The effect of cyclosporine on the use of hospital resources for kidney transplantation

Over the past decade the clinical results of kidney transplantation have improved substantially, with much of the benefit being attributed to the introduction in late 1983 of the immunosuppressive drug cyclosporine. To assess the effect of cyclosporine on the use of hospital services, we studied 702 patients who received kidney transplants at the University of California, San Francisco, between July 1982 and June 1986. All services were priced in constant 1985 dollars, and multiple regression analysis was used to adjust for changing patient and hospital characteristics. The introduction of cyclosporine for patients receiving kidneys from cadavers was associated with a significantly shorter adjusted mean postoperative stay (26.4 days as compared with 37.0 for patients not taking the drug; P less than 0.0001) and lower adjusted mean hospital charges ($28,649 as compared with $37,895; P less than 0.0001), although cyclosporine was not associated with changes in the use of services by patients who received transplants from living related donors. Cyclosporine was also associated with a reduction in the use of certain ancillary services, such as laboratory tests and radiographic procedures. In patients without diabetes who received cadaver kidneys, a sequential cyclosporine regimen (in which a combination of antilymphoblast globulin, prednisone, and azathioprine was given before cyclosporine) reduced the use of hospital services even more than did a cyclosporine regimen in which the combination was not given. The results suggest that new medications, such as cyclosporine, that reduce the frequency of complications and improve outcomes may also reduce the use of hospital resources.

Sickled cells in synovial fluid: clue to unsuspected hemoglobinopathy

In this report, we have described three patients who had hemarthroses, with sickled red blood cells discovered by analysis of synovial fluid. On the basis of this observation, each patient was evaluated for the presence of abnormal hemoglobins, and each was found to have a hemoglobinopathy that was previously unsuspected. These patients differ from those in other reports in that two of the three had no associated arthritic condition that could readily explain synovitis or a condition that predisposed them to bleeding into a joint. Although the accumulated evidence suggests that heterozygous hemoglobinopathies do not produce arthritic syndromes, these reports again raise that question. We cannot conclude, however, that the hemarthroses were definitively caused by the underlying hematologic abnormality. Important when synovial fluid is mixed with blood, since other medical conditions can be diagnosed if abnormal findings are detected.

Natural killer cells can enhance the proliferative responses of B lymphocytes

In addition to lytic activity against malignant and virally transformed target cells, recent evidence has suggested that natural killer (NK) cells can modulate immune activities such as the suppression of B cell responses through noncytotoxic means. Using human B cells and highly purified autologous NK cells, we have demonstrated that NK cells can substantially augment the proliferative responses of B cells stimulated with the surface immunoglobulin crosslinking agents anti-IgM or Staphylococcus aureus Cowan strain I (SAC). This "enhancer" activity of NK cells was quite potent and was observed at an NK:B cell ratio as low as 0.05. Peak blastogenic responses of B cells cocultured with NK cells in the presence of B cell activators were observed at 2-3 days, similar to the responses of B cells in the absence of NK cells. Using the inhibitor of DNA synthesis mitomycin C, we determined that B cells and not NK cells were proliferating in cocultures of these lymphocytes stimulated with SAC. Activated B cells neither prevented the lysis of the isotope-labeled NK-sensitive target cell line K562 nor formed conjugates with NK cells, suggesting that cell contact was not a prerequisite for the effect. These studies have further expanded the functional repertoire of NK cells to include enhancer as well as suppressor and lytic activities.

Suppression of B cell responses by natural killer cells is mediated through direct effects on T cells

