Antigen presentation by autoreactive proteolipid protein peptide-specific T cell clones from chronic progressive multiple sclerosis patients: roles of co-stimulatory B7 molecules and IL-12

To assess the role of T cell antigen (Ag) presentation in multiple sclerosis (MS), proteolipid protein (PLP) peptide reactive CD4+ T cell clones (TCCs) from MS patients and normal subjects were studied. TCCs derived from chronic progressive (CP) MS patients were able to proliferate and secret cytokines in response to PLP peptide stimulation in the absence of professional antigen presenting cells (APCs), suggesting that these T cells can simultaneously present and respond to Ags. However, they did not respond to total PLP protein, suggesting that PLP-peptide TCCs were unable to process and present the whole PLP molecule. The ability of the different TCCs to act as APCs in response to Ag stimulation did not correlate with expression of HLA-class II molecules. However, the degree of expression of B7-1 and B7-2 co-stimulatory molecules showed a significant correlation with APC capacity. Furthermore, a combination of anti-B7-1 and anti-B7-2 mAbs effectively inhibited proliferative responses as well as secretion of IL-10, IFN gamma and TGF beta induced by antigen presenting T cells. By contrast, IL-4 secretion was not affected. Finally, IL-12 significantly enhanced the efficiency of T cell Ag presentation by a pathway independent of Ag processing, suggesting that IL-12 might act as an additional co-stimulatory signal for T cell activation during T-T cell interactions. Together, these observations suggest that Ag presentation by T cells might amplify and perpetuate an autoimmune response previously initiated by professional APCs. These properties may account for progression of MS into a CP phase.

Cervical abnormality and sexually transmitted disease screening in human immunodeficiency virus-positive women

OBJECTIVE

To determine the incidence of genital tract infections and cervical abnormalities in 185 human immunodeficiency virus (HIV)-positive outpatients with a view toward establishing an effective policy for gynecology screening.

METHODS

Gynecology results were reviewed for 185 HIV-positive women seen as outpatients at the Royal Free Hospital in London. All subjects underwent screening for cervical abnormalities (smear and colposcopy) and sexually transmitted disease (STD) at 6-month intervals for 6 years. The STD prevalence was calculated, and the relationship between the occurrence of STDs and the demography and sexual lifestyle of the women was examined to determine whether these factors were predictive for women at risk for STDs. The incidence of cervical intraepithelial neoplasia (CIN) was determined. We reviewed the use of colposcopy in addition to cytology as a primary screening test to see whether it improved the detection rate of CIN.

RESULTS

Sixty-five (35.1%) women had a history of previous STDs, and new STDs were detected in 18 women at their first visits. None were detected at subsequent visits. Sexual lifestyle details did not predict women at risk for STDs. Ninety-eight (53%) cervical smears were reported as normal at the first visit, but there was a 3.1% (95% confidence interval 0, 6.6) false-negative rate when compared with colposcopy and directed biopsy. Five of fifty women (10%) with CIN I had progressed to higher-grade lesions by 6-month follow-up.

CONCLUSIONS

Given the low prevalence of STDs detected, except for initial screening at presentation, regular, repeat STD screening of HIV-positive women appears to be unnecessary. Because of the high incidence of cervical abnormalities, screening for cervical biopsy improved the detection rate of cervical abnormalities.

Infertility among human immunodeficiency virus-positive women: incidence and treatment dilemmas

The increasing demand for fertility advice among human immunodeficiency virus (HIV)-positive women under our care led us to review the incidence of infertility and the ethical problems associated with its management. All HIV-positive women who attended the HIV outpatients clinic from October 1990 to the end of January 1996 were studied. The main outcome measures were: the number of women undergoing infertility investigations before and after HIV diagnosis, their demographic and social details, and the outcome of these investigations. Most of the 183 women studied were in their reproductive years (mean age 32.7 +/- 6.7 years). Nine women had undergone infertility investigations, and/or treatment before HIV diagnosis, three of whom were diagnosed with HIV during routine testing prior to IVF treatment. Six declined further infertility treatment after discovering their HIV status. Eight women have undergone infertility investigations after HIV diagnosis but none have achieved pregnancy to date. Management decisions may have been hampered by ethical uncertainties in several cases. In conclusion therefore, as requests for infertility treatment from HIV-infected women occur and may become more common as the prevalence of HIV infection in women continues to rise, the ethical issues associated with the management of this problem demand urgent attention so that clear guidelines are available to aid treatment decisions.

