[Prognosis and outcome of rheumatoid arthritis--10 to 16 years of anti-rheumatic therapy]

One hundred twenty-eight rheumatoid arthritis (RA) patients were followed up over a long period of time (mean, 13.3 years; range, 10-16 years) in order to determine the role of pharmacotherapy in RA. Patients were aged 48.2 years on the average (23-79 years) and the mean RA duration was 7.8 years (0-58 years) upon initial visit to this unit. Although pharmacotherapy was effective in improving Lansbury's activity index and ESR, articular bone and cartilage destruction and functional impairment progressed gradually, resulting in the need for total hip, knee or ankle arthroplasty in 46 (96 joints) of the 128 patients. This finding indicates that current pharmacotherapy for RA has limitations in that it cannot completely prevent joint destruction and resulting functional impairment. This suggests that new therapeutic modalities, including new drugs, are necessary. Efforts were also made to determine factors which affect the prognosis of RA. The prognosis seemed pessimistic in RA patients with high activity and rheumatoid factor (RAPA) levels, long duration of illness, high Larsen scores and advanced functional impairment at the time of initial active therapy. It appeared necessary to maintain Lansbury's activity index at 30% or below in order to obtain a good prognosis.

The preventive effect of oral administration of type I interferon on collagen-induced arthritis in rats

We investigated the effect of oral administration of type I interferon (IFN) on an autoimmune disease collagen-induced arthritis (CIA) in rats that was induced by immunization with type II collagen (CII). The results showed that the oral administration of IFN before immunization with CII significantly suppressed the development of CIA. Delayed type hypersensitivity, in vitro proliferative responses of lymph node cells to CII, and IL-2 production were also inhibited by the fed cytokine. The serum from IFN-fed animals downregulated the development of CIA and proliferative responses to CII. In contrast, IFN given orally after the onset of CIA failed to affect the proliferation of T cells to CII as well as the progression of the disease. There was a decrease in the production of anti-CII antibody in rats fed IFN before, but not after, immunization with CII. Thus, orally administered IFN may have preventive, but not therapeutic, effects on autoimmune inflammatory joint diseases.

Selective induction of IgM rheumatoid factors by CD14+ monocyte-lineage cells generated from bone marrow of patients with rheumatoid arthritis

OBJECTIVE

To determine the capacity of CD14+ monocyte-lineage cells induced from bone marrow of rheumatoid arthritis (RA) patients to stimulate the production of IgM rheumatoid factor (IgM-RF), in order to explore the functional abnormalities of CD14+ cells and gain insight into the mechanism of selective synthesis of IgM-RF in RA.

METHODS

CD14+ cells were induced by granulocyte-macrophage colony-stimulating factor (GM-CSF) stimulation of CD14- cells purified from bone marrow cells obtained from 6 RA patients and 6 osteoarthritis (OA) patients. The production of IgM and IgM-RF was induced by stimulating B cells from normal healthy individuals with immobilized anti-CD3-activated autologous CD4+ T cells. The effects of CD14+ cells on the proportion of IgM-RF to total IgM produced by the normal B cells were assessed.

RESULTS

CD14+ cells induced by GM-CSF stimulation of bone marrow CD14- cells from the 6 RA patients significantly enhanced the proportion of IgM-RF to total IgM produced by anti-CD3-activated CD4+ T cell-stimulated normal B cells (P < 0.05), whereas GM-CSF-induced CD14+ cells from the bone marrow of the 6 OA patients did not significantly affect IgM-RF production. CD14+ cells induced by GM-CSF obtained from different sites in the same RA patient on different occasions consistently enhanced the proportion of IgM-RF to IgM produced by B cells from different normal subjects.

CONCLUSION

These results indicate that abnormal CD14+ monocytes stimulate RF-producing B cells to be ready to be activated by the signals delivered through noncognate T-B interactions with anti-CD3-activated T helper cells. Moreover, the data suggest that the accelerated generation of such functionally abnormal CD14+ cells from bone marrow precursors might play an important role in the pathogenesis of RA.

Patterns of prostaglandin E2 and leukotriene B4 production in inflammation induced by peptidoglycan-polysaccharide polymers of bacterial cell walls

The changing levels of prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) were compared over a period of 1 h to 15 days in two kinds of inflammatory responses induced in the rat air pouch by chemically similar polymers of peptidoglycan-polysaccharide (PG-PS) isolated from cell walls of group A streptococci. The smaller polymers (100 s, average mol. wt 5.3 x 10(6)) induced a more severe acute response over the first 24 h, whereas, from 3 to 15 days the larger polymers (10 p, average mol. wt 5 x 10(8)) induced greater chronic inflammation, as measured by pouch fluid volume, number of infiltrating cells and weight of granulation tissue. The most prominent difference between the two kinds of responses in the pattern of PGE2 and LTB4 were: (a) A shift between 1 to 6 h to much higher production of PGE2 in the exudate induced by large polymers. During this time the level of LTB4 also increased, but continued to be higher in the exudate induced by small polymers. (b) The sustained production of relatively high levels of LTB4 and PGE2 in the large polymer exudate at 15 days. Changes such as these indicate that this model is useful for analyzing mediators which regulate the evolution of acute into chronic inflammation.

Silicone-induced arthritis in rats and possible role for T cells

Intra-articular injection of silicone into the ankle joint of the rat induced persistent arthritis. Histologically, at 24 h after silicone injection, there was marked edema of the synovial tissue containing many inflammatory cells including polymorphs, monocytes and macrophages. This was followed by marked proliferation of synovium with dense infiltration of mononuclear cells and destruction of cartilage. Immunohistological studies showed that a large number of CD5+ and alpha beta+ T cells infiltrated in synovial tissues in the chronic phase of joint inflammation. Treatment of rats with a monoclonal antibody against TCR alpha beta significantly suppressed the development of chronic, but not acute arthritis. Thus, T cells may play a role in silicone-induced chronic arthritis.

