T follicular-like helper cells in the peripheral blood of patients with primary Sjögren's syndrome

Primary Sjögren's syndrome (pSS) is a chronic autoimmune disease characterized by exocrine gland dysfunction, mainly causing sicca symptoms. B cells have a prominent role in SS, and the T follicular helper (TFH ) cells provide B cells with survival and specialization signals in germinal centres. Here, we investigate peripheral TFH cells in pSS. Sixteen pSS patients and healthy controls were enrolled in the study, with 13 women and 3 men in each group. Whole blood was collected and separated into PBMC and plasma, followed by cryopreservation. Plasma samples were analysed for Ro52, Ro60 and La48 autoantibodies by indirect ELISA. For flow cytometric analysis, we defined 4 subsets of TFH-like cells within the CD3+ CD4+ CXCR5+ population, namely the ICOS- PD-1- , ICOS- PD-1+ , ICOS+ PD-1- and ICOS+ PD-1+ ("TFH") cells. We also investigated 4 CD19+ B cell subsets, the CD20+ CD27+ CD38- memory B cells, CD20+ CD27+ CD38+ memory B cells, CD20- CD27+ CD38++ CD138- plasmablasts and CD20- CD27+ CD38++ CD138+ plasma cells. We observed higher fractions of ICOS+ PD-1- cells, ICOS+ PD-1+ ("TFH ") cells and plasmablasts in pSS patients compared to controls, and lower frequencies of both types of memory B cells. The number of TFH cells correlated positively with the levels of plasmablasts and plasma cells in the pSS patients, but not in the controls. The pSS patients were stratified according to Ro52/Ro60/La48 serology, and a positive association was found between autoantibody levels and increased level of TFH cells, plasmablasts and plasma cells and lowered levels of memory B cells. We observed a higher response to Ro/La stimulation in pSS patients compared to controls of the memory B cells, although only significantly for the CD38- memory B cells. Overall, a pathological relation between the ICOS+ T follicular-like helper cells and B cells in pSS was observed, but further work should be conducted to explore their overall impact upon disease progression.

Patients with Primary Sjögren's Syndrome Have Alterations in Absolute Quantities of Specific Peripheral Leucocyte Populations

An accurate dissection of peripheral blood enumeration is lacking in primary Sjögren's syndrome (pSS). The purpose of this study was to quantify different leucocyte populations in peripheral blood of patients with pSS. Numbers of specific leucocyte subsets were determined in 86 pSS patients and 74 healthy donors quantifying 21 distinct subtypes by flow cytometry. Subgroups of pSS patients were stratified based on presence of extraglandular manifestations (EGMs) and SSA/SSB autoantibodies. Overall, pSS patients manifested decreased lymphocyte subpopulations compared to healthy donors. Such decreases were more pronounced in SSA/SSB positive patients and patients with EGM. Granulocyte and monocyte subpopulations were increased in pSS patients compared to healthy donors, with the greatest increases in SSA/SSB positive patients. Unsupervised hierarchal clustering based on cell quantities was used to further subgroup the pSS patients into four clusters. One of the clusters characterized by higher concentrations of NKT cells, CD56hi NK cells, CD20⁺ CD38^- B cells and CD8⁺ CD38^- T cells was associated with weaker clinical symptoms than the other clusters, possibly marking a milder disease phenotype. In conclusion, our analyses indicate significant alterations in the cellular profiles of peripheral blood leucocytes in patients with pSS and may help to stratify the patients according to disease severity.

Calprotectin (S100A8/A9) and S100A12 are associated with measures of disease activity in a longitudinal study of patients with rheumatoid arthritis treated with infliximab

OBJECTIVES

The pro-inflammatory proteins calprotectin (a heterocomplex of S100A8/A9) and S100A12 have been associated with disease activity in rheumatoid arthritis (RA). The aim of this study was to compare their potential as biomarkers in a prospective study of RA patients starting with infliximab as their first biological disease-modifying anti-rheumatic drug (DMARD).