Efficacy and tolerance of Menorest compared to Premarin in the treatment of postmenopausal women. A randomised, multicentre, double-blind, double-dummy study

Two-hundred and fourteen (214) menopausal women with moderate to severe vasomotor symptoms, aged 40-65 years, were randomised. After a 4-week treatment-free period, each women received a continuous regimen of Menorest 50 twice weekly or Premarin 0.625 mg daily, for 12 weeks. Didrogesterone 10 mg was also given to all women for 12 days of every 28-day cycle. The objectives were to compare the efficacy and safety profiles of Menorest and an oral estrogen. A statistically significant reduction in the mean number of hot flushes occurred in each group compared to baseline with a decrease from 7.1 at baseline to 0.9 at 12 weeks in the Menorest group, and from 6.7 to 0.5 in the oral estrogen group; there was no statistically significant difference between the two groups (P = 0.36). With each successive treatment cycle, there was a continuous improvement in the number of hot flushes. The incidence and severity of menopausal symptoms were reduced in the same manner in both groups. There were no statistically significant differences in the mean plasma estradiol and estrone concentrations between the two treatment groups after 10 weeks of therapy. The mean estradiol to estrone ratio was similar in both groups, as was the number of adverse events observed. In summary, Menorest was as effective as an oral estrogen in alleviating menopausal symptoms.

Spirometry for the primary care physician

The clinician wishing to employ a spirometer in the office must be aware of the equipment available and the current standards for validating and maintaining such equipment. Indications for spirometry are fairly frequent in general medical practice for both diagnosis, response to therapy, and for risk assessment prior to surgery. The criteria for characterizing a spirogram as normal, obstructive or restrictive, are well defined. The information obtained may be very helpful to point to additional specific diagnostic studies or to outline a specific treatment plan.

Isolation and characterization of autoreactive proteolipid protein-peptide specific T-cell clones from multiple sclerosis patients

During the course of multiple sclerosis (MS), myelin proteins are likely antigenic targets for autoreactive T cells. Although most studies have implicated myelin basic protein as a potent encephalitogenic myelin component, proteolipid protein (PLP) appears also to be a possible target antigen in the autoimmune response in MS. In this report, we investigated the human T-cell responses to PLP by using PLP104-117 and PLP142-153 synthetic peptides as target antigens in limiting dilution. One hundred twenty-five CD4+, T-cell receptor (TCR) alpha beta+ T-cell clones (TCCs) were established from the peripheral blood of seven MS patients and five control subjects. Despite the use of enriched cultures no gamma delta TCCs were obtained. Recognition of both PLP epitopes occurred in the context of multiple HLA-DR alleles. We found no differences in restriction element usage between MS patients and control subjects. TCR variable beta-region (V beta) usage was assessed by flow cytometry using a panel of monoclonal antibodies defining different V beta elements. In both MS patients and control subjects, there was a marked heterogeneity in the TCR V beta repertoire. Furthermore, sequential evaluation of MS patients during acute attacks and clinical remissions showed even more broadening of the TCR V beta repertoire. These data demonstrate that a heterogeneous T-cell response to PLP concerning HLA restriction and TCR usage is present in both MS patients and normal subjects.

