Effect of maternal cholestasis and treatment with ursodeoxycholic acid on the expression of genes involved in the secretion of biliary lipids by the neonatal rat liver

In juvenile rats born from mothers with obstructive cholestasis during pregnancy (OCP), transient latent cholestasis together with alterations in the secretion of biliary lipids have been reported. Here we investigated whether the expression of genes involved in this function is already modified at birth and examined the effect of treating pregnant rats with ursodeoxycholic acid (UDCA; i.g., 60 microg/100 g b.w./day). Cholanemia was markedly higher in mothers with OCP, and was further increased by UDCA. In the Control pups, cholanemia increased after birth, whereas in OCP and OCP+UDCA pups, hypercholanemia decreased after birth. Steady-state mRNA levels in neonatal liver were measured by real-time quantitative RT-PCR. The expression of basolateral bile acid transporters was not affected by OCP and was unchanged (Oatp1/1a1 and Oatp4/1b2) or moderately increased (Ntcp and Oatp2/1a4) by UDCA. In both groups, the expression of ABC proteins was either not modified (Bsep, Bcrp and Mrp2) or enhanced (Mrp1 and Mrp3), that of phospholipid flippase Mdr2 was not changed, whereas that of cholesterol transporter Abcg5/Abcg8 was impaired. The expression of the nuclear receptor FXR was not affected by OCP or UDCA, whereas that of SHP and key enzymes in bile acid synthesis (Cyp7a1, Cyp8b1 and Cyp27) was increased in both groups. In conclusion, OCP affects the expression in the neonatal liver of genes involved in hepatobiliary function, which cannot be prevented, at this stage, by treating pregnant rats with UDCA, even though this treatment has been found to partially restore normal lipid secretion later during post-natal development.

A novel promoter polymorphism in the gene encoding complement component 5 receptor 1 on chromosome 19q13.3 is not associated with asthma and atopy in three independent populations

BACKGROUND

The inflammatory functions of complement component 5 (C5) are mediated by its receptor, C5R1, which is expressed on bronchial, epithelial, vascular endothelial and smooth muscle cells. A susceptibility locus for murine allergen-induced airway hyper-responsiveness was identified in a region syntenic to human chromosome 19q13, where linkage to asthma has been demonstrated and where the gene encoding C5R1 is localized.

OBJECTIVE

The aim of this study was to screen for novel polymorphisms in the C5R1 gene and to determine whether any identified polymorphisms are associated with asthma and/or atopy and whether they are functional.

METHODS

Single-nucleotide polymorphism (SNP) detection in the gene encoding C5R1 was performed by direct sequencing. Genotyping was performed in three populations characterized for asthma and/or atopy: (1) 823 German children from The Multicenter Allergy Study; (2) 146 individuals from Tangier Island, Virginia, a Caucasian isolate; and (3) asthma case-parent trios selected from 134 families (N=783) in Barbados. Functional studies were performed to evaluate differences between the wild-type and the variant alleles.

RESULTS

We identified a novel SNP in the promoter region of C5R1 at position -245 (T/C). Frequency of the -245C allele was similar in the German (31.5%) and Tangier Island (36.3%) populations, but higher in the Afro-Caribbean population (53.0%; P=0.0039 to <0.0001). We observed no significant associations between the -245 polymorphism and asthma or atopy phenotypes. Upon examination of the functional consequences of the -245T/C polymorphism, we did not observe any change in promoter activity.

CONCLUSION

This new marker may provide a valuable tool to assess the risk for C5a-associated disorders, but it does not appear to be associated with asthma and/or atopy.

Evaluation of a triple-lumen central venous heparin-coated catheter versus a catheter coated with chlorhexidine and silver sulfadiazine in critically ill patients

OBJECTIVE

To compare the incidence of catheter colonization and catheter-related bloodstream infections between heparin-coated catheters and those coated with a synergistic combination of chlorhexidine and silver sulfadiazine.

DESIGN

Randomized, controlled clinical trial.

SETTING

A 20-bed medical-surgical intensive care unit.

PATIENTS

A total of 180 patients requiring the insertion of a trilumen central venous catheter. INTERVENTIONS. Patients were randomized to receive either a trilumen heparin or chlorhexidine and silver sulfadiazine-coated catheter.

MEASUREMENTS

Catheter colonization was defined by a semiquantitative catheter tip culture yielding 15 or more colony-forming units or quantitative culture of 1,000 or more colony-forming units/ml. Catheter-related bloodstream infection as the isolation of the same microorganism from a peripheral blood culture and catheter tip.

RESULTS

A total of 260 catheters were cultured. Out of 132 heparin-coated catheters, 29 were colonized and out of 128 chlorhexidine and silver sulfadiazine-coated catheters, 13 were colonized ( p=0.03), relative risk RR=2.16 (1.18-3.97). This represents an incidence of 23.5 and 11.5 episodes of catheter colonization per 1,000 catheter-days, respectively ( p=0.0059), RR=2.04 (1.05-3.84). Microorganisms isolated in catheter colonization from heparin-coated catheters were gram-positive cocci 23, gram-negative bacilli 7, and Candida spp 4. In chlorhexidine and silver sulfadiazine-coated catheters were gram-positive cocci 6 and gram-negative bacilli 11 ( p=0.009). The incidence of catheter-related bloodstream infections per 1,000 catheter-days was 3.24 in heparin-coated catheters and 2.6 in chlorhexidine and silver sulfadiazine-coated catheters ( p=0.79), RR=1.22 (0.27-5.43).