We examined the ability of human natural killer (NK) cells to modulate T cell-dependent mitogen-induced B cell responses. Highly purified NK cells inhibited the polyclonal antibody responses of autologous pokeweed mitogen (PWM)-stimulated unfractionated mononuclear cells in a reverse hemolytic plaque-forming cell (PFC) assay. Investigation of the possible mechanism(s) of the suppressor activity of NK cells revealed that lysis of mitogen-stimulated cells was unlikely. Chromium-51 release cytotoxicity assays of PWM-stimulated mononuclear cells did not demonstrate lysis by NK cells. Additionally, the monoclonal antibody 13.3, which abrogates NK cell cytolysis, did not reverse NK cell-dependent suppression of PFC formation. The putative lytic molecule elaborated by NK cells, NK cytotoxic factor, did not suppress B cell responses, further supporting a nonlytic inhibitory mechanism. That NK cell-derived lymphokines such as IFN-alpha, IFN-gamma, or IL-2 were uninvolved in the down-regulation of B cells was corroborated by the failure of antibodies to these mediators to reverse the suppression. NK cells did not suppress PFC formation when T cells were replaced by supernatants from PWM-stimulated T cells; additionally, NK cells had no effect on the generation of these necessary T cell factors. However, the coculture of T cells with NK cells resulted in the induction of suppressor activity within the T cell population suggesting that this was the mechanism of NK cell-mediated suppression of B cell responses.

Growth hormone releasing factor and somatostatin concentrations in the milk of lactating women

The concentrations of growth hormone releasing factor (GRF) and somatostatin, two hypothalamic neuropeptides involved in the regulation of growth hormone secretion, were measured in human milk samples. The study was performed in healthy women within 48 h of delivery or during established lactation (between 1 and 64 weeks post delivery). No statistically significant correlation was found between the levels in milk of either of the neuropeptides and the gestational age at birth. However, lower values of GRF (23 +/- 4.7 pg/ml vs. 40.5 +/- 4.9 pg/ml) were found in milk obtained during established lactation than in milk obtained close to delivery. A positive correlation was observed between somatostatin and GRF concentrations in milk. The possible involvement of milk neuropeptides in the control of growth hormone secretion in the neonate, as well as in the regulation of other physiological processes, are evaluated.

Therapeutic strategies in autoimmune disease: cyclosporin A as a model agent

Cyclosporin A is the derivative of the cyclic undecapeptide which is produced by 2 strains of fungi, Cylindrocapon lucidum Booth and Tolypocladium inflatum Gams. The drug has achieved widespread use in the treatment of organ transplant recipients as a vanguard against rejection, and currently is being evaluated as an immunosuppressive agent for the therapy of primary autoimmune phenomena as well. Its mechanism of action, and application to the treatment of rheumatologic disorders will be discussed.

Novel interleukin 2 (IL-2) receptor appears to mediate IL-2-induced activation of natural killer cells

A novel IL-2 receptor, distinct from the Tac protein, has been identified on the surface of purified human natural killer (NK) cells by chemical cross-linking of 125I-IL-2. This protein is approximately 70,000 D in size (p70) and appears to be identical to the recently recognized second subunit of the human high affinity IL-2 receptor complex. Scatchard analysis of 125I-IL-2 binding to purified NK cells revealed approximately 2,300 p70 binding sites per cell with an apparent dissociation constant of 200 pM, a value intermediate between the previously recognized high and low affinity forms of the human IL-2 receptor. The monoclonal anti-Tac antibody did not inhibit the cross-linking of 125I-IL-2 to the p70 binding sites present on NK cells. Functionally, the addition of high concentrations of recombinant IL-2 to the enriched NK cells promoted a rapid augmentation of cytolytic activity and a more delayed increase in cellular proliferation. Anti-Tac effectively blocked the IL-2-induced proliferative response in these cells, but failed to alter the enhancement of cytotoxicity. Analysis of NK cytoplasmic RNA isolated at various time points after IL-2 stimulation revealed the rapid induction of c-myb and Tac gene expression that was also not inhibited by the anti-Tac antibody. These findings suggest that IL-2 binding to the p70 receptor constitutively expressed on the surface of NK cells may mediate both the development of increased cytolytic activity and rapid changes in gene expression. The activation of the Tac gene may in turn permit the formation of the high affinity IL-2 receptor complex (comprised of at least the Tac and p70 proteins) that appears to transduce the requisite signals involved in NK cell proliferation.

