Autobiographical Case Report: A Rubber Band, a Glass of Orange Juice.

Seemingly simple procedures can go desperately wrong. Physicians are used to "knowing" and "being in charge". When a physician is suddenly the profoundly ill patient, the inversion of roles can be frustrating, frightening, and disorienting.

Enhanced Adhesion and OspC Protein Synthesis of the Lyme Disease Spirochete Borrelia Burgdorferi Cultivated in a Host-Derived Tissue Co-Culture System.

BACKGROUND: The adhesion process of Borrelia burgdorferi to susceptible host cell has not yet been completely understood regarding the function of OspA, OspB and OspC proteins and a conflict exists in the infection process. AIMS: The adhesion rates of pathogenic (low BSK medium passaged or susceptible rat joint tissue co-cultivated) or non-pathogenic Borrelia burgdorferi (high BSK medium passaged) isolate (FNJ) to human umbilical vein endothelial cells (HUVEC) cultured on coverslips and the synthesis of OspA and OspC proteins were investigated to analyze the infection process of this bacterium. STUDY DESIGN: In-vitro study. METHODS: Spirochetes were cultured in BSK medium or in a LEW/N rat tibiotarsal joint tissue feeder layer supported co-culture system using ESG co-culture medium and labelled with 3H-adenine for 48 hours. SDS-PAGE, Western Blotting, Immunogold A labeling as well as radiolabeling experiments were used to compare pathogenic or non pathogenic spirochetes during the adhesion process. RESULTS: Tissue co-cultured B. burgdorferi adhered about ten times faster than BSK-grown spirochetes. Trypsin inhibited attachment to HUVEC and co-culture of trypsinized spirochetes with tissues reversed the inhibition. Also, the synthesis of OspC protein by spirochetes was increased in abundance after tissue co-cultures, as determined by SDS-PAGE and by electron microscopy analysis of protein A-immunogold staining by anti-OspC antibodies. OspA protein was synthesized in similar quantities in all Borrelia cultures analyzed by the same techniques. CONCLUSION: Low BSK passaged or tissue co-cultured pathogenic Lyme disease spirochetes adhere to HUVEC faster than non-pathogenic high BSK passaged forms of this bacterium. Spirochetes synthesized OspC protein during host tissue-associated growth. However, we did not observe a reduction of OspA synthesis during host tissue co-cultivation in vitro.

Basic science for the clinician 59: polymorphonuclear cells: mechanisms in human defense and in the pathogenesis of autoimmune disease.

When I learned about polymorphonuclear neutrophils (PMNs) in medical school, they were presented as pretty much 1-trick ponies: PMNs were phagocytes with no intrinsic specificity; their only specificity was supplied by the Fcγ receptors on their surfaces and that would then be the specificity of the bound immunoglobulin G, nothing intrinsic to the PMN. My, how simple life was in those days! And how wrong! Turns out, these circulating cells are involved in bridging the innate immune system and the acquired immune response in some very interesting ways and may play a crucial role in the immunopathogenesis of some of "our" diseases. Polymorphonuclear neutrophils are often underappreciated as drivers of inflammatory diseases, which is why I think it is time for us to turn our attention to this underappreciated component of the immune response.

Basic science for the clinician 58: IgG subclasses.

In evolutionary terms, IgG is the most recent addition to the human humoral immune response, the most recent of the 5 isotypes (classes). The IgG 4 subclasses and their multiple receptors, each with a unique structure and functions, speak to their broad repertoire of often overlapping functions. The IgG subclasses differ only slightly in structure, but therein lies their unique qualities. Focusing solely on the clinical niches filled by each and the clinical correlations thereof allows one to clearly see nature in its abhorrence of, and skill in filling, vacuums. One of the IgG subclasses, IgG4, the least in serum concentration, has recently become the topic of intense interest, as the linkage of certain diseases with IgG4 becomes apparent. As this association is studied, the molecular biology at the root of these diseases becomes the predominant cytokines explaining the pattern of histopathology.

Basic science for the clinician 57: transforming growth factor ß.

As is so often the case, a molecule gets named for its first identified activity or apparent role and then that initial name sticks, even as new and perhaps fundamentally different activities emerge from later studies. It is the special power of evolution that takes a certain activity and then uses it over and over again in pursuit of apparently disparate goals in a maturing or mature organism. In general terms, transforming growth factor ß (TGF-ß) is intimately involved in a variety of differentiation and growth inhibition processes, in apoptosis, and in deposition of the extracellular matrix. Initially identified in its role in oncogenesis, TGF-ß is now implicated in a number of vascular and rheumatologic disorders, perhaps most notably the scleroderma. TGF-ß has been identified as a powerful influence in angiogenesis, wound healing, joint inflammation, tumor growth and metastasis, and, of course, immunoregulation. So "what is in a name?" A rose by any other name would smell as sweet and would still be immunologically active, even if the name is "misleading."