Hepatosplenic gamma delta T-cell lymphoma. A distinctive aggressive lymphoma type

The T-cell receptor (TCR) expressed on the surface of most T-lymphocytes is of alpha beta type, and only a minority bear the gamma delta-TCR. Similarly, postthymic T-cell lymphomas rarely express gamma delta-TCR. Hepatosplenic gamma delta T-cell lymphoma is an uncommon entity that has so far not been widely recognized. We report one such case that has been comprehensively studied by multiple modalities and showed the unique occurrence of leukemic picture at presentation. The 39-year-old man presented with fever, marked weight loss, and massive splenomegaly. Peripheral blood showed thrombocytopenia and a white cell count of 5.8 x 10(9)/l, with 66% medium-sized lymphoid cells that had a round or folded nucleus, condensed chromatin and a moderate amount of pale blue cytoplasm. Splenectomy was performed and histologic examination of the spleen, bone marrow, liver, and abdominal lymph nodes demonstrated lymphoma infiltration with a predominantly sinusoidal pattern. Immunohistochemical studies of the lymphoma cells showed a T-cell phenotype: CD2+ CD3+ CD5+ CD7+ gamma delta-TCR+ alpha beta-TCR- CD56+ CD4- CD8- CD16- CD57-. Cytogenetic studies showed complex clonal chromosomal abnormalities of 44,X, -Y, -11, -22, + mar in 3/16 cells. Rearrangement of the TCR gamma chain gene was demonstrated by polymerase chain reaction; the TCR beta chain gene was partially chain reaction; the TCR beta chain gene was partially rearranged. The patient did not respond to single agent chemotherapy, but achieved clinical remission with combination chemotherapy. Based on the available data in the literature, hepatosplenic gamma delta T-cell lymphoma exhibits distinctive clinicopathologic features, and probably represents the neoplastic counterpart of splenic gamma delta T-lymphocytes. This disease is associated with a poor prognosis and usually relapses despite initial response to chemotherapy.

Patterns of cytokine secretion by autoreactive proteolipid protein-specific T cell clones during the course of multiple sclerosis

To determine whether cytokine secretion patterns change with disease status in patients with multiple sclerosis (MS), we measured IFN-gamma, TNF-alpha beta, IL-4, IL-6, IL-10 and TGF-beta secretion in a panel of T cell clones (TCCs) specific for proteolipid protein (PLP) after stimulation with PLP peptides or polyclonal activators. During acute attack, the predominant pattern of cytokine secretion resembled that of murine Th1 cells; i.e, IFN-gamma and TNF-alpha beta, and appeared to be restricted to PLP-reactive TCCs. None of the TCCs isolated during acute attack produced TGF-beta in response to PLP, Con A, or anti-CD3 Ab. Half of these TCCs were, however, capable of TGF-beta secretion and mRNA expression upon stimulation with PMA and the calcium inonphore A23187, suggesting a possible defect in activation through the TCR/CD3 pathway. During remission in the same patients all but two PLP-TCCs showed patterns of cytokine secretion resembling that of murine Th0, Th1, and Th2 subsets. The levels of IL-10 secreted by these TCCs were significantly higher than those of TCCs isolated during acute attacks and those derived from normal subjects and patients with other noninflammatory neurologic diseases. Furthermore, 50% of these TCCs were capable of producing TGF-beta after Ag-specific or polyclonal stimulation. All TCCs isolated from control subjects exhibited a Th0 like secretion profile. These data indicate that different stages of disease in MS are characterized by different patterns of cytokine secretion by PLP-specific TCCs, suggesting a role for cytokines in clinical events during the course of MS.

Patterns of cytokine secretion by autoreactive proteolipid protein-specific T cell clones during the course of multiple sclerosis

To determine whether cytokine secretion patterns change with disease status in patients with multiple sclerosis (MS), we measured IFN-gamma, TNF-alpha beta, IL-4, IL-6, IL-10 and TGF-beta secretion in a panel of T cell clones (TCCs) specific for proteolipid protein (PLP) after stimulation with PLP peptides or polyclonal activators. During acute attack, the predominant pattern of cytokine secretion resembled that of murine Th1 cells; i.e, IFN-gamma and TNF-alpha beta, and appeared to be restricted to PLP-reactive TCCs. None of the TCCs isolated during acute attack produced TGF-beta in response to PLP, Con A, or anti-CD3 Ab. Half of these TCCs were, however, capable of TGF-beta secretion and mRNA expression upon stimulation with PMA and the calcium inonphore A23187, suggesting a possible defect in activation through the TCR/CD3 pathway. During remission in the same patients all but two PLP-TCCs showed patterns of cytokine secretion resembling that of murine Th0, Th1, and Th2 subsets. The levels of IL-10 secreted by these TCCs were significantly higher than those of TCCs isolated during acute attacks and those derived from normal subjects and patients with other noninflammatory neurologic diseases. Furthermore, 50% of these TCCs were capable of producing TGF-beta after Ag-specific or polyclonal stimulation. All TCCs isolated from control subjects exhibited a Th0 like secretion profile. These data indicate that different stages of disease in MS are characterized by different patterns of cytokine secretion by PLP-specific TCCs, suggesting a role for cytokines in clinical events during the course of MS.