METHOD

Thirty-nine RA patients were examined and serum samples collected when starting with infliximab and after 3, 6, and 12 months. Calprotectin and S100A12 were analysed by enzyme-linked immunosorbent assays (ELISAs) and, together with C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), measured at all time points. A disease activity score of 28 joints (DAS28) was calculated. Radiographs of the hands, wrists, and feet were taken at baseline and after 3 years, and assessed according to the modified Sharp/van der Heijde (SvH) score. Responsiveness was evaluated according to the European League of Associations for Rheumatology (EULAR) response criteria based on 28 joints.

RESULTS

Both S100 proteins were significantly higher in seropositive than in seronegative patients (p = 0.01). Calprotectin correlated significantly with CRP (ρ = 0.51-0.75), ESR (ρ = 0.32-0.52), and DAS28 (ρ = 0.32-0.62). S100A12 correlated with calprotectin (ρ = 0.62-0.77) and CRP (ρ = 0.32-0.63). The S100 proteins, and especially calprotectin (ρ = 0.23-0.39), showed weak associations with radiographic progression, unlike CRP/ESR. None of the S100 proteins could predict responsiveness.

CONCLUSIONS

Calprotectin showed the strongest correlation with measures of disease activity and may be better than S100A12 when evaluating disease activity in RA patients. More extensive studies are needed to further compare the predictive value of the S100 proteins relative to radiographic progression.

Autoantigen-specific memory B cells in primary Sjögren's syndrome

Sjögren's syndrome (SS) is a systemic rheumatic autoimmune disease affecting the exocrine glandular function and is characterized by the presence of autoantibodies against the ribonucleoprotein particles, SS-A/Ro and SS-B/La, and mononuclear cell infiltration of exocrine tissues. Our aim is to characterize memory B cell pattern and function in relation to the progression of the disease, by analysing samples from a well-defined cohort of patients with primary SS. We have measured the number of Ro/La-specific plasma cells in peripheral blood mononuclear cells (PBMC) from 23 patients and 20 healthy controls by direct enzyme-linked immunospot (ELISPOT) assay. Furthermore, we quantified the Ro- and La-specific memory B cells in these individuals by a 6-day in vitro polyclonal stimulation of PBMC followed by an antigen-specific ELISPOT assay for the detection of memory B cells. In addition to this, ELISA profiling of autoantibodies was carried out using patients' plasma and supernatant, collected post-mitogen stimulation of PBMC. The average Ro60-, Ro52- and La48-specific plasma cells in PB was 9, 17 and 13 cells in 10(5) PBMC, respectively. After in vitro stimulation, these numbers increased to 43, 50 and 26 for Ro60, Ro52 and La48, correspondingly. However, the fraction of memory B cells activated into antibody-secreting cells was lower than the overall IgG B cell population. We conclude that these lower Ro/La-specific memory B cell levels may indicate that a greater portion of the Ro- and La-specific B cells are in an activated stage. This is in tune with previous reports.

Phenotypic diversity of peripheral blood plasma cells in primary Sjögren's syndrome

Production of autoantibodies is one of the main features of primary Sjögren's syndrome (pSS). Long-lived plasma cells (PC) can produce autoantibodies for prolonged period of times without being affected by immunosuppressive therapies. As of today, little is known about the long-lived PC subset and their contribution to autoimmunity. We have characterized the phenotypic and migratory properties of peripheral blood PC isolated from pSS patients (grouped by focus score, FS) and compared them to PC from rheumatoid arthritis (RA) patients and normal non-autoimmune subjects. We observed two populations of PC in all study groups, CD19+ PC and CD19- PC. Interestingly, the CD19- PC subset was most prominent in autoimmune patients (pSS and RA) compared to normal controls. Further investigation of the PC phenotype revealed that a high percentage of both CD19+ and CD19- PC isolated from pSS and RA patients did not express the CD27 marker, which is normally highly expressed on all types of PC. Differences in the expression of markers such as IgM, IgG, CD95 and CXCR3 in the group with high FS compared to FS = 1, underscore the heterogeneity of pSS patient group and demonstrate that phenotypic pattern of circulating PC associates with the severity of inflammation in the salivary glands of these patients. Our migration experiments show that addition of CXCL12 to PC in vitro, do not alter the migration potential of PC in any group tested. However, we observed an overall higher spontaneous migration of PC from pSS compared to both RA and normal controls.