Basic science for the clinician 56: inducible T-cell costimulator--the world of costimulation gets more complicated and interesting.

They say that nothing is assured in this world but change. And this applies in a cynical way to immunology: nothing is assured--we can never rest with an assumption that we know it all because there are always more apparent complications when analyzing immune mechanisms (someday, perhaps we will arrive on a "grand scheme" that elegantly explains it all, just as our brethren in particle physics seek the Higgs boson and the completion of a better model--I am not holding my breath awaiting completion of our task!). In a recent article in this series, we explored CTLA4 as a counterregulator of the CD28-CD80/86 costimulatory pathway. However, treatment with CTLA4 does not entirely shutdown the immune system; engineering animals so that the CD28-CD80/86 pathway no longer functions does not prevent functional protective immune responses. Thus, there must be yet another pathway. And there is--an "inducible T-cell costimulator" (ICOS) is found on T cells (activated, not naive), which has a single ligand on antigen-presenting cells (ICOS ligand, B7-RP-1). The rapid induction of ICOS speaks to its importance in T-cell function; however, ICOS is more relevant to the stimulation of effector and memory T cells than is CD28 signaling. There are similarities and differences, interactions, and overlaps between the 2 pathways, some of which are very useful in understanding the immunopathogenesis of immune diseases.

Basic science for the clinician 55: CTLA-4.

In physiological systems, for every "yang," there must be a "yin," for uncontrolled systems can run amok. This is the case for the T-cell compartment of the immune system, where activation must be modulated, dampened, and ultimately reversed; to not apply the brakes leads to dire consequences. In less than 20 years, CTLA-4 has emerged from being an orphan, next becoming a physiological star with ever-emerging effects, and finally to being a therapeutic target-an impressive example of evolution and one that continues. Understanding the costimulatory effects and mechanisms of CTLA-4 and the redundancies intrinsic to costimulation is important in understanding T-cell function and dysfunction in disease. A future article in this series will describe inducible T-cell costimulator, which is a normal by-pass to CTLA-4's effects.

Basic science for the clinician 54: CD5.

The full story of what surface markers mean about the cells on which they reside twists and turns as the days go by, with previously accepted "truth" changing in light of new findings. Such is the case with CD5, a surface marker on most murine T cells, many thymocytes, and a subset of B cells. The precise role of CD5 in the murine and human immune responses has been a matter of intense speculation for many years. Recent work suggests that CD5 may have a fine-tuning or suppressive effect on signaling through the antigen receptors on both B and T cells. These CD5 B cells were initially thought to be a major source of autoantibodies and/or "natural antibodies," targeting broad arrays of carbohydrate and protein antigens. More recent studies support the latter contention-CD5 B cells do produce "natural antibodies," but the former is far from true-CD5 B cells are not the major source of autoantibodies. In fact, CD5 may be a major negative influence on antigen receptor driven-B-cell function and may serve to control autoimmunity rather than encourage it. Furthermore, another subset of CD5 B cells may represent a distinct regulatory population. CD5 expression is noted on more than three fourths of all T-cell lymphomas. CD5 may be a receptor of pathogen-associated molecular patterns; CD5 may be a marker of decreased dependence of B cells on certain circulating factors. Elevated levels of CD5 are found in a number of autoimmune disorders. Thus, although the precise mechanism is unclear, there is at the very least circumstantial evidence of a role for CD5 in the pathogenesis of autoimmunity and perhaps T cell-derived lymphoid malignancy. New findings put old claims to rest and open up new avenues for research, both basic and clinical, with therapeutic applications not far behind.

Basic science for the clinician 53: mast cells.

Mast cells stand at the interface between the innate immune system and the acquired (adaptive) immune response, serving as sentinels detecting invaders and directing a concerted and coordinated response. Mast cells reside immediately under body surfaces and within lymph nodes, near blood vessels and nerves, perfectly situated to for early detection and defense. They secrete a wide array of prostanoids, cytokines, chemokines, and other proteins mediators and modifiers of a variety of immune and inflammatory functions and bear surface markers suggesting broad functions, including as antigen-presenting cells. Although usually not given their due in medical school lectures, there is great likelihood that mast cells will be implicated in the pathogenesis of rheumatoid arthritis, scleroderma, multiple sclerosis, and perhaps cancer. Thus, better insights into mast cell functions and mast cell-derived effector molecules should command our attention as we move forward in better understanding disease immunopathogenesis and directed intelligent therapeutics development.

