CD8+CD28-, suppressive T cells in systemic lupus erythematosus

Recent studies show that a CD8+CD28- phenotype of T-cell population inhibits the reactivity of T-helper cells either by a contact-dependent mechanism or with secreting suppressive cytokines. In this study, we have explored the peripheral blood CD8+CD28- T-cell population in 53 patients with systemic lupus erythematosus (SLE) in comparison to healthy and diseased control groups. The distribution of CD28- cells within CD8+ population has been found significantly lower in patients with SLE than in healthy individuals. While there were no significant differences in the expression of costimulatory molecules CD80 and CD86, the CD40 expression on monocytes was found significantly lower and there was a slight decrease of expression of Interleukin-10 (IL-10) in CD8+CD28- population in patients with SLE. The Transforming growth factor-beta (TGF-beta) mRNA expression was found higher in CD8+CD28- T cells. Neither activation induced nor time-dependent change in the frequency of CD8+CD28- cells has been observed following stimulation at various time-points indicating that the control of CD28 expression was not dependent on the presence of sustained stimulations. Decrease in CD8+CD28- T cells which normally produce TGF-beta and their low-level IL-10 content may reflect impaired T-cell suppression and accordingly, increased T cell help to autoreactive B cells in patients with SLE.

Serum levels of free heat shock protein 70 and anti-HSP70 are elevated in Behçet's disease

OBJECTIVES

As heat shock proteins (HSPs) are described as candidate self-antigens in Behçet's disease (BD), free HSP70 and anti-HSP70 levels were measured in the sera of patients to investigate their role in the pathogenesis of BD.

METHODS

Free human HSP70 levels were measured in the sera of patients with BD and compared to disease controls [patients with rheumatoid arthritis (RA) or recurrent oral ulcerations (ROU)] and healthy controls (HC) using ELISA. Anti-HSP70 antibody levels were also determined.

RESULTS

Free human HSP70 levels were significantly elevated in BD sera (1.12+/-0.86 ng/ml) compared to HC (0.67+/-0.46 ng/ml, BD vs. HC: p<0.001). However similarly elevated levels were also present in ROU (0.95+/-1.01 ng/ml, p<0.05) and RA (1.1+/-23.3 ng/ml, p<0.01). Anti-HSP70 antibody levels were also significantly higher in BD (668+/-658 microg/ml) compared to HC (490+/-742.05 microg/ml, p<0.05). However no significant anti-HSP70 antibody responses were observed in ROU (634.7+/-548.21 microg/ml) and RA (431.8+/-840.98 microg/ml). No association of any organ manifestation, the disease duration, or treatment with HSP70 or anti-HSP70 antibody levels were observed in BD. A correlation between HSP70 and anti-HSP70 levels was only found in HC (p=0.007).

CONCLUSION

Free human HSP70 and anti-HSP70 antibodies are both elevated in patients with BD. HSP70-mediated innate and adaptive immune responses may participate in proinflammatory cytokine activation and tissue destruction in BD.

Very rare aetiology of giant popliteal pseudoaneurysm: anterior cruciate ligament surgery

There are various causes of the formation of arterial pseudoaneurysms, including trauma, surgical procedures, infection and iatrogenic injuries. A popliteal aneurysm was detected in a patient with pain and discomfort in his leg. The patient had a history of knee surgery. The aneurysm was treated surgically. Aneurysms following penetrating arterial injury resulting from surgical intervention requiring the use of surgical devices is one of the possible traumatic causes.

Activation of neutrophils by testosterone in Behçet's disease

OBJECTIVE

Gender differences, especially in disease severity, are observed in Behçet's disease (BD), a systemic vasculitis of unknown etiology. To determine the putative role of testosterone on neutrophil activity exhibited by patients with BD, peripheral blood neutrophils were examined in vitro before and after treatment with testosterone.

METHODS

Peripheral blood neutrophils of 49 patients with BD (26M:23F), 33 patients with ankylosing spondylitis (AS) (23M:10F), 8 female patients with hirsutism and 31 healthy individuals (19M:12F) were analyzed by flow cytometry. Neutrophil-ROS-generating capacity, anti-CD66b, anti-CD16, Phi-philux and PI staining techniques were used for evaluating neutrophil activation and apoptosis.

RESULTS

Gender differences were striking not only in the mean oxidative burst response but also in the rate of apoptosis. Male BD patients manifested increased burst response before testosterone treatment compared with females (8.0 +/- 4.9 vs. 4.9 +/- 3.3, p < 0.01). Consistent with oxidative burst results, baseline percentages of CD66b (99.1 +/- 0.9 vs. 94.7 +/- 5.3 p < 0.04) and CD16 expressing cells were greater in male BD patients. A decreased apoptosis ratio was observed using phi-philux and PI staining in BD patients. This was especially significant in male compared to female BD patients (2.4 +/- 1.4 vs. 6.8 +/- 5.8, p < 0.002). BD itself rather than the gender was found to be the most important predictor of this altered apoptosis ratio in BD determined by linear regression analysis.

CONCLUSION

Our results suggest that a contribution of testosterone to the BD pathogenesis cannot be ruled out. However, causative factors for disturbed apoptosis especially seen in male BD patients need to be further evaluated.

The role of infectious agents in the pathogenesis, clinical manifestations and treatment strategies in Behçet's disease

Behçet's disease (BD) is a multisystemic disorder characterized by oral, genital ulcers and involvement of the cutaneous (erythema nodosum, pustular vasculitis), ocular (anterior or posterior uveitis), musculoskeletal, vascular (both arterial and venous vasculitis), gastrointestinal and central nervous (meningoencephalitis) systems. It has an unpredictable clinical spectrum from mild mucocutaneous manifestations to severe ocular, vascular or neurological disability. In this review, the aetiology, clinical presentations and treatment modalities of BD are evaluated in the context of microbial factors within the existing literature. The relationships between microbial agents (streptococcia and herpes simplex virus), microbial antigens [heat shock proteins (HSP), lipoteichoic acid (LTA)] and immune mechanisms such as innate and adaptive responses against microorganisms are discussed.