CONCLUSIONS

In critically ill patients the use of trilumen central venous catheters coated with chlorhexidine and silver sulfadiazine reduced the risk of catheter colonization due to prevention of gram-positive cocci and Candida spp.

Live liver donation: a prospective analysis of exclusion criteria for healthy and potential donors

INTRODUCTION

Living donor liver transplantation represents a controversial option to increase the donor pool.

DESIGN

Prospective and descriptive clinical study.

OBJECTIVE

(1) To identify risk factors (exclusion criteria) for live donation; (2) to determine the rate of recipients that benefit from a living donor.

METHODS

Between May 1995 (first adult-to-adult living donor liver transplantation in Spain) and November 2002, we evaluated 74 healthy volunteers and performed 12 living donor liver transplants (no donor mortality).

RESULTS

All actual donors and volunteers are alive and healthy. After a mean time of 3.2+/-0.5 weeks, 72% of potential donors were considered unsuitable for live donation. Exclusion criteria were grouped in three categories: (primary) donor safety reasons (68%); (secondary): ABO mismatch (17%) and (tertiary): cadaveric graft transplantation (15%). Consequently, just 43.7% of the recipients presenting to us with a potential living donor, did finally benefit from these organs. The mortality rate was 8.3% for 43 recipients presenting with a living donor in comparison to 15% for those who did not (321 recipients between May 1995 and November 2001).

CONCLUSIONS

ALDLT can benefit a significant number of recipients on the waiting list (43.7% of those presenting with a donor). The most frequent exclusion criteria concern donor safety, namely, unsuspected chronic liver diseases and unsuspected thrombophilic disorders.

The challenges of conducting clinical research: one research team's experiences

Conducting clinical research is an exciting and a rewarding endeavor. Each project is unique and, because of this uniqueness, research studies require considerable planning. Regardless of all the upfront planning, challenges will occur throughout the life of the study. Clinical research projects are rife with obstacles that range from the lack of administrative and physician support to subject attrition. Some of the challenges, such as subject dropout, are not unexpected, whereas other unanticipated issues can blindside a research team. This case study examines several such challenges experienced in one longitudinal study and presents the solutions engineered by the research team to keep the project on track.

Presence of granulocytic ehrlichia in ticks and serological evidence of human infection in La Rioja, Spain

In order to estimate the risks of human granulocytic ehrlichiosis (HGE) in an endemic area for Lyme disease in the North of Spain (La Rioja), we collected and investigated by PCR specific to the E. phagocytophila group DNA, a total of 6870 Ixodes ricinus ticks. We also used an indirect immunofluorescence (IFI) test to study the presence of antibodies to the HGE agent in 147 human serum samples including patients with Lyme disease (LD), forestry workers, and persons with history of previous tick bite. Fifty serum samples from healthy people resident in urban areas and with no history of tick-bite disorder and without tick exposure were used as controls. Four of 76 adults and 49 of 203 nymphs pools carried E. phagocytophila DNA. This result, and the finding of 1.4% of sera reacting in the IFI test confirms that this tick-borne agent is present in La Rioja, and that humans show evidence of contact with it. HGE should be considered in the differential diagnosis of flu-like syndromes in the study area in the north of Spain.

Anomalous coronary artery origin associated with bicuspid aortic valve in a patient with rheumatic mitral stenosis: a case report

A rare case of an anomalous left coronary artery arising from the right sinus of Valsalva associated with bicuspid aortic valve is presented. This case is unique because these congenital anomalies were associated with rheumatic mitral stenosis. This anomalous coronary origin was found at catheterization before balloon mitral valvuloplasty. The clinical significance of this finding is discussed.

Molecular cloning and expression patterns of mouse cartilage oligomeric matrix protein gene

OBJECTIVE

To develop transgenic mice harboring mutations in the COMP gene as animal models for pseudoachondroplasia (PSACH) and multiple epiphyseal dysplasia (MED), autosomal dominant disorders characterized by early onset osteoarthritis and epiphyseal abnormalities. As a first step in generating a mouse model for COMP mutations, we have cloned the cDNA of mouse COMP and examined its tissue expression pattern.

DESIGN

Total mRNA was isolated from the skeletal tissues of newborn C57BL/6j mice and used as a template for oligo(dT) first-strand cDNA synthesis. The cDNA was used for PCR amplification of COMP using three oligonucleotide primer pairs designed from the published rat COMP cDNA sequence. Nested PCR was used to complete the sequence between the amplified fragments. The entire cDNA was sequenced and the expression pattern of the corresponding transcripts examined by Northern hybridizations.