A longitudinal study of calprotectin in patients with polymyalgia rheumatica or temporal arteritis: relation to disease activity

OBJECTIVE

Calprotectin is a granulocyte and monocyte cytosolic protein that is released during activation of these cells. The plasma level of calprotectin is raised in various inflammatory conditions and correlates with disease activity in a wide range of rheumatic diseases. We wanted to investigate whether calprotectin may be useful as a measure of disease activity in polymyalgia rheumatica (PMR) and temporal arteritis (TA).

METHODS

Forty-seven patients with PMR and/or TA were followed up to 3 years in a prospective longitudinal design. Plasma calprotectin was correlated with acute phase parameters, erythrocyte sedimentation rate (ESR), and peroral steroid usage before start of treatment and at four subsequent time intervals.

RESULTS

Thirty-three patients had PMR, 10 had TA, and four had both diagnoses. Calprotectin was highly correlated with the acute phase parameters and ESR during the study period. Calprotectin was significantly decreased after start of treatment with oral prednisolone, and correlated with the daily dosage of prednisolone (r = 0.36, p < 0.01).

CONCLUSION

Calprotectin plasma levels were significantly associated with acute phase parameters, ESR, and prednisolone usage in PMR and TA, indicating that calprotectin may be a good measure of disease activity in these conditions.

Germinal Centres in Primary Sjögren's Syndrome Indicate a Certain Clinical Immunological Phenotype

Ectopic germinal centers (GCs) can be detected in the salivary glands of approximately 1/5 of patients with Sjögren's syndrome (SS) and appear in both primary and secondary SS. Previously, ectopic GC have been associated with increased local autoantibody production. The aim of this study was to determine whether GC in primary Sjögren's syndrome (pSS) defines a distinct seroimmunological phenotype. Retrospectively, a material of 130 haematoxylin and eosin‐stained paraffin‐embedded tissue sections of minor salivary gland tissue from patients with pSS was morphologically screened for the presence of ectopic GC. GC‐like lesions were detected in 33/130 (25%) of the pSS patients. Seventy‐two pSS patients lacking these structures (GC‐) were randomly selected for comparison. Focus score was significantly increased in the GC⁺ patients compared to the GC^– patients (P = 0.035). In the GC⁺ group, 54.5% of the patients presented with anti‐Ro/SSA compared to 43.7% in the GC^– group. Anti‐La/SSB was detected in 31.3% of the GC⁺ patients compared to 25.7% of the GC^– patients. Sixty‐one percentage of GC⁺ patients presented with increased levels of IgG, a nonsignificant difference when compared to 39.4% in the GC^– patients (P = 0.089). Levels of RF, ANA, ENA, IgM and IgA were similar in both patient groups, as were ESR and CRP. In conclusion, patients with ectopic GC have a higher focus score and more often present with autoantibodies and increased levels of IgG compared to pSS patients with regular focal infiltration (GC^–). Our findings may indicate a certain seroimmunological phenotype and warrant for further prospective studies.

The complex role of vitamin D in autoimmune diseases

Vitamin D, besides having well-known control functions of calcium and phosphorus metabolism, bone formation and mineralization, also has a role in the maintenance of immune-homeostasis. The immune-regulatory role of vitamin D affects both the innate and adaptive immune system contributing to the immune-tolerance of self-structures. Impaired vitamin D supply/regulation, amongst other factors, leads to the development of autoimmune processes in animal models of various autoimmune diseases. The administration of vitamin D in these animals leads to improvement of immune-mediated symptoms. Moreover, in human autoimmune diseases, such as multiple sclerosis, or rheumatoid arthritis the pathogenic role of vitamin D has been described. The review aims at describing the complex immune-regulatory role of vitamin D from the cellular level through autoimmune animal models and depicting the known contribution of vitamin D in the pathogenesis of human autoimmune diseases.

Estimation of the prevalence of primary Sjögren's syndrome in two age-different community-based populations using two sets of classification criteria: the Hordaland Health Study

OBJECTIVE

To estimate the point prevalence of primary Sjögren's syndrome (pSS) in two populations, aged 40-44 and 71-74 years, using two sets of classification criteria.