The influence of homocysteine levels on endothelial function and their relation with microvascular complications in T2DM patients without macrovascular disease

The aim of this study was to investigate the influence of homocysteine (hcy) levels on endothelial function by the method of brachial artery ultrasonography and their relation with microvascular complications in type 2 diabetes mellitus (T2DM) patients without macrovascular disease. Fifty-nine T2DM patients with a mean age of 53.4+/-8.6 years and diabetes duration of 8.1+/-6.2 years and 16 healthy controls with a mean age of 47+/-14.5 years were included in the study. Endothelialdependent and endothelium-independent flow-mediated dilatation (FMD) were evaluated via brachial artery ultrasonography. Fasting plasma glucose (FPG), glycosylated haemoglobin (A1c), lipid profile, hcy, B12 and folic acid levels were measured. Diabetic patients and control group individuals were compared with regard to the laboratory values and brachial artery vascular reactivity. Factors influencing endothelium-dependent FMD were investigated with linear regression analysis. Age, gender, body mass index, lipid profiles and hcy levels were similar in both groups (p>0.05). Endothelium-dependent FMD percentages were significantly lower in diabetics than in the control group (7.7+/-5.9 vs. 11.7+/-7.1%, p<0.05). Endothelial-independent FMD percentage was similar for both groups (p>0.05). The upper limit of the reference hcy value was found to be 12.6 micromol/l in the control group. In the diabetic group, hcy levels were high in 33 patients and normal in 26 patients. No difference was detected between the patients with high hcy levels and those with a normal level with regard to endothelium-dependent and endothelium-independent FMD values (p>0.05). Mean hcy levels were 16+/-1.7 and 13.3+/-4.3 micromol/l in T2DM patients with microvascular complication and those with no microvascular complication, respectively (p<0.05). Regression analysis revealed that the main factors influencing the endothelial-dependent FMD were FPG, total cholesterol (TC), triglycerides (TG) and high-density lipoprotein (HDL-C) levels (p<0.05, p=0.05, p=0.05, p=0.02, respectively). Hcy, folic acid and B12 values did not influence endothelium-dependent FMD (p>0.05). Diabetes duration and A1c levels were close to being significant although they did not reach statistical significance (p=0.07 and p=0.08 respectively). Hcy levels have no effect on endothelium-dependent and endothelium-independent FMD in T2DM patients without macrovascular complications. The influence of classical atherogenic factors (such as FPG, TC, TG and HDL-C levels) on endothelium functions, detected with endothelium-dependent FMD, is greater.

Acute aortic insufficiency after blunt chest trauma: a case report

Traumatic aortic valve regurgitation is a rare complication of non penetrating blunt chest trauma which usually requires surgical management. We describe a case of a 21 year old man with blunt chest trauma who was diagnosed with aortic valve regurgitation due to rupture of the right coronary cusp one month after falling from a high place. Rupture of aortic valve cusp was treated successfully with aortic valve replacement.

Atrial fibrillation after off-pump coronary artery surgery: a prospective, matched study

The effect of cardiopulmonary bypass and myocardial ischaemia on the occurrence of atrial fibrillation (AF) after coronary artery bypass graft (CABG) was studied in 136 patients undergoing off-pump CABG who were matched for age and number of distal anastomoses with 136 patients undergoing on-pump CABG. Possible risk factors for post-operative new-onset AF were recorded. AF occurred in 64 (24%) of the 267 patients for whom data could be analysed. AF occurred in 29 patients (22%) in the off-pump group versus 35 (26%) in the on-pump group, but this difference was not statistically significant. On univariate analysis, age and length of hospital stay were significant risk factors for the occurrence of AF. In a multivariate analysis that included operative technique, age was found to be the only significant risk factor. In conclusion, the occurrence of AF after CABG does not depend on the type of operation.

The assessment of oral health-related quality of life by factor analysis in patients with Behcet's disease and recurrent aphthous stomatitis

BACKGROUND

The aim of the study was to test multidimensional properties of oral health impact profile-14 (OHIP-14) in Behcet's disease (BD) and recurrent aphthous stomatitis (RAS) patients with active oral ulcers.

METHODS

Ninety-six BD patients, 28 patients with RAS and 117 healthy controls (HC) were included in this study. In patients with active oral ulcers, the frequency and healing time of ulcers were recorded. Multidimensional properties of OHIP-14 were examined by factor analysis.

RESULTS

Factor analysis revealed three subscales and explained 66.49% of overall variance in these patients with active oral ulcers. The score of Subscale 1 was positively correlated with the recurrence of oral ulcers per month (P = 0.037). Subscale 3 scores of the patients treated with colchicine were worse than those treated with immunosuppressives (P = 0.035).

CONCLUSIONS

The factor structure of OHIP-14 was found to be reliable and sensitive to clinical parameters and treatment modalities in active patients.

Oral health related quality of life is affected by disease activity in Behçet's disease

OBJECTIVES

This study aimed to investigate oral and general health related quality of life (QoL) in patients with Behçet's Disease (BD) and to assess the performance of Turkish versions of oral health related quality questionnaires.

SUBJECTS AND METHODS

Ninety-four BD patients, 24 patients with recurrent aphthous stomatitis (RAS), 113 healthy controls (HC) and 44 dental patients were investigated. QoL was assessed by oral health impact profile-14 (OHIP-14), oral health related quality of life (OHQoL) and short form-36 (SF-36) questionnaires.

