17-investigator multicenter six-month randomized double-blind parallel group study. The safety and efficacy of nabumetone 1,000 mg taken at bedtime was compared with that of aspirin 900 mg four times daily in the treatment of adult patients with active class II or III classical or definite rheumatoid arthritis. Two hundred sixty-four patients were entered into the study. Two hundred fifty-seven (126 nabumetone and 131 aspirin) patients were evaluable for safety. Two hundred thirty-four (113 nabumetone and 121 aspirin) patients were evaluable for efficacy. There was significant improvement in each of six clinical measurements of efficacy in both treatment groups and little difference between groups. The somewhat greater improvement in articular index and duration of morning stiffness in the nabumetone-treated group did not reach statistical significance. There was an equal percentage of patient withdrawal for lack of efficacy in each group. Overall, the rate of patient withdrawal due to adverse experiences was greater (p = 0.01) for aspirin-treated patients. These experiences were usually dispepsia, abdominal pain, and tinnitus. It was concluded that nabumetone was an effective anti-inflammatory drug in the treatment of rheumatoid arthritis with less toxicity than aspirin.

EBT, a tryptophan contaminant associated with eosinophilia myalgia syndrome, is incorporated into proteins during translation as an amino acid analog.

The tryptophan dimer 1,1'-ethylidenebis[L-tryptophan] was identified as a contaminant of tryptophan preparations associated with Eosinophilia-Myalgia Syndrome. In this paper, we describe experiments examining the hypothesis that 1,1'-ethylidenebis[L-tryptophan] acts as an amino acid analog replacing L-tryptophan during the synthesis of proteins. We propose further that proteins containing 1,1'-ethylidenebis[L-tryptophan] are rejected in an autoimmune process identified clinically as Eosinophilia-Myalgia Syndrome. Rabbit reticulocyte lysates containing an estimated 1 microM L-tryptophan were used to assay the ability of 1,1'-ethylidenebis[L-tryptophan] to compete with 3H-L-tryptophan for incorporation into proteins translated from BMV RNA. 1,1'-Ethylidenebis[L-tryptophan] in concentrations of 40, 80 and 110 microM reduced lysate 3H-L-tryptophan incorporation to 81%, 76% and 75% of control incorporation obtained in the absence of 1,1'-ethylidenebis[L-tryptophan]. In the presence of 20 microM L-tryptophan, 110 microM 1,1'-ethylidenebis[L-tryptophan] reduced 3H-L-tryptophan incorporation to 56% of control incorporation. In contrast, ethyl-L-tryptophan did not significantly reduce 3H-L-tryptophan incorporation. In the presence of 110 microM 1,1'-ethylidenebis[L-tryptophan] and 20 microM L-tryptophan, 3H-L-leucine incorporation was not significantly reduced compared to incorporation in the absence of 1,1'-ethylidenebis[L-tryptophan], demonstrating that proteins were translated to full length during elongation. These findings suggest that 1,1'-ethylidenebis[L-tryptophan], but not ethyl-L-tryptophan, reduced 3H-L-tryptophan incorporation into proteins by substituting for L-tryptophan rather than by causing premature termination or significant slowing of nascent protein chains.

The effect of beta-endorphin on natural cytotoxicity and antibody dependent cellular cytotoxicity.

The ability of the central nervous system to modulate immune responsiveness has received increasing attention. A potential mechanism that would allow the central nervous system to alter the immune system is the release of neuroendocrine and neurotransmitter polypeptides into the peripheral circulation with subsequent modulation of immunocyte function. In this report, we demonstrate that the neuropeptide, beta-[D-ALA2]-endorphin augments natural cytotoxicity but does not effect antibody-dependent cellular cytotoxicity. The observations are discussed in relation to the mechanisms for natural cytotoxicity and antibody dependent cellular cytotoxicity.