Recruitment of pathogenic T cells to synovial tissues of rats injected intraarticularly with nonspecific agents

To study a role for T cells in nonspecifically induced arthritis, rats were injected intraarticularly into ankle joints with mineral oils including 2,6,10,15,19,23-hexamethyltetracosane (squalene) and incomplete Freund's adjuvant. The results showed that moderate joint inflammation had developed by Day 6 after the nonspecific stimulation. This was then followed by induction of severe arthritis, reaching a peak on Day 21. Histologically, the early phase of arthritis was associated with edema of synovial tissues containing many polymorphs and monocytes/macrophages and the late phase of the joint inflammation with marked hyperplasia of synovial membrane with dense infiltration of CD5+ and alpha beta+ T cells. Depletion of alpha beta+ T cells by a monoclonal antibody against TCR alpha beta suppressed both induction and progression of the late phase of arthritis. Thus, pathogenic T cells appear to be recruited to joint tissues following nonspecific stimulation.

[Preliminary report of radical multiple synovectomy in rheumatoid arthritis]

We performed radical multiple synovectomy (RaMS) on rheumatoid arthritis (RA) patients who had multiple swollen joints in the mid or late course of RA. The objectives of this operation are to reduce the quantity of RA synovium as much as possible and to increase the efficacy of anti-rheumatic medication in order to achieve remission.2+ Nineteen RA patients who underwent RaMS were followed up for at least 15 months. In this series, anti-rheumatic medications were not changed after the operation, so that the effectiveness of the RaMS could be evaluated. The patients ranged in age from 44 to 73 years (mean: 55.8 years). The male to female ratio was 2:17. Duration after onset of RA ranged from 2 to 29 years (mean: 15.1 years). The swollen joint score according to Lansbury's evaluation of the RA activity index ranged from 7 to 24% (mean: 14.4%). The synovectomized joint score ranged from 7 to 22% (mean : 13.3%). The weight of the excised RA synovium ranged from 19.0 to 109.9 g (mean : 54.0 g). The number of operations was one in three patients, two in 15 patients and three in one patient. The postoperative results indicated that the modified Lansbury's index (morning stiffness, grip power, ESR, joint score), the values of ESR, CRP, Hb, TNF-alpha and IL-6 in the blood, and the peripheral lymphocyte CD4/CD8 ratio were improved, with a statistically significant difference. At 15 months after the operation, ten of the 19 patients (52.5%) satisfied the proposed criteria for clinical remission of RA.(ABSTRACT TRUNCATED AT 250 WORDS)

Cruciate retained and excised total knee arthroplasty. A comparative study in patients with bilateral total knee arthroplasty

A comparative study of posterior cruciate ligament retention and excision was conducted in patients who underwent bilateral total knee arthroplasty using the total condylar modifier prosthesis. The posterior cruciate ligament was excised in one knee and was retained in the other knee in 28 patients. Postoperative results were assessed using the Hospital for Special Surgery Knee Evaluation Score. In addition, stair activity was tested to determine whether there was preferential dependence on one of the two knees. There was no significant difference between the posterior cruciate ligament retained or excised knees in terms of postoperative Hospital for Special Surgery Knee Evaluation Score. Patients who ascended and descended stairs with one leg at a time tended to prefer the posterior cruciate ligament retention side. Those who could use each leg in sequence to go up and down stairs, however, did not show preferential dependence on either knee.

Combined effects of caffeine and malnutrition during pregnancy on suckling behavior in newborn rats

Six groups of pregnant dams were fed a 20%, 12%, and 6% protein diet with and without caffeine (2 mg/100 g b.wt.), starting on day 7 of gestation. At day 18 of gestation, randomly selected dams of each group were used to record prenatal fetal behavior. The remaining dams were continuously fed their respective diets until the birth of their pups. Upon delivery, newborn pups from the dams fed a 20%, 12%, or 6% protein diet with caffeine were placed with foster dams that the dietary regimen during gestation was a 20%, 12%, or 6% protein diet, respectively. Dams fed a noncaffeine diet, along with their newborns, were fed their respective diets until day 15. Suckling behavior tests for newborns were conducted on days 2, 8, and 15. On day 15, both nondeprived and deprived newborn rats were studied. Caffeine in combination with a malnourished diet has different effects on general activity in prenatal stages compared to postnatal stages. Our findings support the view that prenatal exposure to caffeine may produce greater effects because: a) caffeine and its metabolites pass freely into the embryo and attain a concentration slightly lower than in the maternal plasma; and b) caffeine may be poorly metabolized during pregnancy, causing an accumulation in the fetal tissues. Prenatal caffeine at the dosage we have used in combination with malnutrition may produce lasting metabolic alterations in the nervous system related to the emergence of suckling behavior and general motor activity.

Intraarterial combined immunochemotherapy for unresectable hepatocellular carcinoma: preliminary results

An important objective for patients with unresectable hepatocellular carcinoma (HCC) is the development of effective chemotherapy. We administered a combination of biological response modifiers and anticancer agents to 24 patients with unresectable HCC. Each case had an implanted infuser port which was connected to a catheter placed in the hepatic artery for the intraarterial (i.a.) administration of chemotherapy. The following agents were administered to each patient: recombinant interleukin-2 (800,000 JRU/day infused i.a. continuously for 6 days/week); OK-432 (5 KE injected i.a. twice in 4 weeks and i.m. three times per week); Adriamycin (10 mg injected i.a. twice in 4 weeks); cyclophosphamide (300 mg injected i.a. twice in 4 weeks), and famotidine (40 mg/day administered orally). Objective response was assessed according to tumor size measured by computed tomography and angiography before and after treatment. We observed a complete response (CR) in 4, partial response (PR) in 3, minor response (MR) in 7, no change (NC) in 7, and progressive disease (PD) in 3. The response rate (CR+PR+MR) was 58.3%. The overall 2-year survival rate was 52%. The 2-year survival rate of the responders (CR+PR+MR) was 80%, while that of the non-responders (NC+PD) was 0%. There was a significant difference between the responders and non-responders in respect to survival rate (P < 0.05). The percentages of CD25+ cells, CD56+ cells, and Leu7-CD16+ cells and NK activity in the peripheral blood showed a significant increase following the regimen. Serum levels of tumor necrosis factor alpha TNF alpha rose after the initiation of OK-432. TNF alpha levels were higher in the responders than in the non-responders. Adverse effects included high fever (all patients) and severe transient hypotension (15 patients) that was controlled by conservative therapy. Combined immunochemotherapy administered intraarterially may be a new strategy for treating unresectable HCC.