Mr. Smith goes to Washington? Interview by Renee Blankenau

The five freshman congressmen we're profiling in this issue have a lot more going for them than Mr. Smith did; most importantly, all bring strong community health and welfare concerns to Capitol Hill. A look at representatives of a sometimes surprising new crop of citizen-lawmakers.

Evaluation of recombinant human factor IX: pharmacokinetic studies in the rat and the dog

The pharmacokinetics of intravenously administered recombinant human factor IX (rhFIX) were studied in Sprague-Dawley rats and Beagle dogs. Rats received rhFIX (50 IU/kg once daily) for 28 days, and the plasma half-life was 5 h. Anti-Human Factor IX serum antibody levels were found in only 1 of 12 rats. The pharmacokinetic profiles of rhFIX or Mononine, a purified human plasma-derived factor IX, after single 100 IU/kg i.v. doses in dogs, were similar. Peak plasma concentrations of rhFIX and Mononine were 4-5 micrograms/ml. The mean plasma half-lives were 13.2 +/- 1.6 h for rhFIX and 13.3 +/- 1.6 h for Mononine. Dogs also received rhFIX (40 IU/kg i.v., daily) for 28 days or Mononine (40 IU/kg i.v. daily) for 14 days. Anti-human Factor IX serum antibody levels were determined for each compound. Pharmacokinetic half-lives decreased in these treated dogs which developed antihuman Factor IX antibodies. The antibody responses in 28 day rhFIX (40 IU/kg) dogs were similar to 14 day Mononine (40 IU/kg) dogs.

Clonal analysis of three morphologically distinct lymphomas occurring in the same patient

AIMS

To determine whether three morphologically distinct lymphomas (mucosa associated lymphoid tissue (MALT) lymphoma, monocytoid B cell lymphoma, and large cell anaplastic lymphoma), which occurred in the same patient, were in fact three morphological variants of the same lymphoproliferative process.

METHODS

Previously described methods of clonal analysis using the polymerase chain reaction (PCR) were used to determine the pattern of rearrangements of the immunoglobulin heavy chain gene and the T cell receptor beta and T cell receptor gamma chain genes in the three lymphomas.

RESULTS

All three morphological entities had identical patterns of gene rearrangements.

CONCLUSIONS

This finding confirms the association between MALT lymphoma and monocytoid B cell lymphoma, and also provides evidence that large cell anaplastic lymphoma may not only arise de novo but may also be an end stage morphological picture in lymphoma progression.

Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography

PURPOSE

To characterize endometrial polyps, hyperplasia, and carcinoma with endovaginal ultrasound in postmenopausal women.

MATERIALS AND METHODS

Seventy-three postmenopausal women with abnormally thick endometria on endovaginal sonograms were retrospectively identified. The endometrial appearance was characterized as hyperechoic, containing cystic spaces, or heterogeneous. The final study group consisted of 68 women, in whom the pathologic and sonographic findings were correlated.

RESULTS

Thirty sonograms showed hyperechoic endometria in women with hyperplasia (n = 8), polyps (n = 4), polyps and hyperplasia (n = 2), or atrophy, proliferative change, mild atypia, or normal endometria (n = 16); 27 sonograms showed cystic spaces in women with polyps (n = 21), carcinoma (n = 1), polyps and hyperplasia (n = 2), or atrophy (n = 3); and 11 sonograms showed heterogeneous endometria in women with endometrial carcinoma (n = 7), atrophy (n = 2), proliferative endometrium (n = 1), or secretory endometrium (n = 1). Cystic spaces were predictive of polyps (P = 1.19 x 10(-10)).