METHODS

The participating individuals were recruited from the Hordaland Health Study (HUSK) conducted during 1997-99. A total of 18 592 individuals born 1953-57 and 3346 individuals born 1925-27 were sent a questionnaire covering various health-related questions, including four questions about sicca symptoms. Among those answering positive to at least one of the four questions, 99 and 90 individuals born 1953-57 and 1925-27, respectively, were examined further. For diagnosis of pSS two classifications were used, the preliminary European criteria from 1993, and the revised European criteria from 1996.

RESULTS

By using the two classification criteria from 1993 and 1996, the point prevalences were 0.44% [95% confidence interval (CI) 0.34-0.57] and 0.22% (95% CI 0.15-0.32), respectively, for the population group born 1953-57. The corresponding estimates were 3.39% (95% CI 2.77-4.14) and 1.40% (95% CI 1.02-1.92) for the population born 1925-27.

CONCLUSION

The point prevalence of pSS was approximately seven times higher in the elderly population aged 71-74 years compared to individuals aged 40-44 years, regardless of the classification criteria used.

Circulating cytokines in Norwegian patients with psoriatic arthritis determined by a multiplex cytokine array system

OBJECTIVES

Serum cytokines play an important role in the pathogenesis of psoriatic arthritis (PsA) by initiating and perpetuating various cellular and humoral autoimmune processes. The aim of this study was to describe a broad spectrum of T- and B-cell cytokines, growth factors and chemokines in patients with PsA and healthy individuals.

METHODS

A novel protein array system, denoted as multiplex cytokine assay was utilized to measure simultaneously the levels of 23 circulating cytokines of patients with PsA and healthy individuals. Additionally, correlational clustering and discriminant function analysis (DFA), two multivariate, supervised analysis methods were employed to identify a subset of biomarkers in order to describe potential functional inter-relationships among these pathological cytokines and identify biomarkers with prognostic and diagnostic utility.

RESULTS

Univariate analysis demonstrated that serum levels of a complex set of immune and inflammatory modulating cytokines are significantly up-regulated in patients with PsA relative to unaffected controls including interleukin (IL)-10, IL-13, interferen (IFN)-alpha, epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), fibroblast growth factor [CCL3 macrophage inflammatory protein (MIP)-1alpha], CCL4 (MIP-1beta) and CCL11 (Eotaxin), while granulocyte-colony stimulating factor was significantly reduced in PsA patients. Correlational clustering was able to discriminate among, and hence subclassify, patients with varying levels of disease activity, which may prove useful in guiding therapy in these apparently phenotypically distinct disease subsets. DFA identified EGF, IFN-alpha, VEGF, CCL3 (MIP-1alpha) and IL-12p40 as analytes with the strongest discriminatory power among various PsA patients and controls.

CONCLUSIONS

Our findings suggest that these factors modulate PsA pathology and the articular involvement in a synergistic manner. Identifying factors could be used in the development of clinical diagnostic tests, which are valuable to guide evidence-based diagnosis and disease management of PsA.

Synovial inflammation in active rheumatoid arthritis and psoriatic arthritis facilitates trapping of a variety of oral bacterial DNAs

OBJECTIVE

To investigate the presence of oral bacterial DNAs in serum and synovial fluid (SF) of patients with active rheumatoid arthritis (RA) and psoriatic arthritis (PsA).

METHODS

Serum and SF samples from 16 RA patients, 14 PsA patients, and 9 osteoarthritis (controls) patients were extracted for oral bacterial DNA. This was used in a checkerboard DNA-DNA-hybridization set up, to identify 40 different bacteria.

RESULTS

Mean number +/- standard deviation (SD) of oral bacterial species in sera were 6.2 (3.2) in the RA group (p = 0.004) and 5.4 (2.7) in the PsA group (p = 0.009) compared to 2.1 (1.7) in the controls. Periodontitis associated species Porphyromonas gingivalis and Prevotella nigrescens were exclusively detected in RA and PsA. Mean number (+/- SD) of oral bacterial species in SF were 14.0 (6.8) in the RA (p = 0.001) and 19.4 (7.1) in the PsA group (p < 0.001) compared to 4.0 (1.7) in controls. P. gingivalis, Tannerella forsythensis and Prevotella intermedia were exclusively identified in RA and PsA SF. Higher means of DNAs were found in RA SF compared to RA serum (p < 0.001), and in PsA SF compared to PsA serum (p < 0.001). Higher concentrations of bacterial DNAs were found in RA and PsA compared to controls.