RESULTS

A full-length COMP cDNA was isolated. Analysis showed that the entire translated region of the mouse COMP gene is 2268 bp and the derived amino acid sequence shows 90% homology to human COMP. Of eight adult mouse non-cartilage tissues tested, COMP expression was detected only in testis.

Pemphigus vulgaris induced by D-penicillamine therapy in a patient with systemic sclerosis

D: -Penicillamine-induced pemphigus occurs infrequently, typically in patients with rheumatoid arthritis. We describe a patient with systemic sclerosis who experienced this complication 3 months after starting D -penicillamine therapy. Nikolsky's sign, histopathologic findings, and direct immunofluorescence all confirmed the diagnosis. Termination of disease progression required intravenous pulse glucocorticoids, azathioprine, and 3 courses of plasmapheresis. The presentation, treatment, and etiology of D -penicillamine-induced pemphigus are reviewed, and the incidence of this complication in scleroderma patients is examined.

Culture of Blomia tropicalis and IgE immunoblot characterization of its allergenicity

Blomia tropicalis is an important triggering factor for allergic diseases such as asthma, rhinitis and atopic dermatitis in tropical and subtropical regions, which climate favours the growth of this species. Our previous mite fauna study revealed that Blomia tropicalis is the most dominant species present in Singapore house dust The main objective of this study is to establish a mass culture of Blomia tropicalis for further characterization of the antigenic and molecular properties of this mite. Approximately one gram of mites could be obtained for every 300-gram of culture medium by culturing under natural condition with a mean annual temperature of 30 degrees C and a mean relative humidity of 80%, and harvested by modified Tullgren funnel. Allergen characterization by IgE immunoblot analysis with crude mite extracts showed some IgE reactivity differences between Blomia tropicalis mite extract from Singapore and Colombia. The possible reasons for these findings are the quality and source of the mite protein extracts used, or selective differences in the population under evaluation. Further, the atopic sera tested showed differences in the pattern and Intensity of IgE immunoblot reactivity to crude extracts of Blomia tropicalis and Dermatophagoides pteronyssinus, the other highly prevalent mite in Singapore. These data support the existence of species-specific allergens. In conclusion, we have been successful in setting up B. tropicalis mass cultures and have prepared extracts of high allergenicity.

A review of the collaborative exercises on DNA typing of the Spanish and Portuguese ISFH Working Group. International Society for Forensic Haemogenetics

Since 1992 the Spanish and Portuguese Working Group (GEP) of the International Society for Forensic Haemogenetics (ISFH) has been organizing collaborative exercises on DNA profiling with the aim of making progress on standardization and discussing technical and statistical problems in DNA analysis. A total of four exercises (GEP-92 to GEP-95) have been carried out until now. A consequence of these exercises was the creation of a quality control programme in Spain and Portugal in 1995 which was carried out simultaneously with the GEP-95 exercise. The number of participating laboratories increased from 10 in the first exercise (GEP-92) to 19 in the last exercise (GEP-95). Despite this increasing number of participating laboratories, results remained satisfactory. In the last exercises, all the laboratories used PCR-based DNA polymorphisms with an increasing number of markers obtaining good results. SLPs were used by only 30% of laboratories in the last two exercises but the results indicated a good level of expertise in most of these laboratories. The reasons for these successful results are the common use of the EDNAP protocol for SLP analysis and commercially available kits or common sequenced allelic ladders for PCR-based DNA polymorphisms.

Cloning and IgE binding of a recombinant allergen from the mite Blomia tropicalis, homologous with fatty acid-binding proteins

To characterize the allergens of Blomia tropicalis, a cDNA library was constructed and screened with allergic sera from asthmatic patients. One clone, Bt6, was subcloned and sequenced. The nucleotide sequence of 934 bp length shows a 390-bp reading frame which encodes a 130-amino acid protein with a MW 14.8 kD. No potential glycosylation site was found in the predicted protein. The inferred amino acid sequence has no homology to known allergens. It has a cytosolic fatty acid-binding protein (FABP) signature at 5-22 amino acid residues, 42.3% identity with the Sm14-FABP of Schistosoma mansoni and 36% identity with FABPs from rat, mouse, bovine and human. The protein was expressed as a GST fusion protein and the purified GST-Bt6 used for dot blot, RAST and RAST inhibition assays. The frequency of IgE binding of allergic sera to Bt6 was low (11%) and usually weak. One positive serum did, however, show strong reactivity by RAST and dot blot and Bt6 could inhibit 60% of the IgE binding of this serum to the B. tropicalis extract. These data show that Bt6 encodes a mite FABP with allergenic properties, which are pronounced in some atopic subjects.