CONCLUSION

Endovaginal sonography may be useful for differentiation of endometrial polyps, hyperplasia, and carcinoma.

Topoisomerase II mediated DNA lesions induced by acridine-4-carboxamide and 2-(4-pyridyl)quinoline-8-carboxamide

Acridine-4-carboxamide and 2-(4-pyridyl)quinoline-8-carboxamide represent a new generation of antitumor intercalators related to amsacrine (m-AMSA), a classic topoisomerase II-targeted drug. We examined the ability of these tricyclic carboxamides to induce DNA lesions that reflect the stabilization of topoisomerase II cleavage complexes. DNA-protein cross-links (DPC) and DNA double-strand breaks (DSB) were assessed in mouse fibrosarcoma cells (line 935.1). DPC were rapidly formed and readily reversible. A bell-shape concentration dependence suggested a self-inhibition of DPC at higher drug levels. In isolated nuclei, DPC formation by 2-(4-pyridyl)quinoline-8-carboxamide required ATP and was inhibited by novobiocin, a topoisomerase II inhibitor. Acridine-4-carboxamide and 2-(4-pyridyl)quinoline-8-carboxamide were also potent inducers of DSB. In contrast to DPC, however, DNA breaks continued to increase with drug concentration. These DSB were masked (presumably by non-covalently associated proteins) when analyzed by nucleoid sedimentation. Thus, while both DPC and DSB seemed to be topoisomerase mediated, at least some DSB appeared to lack the enzyme bound covalently. DNA lesions by tricyclic carboxamides occurred, in general, at drug concentrations comparable to those needed to inhibit cell survival. Also, the tricyclic carboxamides inhibited the catalytic activity of isolated topoisomerase II. The results indicate that tricyclic carboxamides interfere with the action of topoisomerase II. However, the mechanisms of enzyme inhibition by these drugs differ from the classical trapping of topoisomerase in covalent cleavage complex m-AMSA.

Physician-ordered respiratory care vs physician-ordered use of a respiratory therapy consult service: early experience at The Cleveland Clinic Foundation

BACKGROUND

Accumulative evidence suggests that respiratory care is frequently misallocated. We report the results of a pilot study of a delivery system aimed at correcting such misallocation.

METHODS

The delivery system (Respiratory Therapy Consult Service, or RTCS) allows respiratory therapists (when requested by the case-managing physician) to determine respiratory care, with decisions guided by algorithm (ie, Consult patients). In the pilot study, Therapist Evaluators responded to requests for Consults on two study wards. All staff therapists participated in implementing Evaluator-determined treatment.

STUDY DESIGN

We evaluated 38 patients (20 of whom were Consult patients) randomly selected from a total of 82 patients undergoing abdominal surgery during the study period.

RESULTS

Consult patients were significantly older than non-Consult patients, more likely to be heavy smokers (67 vs 43%), and sicker as suggested by a higher Triage Score. Consult patients received more types and more total respiratory care services, demonstrated a trend toward longer stay, and had significantly higher respiratory therapy charges.

CONCLUSION

Our experience shows that a consult program can be successfully implemented in a large, tertiary care institution with widespread physician and nursing support. Whether the RTCS fulfills its goal of ameliorating misallocation of respiratory care has yet to be proven and awaits the completion of other studies currently under way.

Effectiveness of combined induction chemotherapy and radiotherapy in advanced nasopharyngeal carcinoma

PURPOSE

This prospective trial was conducted with the goal of achieving an improvement in both overall and progression-free survival in previously untreated patients with stage IV nasopharyngeal carcinoma who received an induction chemotherapy regimen of fluorouracil (5-FU) and cisplatin followed by radiotherapy.

PATIENTS AND METHODS

From January 1985 to January 1990, 47 patients with T1-4N2-3M0 squamous cell carcinoma of the nasopharynx were treated at The University of Texas M.D. Anderson Cancer Center with two to three cycles of 5-FU (1,000 mg/m2 continuous infusion per day x 5 days) plus cisplatin (100 mg/m2 continuous infusion on day 1 only) followed by radiotherapy using the conventional time/dose schedule.