Basic science for the clinician 51: the inflammasome.

The innate immune system is packaged in a number of discrete, but intercommunicating, systems. The inflammasome is a multimolecular complex that detects intracellular foreign molecules of a variety of sorts and promptly promotes the secretion of IL-1ß and IL-18. When all goes well, defense of the organism in the early period of infection is enhanced by this system; when certain elements of the inflammasomal systems go awry, inflammatory diseases of a variety of sorts result. A family of multimolecular detection systems are activated at times of infection and tissue damage; it is the dysfunction of this innate immune defense system that intrigues rheumatologists, as this is the cause of a series of newly described autoinflammatory diseases.

Musculoskeletal features of Lyme disease: understanding the pathogenesis of clinical findings helps make appropriate therapeutic choices.

Patients with Lyme disease, that is, active infection with Borrelia burgdorferi, experience many types of musculoskeletal complaints, with different explanatory mechanisms. Appropriate therapy depends on understanding the underlying cause of the complaint and addressing that specific root cause. In the case of active infection the dosage, duration, drug, and method of administration of antibiotics should be determined by the state of the infection and history of prior therapy, according to the established and validated recommendations of the Infectious Disease Society of America. Many patients have musculoskeletal complaints not attributable to active infection; some patients have residual complaints following a documented infection that has been adequately treated with antibiotics previously, and others never had true B. burgdorferi infection in the first place. For such patients, antibiotics are not warranted and in fact may be physically and emotionally harmful. Complaints following an episode of Lyme disease are not necessarily due to ongoing infection, especially adequately treated. Consideration of other diagnoses may suggest use of other effective modalities, including physical therapy and emotional support. Appropriate ordering and interpretation of the various validated seroconfirmatory tests available to study B. burgdorferi infection are critical, as these tests are often misapplied and misconstrued in pursuit of strategies aimed at eliminating patients' suffering. Although seronegative Lyme disease has been reported, seronegativity in a reputable laboratory makes the likelihood of Lyme arthritis very low. On the other hand, a positive result from certain unvalidated laboratories or novel assays proves nothing and should not be viewed as substantiating the diagnosis.

Basic Science for the Clinician 52: adipokines.

Adipocytes, the cells that maintain fat stores and influence energy metabolism, produce a variety of messengers, called adipokines (or adipocytokines). These proteins have broad reaching effects on glucose and fat metabolism, but also influence inflammation, by modulating the production of inflammatory cytokines and modifying how established cytokines such as interleukin 6 and tumor necrosis factor α themselves induce or modulate inflammation; some of these proteins are produced by synovial tissue adipocytes, suggesting a very direct effect on the modification of local inflammation. Adipokines provide mechanisms that might explain accelerated atherosclerosis and impaired glucose metabolism in some of our chronic inflammatory diseases and offer potential unique therapeutic approaches to control these and other manifestations of inflammation.

Abatacept improves health-related quality of life, pain, sleep quality, and daily participation in subjects with juvenile idiopathic arthritis.

OBJECTIVE: To assess health-related quality of life (HRQOL) in abatacept-treated children/adolescents with juvenile idiopathic arthritis (JIA). METHODS: In this phase III, double-blind, placebo-controlled trial, subjects with active polyarticular course JIA and an inadequate response/intolerance to ≥1 disease-modifying antirheumatic drug (including biologics) received abatacept 10 mg/kg plus methotrexate (MTX) during the 4-month open-label period (period A). Subjects achieving the American College of Rheumatology Pediatric 30 criteria for improvement (defined "responders") were randomized to abatacept or placebo (plus MTX) in the 6-month double-blind withdrawal period (period B). HRQOL assessments included 15 Child Health Questionnaire (CHQ) health concepts plus the physical (PhS) and psychosocial summary scores (PsS), pain (100-mm visual analog scale), the Children's Sleep Habits Questionnaire, and a daily activity participation questionnaire. RESULTS: A total of 190 subjects from period A and 122 from period B were eligible for analysis. In period A, there were substantial improvements across all of the CHQ domains (greatest improvement was in pain/discomfort) and the PhS (8.3 units) and PsS (4.3 units) with abatacept. At the end of period B, abatacept-treated subjects had greater improvements versus placebo in all domains (except behavior) and both summary scores. Similar improvement patterns were seen with pain and sleep. For participation in daily activities, an additional 2.6 school days/month and 2.3 parents' usual activity days/month were gained in period A responders with abatacept, and further gains were made in period B (1.9 versus 0.9 [P = 0.033] and 0.2 versus -1.3 [P = 0.109] school days/month and parents' usual activity days/month, respectively, in abatacept- versus placebo-treated subjects). CONCLUSION: Improvements in HRQOL were observed with abatacept, providing real-life tangible benefits to children with JIA and their parents/caregivers.