[A study of neuropeptides and cytokines in sera from patients with rheumatoid arthritis]

Neuropeptides and cytokines are known as substances which produce various effects on local disease sites. Many studies of these substances role in rheumatoid arthritis (RA) have been carried out in connection with synovial effusion and synovium, but very few in connection with sera. We studied the substances in sera from patients with RA, hypothesizing that the serum levels should reflect the degree of RA activity. We selected nine neuropeptides and cytokines, and measured their serum levels in twenty-five RA patients. For comparison, ten healthy persons were also studied. The results showed that low levels of CRF, ACTH and cortisol, and the high levels of SP, IL-6 and TNF-alpha in sera from the patients with RA compared with those from healthy persons. IL-6 and TNF-alpha correlated with RA activity indexes. We conclude that some neuropeptides and cytokines should act actively on RA through the circulatory blood. The measurement of serum neuropeptides and cytokines in patients with RA is a useful indicator of the degree of RA activity.

Cariogenic effect of caffeine intake during lactation on first molars of newborn rats

Lactating dams with eight suckling pups were fed either a 20% protein diet as a control or experimentally a 20% protein diet supplemented with caffeine (2 mg/100g body weight) from the birth of the pups to day 22. At day 22, the pups from both groups were weaned and fed a cariogenic diet until day 50, when they were killed. Dental caries of the molars were scored from randomized mandibles. The enamel of the first molars in the caffeine group showed significantly higher caries scores than that of the controls. This appears to be the first unequivocal evidence that caffeine is a cariogenic agent when newborns are exposed to it during critical periods of tooth development. Therefore, the widespread human consumption of caffeine could be a threat to the healthy development of teeth.

Total knee arthroplasty in Charcot's joint

The authors report three cases with neuropathic (Charcot) knee joint due to tabes dorsalis in which total knee arthroplasty (TKA) was performed. Three cases (5 joints) were observed for more than 8 years after TKA. No ataxia was seen before or after surgery. The postoperative clinical course had been satisfactory in two cases (3 joints) for 9-10 years after TKA with no evidence of loosening. Although the other case had medial condylar fracture of the right upper tibia during postoperative treatment, the clinical course of the right knee had been satisfactory over the 7 years since revision arthroplasty using a tibial component with a long stem. This case also had loosening of the left tibial component 8 years after TKA. Total knee arthroplasty appears to be useful for the treatment of Charcot's joint with no ataxia at Eichenholtz' stage of coalescence and reconstruction if (1) proper surgical techniques to establish good ligamentous balancing and bony alignment by releasing ligaments are employed; (2) an adequate amount of bone is resected and remaining bony defects are reinforced with bone graft; (3) long-stem components are used on both the femoral and tibial sides.

[Nutrition for total gastrectomy. Especially the usefulness of enteral hyperalimentation]

A large number of reports have dealt with comparative studies of total parenteral nutrition (TPN) and enteral hyperalimentation (EH). However, there have been few reports on comparative studies in which patients were stringently selected for identical observation periods. We divided patients who underwent total gastrectomy for stomach carcinoma into two groups. The two groups were given TPN and EH, respectively, for three weeks to investigate immunological competence and nutritional conditions. There were ten patients in the TPN group and ten in the EH group was IgG, IgA, IgM, and complements (C3 and CH50) selected as the immunological indices. At the same time, TP, Alb, Tf, PA and RBP were used as the nutritional indices. Immunological competence dropped from one to three days after surgery in both groups, but gradually increased thereafter. Up to three weeks after surgery, immunological indices showed preoperative values or above though there were no significant differences between the two groups. The nutritional indices were low from three to four days after surgery but gradually increased thereafter and returned to preoperative levels or above, no significant differences were noted between the two groups. This was probably because malignant tumors were resected, and nutritional was supplemented from three to four days after surgery which led to the improvement of immunological and nutritional indices. Since the patients in both groups experienced uneventful clinical courses without developing any complications, there were no significant differences in these indices between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of prenatal caffeine exposure on the enamel surface of the first molars of newborn rats

Timed-pregnant rats were randomly divided into three groups at day 7 of gestation. A caffeine tablet was implanted subcutaneously in the experimental group and a placebo tablet in the control group. The third group was used as surrogate dams. At birth, eight randomly selected pups born either to the experimental or control dams were placed with surrogate dams that had produced pups on the same day; these were then used in either the experimental or the control group, and so the surrogate dams raised pups that came from either the experimental or control group. At day 22 after birth, the pups were killed, and their first and second maxillary and mandibular molars were removed. They were then placed in a specially designed chamber and exposed to an acid solution. The outflowing acid solution was collected every 20 min and up to 80 min. Then the calcium, phosphorus, and magnesium contents of each fraction were measured. The enamel surfaces of untreated and acid-treated first molars of the caffeine and control groups were examined by scanning electron microscopy. Untreated teeth were powdered and separated into enamel and dentine. Pure enamel samples were examined with a Gandolfi X-ray powder camera to measure the crystallite size. At 20-, 40- and 60-min intervals, calcium and phosphorus contents of the first molars of the caffeine group were significantly higher than those of the control. The enamel surface of the untreated and acid-treated first molars of the caffeine group had significantly different scanning microscopic appearances from those of the non-caffeine untreated and acid-treated control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Renal cell carcinoma in a horseshoe kidney: report of two cases]

We report 2 patients with renal cell carcinoma in a horseshoe kidney. A renal tumor was diagnosed during evaluation of right humeral metastatic cancer of unknown origin in case 1 (64-year-old male) and gross hematuria in case 2 (54-year-old male). Both patients underwent radical nephrectomy with division of isthmus and retroperitoneal lymph node dissection. The tumors were staged pathologically as pT2bpN0pV0pM1(oss) and pT3pN0pV1bM0, respectively. Only 27 cases of renal cell carcinoma developed in a horseshoe kidney, including the present two cases, have been reported in the Japanese literature. The blood supply to the horseshoe kidney and its evaluation by preoperative angiography were discussed.