RESULTS

The response rate to chemotherapy was 93.2% (20.5% complete response [CR]; 72.7% partial response [PR]), and the overall CR rate after radiotherapy was 86%. With a median follow-up period of 53 months, the 2-, 4-, and 6-year survival rates were 80%, 71.6%, and 67.4%; the overall treatment failure rate was 27%. Treatment was well tolerated and without significant acute or chronic toxic effects.

CONCLUSION

The results of this prospective study demonstrate that 5-FU plus cisplatin followed by radiotherapy can induce a durable remission in a high proportion of patients with poor-prognosis stage IV nasopharyngeal carcinoma.

Trial of standard versus modified expiration to achieve end-of-test spirometry criteria

To assess whether satisfying American Thoracic Society (ATS) end-of-test spirometry criteria can be enhanced by modifying the patient's expiratory technique, we conducted a cross-over trial of two expiratory techniques in 48 patients with a range of pulmonary functions (Group 1, n = 12: FEV1/FVC < 0.45; Group 2, n = 11: FEV1/FVC, 0.45 to 0.60; Group 3, n = 16: FEV1/FVC, 0.61 to 0.74; Group 4, n = 9: FEV1/FVC > or = 0.75). After randomizing the order of testing, each patient performed three exhalations using a "standard" forced expiratory maneuver and a modified expiratory technique consisting of an initial maximal expiratory effort followed by a "relaxed expiration" for as long as possible. Patients initiated "relaxed expiration" when instructed by the supervising technician, who issued the instruction to relax when expiratory airflow fell to < or = 200 ml/s (as determined by flow-volume loop analysis). ATS end-of-test criteria were satisfied significantly more often using the modified expiratory technique (58.3% of testing sessions) than using the standard technique (18.7% of sessions, p = 0.001) because of prolongation of the forced expiratory time (FET) with the modified technique in all patient groups. In the 38 patients with FEV1/FVC < or = 0.75, the largest FVC and FET rose significantly using the modified expiratory technique, without compromising the largest FEV1 in any group. In patients with FEV1/FVC > or = 0.75, FET increased without concomitant changes in FVC or FEV1.(ABSTRACT TRUNCATED AT 250 WORDS)

FcR+/- subsets of Ia+ pulmonary dendritic cells in the rat display differences in their abilities to provide accessory co-stimulation for naive (OX-22+) and sensitized (OX-22-) T cells

A substantial body of evidence indicates that the primary sensitization of naive T cells to inhaled antigens occurs in the regional lymph nodes, whereas secondary responses may be generated directly within lung tissue. Ia+ pulmonary dendritic cells are widely distributed within the rat lung where they can participate in the induction of the immune response to inhaled antigens. Recently, two subsets of Ia+ pulmonary dendritic cells have been distinguished based on their expression of Fc receptors (FcR), but little is known concerning their abilities to support the responses of naive or sensitized T cells. In order to address this question, pulmonary FcR+/- dendritic cells have been purified from enzymatic digests of Lewis rat lungs, based on their differential binding to heat-aggregated immunoglobulin. The FcR+/- dendritic cell subsets differed with respect to their light microscopic appearance and in their expression of non-specific esterase. Only the FcR+ subset was able to phagocytize latex beads and showed intracellular phagolysosomes by electron microscopy. Both of the FcR+/- subsets rapidly formed clusters with naive (OX-22+) and sensitized (OX-22-) T cells. However, the clusters yielded by the FcR+ subset were substantially smaller, possibly reflecting their diminished surface membrane expression of the intercellular adhesion molecule-1. The FcR+/- subsets were capable of presenting soluble and particulate antigens to OX-22- T cells. FcR+ cells were less effective than FcR- cells in promoting the proliferative response of OX-22+ T cells to concanavalin A and in the primary mixed leukocyte reaction. We conclude that the FcR+/- pulmonary dendritic cells differ in their abilities to support the responses of naive and sensitized T lymphocytes. This observation may have significance for how primary and secondary pulmonary cell-mediated immune responses are generated.