RESULTS

OHQoL, OHIP-14 and SF-36 subscale scores were significantly worse in patients with BD compared with those in HC (P < 0.05). Both OHIP-14 and OHQoL scores were significantly worse in active patients compared with inactives in BD and RAS (P < 0.05). Scores of SF-36 Role physical, Role emotional and Vitality were also lower in active patients than in inactives in BD (P < 0.05). Scores of OHIP-14 and OHQoL were significantly worse in patients treated with colchicine compared with those treated with immunosuppressives (P < 0.05).

CONCLUSIONS

Both oral and general QoL was impaired in BD and associated with disease activity and treatment modalities. Translated Turkish versions of OHIP-14 and OHQoL were also observed to be valid and reliable questionnaires for further studies.

Effect of colchicine on cyclosporine nephrotoxicity, reduction of TGF-beta overexpression, apoptosis, and oxidative damage: an experimental animal study

BACKGROUND

Proinflamatory and profibrotic cytokines may be responsible for the cyclosporine A nephrotoxicity. Increased levels of apoptosis, free oxygen redicals, and transforming growth factor beta (TGF-beta), may play an important roles in the pathogenesis of nephrotoxicity. In this experimental animal study, we sought to investigate the effects of colchicine on the cyclosporine nephrotoxicity.

METHOD

Twenty-four Wistar albino rats were divided into three groups: cyclosporine 15 mg/kg subcutaneously (SC); cyclosporine 15 mg/kg SC plus colchicine 30 mcg/kg orally; and a control group; equal doses of olive oil orally were administered to groups 1, 2, and 3. Renal function, cyclosporine levels, and serum malonyldialdehyde (MDA) levels were measured at the end of 4 weeks. Apoptosis, TGF-beta, and other findings were detected in renal tissue with the TUNEL method, with a immunohistochemical method, and with routine staining procedures, respectively.

RESULTS

There were significant differences in the values of mean creatinine clearance between group 1 and group 3 and between group 2 and group 3 (P < .05 for each comparison), but not between group 1 and group 2 (P > .05). MDA levels in group 1 were high compared with the control group (P < .05) with a trend toward elevation relative to group 2 but the results were not statistically significant (P > .05). Renal tubular vacuolization in group 1 and group 2 animal were greater than in the control group, but no significant difference were observed between any of the groups (P > .05). Mononuclear cell infiltration in group 1 and group 2 hosts were higher than the control group, but there was no significant differences between the groups (P > .05). Afferent arteriolar hyalinization was observed group 1 and 2 but not group 3. There was a statistically significant difference between group 1 and group 3 and between group 2 and group 3 (P < .05 for each comparison). The expression level of TGF-beta was higher in group 1 than group 2 or group 3 (P <.05 for each comparison) but group 2 and group 3 were similar (P > .05). Apoptotic cell death count of group 1 was higher than that in group 2 or group 3 (P < .05, for each comparison); moreover, group 2 also showed greater numbers of apoptotic cells than group 3 (P < .001). At the end of the 4 weeks, there was no intersititial fibrosis in any of the hosts.

CONCLUSION

While cyclosporine caused increased TGF-beta expression and apoptotic cell death in the renal tissue of rats colchicine prevented the increase in MDA serum levels, TGF-beta expression, and apoptosis in renal tissue. Our study suggests that colchicine may diminish the cyclosporine nephrotoxicity by its suppressing the expression of TGF-beta, apoptotic cell death, and MDA production.

Clinical and immunological effects of azithromycin in Behcet's disease

BACKGROUND

The aim of this study was to evaluate the effects of azithromycin on mucocutaneous manifestations, oral health and immune response in Behçet's disease (BD).

METHODS

Eight BD patients with active mucocutaneous symptoms were treated with azithromycin for 4 weeks. Oral health, clinical manifestations and in vitro interleukin (IL)-12, interferon (IFN)-gamma, IL-10 and monocyte chemotactic protein (MCP)-1 responses were evaluated before and after treatment.

RESULTS

The number of folliculitic lesions, healing time of oral ulcers and scores of plaque indexes (PLIs) were lower after azithromycin treatment (P<0.05). Scores of PLIs correlated positively with the healing time of oral ulcers (P=0.02). Although a trend towards increased stimulated IL-10 responses with azithromycin was observed, no statistically significant difference was found. Stimulated and unstimulated MCP-1, IFN-gamma and IL-12 responses were similar before and after treatment (P>0.05).

CONCLUSION

Azithromycin was observed to be effective in decreasing folliculitic lesions and fastening the healing time of oral ulcers in BD.

Anti-Ro/SSA and anti-La/SSB autoantibodies in the tear fluid of patients with Sjögren's syndrome

PURPOSE

To investigate the presence of anti-Ro/SSA and anti-La/SSB antibodies in the tear fluid and serum of patients with Sjögren's syndrome and to evaluate the association of these autoantibodies with the severity of keratoconjunctivitis sicca.

METHODS

Tear fluid and serum were obtained from 28 patients with Sjögren's syndrome and 17 age matched normal control subjects. Evaluation of tear fluid and sera anti-Ro/SSA and anti-La/SSB levels was done by using a quantitative enzyme linked immunosorbent assay kit designed for the quantitative measurement of IgG class autoantibodies directed against highly purified SSA and SSB antigens. Tear function and ocular surface were evaluated by Schirmer I test, tear break up time, and rose bengal staining. Dry eye symptom scores were recorded.