Biochemical evidence of thiamine depletion during the Cuban neuropathy epidemic, 1992-1993

During an epidemic outbreak of neuropathy in Cuba during 1992-1993, blood and urine samples were collected from 107 persons with confirmed neuropathy, from 106 control subjects without clinical abnormality who were broadly matched with the affected persons by age and domicile, and from 537 unmatched subjects, also free from clinical abnormality. The unmatched subjects lived in two locations in Cuba; at each location they were drawn from two age ranges: 11-15-y-old secondary school students and 16-64-y-old adults. Measurements of urinary thiamine and blood transketolase and its activation with thiamine pyrophosphate were made. For the neuropathy subjects, these measurements were repeated after 3 wk of rehabilitation. All groups showed biochemical evidence of thiamine depletion affecting 30-70% of their members, which is a high prevalence. Severity of biochemical depletion was, however, no greater in the neuropathy subjects than in the control subjects (P > 0.05). However, it was greater in Pinar del Rio, where the incidence of disease was higher, than in the city of Havana, where less disease was seen. Although the majority of the affected subjects responded biochemically to a daily oral multivitamin supplement containing thiamine (P < 0.001), in some cases normal biochemical status was not achieved even after 3 wk of intensive treatment. In the affected group, thiamine status was inversely correlated with the amount of alcohol consumed (P = 0.007). Thiamine status at the outset was correlated with clinical outcome after treatment. Although neither thiamine depletion nor alcohol abuse were likely to have been the sole cause of the neuropathy epidemic, they may have been contributory factors. Thiamine supplementation or food fortification may therefore be necessary in Cuba.

The relationship of thoracic lymphadenopathy to pulmonary interstitial disease in diffuse and limited systemic sclerosis: CT findings

OBJECTIVE

Mediastinal lymphadenopathy is frequently associated with interstitial lung disease (ILD) in patients with systemic sclerosis (SSc). This study compared the extent of lymphadenopathy in diffuse and limited SSc with the presence and type of ILD found on CT scans.

SUBJECTS AND METHODS

Seventy-three patients with diffuse and limited SSc underwent thoracic CT. The presence of lymphadenopathy was correlated with the frequency and type of ILD.

RESULTS

Fifty-eight percent (18/31) of patients with diffuse cutaneous SSc and 40% (17/42) of patients with limited cutaneous SSc had lymphadenopathy. A significant relationship was found between lymphadenopathy and the presence of interstitial disease (p = .0002). Seventy-two percent (18/25) of patients with a ground-glass parenchymal pattern of interstitial disease and 74% (14/19) of patients with a honeycomb pattern had lymphadenopathy.

CONCLUSION

Lymphadenopathy is prevalent in patients with SSc and ILD regardless of clinical subtype or interstitial pattern. Lymphadenopathy appears to increase as a function of the profusion rather than the morphology of ILD.

Lung involvement in systemic sclerosis (scleroderma): relation to classification based on extent of skin involvement or autoantibody status

Lung involvement accounts for significant morbidity and is a leading cause of mortality in patients with systemic sclerosis (SSc). It has been shown that different patterns of pulmonary involvement are seen in different subtypes of SSc. This paper reports a retrospective review of 72 patients with SSc to determine whether disease classification according to the extent of skin involvement alone (diffuse vs. limited) or autoantibody status was predictive of pulmonary parenchymal involvement. The diagnosis of interstitial lung disease was based on pulmonary function tests and chest radiographs. Restrictive lung disease was common in both limited SSc (lSSc) and diffuse SSc (dSSc), occurring in 30% and 50% of these patients respectively (P = 0.16). Radiographic evidence of significant interstitial disease was also comparable between the groups [nine of 32 lSSc patients (28%) vs. six of 17 dSSc patients (32%), P = n.s.]. No significant difference in mean lung function was found between patients with anti-Scl 70 antibody (n = 12) compared to those without (n = 60) (TLC 79.0 +/- SE 5.1% predicted vs. 82.8 +/- 2.2, P = n.s.; DLCO 63.0 +/- 5.1 vs. 59.7 +/- 2.5, P = n.s.). By contrast, statistically significant differences in mean lung function were found between patients with anticentromere antibody (ACA) (n = 24) and those without ACA (n = 48) (TLC 98.6 +/- SE 3.9% predicted vs. 79.7 +/- 3.1%, P < 0.001); and less frequent radiographic evidence of severe interstitial disease (0 of 17 with significant interstitial changes on chest radiograph vs. 15 of 32 (47%), P = 0.002). It is concluded that classification of SSc patients on the basis of the distribution of skin involvement poorly predicts the occurrence of interstitial lung disease. On the other hand, ACA is highly associated with the absence of interstitial lung disease.

Autoantibodies in sera from patients with L-tryptophan-associated eosinophilia-myalgia syndrome. Demonstration of unique antigen-antibody specificities

The purpose of this study was to determine whether specific autoantibodies could be identified that are associated with eosinophilia-myalgia syndrome (EMS). Sera from 44 patients with EMS were tested by indirect immunofluorescence, immunodiffusion against calf thymus extract, and immunoprecipitation from HeLa cell extract. Antinuclear antibodies were detected in the sera of 24/39 patients with EMS (61.5%) by indirect immunofluorescence against HEp-2 cells. Seven patients (16%) were demonstrated to have specific autoantibodies by immunoprecipitation in which at least two shared patterns were noted. In three sera immunoprecipitation identified a similar 63-kDa band (Ab-1). An additional four sera shared a pattern of bands consisting of a strong 110-kDa protein and a weak 95-kDa protein (Ab-2). Absorption of HeLa extract with a strongly positive Ab-2 serum confirmed that the four patients shared the same antibody. In conclusion, the detection of these autoantibodies provides evidence of autoimmunity in EMS, and may distinguish this syndrome from clinically related conditions.