[Role of opioid peptide in rheumatoid arthritis--detection of methionine-enkephalin and leucine-enkephalin in synovial tissue]

A relationship between rheumatoid arthritis (RA) and endocrinological abnormality has been suspected for many years. In the present study, we immunohistologically identified the presence of methionine-enkephalin (Met-enk) and leucine-enkephalin (Leu-enk), in synovial tissues collected from RA patients and determined the amount of these peptides and interleukin 1 beta (IL-1 beta) in the culture supernatant of tissue explants by RI and ELISA. Synovial membrane samples obtained by biopsy during artificial joint replacement and plasma samples simultaneously collected from 11 RA patients (11 joint) diagnosed as having classic or definite RA according to the diagnostic criteria of the American Rheumatism Association were used. All 11 patients were females and aged between 36 and 64 years (mean: 45.8 years). As a result of immunohistological standing (ABC method), Met-enk was detected in vascular endothelial cells and Leu-enk in superficial cells, vascular endothelial cells and interstitial cells. Leu-enk concentrations (42.3 +/- 15.8 pg/ml) were higher in the culture supernatant of the synovial membrane than in the plasma (20.7 +/- 13.3 pg/ml). Furthermore, in the culture supernatant the concentration of Leu-enk was positively correlated with that of IL-1 beta (r = 0.789). These findings suggest that Met-enk and Leu-enk are locally produced by synovial tissues and may exert an immunological and/or inflammatory role in RA synovitis.

The characterization of peritoneal and pleural exudate cells from malignant effusions

The immune function of peripheral blood cells and cells from the pleural and abdominal effusions of patients with advanced cancer was compared to that of peripheral blood cells from controls. The parameters examined included lymphocyte subsets, natural killer (NK) cell activity, and anti-Daudi and lymphokine-activated killer (LAK) cell activity. The percentage of CD4+ pleural and peritoneal exudate cells (PEC) was significantly higher than the percentage of peripheral blood mononuclear cells (PBMC) in the patients. The percentage of CD8+CD11+ PEC and PBMC, being the suppressor T-cells, of the patients was increased compared with controls, while the percentage of CD8+CD11- PEC, being the cytotoxic T-cells, was identical to the PBMC of both patients and controls. The NK activity of PEC was significantly lower than that of PBMC in both patients and controls, and there was no correlation between the NK activity of PBMC and PEC. Although the anti-Daudi activity of PEC was markedly low, LAK cells with high activity could be induced by culture with interleukin-2 for 4 days. These results suggest that the immune function of cells in malignant effusions may be depressed due to a low population of cytotoxic T cells, low NK activity and increased suppressor T cells, while the local administration of interleukin-2 may induce LAK cells. Therefore, effective local immunotherapy for malignant effusions should not only augment effector cells, but also inhibit suppressor cells.

Natural killer activity and serum immunosuppressive acidic protein levels in esophageal and gastric cancers

The natural killer (NK) activity of peripheral blood mononuclear cells and serum immunosuppressive acidic protein (IAP) levels were examined in patients with esophageal or gastric cancer, before and after surgery. Patients with stage IV esophageal or stage IV gastric cancer had significantly lower NK activity (39.5 +/- 14.8% and 37 +/- 11.6%, respectively), and also higher serum IAP levels (778 +/- 264 micrograms/mL and 633 +/- 156 micrograms/mL, respectively), than the corresponding control values (50 +/- 5.6% and 375 +/- 26 micrograms/mL, respectively). Patients with esophageal or gastric cancer who underwent curative resection had high NK activity (54.8 +/- 11.6% and 54.8 +/- 8.0%, respectively), and low IAP levels (471 +/- 116 micrograms/mL and 490 +/- 42 micrograms/mL, respectively), compared with those who underwent non-curative resection. Patients who underwent non-curative resection had lower NK activity and higher serum IAP levels than those who underwent curative resection, even 1 month after surgery. Mononuclear cells in the regional lymph nodes and tumor specimens showed significantly lower NK activity than those in the peripheral blood and spleen. Thus, NK activity and the IAP level reflected the immunocompetence, clinical course, and surgical curability of those patients. NK cells appeared not to have any significant antitumor activity in the regional lymph nodes or in the tumor itself, although they were still active in the peripheral blood.

Suppression of chronic antigen-induced arthritis in rats by a monoclonal antibody against the T cell receptor alpha beta

We have investigated a role for T cells in chronic antigen-induced arthritis in rats employing a monoclonal antibody (R73 mAb) against the T cell receptor alpha beta. Treatment with R73 mAb from the time of intra-articular antigenic challenge blocked completely the induction of chronic, but not acute ovalbumin-induced arthritis in sensitized rats. Histologically, treatment-controlled arthritic rats exhibited marked hyperplasia of synovial membrane with pronounced infiltration of inflammatory cells including alpha beta + T cells in the chronic phase of arthritis. In contrast, R73 mAb-treated rats had almost normal joint histology. Treatment with R73 mAb after onset of arthritis was also effective in suppressing the progression of chronic antigen-induced joint inflammation. The preventive and suppressive effects of the mAb on chronic antigen-induced arthritis were associated with marked depletion of alpha beta + T cells in peripheral blood. The DTH but not the humoral response to ovalbumin in sensitized rats was suppressed significantly by R73 mAb. Thus, alpha beta + T cells appear to have a central role in both induction and progression of chronic antigen-induced arthritis.

Prognostic significance of regional lymph node reaction after curative resection of advanced gastric cancer

The prognosis of patients with advanced gastric cancer who undergo curative resection is still unsatisfactory. The relationship between prognosis and various factors such as stage, lymph node metastasis, serosal invasion and regional lymph node reaction (follicular hyperplasia and sinus histiocytosis) was evaluated. Of the factors studied, the only one that correlated well with survival was sinus histiocytosis. Lymph node metastasis was related weakly to prognosis. No correlation between prognosis and stage, serosal invasion or follicular hyperplasia was observed. Sinus histiocytosis may represent the morphological tumour-host immune reaction. Lymph node metastases or histological types were not related to regional lymph node reaction. These results suggest that sinus histiocytosis could be a useful prognostic factor for gastric cancer. Intensive postoperative follow-up for recurrence may be necessary even for patients with low-grade sinus histiocytosis in whom curative surgery is attempted.