RESULTS

Increased levels of anti-Ro/SSA and anti-La/SSB antibodies were detected in sera of 57.1% and 50% of SS patients, respectively. Six patients had increased levels of anti-Ro/SSA in the tear fluid, in one case anti-Ro/SSA being detected in tear fluid when it was negative in serum. Ten patients had positive anti-La/SSB titres in tear fluid and in four of these patients, anti-La/SSB titres were not elevated in serum. A positive correlation was observed between serum and tear fluid titres of anti-Ro/SSA (r = 0.43, p = 0.02), but not of anti-La/SSB. Serum anti-Ro/SSA and anti-La/SSB concentrations correlated positively with dry eye symptom scores (r = 0.42, p = 0.02 and r = 0.48, p = 0.01, respectively) and negatively correlated with Schirmer I test scores (r = -0.39, p = 0.04 and r = -0.40, p = 0.03, respectively). Significant correlations were found between tear anti-La/SSB concentrations and dry eye symptom score (r = 0.56, p = 0.02) and also rose bengal staining scores of the ocular surface (r = 0.44, p = 0.02).

CONCLUSION

This study shows that autoantibodies against Ro/SSA and La/SSB antigens are present in the tear fluid of some patients with SS and their presence in serum or tear fluid is associated with the severity of keratoconjunctivitis sicca. Additional measurement of tear fluid levels of anti-Ro/SSA and anti-La/SSB may serve as a valuable diagnostic indicator of SS.

Survivin and aven: two distinct antiapoptotic signals in acute leukemias

BACKGROUND

Antiapoptotic signals are important in the development, progression and prognosis of malignant tumors. The aim of this study was to determine the two distinct antiapoptotic signals-survivin and aven-in acute leukemias and compare them with clinical and hematological findings and response to therapy. Real-time quantitative PCR was used and survivin and aven were detected at the messenger (m)RNA level.

PATIENTS AND METHODS

Sixty-five patients with acute leukemia [37 with acute myeloblastic leukemia (AML) and 28 with acute lymphoblastic leukemia (ALL)] were used as the study group and 10 healthy subjects were used as the control group.

RESULTS

Survivin was between 0.0 and 0.829 copy number/cell (median 0.0721, mean 0.5424301909 +/- 0.139799488589) and aven was between 0.0 and 0.853 copy number/cell (median 0.0124, mean 0.070335542 +/- 0.1524685709). We found an important association between survivin and aven (P = 0.000). Both survivin and aven were higher in the study group than in the controls (P = 0.001 and 0.035, respectively). When we compared survivin and aven with other clinical and hematological parameters, there was an important association between survivin and extramedullary involvement (P = 0.033), survivin and alkaline phosphatase (P = 0.06), white blood cell (WBC) count and lactate dehydrogenase (LDH) (P = 0.000), WBC count and uric acid (P = 0.074), hemoglobin level and LDH (P = 0.072), LDH and uric acid (P = 0.057), CD7 expression and survivin (P = 0.097), and CD34 expression and aven (P = 0.058). Response to therapy was evaluated according to the survivin and aven levels. Survivin level was lower in refractory patients as compared with complete responders (P = 0.085). Aven level was higher in patients with relapse as compared with non-relapse patients (P = 0.04). There was no important association between survivin or aven and performance status, lymphadenopathy or organomegaly.

CONCLUSIONS

Both survivin and aven are important antiapoptotic signals in acute leukemias, and the association between extramedullary involvement, CD7 expression and CD34 expression, which are important poor prognostic indicators in acute leukemias, suggests that survivin and/or aven may be novel prognostic indicators in acute leukemias. Further studies with a higher number of patients will be more informative.

Coronary stent implantation in Behçet's disease

Behçet's disease (BD) is a systemic vasculitis that rarely involves the coronary arteries. Coronary arteritis may lead to myocardial infarction and death, and the management of coronary lesions due to BD has been described only in a small number of patients. The outcome of a young patient with BD is reported who was admitted with acute coronary syndrome and underwent balloon angioplasty and coronary stent implantation. Coronary stent implantation is an alternative treatment for coronary artery lesions of BD but careful monitoring is mandatory due to the progressive vasculities.

Renal dose dopamine in open heart surgery. Does it protect renal tubular function?

BACKGROUND

This prospective, randomized study assessed the effect of dopamine on renal tubular function in patients who had coronary artery bypass grafting.

METHODS

Two groups of patients with normal preoperative renal function were randomly divided into a dopamine group (n=11), who received dopamine in a dose of 2 mg/kg x min, and a control group (n=11), who received no treatment. Dopamine infusion was initiated 24 hours before the operation and was continued for 48 hours postoperatively. Measurements of renal function obtained 2 days before the operation were considered preoperative and were repeated on the 1st, 3rd, and 7th postoperative days. Urinary excretion of b2-Microglobulin (b2-M), considered a sensitive means for diagnosing proximal tubular damage, was measured during the early (day 3) and late (day 7) postoperative period.

RESULTS

There were no significant differences respect to the clearances of creatinine, osmotic, and free-water in the dopamine group compared with the control group (p>0.05). Urine microalbumin levels significantly increased on postoperative day 3 in both groups. During the early postoperative period, excretion of urine b2-M was significantly greater in the dopamine group than in the control group (p<0.05).

CONCLUSIONS

Consequently, in patients with normal preoperative renal and cardiac function scheduled for elective coronary artery bypass grafting, renal dose dopamine infusion alone may not provide sufficient protection on tubular function and increases renal tubular injury during the early postoperative period.