Familial Hydroxyapatite Chondrocalcinosis with Spondyloepiphyseal Dysplasia: Clinical Course and Absence of Genetic Linkage to the Type II Procollagen Gene

We describe the course of the articular manifestations in a kindred with familial hydroxyapatite chondrocalcinosis and because of an associated spondyloepiphyseal dysplasia (SED) have investigated the linkage between the disease and markers in the type II procollagen gene (COL2A1). Twenty-seven family members from a large pedigree underwent musculoskeletal and radiographic examinations. In 12 patients, the progression of the disease was evaluated by comparative radiographic surveys obtained 12 years apart. Seven of the 12 family members who were studied in 1978 had severe progression of erosive hand osteoarthritis, whereas there was only minimal progression of the previously observed intervertebral disc or periarticular calcifications. The disease was recognized in seven other siblings from the third generation at a mean age of 24 years. Mild SED was present in several previously and newly diagnosed patients. Nevertheless, no genetic linkage between the disease and COL2A1 polymorphic markers was found. Hydroxyapatite chondrocalcinosis in this kindred displays a variable spectrum of phenotypic manifestations, which include spondyloepiphyseal dysplasia, precocious and progressive erosive hand osteoarthritis, and intervertebral disc and costal cartilage calcification. The gene responsible for the occurrence of hydroxyapatite chondrocalcinosis, osteoarthritis, and mild epiphyseal dysplasia in this family must be one that encodes a protein other than type II procollagen. The mild SED was most easily detected by examining younger affected members. The apatite deposits in this family seem to be secondary to the SED and should be distinguished from those in primary hydroxyapatite disease as in calcific periarthritis.

Sarcoidosis in systemic sclerosis: report of 7 cases

OBJECTIVE

To describe the clinical, radiologic, and pathologic features of coexistent systemic sclerosis (SSc) and sarcoidosis, 2 conditions of unknown cause associated with altered cellular immune response.

METHODS

We reviewed clinical information, results from laboratory and radiologic studies, and lung or lymph node biopsy samples of 7 patients with concurrent SSc and sarcoidosis evaluated at 2 academic referral centers between 1989 and 1993.

RESULTS

Each patient fulfilled American College of Rheumatology criteria for the classification of SSc. SSc and sarcoidosis developed simultaneously in 4 patients, whereas in 3 others sarcoidosis was diagnosed more than 6 years after the onset of SSc. The onset of sarcoidosis was characterized by fever, weight loss, or increasing respiratory symptoms. Each patient had radiographic evidence of intrathoracic lymphadenopathy and/or interstitial lung disease. Examination of lung or lymph node biopsies demonstrated noncaseating granulomas. Treatment with corticosteroids was associated with improved lung function.

CONCLUSION

Since sarcoidosis coexists with SSc more frequently than previously suggested, it should be considered in patients with SSc presenting with new pulmonary symptoms. Recognizing sarcoidosis in patients with SSc is important, since these patients may benefit from corticosteroid therapy.

Linkage of early-onset osteoarthritis and chondrocalcinosis to human chromosome 8q

Calcium pyrophosphate-deposition disease (CPDD), also called "chondrocalcinosis" or "pseudogout," is a disorder characterized by the deposition of calcium-containing crystals in joint tissue, which leads to arthritis-like symptoms. The presence of these crystals in joint tissue is a common finding in the elderly, and, in this population, there is a poor correlation with joint pain. In contrast, early-onset CPDD has been described in several large families in which the disease progresses to severe degenerative osteoarthritis (OA). In these families, an autosomal dominant mode of inheritance is observed, with an age at onset between the 2d and 5th decades of life. In this report, we describe a large New England family with early-onset CPDD and severe degenerative OA. We found genetic linkage between the disease in this family and chromosome 8q, with a multipoint lod score of 4.06. These results suggest that a defective gene at this location causes the disease in this family.

Is it possible to reduce tobacco consumption via alcohol taxation?

Recent studies with Spanish data suggest that indirect taxation is a potential instrument to reduce tobacco consumption but the magnitude of the estimated price elasticity limits the effectiveness of the taxes. However, if the separability restriction does not hold between tobacco and other goods, the results obtained could be misleading. This shortcoming of previous analyses leads us to formulate a demand system with alcohol, tobacco and other goods so as to estimate and test complementary effects and to assess the possibility for reducing consumption by indirect taxation of complementary commodities. We use the Spanish Family Expenditure Survey to carry out a cross-section study which allows us to estimate demand models under different assumptions about the nature of zero expenditures and to test the effectiveness of indirect taxation. The findings tend to support our initial suspicions about the inadequacy of imposing separability and point out the importance of alcohol taxation to reduce tobacco consumption. However, given the structure of the data used, these results should be viewed with caution and must be confirmed by additional evidence.