Long-term safety and efficacy of abatacept in children with juvenile idiopathic arthritis.

OBJECTIVE: We previously documented that abatacept was effective and safe in patients with juvenile idiopathic arthritis (JIA) who had not previously achieved a satisfactory clinical response with disease-modifying antirheumatic drugs or tumor necrosis factor blockade. Here, we report results from the long-term extension (LTE) phase of that study. METHODS: This report describes the long-term, open-label extension phase of a double-blind, randomized, controlled withdrawal trial in 190 patients with JIA ages 6-17 years. Children were treated with 10 mg/kg abatacept administered intravenously every 4 weeks, with or without methotrexate. Efficacy results were based on data derived from the 153 patients who entered the open-label LTE phase and reflect >or=21 months (589 days) of treatment. Safety results include all available open-label data as of May 7, 2008. RESULTS: Of the 190 enrolled patients, 153 entered the LTE. By day 589, 90%, 88%, 75%, 57%, and 39% of patients treated with abatacept during the double-blind and LTE phases achieved responses according to the American College of Rheumatology (ACR) Pediatric 30 (Pedi 30), Pedi 50, Pedi 70, Pedi 90, and Pedi 100 criteria for improvement, respectively. Similar response rates were observed by day 589 among patients previously treated with placebo. Among patients who had not achieved an ACR Pedi 30 response at the end of the open-label lead-in phase and who proceeded directly into the LTE, 73%, 64%, 46%, 18%, and 5% achieved ACR Pedi 30, Pedi 50, Pedi 70, Pedi 90, and Pedi 100 responses, respectively, by day 589 of the LTE. No cases of tuberculosis and no malignancies were reported during the LTE. Pneumonia developed in 3 patients, and multiple sclerosis developed in 1 patient. CONCLUSION: Abatacept provided clinically significant and durable efficacy in patients with JIA, including those who did not initially achieve an ACR Pedi 30 response during the initial 4-month open-label lead-in phase.

Psychiatric comorbidity and other psychological factors in patients with "chronic Lyme disease".

BACKGROUND: There is no evidence of current or previous Borrelia burgdorferi infection in most patients evaluated at university-based Lyme disease referral centers. Instead, psychological factors likely exacerbate the persistent diffuse symptoms or "Chronic Multisymptom Illness" (CMI) incorrectly ascribed to an ongoing chronic infection with B. burgdorferi. The objective of this study was to assess the medical and psychiatric status of such patients and compare these findings to those from patients without CMI. METHODS: There were 240 consecutive patients who underwent medical evaluation and were screened for clinical disorders (eg, depression and anxiety) with diagnoses confirmed by structured clinical interviews at an academic Lyme disease referral center in New Jersey. Personality disorders, catastrophizing, and negative and positive affect also were evaluated, and all factors were compared between groups and with functional outcomes. RESULTS: Of our sample, 60.4% had symptoms that could not be explained by current Lyme disease or another medical condition other than CMI. After adjusting for age and sex, clinical disorders were more common in CMI than in the comparison group (P <.001, odds ratio 3.54, 95% confidence interval, 1.97-6.55), but personality disorders were not significantly more common. CMI patients had higher negative affect, lower positive affect, and a greater tendency to catastrophize pain (P <.001) than did the comparison group. Except for personality disorders, all psychological factors were related to worse functioning. Our explanatory model based on these factors was confirmed. CONCLUSIONS: Psychiatric comorbidity and other psychological factors are prominent in the presentation and outcome of some patients who inaccurately ascribe longstanding symptoms to "chronic Lyme disease."

Basic science for the clinician 49: expanding the description of the RNA universe.