Telomerase activity in patients with chronic myeloid leukemia and lymphoma

Telomeres are repeated DNA sequences, positioned at the ends of chromosomes and are essential for the stable maintenance of chromosomes. The telomere length serves as a mitotic clock determining the remaining replicative capacity of the cell. Telomeric sequences are lost during each cell division, leading to a process thought to contribute to senescence and cell death. The enzyme telomerase adds 5'-TTAGGG-3' repeats to the mammalian telomeres and maintains the telomere length. Telomerase is normally inactive in most somatic cells but telomerase activity is observed in malignancies. In this study telomerase activity was analyzed in patients with chronic myeloid leukemia (CML) and lymphoma by PCR and ELISA. This approach combines highly specific amplification of the telomerase-mediated elongation products with nonradioactive detection in a highly sensitive photometric ELISA. The PCR products were also analyzed by Southern blotting. The telomerase-specific PCR products were seperated by electrophoresis and transferred to a nylon membrane with subsequent detection of the biotinylated amplificates. High activity levels were detected in 17 CML ( 34%) patients. On the other hand, no activity was observed in lymphoma patients. An increase in the shorter telomeric bands was observed in CML patients who displayed a high level of telomerase activity. In contrast to the low enzyme activity, evidence of telomeric repeats were also found in some lymphoma patients by Southern blotting. This may indicate that lymphoma cells may make use of different pathways for maintaining the length of their telomeres.

Neutrophil activation in Behçet's disease

OBJECTIVE

Neutrophils are implicated in the pathogenesis of Behçet's disease (BD). Various functions of neutrophils are studied to clarify this role.

METHODS

The oxidative burst and phagocytic functions of neutrophils and surface molecules associated with neutrophil activation (CD10, CD14 and CD16) were investigated in BD patients by flow cytometric methods. Patients with inflammatory arthropathies, sepsis and healthy controls were also studied.

RESULTS

In the oxidative burst experiments, after fMLP and PMA stimulation, stimulation index was found to be significantly decreased in patients both with BD and sepsis compared to healthy controls and inflammatory arthropathies (p < 0.001 and p < 0.01, respectively). The phagocytosis of labelled E. coli particles in patients with BD was not different from that of the healthy controls, while it was decreased in diseased controls (p < 0.001). The surface density of neutral endopeptidase (CD10) and the mean percentage of LPS receptor (CD14) was found to be significantly higher in both BD patients and diseased controls (p < 0.001). The mean percentage of CD16 expression was only low in patients with sepsis (p < 0.001), whereas CD16 intensity on cells was found to be lower in patients with BD as well as in sepsis (p < 0.01).

CONCLUSION

These findings indicate the presence of in vivo pre-activated neutrophils in BD. A similar activation was also a feature of severe inflammatory disorders.

Effect of papaverine applications on blood flow of the internal mammary artery

The aim of this prospective study was to compare the effect of different papaverine applications on the free blood flow in the internal mammary artery (IMA) prepared for coronary artery bypass grafting (CABG). The patients were divided into three groups: group I (n=50; intraluminal papaverine application), group II (n=50; topical papaverine application), and group III (n=50; periarterial papaverine application). The free flow from the distal cut end of the IMA was measured under controlled hemodynamic conditions (Flow 1). Just before the establishment of cardiopulmonary bypass, the flows of the IMA were measured again (Flow 2). The mean blood flow in the IMA was 60.7+/-6.0 ml/min before papaverine application. After papaverine application, the mean blood flow in group I was 129.3+/-10.0 ml/min, in group II, it was 87.7+/-3.8 ml/min, and in group III, it was 130.6+/-9.2 ml/min (p<0.0001). Proportional increases in blood flow observed in group I (106.3%) and group III (116.2%) were higher than in group II (44.2%) (p<0.0001). Consequently, to relieve perioperative spasm of the IMA, application of papaverine injected into the periarterial tissues of its pedicle was considered to be a safe and effective alternative to topical or intraluminal application.

Remitting seronegative symmetrical synovitis with pitting oedema associated with chronic lymphocytic leukaemia

We describe a case of remitting seronegative symmetrical synovitis with pitting oedema (RS3PE syndrome) in a 67-year-old man. Immunophenotyping studies and histology of biopsy specimens revealed chronic lymphocytic leukaemia (CLL). Polyarthritis and oedema were revealed by small doses of corticosteroids. The association of RS3PE syndrome with rheumatological and malign disorders are discussed.

Comparative characteristics of mu chain and alpha chain transcripts expressed by individual tonsil plasma cells

Plasma cells (PCs) are one of the two major cell types generated during germinal center reactions. To test the hypothesis that PCs express a unique repertoire of immunoglobulin (Ig) genes resulting from intensive antigenic stimulation and selection, the mutational pattern and distribution of V(H) gene segments within 178 transcripts amplified from individual IgM and IgA secreting tonsil PCs were analyzed. The results demonstrated that both mu and alpha transcripts expressed repertoires with limited diversity. Moreover, both mu and alpha transcripts were heavily mutated, with a significantly increased mutational frequency noted for alpha compared to mu transcripts (5.0 x 10(-2) vs 1.8 x 10(-2), P<0.001). In addition, both mu and alpha transcripts showed significantly greater targeting of mutations to RGYW motifs (purine/guanine/pyrimidine/A or T) compared to memory B cells. Finally, clonally expanded cells were detected in alpha but not mu PC compartments. These results indicate that antigen driven stimulation and selection shape the entire expressed PC repertoire, but the impact is greater in alpha expressing PCs.

Synovial stromal cells from rheumatoid arthritis patients attract monocytes by producing MCP-1 and IL-8

Macrophages that accumulate in the synovium of rheumatoid arthritis patients play an important role in the pathogenesis of this inflammatory disease. However, the mechanism by which macrophages are attracted into the inflamed synovium and accumulate there has not been completely delineated. The results of this study show that rheumatoid arthritis synovial stromal cells produce the chemokines monocyte chemotactic protein-1 and IL-8, and these have the capacity to attract peripheral monocytes. These results suggest that one of the mechanisms by which macrophages accumulate in the inflamed synovium is by responding to the chemokines produced locally.