Intravenous iloprost infusion in patients with Raynaud phenomenon secondary to systemic sclerosis. A multicenter, placebo-controlled, double-blind study

OBJECTIVE

To evaluate the efficacy and safety of iloprost, a prostacyclin analog, administered intravenously in patients with Raynaud phenomenon secondary to systemic sclerosis.

DESIGN

Multicenter, randomized, parallel placebo-controlled, double-blind study.

SETTING

University medical centers.

PATIENTS

131 patients with systemic sclerosis (101 women, 30 men) ages 20 to 79 years.

INTERVENTION

Patients were randomly assigned to receive one of two parallel treatments of five daily sequential, 6-hour intravenous infusions of iloprost (0.5 to 2.0 ng/kg per min) or to receive a similar volume of placebo.

MEASUREMENTS

Frequency of Raynaud attacks, Raynaud severity score, physician's overall rating of treatment effect, and digital cutaneous lesion healing.

RESULTS

Of the 131 patients enrolled, 126 completed the 5-day infusion and 114 (87%) completed at least 6 weeks of follow-up. Sixty-four patients were randomly assigned to receive iloprost and 67 patients, to receive placebo. The mean weekly number of Raynaud attacks decreased 39.1% with iloprost and 22.2% with placebo (P = 0.005). In addition, the mean percentage of improvement in a global Raynaud severity score during the entire 9-week follow-up was greater in patients given iloprost (34.8%) than in those receiving placebo (19.7%) (P = 0.011). The physician's overall rating of treatment effect showed greater improvement with iloprost than with placebo at week 6 (52.4% compared with 27.4%; P = 0.008) and week 9 (60.9% compared with 26.9%; P < 0.001). At week 3, 14.6% more patients receiving iloprost had 50% or more lesions heal compared with those given placebo (95% CI, 0.9% to 30%). During the infusion, 59 (92%) of the patients receiving iloprost had one or more side effects compared with 38 (57%) of the patients receiving placebo.

CONCLUSION

Iloprost is effective for the short-term palliation of severe Raynaud phenomenon in patients with systemic sclerosis.

Spondyloepiphyseal dysplasia and precocious osteoarthritis in a family with an Arg75-->Cys mutation in the procollagen type II gene (COL2A1)

Direct sequencing of polymerase chain reaction (PCR)-amplified genomic DNA from a patient with spondyloepiphyseal dysplasia and precocious osteoarthritis revealed a single-base change in exon 11 of the type II procollagen gene (COL2A1), which produces an Arg-->Cys mutation in one allele. The proband is a member of a large Chilean kindred presenting with chondrodysplasia of the hips, knees, shoulders, elbows, and spine associated with severe, early-onset osteoarthritis. All affected individuals exhibit mildly short stature; in addition, five out of seven affected family members display shortened metacarpals or metatarsals. DNA from affected and unaffected family members was PCR-amplified and analysis of restriction digests of the products determined that the mutation segregated with the disease with a lod score of 2.2 at zero recombination. The mutation, which resides in the triple-helical region of type II procollagen at amino acid position 75, is the second example of an Arg-->Cys mutation in the COL2A1 gene in heritable cartilaginous disease and is the first example of a point mutation in the amino terminal region of the alpha 1(II) chain, that results in a spondyloepiphyseal dysplastic phenotype.

A study of sensory recovery following carpal tunnel release

The purpose of this study was to define the testing parameters that are most sensitive to sensory loss in carpal tunnel syndrome and then to track recovery of these sensations postoperatively. Two dozen patients underwent standard nerve decompression and were subsequently re-evaluated at six weeks, three months, and six months. The test battery included provocative maneuvers, light-touch threshold determined by manually applied monofilaments and skin indentation with the Automated Tactile Tester (ATT), manual two-point discrimination, manual high-frequency vibration and ATT low-frequency vibration, and ATT warmth detection. The most sensitive indicators of sensory abnormality were the ATT low-frequency vibration and skin indentation tests. Responses to all but these two tests returned to normal within two months postoperatively. The ATT indentation and vibration tests showed continual improvement over the study period, returning to nearly normal values by six months. Recommendations concerning the use of automated methods for testing sensory function are made in light of these findings.

Demonstration of interleukin 8 and autoantibodies to interleukin 8 in the serum of patients with systemic sclerosis and related disorders

BACKGROUND AND DESIGN

Interleukin 8 (IL-8), a chemotactic cytokine produced by various cell types, displays structural homology to the connective tissue-activating peptide III. Little is known of the possible role of IL-8 in connective tissue disorders. We therefore determined serum concentrations of IL-8 and autoantibodies to IL-8 in 134 patients with systemic sclerosis (SSc) and related connective tissue disorders, as well as in pooled serum from 28 healthy control subjects by a sensitive enzyme-linked immunosorbent assay.