We have come a long way in paying RNA its due respect. Originally thought to be nothing more than a shuttle of information from DNA to protein, a bearer of amino acids to the ribosome, and a splicer of messenger RNA, we now know that other RNA species are pivotal in controlling cellular functions that assure normal development and differentiation of immune cells, modulation of inflammatory mechanisms, control of proliferation of a number of hematologic lineages, and spermatogenesis (clearly, vital for the maintenance of the species!). In the future, ribozymes, antisense RNA and oligonucleotides, decoy RNA, peptide-nucleic acid chimeras, and other RNAs will probably be part of the routine armamentarium in a variety of medical practices. Targeting these to the appropriate cell may allow for highly directed therapies, maximizing efficacy and minimizing toxicity. It is a new world, an RNA world, and we will all benefit from the insights broadly outlined in this article. When I was in college and medical school, RNA was known to come in only a few varieties. There was messenger RNA, ribosomal RNA, transfer RNA, and double-stranded RNA in some viruses. And that was that! My, how times have changed!! The truth, as always, is much more complicated than we had thought. We now know that RNA is involved in splicing of mRNA and in cleaving RNA. And, recent studies have revealed even more: DNA transcription, mRNA stability, and levels of protein synthesis are all, to some degree, controlled by an entirely different set of RNAs, such as small RNAs, which come in at least 3 different broad varieties. Thus, there are now at least 10 varieties of RNAs of which I am aware at the time I write these words, and who is to say that there are not more out there? Just as the entire repertoire of the known classes of small RNAs has not yet been described, there may be different RNAs out there yet to be identified. If, in fact, the bio-universe was initially determined by RNA, not DNA, there may be new RNAs with unexpected mechanisms and consequences.

Role of psychiatric comorbidity in chronic Lyme disease.

OBJECTIVE: To evaluate the prevalence and role of psychiatric comorbidity and other psychological factors in patients with chronic Lyme disease (CLD). METHODS: We assessed 159 patients drawn from a cohort of 240 patients evaluated at an academic Lyme disease referral center. Patients were screened for common axis I psychiatric disorders (e.g., depressive and anxiety disorders); structured clinical interviews confirmed diagnoses. Axis II personality disorders, functional status, and traits like negative and positive affect and pain catastrophizing were also evaluated. A physician blind to psychiatric assessment results performed a medical evaluation. Two groups of CLD patients (those with post-Lyme disease syndrome and those with medically unexplained symptoms attributed to Lyme disease but without Borrelia burgdorferi infection) were compared with 2 groups of patients without CLD (patients recovered from Lyme disease and those with an identifiable medical condition explaining symptoms attributed to Lyme disease). RESULTS: After adjusting for age and sex, axis I psychiatric disorders were more common in CLD patients than in comparison patients (P = 0.02, odds ratio 2.64, 95% confidence interval 1.30-5.35), but personality disorders were not. Patients with CLD had higher negative affect, lower positive affect, and a greater tendency to catastrophize pain (P < 0.001) than comparison patients. All psychological factors except personality disorders were related to level of functioning. A predictive model based on these psychological variables was confirmed. Fibromyalgia was diagnosed in 46.8% of CLD patients. CONCLUSION: Psychiatric comorbidity and other psychological factors distinguished CLD patients from other patients commonly seen in Lyme disease referral centers, and were related to poor functional outcomes.

Effects of external qigong therapy on osteoarthritis of the knee. A randomized controlled trial.

The objective of our study was to assess the efficacy of external qigong therapy (EQT), a traditional Chinese medicine practice, in reducing pain and improving functionality of patients with knee osteoarthritis (OA). One hundred twelve adults with knee OA were randomized to EQT or sham treatment (control); 106 completed treatment and were analyzed. Two therapists performed EQT individually, five to six sessions in 3 weeks. The sham healer mimicked EQT for the same number of sessions and duration. Patients and examining physician were blinded. Primary outcomes were Western Ontario MacMaster (WOMAC) pain and function; other outcomes included McGill Pain Questionnaire, time to walk 15 m, and range of motion squatting. Results of patients treated by the two healers were analyzed separately. Both treatment groups reported significant reduction in WOMAC scores after intervention. Patients treated by healer 2 reported greater reduction in pain (mean improvement -25.7 +/- 6.6 vs. -13.1 +/- 3.0; p < 0.01) and more improvement in functionality (-28.1 +/- 9.7 vs. -13.2 +/- 3.4; p < 0.01) than those in sham control and reduction in negative mood but not in anxiety or depression. Patients treated by healer 1 experienced improvement similar to control. The results of therapy persisted at 3 months follow-up for all groups. Mixed-effect models confirmed these findings with controlling for possible confounders. EQT might have a role in the treatment of OA, but our data indicate that all EQT healers are not equivalent. The apparent efficacy of EQT appears to be dependent on some quality of the healer. Further study on a larger scale with multiple EQT healers is necessary to determine the role (if any) of EQT in the treatment of OA and to identify differences in EQT techniques.