Immunological analysis and clinical effects of intraabdominal and intrapleural injection of lentinan for malignant ascites and pleural effusion

Twenty effusions in sixteen patients with malignant peritoneal and/or pleural effusions were treated with intracavitary injection of lentinan. Lentinan was injected at a dosage of 4 mg/week for 4 weeks. In total, sixteen (80%) of twenty lesions demonstrated clinical responses. Performance status was improved in seven patients. The average survival time in responders was 129 days, while, in non-responders, it was 49 days. Serious toxicities were not observed. NK activity of PBMC significantly decreased after lentinan injection. NK activity of PEC in responders was augmented significantly. Anti-Daudi and lymphokine activated killer activity were also augmented or maintained after lentinan injection.

[Role of opioid peptide in rheumatoid arthritis--detection of beta-endorphin in synovial tissue]

The presence of beta-endorphin (beta-end) was immunohistologically identified in synovial tissue samples biopsied from patients with rheumatoid arthritis (RA) and osteoarthritis (OA). The amount of beta-end in culture supernatants of synovial tissue explants was also determined by RIA. beta-end was strongly detected in mainly superficial synovial cells, vascular endothelial cells and a few synovial interstitial cells in RA patients, but not in OA patients. In RA patients the beta-end concentration was significantly higher in the supernatants of tissue explants (26.4 +/- 8.3 pg/ml) than in the plasma of the same patients (15.3 +/- 2.5 pg/ml) (p < 0.01). Using isolated synovial cells, the beta-end concentration in the culture supernatants of non-adherent cells (19.4 pg/ml) was higher than that of adherent cells (4.0 pg/ml). It is suggested that beta-end is produced by non-adherent cells such as lymphocytes and neutrophils in addition to synovial lining cells and endothelial cells and may play some role in the pathology of RA synovial inflammation.

[A case report of rheumatoid arthritis patient with thoracic myelopathy]

The authors report a 39-year-old woman with rheumatoid arthritis associated with myelopathy at the thoracic level. X-ray films of thoracic spine showed scoliosis which had its apex at T6. Myelography demonstrated incomplete block at the level of T6. Computerized tomogram revealed destruction of left pedicle of the sixth thoracic vertebra and dislocation of the sixth rib into the spinal canal which compressed cord at T6 level. Hemi-laminectomy at T5-T7 level and decompression were performed. Pathological investigations of soft tissue around the cord and dura mater showed infiltration of small round cells. We concluded that the synovitis of costo-transverse joint or costovertebral joint led to the destruction of the pedicle. As a result, dislocation of the rib, scoliotic deformity and thoracic myelopathy occurred.

[A study of opioid peptides in synovial fluid and synovial tissue in patients with rheumatoid arthritis]

Authors have often experienced that psychological stress influences rheumatoid arthritis (RA). In addition, recent reports show a modulatory role for neuropeptide such as substance P in arthritis. These findings prompted us to study endogenous opioid peptides in RA, which are found mainly in the brain and have an effect on the central nervous system. We examined methionine-enkephalin (Met-enk), leucine-enkephalin (Leu-enk) and beta-endorphin (beta-end) in opioid peptides. We measured these peptides in plasma and synovial fluid samples obtained from 28 knees of 24 RA patients and the quantity in the synovial tissue of 13 knees. We also measured plasma and synovial fluid samples from patients with osteoarthritis of the knee and plasma samples from healthy candidates. Leu-enk and beta-end levels in synovial fluid were significantly higher than plasma levels only in RA. Larger quantity of Leu-end and beta-end were contained apparently in the synovial tissue than Met-enk. The synovial tissue with proliferative change tends to contain larger quantity of opioid peptides. These results indicate that the synovial tissue produces or secretes Leu-enk and beta-end and that opioid peptides are related to the degree of inflammation in RA.

Effects of caffeine on the DNA and protein synthesis of the protein-energy malnourished neonatal cardiac muscle cells in culture

1. The growth of cardiac cells derived from newborn rats whose dams were either malnourished or malnourished with caffeine during pregnancy was inhibited in culture over the period of 5 days as compared to that of the normally nourished cells. 2. Cells derived from malnourished rats with caffeine added to their diets showed a greater inhibition than those from the malnourished rats not given caffeine. 3. Both DNA and protein synthesis showed an inhibition due to caffeine in a dose-dependent manner using normally nourished cells. 4. In the presence of exogenous 2 mM caffeine, the degree of percent inhibition of DNA and protein synthesis of cells derived from rats malnourished with caffeine was less than that from the rats with malnutrition alone. 5. The present data indicated that malnutrition combined with caffeine during pregnancy exerted a greater negative effect on the nature of cell growth than malnutrition alone and these cells became less sensitive to exogenous caffeine.

Depletion of alpha/beta T cells by a monoclonal antibody against the alpha/beta T cell receptor suppresses established adjuvant arthritis, but not established collagen-induced arthritis in rats

The effects of treatment with a monoclonal antibody (R73 mAb) against T cell receptor alpha/beta (TCR-alpha/beta) on both established adjuvant arthritis (EAA) and established collagen-induced arthritis (ECIA) in rats have been investigated. Rats were treated with R73 mAb when arthritis reached a peak. Treatment with the anti-TCR-alpha/beta mAb markedly suppressed EAA, whereas ECIA was not affected by the mAb treatment. Histologically, R73 mAb-treated rats with EAA showed mild hyperplasia of synovial tissues, sparse infiltration of inflammatory cells, and minimal erosion of cartilage, whereas arthritic rats treated with PBS and an irrelevant control mAb against Giardia had marked hyperplasia of synovium with pannus, massive inflammatory cell infiltrate, and severe destruction of cartilage and subchondral bone. R73 mAb-treated rats with ECIA exhibited pronounced formation of pannus containing many inflammatory cells and marked cartilage and subchondral damage similar to those in arthritic rats that received the control treatments. Treatment with R73 mAb depleted markedly alpha/beta+ T cells in both peripheral blood and synovial tissues of rats with EAA and ECIA. R73 mAb treatment was associated with marked reduction in arthritogen-specific delayed-type hypersensitivity responses in both EAA and ECIA. The titers of antibodies against type II collagen produced in rats with ECIA were not affected by the mAb. Thus, alpha/beta+ T cells appear to have a central role in EAA, but not in chronic ECIA.