RESULTS

Interleukin 8 was undetectable in the pooled serum from 28 healthy controls, but detectable in serum samples from 24 of the 134 patients described above. It was detected in 13 of 60 patients with limited SSc and in eight of 48 patients with diffuse SSc. It was also detectable in one of three patients with eosinophilic fasciitis and in two of 10 patients with Raynaud's syndrome without skin involvement. In contrast, none of the three patients with morphea or the 10 patients with eosinophilia-myalgia syndrome had detectable IL-8 levels. We further determined the concentration of autoantibodies to IL-8 in the same serum samples. The values in healthy controls were 6.7 +/- 0.2 ng/mL (mean +/- SEM). Significantly elevated autoantibody levels were detected in patients with limited SSc (21.5 +/- 1.7), diffuse SSc (23.4 +/- 2.2), and Raynaud's syndrome (20.5 +/- 3.7). Elevated levels were also detected in patients with eosinophilic fasciitis (43.7 +/- 8.6) and morphea (14.7 +/- 3.2). Normal levels (7.5 +/- 2.0) were found in patients with eosinophilia-myalgia syndrome. Analysis of variance between the levels of autoantibodies to IL-8 and duration of the disease, extent of skin involvement, drug therapy, or serologic findings failed to show a significant correlation.

CONCLUSIONS

These results suggest that increased production of IL-8 may relate to activation of mononuclear phagocytes, fibroblasts, or endothelial cells, among other cell types, in patients with SSc, but not in those with eosinophilia-myalgia syndrome. This activation could be related to the production of autoantibodies to IL-8.

An Automated Tactile Tester for evaluation of cutaneous sensibility

The Automated Tactile Tester (ATT) is a computer-controlled device designed to measure patients' cutaneous perception of touch, vibration, temperature, and pain. The ATT provides repeatable and precise control of the amplitude, rate of application, and duration of stimuli. Threshold values for skin indentation (touch), high- and low-frequency vibration, pinprick (sharpness), warmth, and two-point discrimination were obtained with the ATT from the fingers of 62 normal subjects. Manual monofilament and two-point discrimination tests were also performed on the same subjects. All the tests with the ATT, except pinprick, showed a statistically significant increase in threshold with age. There were no significant differences attributable to the hand or digit tested or the sex of the subject. These data were used to derive age-adjusted criteria for normal sensory function in the glabrous skin of the fingers. Thresholds were found to remain within normal limits when these subjects were retested at various time intervals. We conclude that the ATT provides repeatable and reliable measurements of sensory function in the skin and has potential application in the diagnosis and evaluation of compression and other peripheral neuropathies.

Evaluation of nerve compression with the Automated Tactile Tester

The Automated Tactile Tester (ATT) was used to measure threshold values for trapezoidal skin indentation (light touch), low- and high-frequency vibration (50 and 150 Hz), pinprick (sharp-dull transition point), warming (temperature awareness), and two-point discrimination in 61 patients with symptoms of median nerve compression at the wrist. We compared these data with values obtained in the same patients with manual monofilament tests, manual two-point discrimination measurements, and electrophysiologic nerve conduction studies. The ATT detected abnormal sensation in 71% of the hands tested, nerve conduction velocity was abnormal in 44% of the cases, and the manual tests indicated abnormality in 42% of the hands. The most indicative single test among those included in the present study for detecting sensory abnormality in these patients was threshold to a 50 Hz vibration administered by the ATT. We conclude that the ATT is a sensitive tool for the diagnosis and evaluation of compressive peripheral neuropathy and may allow objective documentation in a higher percent of patients than do more traditional testing methods.

Frequency of DPB1*0401 is significantly decreased in patients with allergic asthma in a mulatto population

Allergic asthma (AA) is a multifactorial disease in which the IgE hyperresponsiveness to mite allergens is determinant for its pathogenesis and clinical picture. We have reported previously that IgE responsiveness to mite allergens in AA patients is linked to HLA and possibly controlled by a dominant suppression (Is) gene of that region. The present population study was done to detect alleles involved in the genetic control of mite IgE response that accompanies AA, using polymerase chain reaction and oligonucleotide DNA typing of DP locus. Instead of finding any significant positive association with AA, in this study we found that the allele DPB1*0401 is present mainly in the nonallergic control population and strikingly absent in patients (p less than 0.008), suggesting that this gene could confer resistance to AA and other atopic diseases. Our results add more evidence regarding the existence of Is genes in the HLA region involved in the control of IgE immune response to environmental allergens. Furthermore, they suggest that genes of HLA are important genetic components involved in the etiology of AA.

Development of diffuse fasciitis with eosinophilia during L-tryptophan treatment: demonstration of elevated type I collagen gene expression in affected tissues. A clinicopathologic study of four patients

We describe the cases of four women who developed a scleroderma-like syndrome during L-tryptophan treatment for insomnia or tinnitus. The illness was characterized by swelling of the extremities, skin rash, myalgia, and elevation of the peripheral blood eosinophil count, followed by rapidly progressive cutaneous and subcutaneous induration. The histopathologic examination of affected skin showed thickening of the fascia, deep dermal fibrosis, and accumulation of mononuclear cells and abundant eosinophils. The expression of the type I procollagen gene was examined by in-situ hybridizations of affected skin with a human sequence-specific complementary DNA (cDNA). Increased hybridization signals were detected in the deep dermis and fascia, indicating enhanced expression of the collagen gene. The temporal association of L-tryptophan use and the development of a scleroderma-like illness in these four patients suggests a causal relation between L-tryptophan or its metabolites and the stimulation of fibroblast collagen gene expression that results in dermal and fascial fibrosis.