Stromal cell-derived factor-1-CXC chemokine receptor 4 interactions play a central role in CD4+ T cell accumulation in rheumatoid arthritis synovium

Rheumatoid arthritis (RA) is characterized by the accumulation of CD4(+) memory T cells in the inflamed synovium. To address the mechanism, we analyzed chemokine receptor expression and found that the frequency of CXC chemokine receptor (CXCR)4 expressing synovial tissue CD4(+) memory T cells was significantly elevated. CXCR4 expression could be enhanced by IL-15, whereas stromal cell-derived factor (SDF)-1, the ligand of CXCR4, was expressed in the RA synovium and could be increased by CD40 stimulation. SDF-1 stimulated migration of rheumatoid synovial T cells and also inhibited activation-induced apoptosis of T cells. These results indicate that SDF-1-CXCR4 interactions play important roles in CD4(+) memory T cell accumulation in the RA synovium, and emphasize the role of stromal cells in regulating rheumatoid inflammation.

The association of thyrotoxicosis and chronic lymphoproliferative disorders

We diagnosed thyrotoxicosis (Tx) and chronic lymphoproliferative disease (LPD) in nine cases; seven had chronic lymphocytic leukemia (CLL), one had hairy cell leukemia (HCL) and one had non-Hodgkin's lymphoma (NHL). In a literature review, we found only one reported case with Tx and CLL and documentation of an higher incidence of Tx in the relatives of CLL patients. We report these nine cases here and discuss this interesting association.

The use of transesophageal echocardiography guidance of thrombolytic therapy in prosthetic mitral valve thrombosis

BACKGROUND AND AIM OF THE STUDY

The aim of the study was to assess the use of transesophageal echocardiography (TEE) to guide thrombolytic therapy in prosthetic mitral valve thrombosis.

METHODS

Twenty-nine consecutive cases of prosthetic mitral valve thrombus diagnosed between January 1995 and May 1998 were managed according to data obtained by TEE. Three patients with pedunculated thrombus and five in NYHA functional classes I-II were referred for surgery. Patients who refused surgery or who were in NYHA classes III-IV and had unpedunculated thrombus were selected for thrombolytic therapy. Twenty-one patients (seven males, 14 females; mean age 47 +/- 8 years) received streptokinase for thrombolysis.

RESULTS

The mean period from valve replacement surgery was 36 +/- 23 months, and mean time from onset of symptoms 9.2 +/- 14.3 days. Anticoagulant use was inadequate in 18 (86%) patients. Fourteen cases (66%) were NYHA class IV, four (19%) in class III, and three (15%) in class II. Ten patients (48%) were in atrial fibrillation. During the first 24 h of thrombolytic therapy, mean mitral valve peak and mean gradients fell from 25.6 +/- 4 and 13.8 +/- 2.5 mmHg to 11.7 +/- 5.3 and 7.1 +/- 3.1 mmHg respectively (p <0.0001). Five cases with inadequate response to thrombolysis were treated for an additional 24 h. The mitral valve area increased from 1.0 +/- 0.1 cm2 to 2.3 +/- 0.7 cm2 after the first month (p <0.0001). Complete early success in thrombolysis was achieved in 17 (81%) cases, three cases (14%) had partial success, and one case (5%) was referred for surgery on the third day because of failed thrombolysis. Two minor skin bleedings (9%) not requiring transfusion were attributed to thrombolytic therapy. One case (5%) of successful thrombolysis had a non-fatal stroke after therapy and one (5%) was referred for surgery for recurrent prosthetic mitral valve thrombosis at six months' follow up. None of the surgically treated patients died.

CONCLUSION

Guidance of thrombolysis by TEE may reduce, but not eliminate, the risk of thromboembolic complications. Response to thrombolysis became apparent within 24 h, but extending treatment beyond this time provided no additional short-term benefit.

IL-8 producing cells in patients with Behçet's disease

OBJECTIVE

IL-8 is thought to be the principal chemokine responsible for neutrophil activation and tissue infiltration in patients with Behçet's disease (BD). In various studies serum levels of IL-8 were reported to be increased.

METHODS

IL-8 mRNA was purified from both peripheral whole blood samples and separated lymphocytes, granulocytes and monocytes of patients with BD and compared to that from healthy (HC) and disease controls. IL-8 sequences were revealed by PCR amplification using appropriate sequence-specific primers. mRNA levels were determined semi-quantitatively using an image analyser in comparison with beta-actin.

RESULTS

Although the differences did not reach statistical significance, BD patients tended to have higher IL-8 mRNA levels compared to HC in whole blood samples (2.0 +/- 1.4 vs 1.5 +/- 1.2) as well as in their lymphocytes (2.7 +/- 1.6 vs 1.5 +/- 0.9). No differences were observed between BD and HC in monocyte or granulocyte IL-8 mRNA levels.

CONCLUSION

Our results suggest that the cellular source of IL-8 is diverse in BD with a possible major contribution by lymphocytes.

T cell responses to 60/65 kDa heat shock protein derived peptides in Turkish patients with Behçet's disease

OBJECTIVE

Sequence homology and cross reactivity between microbial and human heat shock proteins (HSP) led to the concept that HSP might be involved in the etiopathogenesis of Behçet's disease (BD). We investigated T cell responses to 8 synthetic peptides derived from the mycobacterial 65 kDa and homologous human 60 kDa HSP in patients with BD.

METHODS

T cell proliferative responses to synthetic peptides were studied in 49 patients with BD and 46 disease (DC) and 34 healthy controls (HC) with 3H-thymidine uptake test.

RESULTS

Positive T cell responses to one or more of the mycobacterial peptides were observed in 52% (12/23) of patients with BD compared with 17% (3/18) of DC (p = 0.02) and to homologous human peptides in 57% (13/23) of BD and 11% (2/18) of DC (p < 0.01). Responses to the mixtures of 4 mycobacterial peptides were also significantly higher in BD compared with controls (stimulation index in BD 4.7 +/- 3.5 vs DC 2.0 +/- 1.2, HC 1.6 +/- 0.4; BD vs DC and HC, p < 0.001). Similar elevated responses to the mixture of 4 human peptides was also observed in patients with BD (BD 3.4 +/- 2.3; DC 1.9 +/- 0.8; HC 1.4 +/- 0.6; BD vs DC, p < 0.01; BD vs HC, p < 0.001).