[Psychosomatic medicine in rheumatoid arthritis]

Recent studies have shown that neuropeptides, such as substance P, are responsible for arthritis. We therefore studied opioid peptides (beta-endorphin, Methionine-enkephalin, Leucine-enkephalin) in order to confirm our belief that mental status may have some influence on the activity of rheumatoid arthritis (RA). We examined opioid peptides, lymphocyte subsets, psycologic test (Cornell Medical Index-Health questionnaire (CMI), the Face scale) and clinical data in patients with RA. Plasma Leu-enk, % Leu2a+ Leu15- cells,% Leu3a+ Leu8- cells and % Leu11+ Leu7- cells were higher in patients with a larger number of psycologic complaints in CMI. Plasma Leu-enk concentration was higher while % Leu11+ Leu7- cells was lower in proportion to the degree of neurosis, as indicated by the descrimitive chart of CMI. Plasma Met-enk concentration, % Leu2a+ Leu15- cells, and Lansbury's index were significantly higher in the group of patients whose facial expression was more severe. These findings suggest that mentala status have some relationship with the plasma level of opioid peptides (enkephalins) and immunologic functions, and that it may exert indirect effects on RA.

Treatment of collagen-induced arthritis in rats with a monoclonal antibody against the alpha/beta T cell antigen receptor

A monoclonal antibody (MAb) to the alpha/beta T cell receptor (TCR alpha/beta), R73 MAb, completely blocked the induction of collagen-induced arthritis (CIA) in rats when the MAb was administered at the time of immunization with type II collagen. When administered after CIA had begun, the progression of the arthritis was suppressed significantly by R73 MAb treatment. The preventive and suppressive effects of R73 MAb on CIA were associated with the depletion of peripheral blood alpha/beta-positive T cells. These results indicate that alpha/beta-positive T cells play a role in the progression of existing CIA as well as in its induction.

Prevention of chronic erosive streptococcal cell wall-induced arthritis in rats by treatment with a monoclonal antibody against the T cell antigen receptor alpha beta

Rats treated with an mAb (R73) against the TCR-alpha beta failed to develop chronic persistent arthritis after injection of streptococcal cell walls. Histologically, R73 mAb-treated rats had mild hyperplasia of synovial lining cells and minimal destruction of cartilage. In contrast, control-treated animals developed marked pannus formation, with pronounced infiltration of mononuclear cells and severe destruction of cartilage and subchondral bone. The preventive effect of R73 mAb on streptococcal cell wall-induced arthritis was associated with the marked depletion of alpha beta + T cells by R73 mAb. These results indicate that T cells play a crucial role in chronic erosive streptococcal cell wall-induced arthritis.

Prevention of chronic erosive streptococcal cell wall-induced arthritis in rats by treatment with a monoclonal antibody against the T cell antigen receptor alpha beta

Rats treated with an mAb (R73) against the TCR-alpha beta failed to develop chronic persistent arthritis after injection of streptococcal cell walls. Histologically, R73 mAb-treated rats had mild hyperplasia of synovial lining cells and minimal destruction of cartilage. In contrast, control-treated animals developed marked pannus formation, with pronounced infiltration of mononuclear cells and severe destruction of cartilage and subchondral bone. The preventive effect of R73 mAb on streptococcal cell wall-induced arthritis was associated with the marked depletion of alpha beta + T cells by R73 mAb. These results indicate that T cells play a crucial role in chronic erosive streptococcal cell wall-induced arthritis.

Do gamma delta T cells play an important role in autoimmune disease?

A T cell subpopulation using an alternative receptor heterodimer (gamma delta T cells) contributes 0.5-10% to the T cell population in the normal peripheral blood. One subset of gamma delta T cells (V gamma 9+/V delta 2+/ C gamma 1) preferentially recognizes mycobacterial antigens, which are the triggering antigens in the rat adjuvant arthritis (AA), an animal model with some similarities with rheumatoid arthritis (RA). Here we summarize data on the prevalence of gamma delta T cells in peripheral blood, synovial fluid and synovial membranes of RA patients which show that gamma delta T cells, in particular the subset reactive with mycobacterial antigens in normal individuals, are rare in all studied compartments. Furthermore, there was no enrichment of gamma delta T cells in the peripheral blood of patients with ankylosing spondylitis or systemic lupus erythematosus, autoimmune diseases with involvement of the joints. In the AA model depletion of the "conventional" alpha beta T cells completely prevented the induction of the disease and very effectively improved ongoing arthritis even though substantial numbers of gamma delta T cells were present in these animals. Taken together, our data do not support the notion of a significant contribution of gamma delta T cells to chronic joint inflammation in the autoimmune diseases studied or in adjuvant arthritis.

Suppression and prevention of adjuvant arthritis in rats by a monoclonal antibody to the alpha/beta T cell receptor

Adjuvant arthritis (AA) in rats is an experimentally induced autoimmune disease mediated by T lymphocytes specific for Mycobacterium tuberculosis. We raised the question whether T cells carrying the gamma/delta T cell receptor (TcR), reactive or not to mycobacterial antigens, are involved in the pathogenesis of AA. For this purpose, T cells bearing the TcR alpha/beta were depleted from circulation by treatment with a monoclonal antibody against the rat TcR alpha/beta (R73). This treatment efficiently suppressed existing disease. Even more efficient was pretreatment with R73 from birth, which prevented AA induction completely. In these alpha/beta+ T cell-depleted animals an elevated level of alpha/beta- T cells (about 15% vs. 1% in normal rats) was evident, which was not significantly increased by Mycobacterium tuberculosis injection. We found no positive evidence that gamma/delta + T cells do contribute to AA induction. Moreover, treatment with an anti-TcR alpha/beta monoclonal antibody may be very efficient treatment of T cell-mediated autoimmune diseases.

[Effect of intrapleural and/or intraperitoneal lentinan therapy in carcinomatous pleuritis and peritonitis]

Seventeen lesions in fourteen patients with malignant pleural and/or peritoneal effusion were treated with the intrapleural and/or intraperitoneal Lentinan therapy (4 mg/week x 4). The following results were obtained. Malignant effusion disappeared in four lesions and diminished in two. In ten lesions, the cytological grade decreased. Totally, thirteen lesions (76.5%) revealed clinical effect. Toxicity, caused a high fever in only one case. Subpopulations (CD4, CD8, Leu7, CD8+ CD11+) of pleural or peritoneal effusion mononuclear cells (PEM) and peripheral blood mononuclear cells (PBM) showed no change during the course of Lentinan therapy. NK and anti-Daudi activities of PEM tended to be augmented and high LAK activities of PEM were maintained by Lentinan therapy. However, NK activities of PBM after this therapy were significantly lower than before therapy (p less than 0.05). Augmentation of cytotoxicity in PEM induced by Lentinan may lead to clinical effect. Thus, this therapy may be useful for even patients with end-stage carcinoma.