Traditional thought and modern Western surgery

This study, based in part on anthropological field work with surgeons, is an examination of some aspects of traditional thinking and practices which coexist with, and are embedded in, the scientific thinking and practices of modern surgery. The focus is on the role of these beliefs and practices in modern surgical culture in understanding the causes and prevention of post-operative infections. Three beliefs and practices that exist in traditional and modern medical systems are examined: (A) personalistic disease causes and cures; (B) myriad endogenous and exogenous disease causes; and (C) ritual practices. The adaptive and nonadaptive functions of these beliefs and practices in modern surgery are explored.

Granulomatous musculoskeletal disease: sarcoidosis versus tuberculosis

A patient with systemic sarcoidosis insidiously developed tuberculous arthritis. The concurrence of these diagnoses in any individual patient is rare. Musculoskeletal features of sarcoidosis and tuberculosis are reviewed, and the importance of obtaining appropriate cultures to differentiate these granulomatous disorders is illustrated.

Technetium pyrophosphate muscle scans in inflammatory muscle disease

Technetium-99M pyrophosphate (TcPYP) nuclear scans of extremities were performed on 15 patients at 10 minutes and 2 hours after isotope injection. Scans were carried out both to confirm the diagnosis of myositis and to direct subsequent muscle biopsy. Five of six patients with clinical features strongly suggestive of inflammatory muscle disease had positive scans. All muscle biopsies performed at areas of increased isotope uptake showed inflammatory muscle disease. All nine patients not suspected of active inflammatory muscle disease had negative scans. Two of these underwent muscle biopsy with negative results. Our observations suggest that TcPYP muscle scans may be useful both to confirm the clinical suspicion of inflammatory muscle disease and in directing the choice of site for muscle biopsy.

A second human interleukin-2 binding protein that may be a component of high-affinity interleukin-2 receptors

Although activated human T and B lymphocytes express both high-affinity and low-affinity membrane receptors for interleukin-2 (IL-2), the structural features that distinguish these receptors have remained unresolved. The high-affinity receptors appear to mediate IL-2 induced T cell growth and internalization of IL-2, whereas no function has yet been ascribed to the low-affinity receptors. The Tac antigen is an IL-2 binding protein of relative molecular mass 55,000 (Mr 55K) that participates in the formation of both high- and low-affinity receptors. But Tac complementary DNA transfection and membrane fusion studies have suggested that additional T-cell components are required to produce high-affinity IL-2 receptors. In this study, we report the identification of a second human IL-2 binding protein that (1) has an Mr of approximately 70K, (2) lacks reactivity with the anti-Tac antibody, (3) binds IL-2 with intermediate affinity and (4) is present on the surface of resting T cells, large granular lymphocytes (natural killer cells), and certain T and B cell lines in the absence of the Tac antigen. Chemical crosslinking of 125I-labelled IL-2 bound to high-affinity IL-2 receptors produces labelling of both the p70 protein and the Tac antigen and the anti-Tac antibody blocks the crosslink detection of both of these proteins. Expression of Tac cDNA in a T cell line expressing the p70 protein, but lacking both Tac and high-affinity receptors, results in the reconstitution of high-affinity IL-2 receptors in these cells. Together, these findings suggest that the high-affinity human IL-2 receptor may be a membrane complex composed of at least the p70 protein and Tac antigen.

Adrenal cortical adenoma and adrenal medullary hyperplasia of the right adrenal gland--a case report

The normal adrenal gland contains two types of tissue, the adrenal cortical tissue and the adrenal medullary tissue. The cortex is divided into three portions: the outermost "zona glomerulosa," the central "zona fasciculata," and the innermost "zona recticularis." The adrenal medulla is a developmentally separate organ, derived from neuroectoderm, and is the site of epinephrine and norepinephrine production. Adrenal cortical adenoma is commonly the result of a basophilic tumor of the anterior pituitary that secretes excessive amounts of ACTH. Adrenal medullary hyperplasia (or pheochromocytoma) are clinically hazardous tumors because of their excessive secretion of catecholamines. Combined adrenal cortical adenoma and adrenal medullary hyperplasia of the right adrenal gland has never been described previously.