CONCLUSION

These results suggest that cellular immunity against the 65 kDa mycobacterial and 60 kDa human HSP derived peptides is significantly increased in Turkish patients with BD compared to controls, as observed in the UK and Japan.

Lymphomatous skin infiltration at the site of previous varicella zoster virus infection in a patient with T cell lymphoma

Cutaneous infiltrations in hemopoietic neoplasias are not uncommon. They are generally localized on the legs, arms, back, anterior chest, scalp and face. In rare cases specific infiltration of neoplastic cells is localized in the site of herpes zoster and herpes simplex scars. In this report a case with T cell lymphoma in leukemic phase with skin infiltration in the previous Varicella Zoster Virus (VZV) site of infection is reported and literature is reviewed.

Postmastectomy malignant lymphoma

Postmastectomy lymphedema (PML) is a morbid condition occurring in patients with breast carcinoma treated with radical/modified radical mastectomy. Postmastectomy angiosarcoma (PMA) is the most common neoplasia seen in these patients. Primary malignant lymphoma arising in PML is a rare neoplasia and 3 cases have been reported until now. In this report a patient with diffuse large cell lymphoma (DLCL) arising in PML is reported and the other three cases are reviewed.

Oligoclonal T cell expansions in patients with Behçet's disease

Behçet's disease (BD) is a multisystem disorder with oral and genital ulcers, mucocutaneous, ocular, joint, vascular and central nervous system involvement. In this study, the peripheral T cell repertoire was analysed in patients with BD with MoAbs against T cell receptor (TCR) Vbeta gene products in CD4+ and CD8+ T cell compartments, and these were compared with rheumatoid arthritis (RA) patients and healthy controls (HC). In the CD4+ T cell compartment, oligoclonal TCR Vbeta expression was observed in 56% of BD (10/18), 71% of RA (5/7) patients and 21% (3/14) of HC. In the CD8+ T cell group 50% of BD (9/18), 57% of RA patients and 28% of HC (4/14) had an oligoclonal TCR repertoire. An increase of TCR Vbeta5.1 subset was observed in five BD patients among CD8+ T cells. Other elevations of TCR Vbeta subsets were heterogeneously distributed with one to three different Vbeta subsets. Our results suggest an antigen-driven oligoclonal increase of T cells in BD. There was no overall increase in any Vbeta group to suggest a superantigen effect. Analysis of the responsible antigens causing the increase in T cell subsets may give insights into the aetiopathogenesis of BD and immunomodulation of these T cells may lead to new treatments.

Congenital aortic insufficiency due to aortic cusp stretching: 'kite anomaly'

Aortic insufficiency may be either acquired or congenital. A 46-year-old male had a congenital pathology which resulted in aortic insufficiency due to the presence of a fibrous band that stretched from the non-coronary cusp to the aortic wall. The patient underwent successful aortic valve replacement. At surgery, the fibrous band was stretching the non-coronary cusp so that it prevented coaptation of the aortic valve. The situation was termed by us as the 'kite anomaly'.

Phenotypic characteristics of B cells in Behçet's disease: increased activity in B cell subsets

OBJECTIVE

Increased numbers of spontaneous Ig secreting B cells and elevated immunoglobulin levels have been described in Behçet's disease (BD), in addition to changes in numbers and activities of T cells, natural killer cells, and monocyte-macrophages. We investigated other characteristics of B cells in BD.

METHODS

B lymphocyte subsets (CD19+CD5+, CD19+CD13+, CD19+CD28+, CD19+CD33+, CD19+CD80+, CD5+CD19+CD45RA+, CD5+CD19+CD45RO+) were phenotypically evaluated in 50 patients with BD, 80 healthy subjects, and 20 other patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and sepsis.

RESULTS

Although the B cell number (CD19+) was normal, CD13 and CD33 positive B cells were more numerous in BD and sepsis compared to healthy controls and patients with RA and SLE. The percentage of CD45RO positive B cells was higher in both BD and sepsis, while the percentage of CD80 positive B cells was high only in BD. There was no increase in the CD5+CD19+ B cell subset, previously shown to be increased in several autoimmune diseases. Naive (CD45RA) and memory (CD45RO) status of CD5+CD19+ and CD5-CD19+ B cells showed that CD45RA expression was higher in CD5+CD19+ B cells, whereas expression of both CD45RA and CD45RO was higher in the CD5-CD19+ B cell group compared with healthy controls.

CONCLUSION

Although the total B cell number was normal, increased levels of activated and memory B cell subsets suggest a modified B cell function in BD, which may be related to a weak stimulus by an unknown external antigen.

Skin hyperreactivity of Behçet's patients (pathergy reaction) is also positive in interferon alpha-treated chronic myeloid leukaemia patients, indicating similarly altered neutrophil functions in both disorders

Typical manifestations of Behcet's disease (BD) and a positive pathergy reaction were observed in a few patients with chronic myeloid leukaemia (CML) on interferon alpha (IFN-alpha) therapy and the significance of this observation was assessed in a prospective study. The skin pathergy test was applied to 15 patients with CML prior to IFN-alpha therapy, 29 patients with CML following IFN-alpha therapy and 30 patients with BD. Twenty-five patients with inflammatory arthropathies (IA), 20 patients with recurrent oral ulcers (ROU), 23 patients treated with IFN-alpha for various disorders and 20 normal individuals were also studied as control groups. The pathergy reaction was positive in nearly a quarter of IFN-alpha-treated CML cases (24%) as well as one-half of the patients with BD (50%). All CML patients prior to IFN-alpha treatment and all patients using IFN-alpha for other diseases were negative for the pathergy reaction. These results may indicate a similarly altered neutrophil function in both BD and IFN-alpha-treated CML patients.

