[Percutaneous intentional extraluminal recanalization of the femoropopliteal artery. Initial experiences and results]. / Percutane intentionele extraluminele recanalisatie van de femoropopliteale arterie. Initiele ervaringen en resultaten.

Between July 1994 and April 1995, 14 patients with a chronic occlusion of the femoropopliteal artery were treated by percutaneous intentional extraluminal recanalisation (PIER). It concerned 11 males and 3 females with a mean age of 65 years (50-76 years). Twelve patients were smokers, two patients had diabetes mellitus. Ten patients had severe claudication, four patients suffered from rest pain, three of the latter had ulcerations. In all patients, recanalisation and balloon dilatation could be established. However, angiographic result was unsatisfactory in one case. There were no complications. Clinical follow-up varied from 2 weeks to 9 months. Two patients needed a surgical femoropopliteal bypass respectively 4 and 7 months after recanalisation because of claudication recurrence. A third patient had two percutaneous redilatations of a restenosis. The remaining 11 patients became free of complaints. PIER seems to be a feasible treatment for patients with chronic femoropopliteal occlusions with a very good technical success, low complication rate and promising initial clinical outcome. Follow-up studies have to prove its superiority over the established revascularisation techniques.

[Cockett syndrome. Initial results with percutaneous treatment in 6 patients]. / Het syndroom van Cockett. Initiële ervaring met percutane behandeling in 6 patiënten.

Intimal hypertrophy with venous spur formation caused by compression of the left common iliac vein by the right common iliac artery is advanced as the etiology of the higher incidence of deep venous thrombosis involving the left leg. In most cases of left iliofemoral thrombosis no underlying compression syndrome is detected or treated because the left common iliac vein has to be cleared from thrombi before compression can be identified. A series of 6 consecutive retrospectively analyzed patients with acute left iliofemoral thrombosis is presented. In these patients a left iliac vein compression syndrome was detected after percutaneous intraluminal thrombolysis with Actilyse (rt-PA). This compression was successfully relieved by insertion of a wall stent. Percutaneous treatment of Cockett's syndrome seems an attractive alternative for conservative and/or surgical management.

Cranial CT revisited: do we really need contrast enhancement?

The aim of this study was to define guidelines for intravenous contrast administration in cranial CT, as currently there are no recent guidelines based on a large series of patients. In 1900 consecutive patients (1480 adults and 420 children) pre- and post-contrast scan was analysed in order to assess the contribution of contrast enhancement to the diagnosis. The findings were grouped according to whether abnormalities were seen on the pre- and/or post-contrast scan, or whether no abnormalities were seen at all. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of a pre-contrast scan were used to determine validity. Intravenous contrast enhancement only contributes to the diagnosis if a suspicious abnormality is seen on the unenhanced scan or in the appropriate clinical setting (33.6%). In the remaining patients (65.6%) there is no diagnostic contribution, except for a small number of abnormalities (0.8%). These are often anatomical variants and have no therapeutic impact. The number of contrast-enhanced cranial CT examinations can significantly be reduced by using four general guidelines for contrast administration resulting in considerable cost savings without affecting the quality of service to the patient. These guidelines are defined by the clinical findings/presentation or by the findings on the unenhanced scan. The number of contrast-related complications will be reduced, which may have medicolegal implications. These guidelines can be applied in any radiology department.

Bacterial lipopolysaccharide stimulates the production of cytokines and the expression of costimulatory molecules by human peripheral blood dendritic cells: evidence for a soluble CD14-dependent pathway.

To investigate the responses of dendritic cells (DC) during Gram-negative infections, we analyzed the effects of graded doses of LPS on the cytokine profile, phenotype, and allostimulatory potential of human DC generated by culturing plastic-adherent PBMC in presence of IL-4 and granulocyte-macrophage-CSF. First, we found that LPS stimulates the production of high levels of TNF-alpha, IL-6, IL-8, IL-12 by DC and up-regulates their expression of HLA-DR, B7-1, B7-2, and CD40. The effects of LPS were dose dependent, with a significant stimulatory effect already observed at a concentration of 0.1 ng/ml and a plateau being reached at 10 ng/ml. These phenotypic changes correlated with increased allostimulatory properties of LPS-activated DC because DC treated with LPS were significantly more efficient than untreated DC in eliciting IL-2 and IFN-gamma synthesis by alloreactive T cells and stimulating their proliferation. Experiments using neutralizing anti-IL-12 mAb indicated that LPS-induced IL-12 is responsible for the increased production of IFN-gamma but not for the increased proliferation during MLR. Finally, we observed that the DC responses to low levels of LPS (1 ng/ml) were dramatically inhibited by a blocking anti-CD14 mAb, although DC do not express CD14 molecules on their membrane. Experiments using serum depleted of soluble CD14 (sCD14) and sCD14 either purified from human serum or in recombinant form further established that DC respond to LPS via a soluble CD14-dependent pathway.