[Intraarterial combination immunotherapy in hepatocellular carcinoma]

Unresectable hepatocellular carcinoma (HCC) has a poor prognosis and little sensitivity to anticancer agents. We planned a combination immunotherapy, associating with rIL-2 continuous injection. Combination immunotherapy consists of 5 different biological response modifiers (BRM), i.e., rIL-2, OK-432, adriamycin (ADR), cyclophosphamide (Cy), and famotidine (Fa). rIL-2, OK-432 and ADR were administered from implantable infuser port connecting to a catheter which was injected into the hepatic artery via the gastroduodenal artery under laparotomy. OK-432, Cy, and Fa were also administered systemically. From 1988 to 1990, seven patients with unresectable HCC and two patients who underwent curative resection were treated by this therapy. The objective responses were evaluated by CT and angiography. This combination immunotherapy produced 3 cases of complete response and 2 of minor response. Immunological monitoring of lymphocyte subsets and NK activity of peripheral blood mononuclear cells was also performed. NK activity was significantly augmented and the percentage of Leu 7(-) NCD 16(+) cells increased during this therapy. Serious toxicity, but transient high fever and hypotension, was not observed during this therapy. All of these patients left the hospital within two weeks and returned to their previous job or similar life activity. These results suggest that this combination immunotherapy is worth performing in further clinical trials for hepatocellular carcinoma.

Factors affecting postoperative flexion in total knee arthroplasty

In the review of 67 cases with total condylar (TC) prostheses, 59 with TC posterior stabilizers, 70 with TC prostheses modified with flat posterior tibial plateau, and 35 with porous-coated arthroplasty (PCA) prostheses, multiple cross-examinations of various factors for postoperative flexion were performed. Follow up was 2 to 9 years. In nearly all cases, no further improvement of flexion was noted after 1 year following surgery. The most influential factor for good postoperative flexion was intense physical therapy, leading to good suprapatellar pouch reconstitution. Residual flexion contracture was more frequent when the posterior cruciate ligament (PCL) was retained in the cases with significant preoperative flexion contracture. However, retention of PCL or preoperative ACL condition did not bear any significance to the ultimate flexion.

[A clinical study on transitional cell carcinoma of the renal pelvis and ureter]

Thirty-three patients in which transitional cell carcinoma was histologically diagnosed in the upper urinary tracts were statistically analyzed. Clinical analysis was done according to a new TNM system proposed by Akaza. Tumor grade and stage well correlated with survival. TS and TE group showed 89.5 and 17.1% 3-year survival, respectively. The survival rates showed significant difference between grade, 1, 2 and 3. T category and grade were also significantly correlated. Furthermore, histology and cytology were well correlated. Finally, prognosis in our series was significantly influenced by stage and grade of the tumor. Prognosis is considered to be good for 1) grade 1, 2) grade 2, superficial tumors with negative cytology, and 3) No and M0 cases. We emphasize that the new classification proposed by Akaza correlates well to survival and adapts well to the definition of regional lymph nodes.

Experimental studies on the oxygen tension in the myocardium and changes of cardiac function in hypoxia

Using adult mongrel dogs, experiments were performed to elucidate the relationship between the changes in the myocardial oxygen tension (PmO2) in anoxia and disturbances of cardiac function. Dogs, forced to inspire 100% N2, suffered from a respiratory arrest after 5 min, and developed acute anoxia. However, by 100% O2 inhalation 2 min after the onset of the respiratory arrest, the anoxia rapidly resolved. The arterial oxygen tension (PaO2), left intra ventricular oxygen tension (PLVO2) and PmO2 showed the most pronounced fall 2 min after the respiratory arrest induced by N2 inhalation. The arterial carbon deoxide tension (PaCO2) decreased until the respiratory arrest, after which it started to rise. When inhalation of 100% O2 was initiated at the anoxia, the PaO2, PLVO2 and PmO2 recovered within 1 min followed by a rise beyond the baseline value. Left ventricular end-diastolic pressure (LVEDP), left atrial mean pressure (LAm), left ventricular systolic pressure (LVSP), aortic mean pressure (Aom), maximum rate of force development by left ventricle (LVmax.dp/dt), total peripheral resistance (TPR), cardiac output (CO) and heart rate (HR) were measured. At the onset of anoxia, these parameters decreased sharply. When inhalation of 100% O2 was initiated within 2 min of the respiratory arrest, these disturbances of cardiac function recovered rapidly. The fall of PmO2 plays an important role in the impairment of cardiac function.

Full flexion after total knee replacement in rheumatoid arthritis

The results of the Y-S total knee replacement are reported in 152 patients with rheumatoid arthritis (227 knees). The follow up was from 2 to 4 years (average 2.7 years). The good range of motion generally achieved was attributed to the use of a calibrated distractor for soft tissue balancing, a tibial prosthesis with a flattened plateau and extensive postoperative rehabilitation. Fourteen patients (27 knees) were able to squat fully after operation. A good range of motion before operation was related to a good range after operation. The range and overall results did not differ in patients with rheumatoid arthritis or osteoarthritis. The knees which recovered full flexion were no different from those with less than full flexion as far as stability and radiographic findings were concerned.

[Opioid peptides in RA: modulation of immunologic mechanisms and mental states]

Rheumatoid arthritis (RA) patients were investigated for relationships between the concentrations of various plasma opioid peptides (beta-endorphin (beta-end), methionine-enkephalin (Met-enk), leucine-enkephalin (Leu-enk) and the lymphocyte subsets, serum immunoglobulins, the patient's mood or emotion, and the RA activity. A mental state and patient mood were assessed by the Cornell Medical Index (CMI) and the Face Scale. RA activity was expressed by Lansbury's index. The plasma Met-enk concentration was correlated significantly with the %Leu11+ and %Leu11+Leu7+ cells. The plasma Leu-enk concentration also correlated significantly with the %Leu2a+Leu15- cells. The plasma Leu-enk concentration and pain score were higher while the %Leu11+Leu7- cells was lower in proportion of the degree of neurosis of the RA patient as indicated by the CMI. The plasma Met-enk concentration, the %Leu2a+Leu15-, IgG, pain score and Lansbury's index were significantly higher in the group of RA patients whose facial expression was more severe. These findings suggest that enkephalins have some relationship with the patient's mood and immunologic functions, and that enkephalins have a possibility of exerting indirect effects on RA.