Barrett's metaplasia and adenocarcinoma of the esophagus in scleroderma

Gastroesophageal reflux is well documented in scleroderma, but the complications of Barrett's metaplasia and adenocarcinoma are not well described. The records of 75 patients with scleroderma seen over a four-year period at the Hospital of the University of Pennsylvania were retrospectively reviewed to determine the prevalence of Barrett's metaplasia and adenocarcinoma of the esophagus and to identify clinical, manometric, laboratory, or radiographic criteria that might predict the presence of these lesions. Twenty-four of these patients underwent endoscopy. In this group, the prevalence of Barrett's metaplasia was 37 percent (nine patients) and adenocarcinoma was also present in two of these patients. The patients with and without Barrett's metaplasia were similar in age (range, 22 to 64 compared with 28 to 79, respectively), sex (six of nine compared with 12 of 15 female, respectively), frequency of esophageal motility disorders, presence of proximal skin involvement, digital ulceration, and pulmonary involvement as measured by diffusion capacity. Barrett's metaplasia was diagnosed on the basis of double-contrast esophagographic results in only one of eight patients with Barrett's metaplasia so-studied. Patients with Barrett's metaplasia tended to have longer duration of heartburn (90 +/- 40 months compared with 11 +/- 35 months) and dysphagia (39 +/- 22 months compared with 7 +/- 3 months). Patients with Barrett's metaplasia also tended to have greater impairment of lower esophageal sphincter pressure either at end-expiration (4.0 +/- 2.1 compared with 6.1 +/- 1.8 mm Hg) or mid-respiration (13.0 +/- 3.0 compared with 16.9 +/- 2.5 mm Hg). Using chi-square analysis, however, none of these differences reached statistical significance. Discrimination did occur on the basis of the presence of the CREST (calcinosis, Raynaud's phenomenon, esophageal manifestations of scleroderma, sclerodactyly, and telangiectasis) variant (55 percent compared with 7 percent, p less than 0.01), a duration of dysphagia of more than five months (p less than 0.03), and mid-respiratory lower esophageal sphincter pressure of less than 10 mm Hg (p less than 0.05). It is suggested that: Barrett's metaplasia of the esophagus occurs in one third of patients with scleroderma; clinical, manometric, laboratory, and radiographic features are poor predictors of the presence of Barrett's metaplasia; patients with CREST syndrome, prolonged dysphagia, or a very low lower esophageal sphincter pressure may have an increased risk for the development of metaplasia; patients with scleroderma and Barrett's metaplasia have an increased risk of complications such as stricture or adenocarcinoma.(ABSTRACT TRUNCATED AT 400 WORDS)

Characterization of a lymphokine produced by human T cells which inhibits collagen synthesis

Human lymphocytes, isolated from peripheral blood, were cultured for 48 hr in a defined medium containing 10 mg/ml bovine serum albumin and phytohemagglutinin. A lymphokine which inhibits collagen synthesis by cultured human dermal fibroblasts was purified from the lymphocyte incubation medium by successive steps of ammonium sulfate precipitation, gel filtration chromatography, and isoelectric focusing. Good recovery of this collagen synthesis inhibitory factor (CSIF) was obtained and a factor with an approximate molecular weight of 55,000 and a pI of 6.2 was isolated. The purification of the factor should permit further studies on its mechanism of action.

Lymphokine modulation of fibroblast proliferation

In an experimental model of interstitial nephritis resulting in fibrosis, lymphokines secreted by a common population of antigen-reactive T lymphocytes have been shown to exert a bidirectional influence on fibroblast proliferation and collagen synthesis. We report that these lymphokines can be chromatographically separated into two fractions. The larger m.w. fraction stimulated fibroblast proliferation whereas the smaller m.w. fraction was inhibitory. These results further clarify potentially important immune regulators of fibrogenesis.

Lymphokine modulation of fibroblast proliferation

In an experimental model of interstitial nephritis resulting in fibrosis, lymphokines secreted by a common population of antigen-reactive T lymphocytes have been shown to exert a bidirectional influence on fibroblast proliferation and collagen synthesis. We report that these lymphokines can be chromatographically separated into two fractions. The larger m.w. fraction stimulated fibroblast proliferation whereas the smaller m.w. fraction was inhibitory. These results further clarify potentially important immune regulators of fibrogenesis.

Synovitis in secondary syphilis. Clinical, light, and electron microscopic studies

Polyarthritis and tenosynovitis were seen as the presenting complaints in 7 patients with secondary syphilis. Synovial needle biopsy was obtained in 3 cases and showed mild synovitis with infiltration by lymphocytes, plasma cells, and polymorphonuclear leukocytes; vascular congestion; and slightly increased synovial lining cells. In addition, electron microscopy in these synovial membranes showed many necrotic polymorphonuclear leukocytes, much interstitial debris and fibrin, and in 2 patients, bodies suggestive of Treponema pallidum in the interstitium and in vessel lumens.