Fibromyalgia in Behçet's syndrome

OBJECTIVE

To ascertain the frequency of fibromyalgia (FM) in Behçet's syndrome (BS) and to evaluate the relationship of FM to Behçet's disease activity.

METHOD

Self-questionnaires were completed by 108 patients with BS. Each patient was evaluated by an observer blinded to diagnosis; evaluation included assessment of tender points by palpation. Another observer determined the disease activity of patients at that time.

RESULTS

Ten of 108 patients (9.2%) met the American College of Rheumatology criteria for FM. Nine of the patients who met the criteria for FM were women. In contrast to patients without FM, patients with FM had mild to moderate disease activity in which musculoskeletal complaints were common.

CONCLUSION

There is a trend for an increased frequency of FM in female BS patients.

Genetic anticipation in Behçet's syndrome

OBJECTIVE

To examine the presence of genetic anticipation in families with Behçet's syndrome (BS).

METHODS

A total of 18 families with 40 affected members in two successive generations were evaluated by interviewing them for their ages at the onset of the first symptom of BS and for their ages at the time they fulfilled the diagnostic criteria.

RESULTS

It was noted that the age of onset of the first symptom was lower in the second generation in 14 families (p = 0.01) with a mean (SD) age of 20.57 (7.47) years in the children compared with 33.29 (9.92) years in the parents (t = 7.79, p < 0.0001), whereas the diagnostic criteria were fulfilled at an earlier age in the children in 15 families (p = 0.01) with a mean age of 21.2 (6.74) years in the children compared with 36.4 (9.55) years in the parents (t = 7.41, p < 0.0001).

CONCLUSION

Genetic anticipation was present in 15 of 18 (84%) of the families with BS in the form of earlier disease onset in the children compared with their parents.

Evaluation of chimerism with DNA polymorphisms in bone marrow transplantation

Evaluation of chimeric status following allogenic BMT is an important tool for monitoring the replacement of host cells with donor cells and for determining the risk of relapse. Polymorphic DNA sequences can be used as powerful markers in identification of donor/recipient genotype differences, even between close relatives. Polymerase chain reaction (PCR) amplification of three variable number of tandem repeat (VNTR) loci and five single-locus polymorphisms (SLP) was used to identify chimerism in 40 recipient-donor pairs. Mixed chimerism was present in 11 patients, and complete chimerism in 29. This PCR method is a rapid and sensitive assay to detect engraftment and evaluate relapse potential, and thus is very useful in the clinical management of BMT patients.

An unusual coursing of the facial vein

During the dissections of 50 adult cadavers for educational purposes, we found a 45-year-old male cadaver with an abnormally coursing facial vein which has joined the retromandibular vein at a higher level--in the parotid gland--on the right side of the face. This anomaly has also been detected radiologically.

Morphology of the retromandibular vein in relation to the facial nerve in the parotid gland

In order to help avoid complications of parotid surgery, we investigated the relationship between the facial nerve and the retromandibular vein. Fifty dissections were performed on 30 cadavers. In 45 (90%) of the cases the retromandibular vein was located on the medial side of the upper and lower trunks of the facial nerve, and in 5 (10%), the course of the retromandibular vein was lateral to the lower trunks and medial to the upper trunks. These variations were divided into subgroups. The most commonly encountered variation was that the retromandibular vein crossed the facial nerve from the medial (34 cases) or lateral side (3 cases) at a point between the bifurcation and ramification points of the lower facial trunk. In one case, the retromandibular vein was detected on the lateral side of the facial nerve at the bifurcation. In 3 cases (15%), the course of the retromandibular vein was different on the right and left sides of the face in the same cadaver.

Distribution of facial nerve in parotid gland: analysis of 50 cases

The purpose of the present study is to reduce the postoperative morbidity related to facial paralysis during parotid surgery and to layout the different characteristics related to intraparotideal distribution and anastomoses of the facial nerve in our community. We also report new variations in the facial nerve branchings that have not been previously published. In this paper, facial nerves from 48 cadavers and 2 patients of which 45(90%) were males and 5(10%) were females; 26(52%) being right and 24(48%) being left facial nerves were put forward. Their photographs were taken and the diagrams of intraparotideal distributions of each facial nerve were drawn. The intraparotideal configuration of the facial nerve was evaluated in 5 types. Twenty-four% of the facial nerves had no anastomoses (Type I); 12% had a ring-like shape anastomosis between the buccal and the zygomatic branches (Type II); 14% anastomoses were between the buccal and the other branches in a ring-like shape (Type III); 38% of the facial nerves had multiple complex anastomoses and were named as multiple loops (Type IV); 12% had two main trunks (Type V). Of the bilateral cadaver dissections, the facial nerve distribution in 9(47.3%) were bilaterally the same and in 10(52.7%) main trunks were different. A facial nerve trifurcation composed of two main trunks were also established. There were no statistical differences between branching of the facial nerves in the right and left side of the faces.(ABSTRACT TRUNCATED AT 250 WORDS)

[Relation between serum and salivary IgA and oral aerobic bacterial flora in patients with chronic bronchitis]

Serum and salivary IgA and oral bacterial flora was determined in specimens collected from 28 patients with chronic bronchitis and 7 healthy persons. However, in serum IgA levels, the difference between the patients and controls was not found statistically significant, the mean salivary IgA level was significantly higher in the patients with spastic bronchitis than in infectious bronchitis and controls (p less than 0.01). The mean salivary IgA level was significantly higher in the patients from whom Haemophilus influenzae was isolated, it was lower in the specimens in which gram negative bacilli were isolated (p less than 0.01).