Interleukin-10 prevents the generation of dendritic cells from human peripheral blood mononuclear cells cultured with interleukin-4 and granulocyte/macrophage-colony-stimulating factor.

We evaluated the effects of interleukin (IL)-10 on the differentiation of dendritic cells (DC) obtained by culturing plastic-adherent peripheral blood mononuclear cells for 7 days in presence of granulocyte/macrophage-colony-stimulating factor (GM-CSF) + IL-4. The addition of IL-10 at the initiation of culture resulted in the generation of macrophage-like cells with expressing high levels of CD14 and decreased levels of CD1a and CD1c. Furthermore, cells generated in presence of IL-10 secreted lower levels of IL-12, but higher levels of IL-8 compared with DC generated in absence of IL-10, both spontaneously and after CD40 engagement. Finally, cells generated in presence of IL-10 were less efficient than DC in stimulating the production of IL-2, interferon-gamma, and IL-4 by allogeneic T cells. We conclude that IL-10 prevents the generation of DC induced by GM-CSF + IL-4 and favors the development of macrophages with a lower T cell stimulatory potential, but secreting higher levels of IL-8 than DC.

Human dendritic cell responses to lipopolysaccharide and CD40 ligation are differentially regulated by interleukin-10.

We evaluated the effects of interleukin (IL)-10 on the maturation of human dendritic cells (DC) induced either by lipopolysaccharide (LPS) or CD40 engagement. For this purpose, DC generated by culturing plastic-adherent peripheral blood mononuclear cells for 7 days with granulocyte/macrophage-colony-stimulating factor and IL-4 were incubated for 3 days with either LPS (10 ng/ml) or 3T6 fibroblasts transfected with the gene encoding CD40 ligand, in absence or presence of IL-10. First we found that the membrane expression of CD83, a marker of mature DC, was inhibited by IL-10 when induced by LPS but not by CD40 engagement. Likewise, IL-10 inhibited LPS-induced but not CD40-dependent CD86 (B7.2) up-regulation on DC. Furthermore, IL-10 inhibited the production of IL-8 and tumor necrosis factor-alpha by DC when activated by LPS but not by CD40. In contrast, IL-10 inhibited IL-12 production in both activation systems. We conclude that IL-10 differentially influences LPS-dependent and CD40-dependent pathways of DC maturation.

Interleukin-10 differentially regulates B7-1 (CD80) and B7-2 (CD86) expression on human peripheral blood dendritic cells.

Most of the immunosuppressive effects of interleukin-10 (IL-10) are related to functional inhibition of antigen-presenting cells (APC). Herein, we investigate the influence of recombinant (r)IL-10 on human dendritic cells (DC) purified from peripheral blood of healthy volunteers. First, we found that rIL-10 inhibited in a dose-dependent manner the proliferative responses as well as the production of IL-2 and interferon-gamma (IFN-gamma) in mixed lymphocyte reaction (MLR) between purified T cells and DC. This rIL-10 effect could be attributed to a direct effect on DC, as DC preincubated with rIL-10 were found to be deficient in the induction of alloreactive T cells even when anti-IL-10 neutralizing mAb was added at the time of MLR. Flow cytometric analysis indicated that rIL-10 did not modify the expression of ICAM-1 (CD54) and B7-1 (CD80), but decreased HLA-DR and B7-2 (CD86) expression at the DC surface. We conclude that the inhibitory effect of rIL-10 on primary alloreactive T cell responses involves down-regulation of class II MHC and B7-2 expression at the DC surface.

[Anti-tumor immunotherapy based on dendritic cells]. / L'immunothérapie anti-tumorale à base de cellules dendritiques.

In cancer immunotherapy, the use of dendritic cells (DC) loaded with tumor-associated antigens (TAA) emerged as a promising strategy. We initiated 3 pilot clinical trials with immunological endpoints using TAA loaded autologous DC. These trials showed that this approach was safe and associated with the induction of potent TAA specific IFN-gamma responses, which were transient despite the providing a further help through KLH presentation. Subcutaneous (s.c.) IL-2 administration was associated with long-lasting TAA specific IL-5 production. Clinical responses were observed in about 1/3 of the patients. Further improvements will take advantage of the use of a new type of DC cells (IL-3/IFN-beta DC) and of tumor cell-DC hybrids.