Detection of Duchenne muscular dystrophy carriers: quantitative echography and creatine kinasemia

Data obtained from simultaneous determinations of serum creatine-kinase levels and estimation of ultrasound attenuation values in muscles greatly improved the detection of obligate carriers of Duchenne muscular dystrophy than when only one of these methods was employed alone. Eleven carriers out of 19 had a high creatine-kinasemia level and nine carriers out of 19 had a high (abnormal) attenuation value. Because of the limited overlapping between the two parameters studied, we were able to recognize 17 obligate carriers out of the 19. This indicates that the parameters studied concern different features of the disease, and the practical and theoretical considerations are discussed. The techniques are discussed together with molecular genetic investigations.

Use of an electronic stimulator for the treatment of dry mouth

This paper presents an innovative approach to the treatment of xerostomia through normal physiologic mechanisms with a device that provides electrical stimulation to the oral and pharyngeal afferent nervous system; the result is a reflex volley of efferent impulses to the salivary glands, causing salivation. The device has been successful in treating xerostomic patients regardless of the etiology of their dry mouths.

Rheumatoid-like arthritis presenting as idiopathic pulmonary hemosiderosis: a report and review of the literature

Idiopathic pulmonary hemosiderosis, an unusual form of the alveolar hemorrhage syndromes, has been reported in association with several connective tissue disorders. Rheumatoid arthritis (RA), however, rarely presents in this manner. We discuss a young adult with recent onset RA following idiopathic pulmonary hemosiderosis, and review the 3 cases previously reported.

Characterization of corticosteroid receptors in natural killer cells: comparison with circulating lymphoid and myeloid cells

Lymphocytes mediating natural killer (NK) and antibody-dependent cellular cytotoxicity (ADCC) activities are relatively refractory to the changes in circulatory traffic and intrinsic function induced in other cell types by in vivo and in vitro corticosteroids (CS). To investigate if such drug resistance could be attributed to differences in the CS receptor number of affinity (Kd) of these cells, these characteristics were determined in purified populations of large granular lymphocytes (LGL), monocytes, neutrophils (PMN), and T cells. All cell types displayed a single class of CS receptor of uniform affinity; however, LGL resembled monocytes and PMN in receptor number and Kd while T cells had significantly fewer sites per cell with lower Kd. These studies suggest that the unresponsiveness of NK activity to CS is not secondary to differences in CS receptor capacity or affinity.

Detection and quantitation of circulating immune complexes in arterial blood of patients with rheumatic disease

We developed antigen-nonspecific enzyme-linked immunoassays (ELISA) to quantitate IgG-C3- and IgM-C3-containing circulating immune complexes (CIC) in venous and arterial blood from rheumatic disease patients. Standards were diethylaminoethyl (DEAE)-purified, heat-aggregated IgG incubated with fresh human serum (for IgG-C3 CIC) and IgM rheumatoid factor-rich serum incubated with reduced, alkylated IgG and then with fresh human serum (for IgM-IgG-C3 CIC). Venous serum and plasma IgG-C3 and IgM-C3 CIC correlated closely (P less than 0.01). Rheumatoid arthritis (RA) and systemic lupus erythematous (SLE) patients had elevated levels of venous IgM-C3 CIC (P less than 0.0001) but not IgG-C3 CIC; patients with vasculitis, inflammatory rheumatic diseases, or noninflammatory rheumatic diseases had mean values similar to normal individuals. Venous IgG-C3 and IgM-C3 CIC did not correlate. Paired venous and arterial samples from 16 rheumatic disease patients averaged comparable amounts of IgG-C3 and IgM-C3 CIC, respectively; venous and arterial IgM-C3 CIC levels in patients significantly exceeded normals (P less than 0.05). Venous and arterial IgG-C3 CIC levels correlated closely (P less than 0.01) as did venous and arterial IgM-C3 levels (P less than 0.05). Thus, arterial CIC offered no advantage over venous determinations for rheumatic disease patients. IgM-C3 CIC were elevated in patients with RA and SLE when IgG-C3 CIC were not. Ig isotype-specific CIC quantitation may be useful for certain rheumatic diseases.