A solution for removal of resin from epoxy sections

Development of a resin-dissolving solution for use at low alkali concentrations is described. Crown ether dissolved in dimethyl-sulfoxide produces a superbasic alkoxide anion. A five minute treatment resulted in complete resin removal from kidney biopsy specimens embedded in Epon 812. Specimens were well stained by Loeffler's methylene blue. Periodic acid-methenamine silver and Giemsa stains yielded good results. Application of PAS reaction and subsequent hematoxylin counterstaining was practicable for diagnosis.

The suppressive effect of an antibody to the alpha beta cell receptor in rat adjuvant arthritis: studies on optimal treatment protocols

An antibody (R73) to the alpha beta T cell receptor (TCR) was able to dramatically suppress adjuvant arthritis (AA) in rats. The efficacy of R73 treatment was investigated with regard to antibody dosage, injection route and timing of injections. R73 was equally effective in reducing joint swelling throughout a wide dose range (80 to 2000 microgram/dose) when given on day 15, 18, and 21 after arthritis induction. Both i.p. and i.v. injection were able to suppress the pre-existing joint swelling to the same extent. However, R73 was only effective when given before or at the peak of joint swelling which occurred between day 18 to 24. Synovial membrane hyperplasia, mononuclear cell infiltration as well as cartilage and bone destruction were markedly reduced after therapy. The effect of R73 was associated with depletion of alpha beta+ T cells from the circulation even at low antibody doses. Only few alpha beta+ T cells were found in the pannus tissue. Late treatment on day 27, 30 and 33 after arthritis induction did not influence clinical scoring of the disease and histological examination thereafter did not show any difference between treated animals and controls. We conclude that antibody therapy directed at the TCR seems to be very effective even in pre-existing autoimmune diseases if the relevant T cell population is affected. However, inflammation and joint destruction may reach a state at which anti-TCR treatment is no longer effective.

[Liver disorder owing to estrogen therapy in prostatic cancer, examined histopathologically in six autopsy cases]

The parenchymal damage of the liver after estrogen therapy for prostatic cancer, mainly treated with diethylstilbestrol diphosphate (DES-DP), was studied in the six autopsied cases, herein. The parenchymal disorder of the liver was "nonalcoholic steatohepatitis", reported by Ludwig et al., and its degree of disorder was dependent upon the administered dose of estrogen. The acceptable total dose of DES-DP was supposed to be about 150 g at maximum, according to the various degrees of damage examined histopathologically in the six cases who were administered at total doses of DES-DP from 12.6 g to 619 g. Comparison of the histopathologic damage to the liver function tests performed within 10 days before death revealed that only the serum levels of cholinesterase (ChE) were abnormally decreased, suggesting its importance to predict the degree of "nonalcoholic steatohepatitis" by monitoring of ChE.

[Liver disorder owing to estrogen therapy in prostatic cancer. The correlation between serum level of cholinesterase and dose of diethylstilbestrol diphosphate]

We have examined the value of cholinesterase (ChE) that indicates the preservation ability of liver function, to assess the liver disorder owing to diethylstilbestrol diphosphate (DES-DP) administration in 25 prostatic cancer patients without castration. The correlation between ChE and the other factors such as age, total dose of DES-DP, duration of administration or ratio (total dose/duration), were studied by means of multiple regression analysis (MRA). In sixteen patients treated for less than 6 months, ChE was correlated with all factors by MRA with the coefficient of 0.645, and the coefficients of simple correlation between ChE and total dose and between ChE and administered duration, were -0.521 (p less than 0.05) and -0.596 (p less than 0.05), respectively. In nine patients treated for more than 6 months, ChE was correlated with all factors by MRA with the coefficient of 0.803, and the coefficient of simple correlation between ChE and ratio was -0.707 (p less than 0.05). According to these results and the permissible range of ChE, the total dose of administration for less than 6 months was estimated to be under 50 gram and its duration was within 100 days. The ratio in patients administered for more than 6 months was under 300 mg/day. Therefore, as far as the long-term hormonal treatment for prostatic cancer and preservation of liver function, we concluded that total dose of DES-DP should be less than 50 gram in less than 100 days for induction therapy and the daily dose of DES-DP should be less than 300 mg/day for maintenance therapy.

[Usefulness of measurement of hepatic arterial blood flow during surgery to insert an arterial reservoir in unresectable hepatocellular carcinoma]

In a case of hepatocellular carcinoma, complicated with celiac arterial constriction, for which resection was impossible, we measured the blood flow in the hepatic artery using an ultrasonic, transit-time rheometer during surgery, and consequently inserted a reservoir safely. The measurement of the blood flow in this case demonstrated that the proper hepatic artery was provided with blood from superior mesenteric artery by the gastroduodenal artery and that the blood flow of the common hepatic artery was directed to the root part of the celiac artery. Moreover, because blood flow through the proper hepatic artery was greater while clamping the common hepatic artery than the gastroduodenal artery, cannulation was carried out from the common hepatic artery. Postoperatively, when recombinant interleukin-2(rIL-2) was infused from the reservoir, the tumor disappeared on imaging pictures, and the level of AFP (which was high preoperatively) was reduced, which was thus judged as a complete response. These results indicated the usefulness of measurement of blood flow in surgery of inserting a reservoir in cases with abnormal blood circulatory dynamics.

Patellar replacement in bilateral total knee arthroplasty. A study of patients who had rheumatoid arthritis and no gross deformity of the patella

Thirty-five patients who had rheumatoid arthritis of both knees, but no gross deformity of the patella, had bilateral total knee arthroplasty. In each patient, one knee had a patellar replacement and the other did not. All of the patients were followed for a minimum of two years. The results were the same in both knees in terms of relief of pain and improvement in function, arc of motion, and muscle power. Although no complications that were related to patellar replacement developed in these patients, routine replacement of patellae that have little or no deformity does not seem advisable.