CONCLUSION

Higher variety and concentrations of oral bacterial DNAs were found in SF compared to serum of RA and PsA patients. These findings indicate that synovial inflammation in RA and PsA may favor trapping of oral bacterial DNAs, suggesting a perpetuating effect of oral pathogens in joint disease.

Salivary gland and temporomandibular joint involvement in rheumatoid arthritis: relation to disease activity

OBJECTIVES

To study temporomandibular joint (TMJ) involvement, salivary gland dysfunction and oral mucosal lesions in rheumatoid arthritis (RA), and to investigate the relationship to general disease activity.

SUBJECTS AND METHODS

The TMJ dysfunction index (D(i)), mean salivary flow and disease activity score (DAS28), were calculated for 50 RA-patients, and 23 non-RA patients (controls).

RESULTS

Median D(i) was 5.5 (range: 0-21) for the RA-patients compared with 2.0 (range: 0-9) for the controls (P < 0.0001). Pain on movement of the TMJ (P = 0.015), muscular pain (P = 0.006), TMJ pain (P = 0.019) and D(i) as a total (P = 0.009), significantly correlated with DAS28. Mean resting whole saliva (RWS) flow was 2.6 (s.d. 2.4) ml per 15 min for the RA-patients and 4.5 (s.d. 3.0) for the controls (P = 0.003). RWS correlated positively with haemoglobin (P = 0.021) and negatively with Westergren erythrocyte sedimentation rate (ESR) (P = 0.029). No major differences in frequency of oral mucosal lesions were seen between RA-patients and controls.

CONCLUSIONS

Higher frequency of TMJ and salivary gland dysfunction in RA-patients compared with controls has been demonstrated. RA disease activity is associated with hyposalivation and TMJ dysfunction.

Reduced joint pain after short-term duodenal administration of seal oil in patients with inflammatory bowel disease: comparison with soy oil

BACKGROUND

Rheumatic joint pain is a common extra-intestinal complication of inflammatory bowel disease (IBD). Because the high ratio of n-6 to n-3 fatty acids (FAs) of the Western diet might promote rheumatic disorders, we sought to compare the effects of short-term duodenal administration of n-3-rich seal oil and n-6-rich soy oil on IBD-related joint pain.

METHODS

Nineteen patients with IBD-related joint pain were included in the study; 9 had Crohn disease and 10 had ulcerative colitis. Ten millilitres seal oil (n = 10) or soy oil (n = 9) was self-administered through a nasoduodenal feeding tube 3 times daily for 10 days.

RESULTS

Compared with soy oil treatment, seal oil significantly reduced the duration of morning stiffness (P = 0.024), number of tender joints (P = 0.035), intensity of pain (P = 0.025) and the doctor's scoring of rheumatic disease activity (P = 0.025) at the end of the 10-day treatment period. Analysis of the effects as area under the curve (area between the curve and baseline, zero) for the entire period from start of treatment until 6 months' post-treatment suggested a long-lasting beneficial effect of seal oil administration on joint pain, whereas soy oil tended (not significantly) to aggravate the condition. Consistently, the serum ratios of n-6 to n-3 FAs (P < 0.01) and arachidonic acid to eicosapentaenoic acid (P < 0.01) were reduced after treatment with seal oil.

CONCLUSION

The results suggest distinctive, differential prolonged effects on IBD-related joint pain of short-term duodenal administration of n-3-rich seal oil (significant improvement) and n-6-rich soy oil (tendency to exacerbation).

Circulating cytokines in primary Sjögren's syndrome determined by a multiplex cytokine array system

Plasma cytokines play an important role in the pathogenesis of Sjögren's syndrome (SS) by initiating and perpetuating various cellular and humoural autoimmune processes. The aim of the present study was to describe a broad spectrum of T-cell and B-cell cytokines, growth factors, chemokines and molecules that could contribute to cell death in SS. A novel protein array system was utilized to measure simultaneously the levels of 25 plasma cytokines of patients with primary SS and healthy individuals. Furthermore, we correlated these plasma cytokine levels with potential laboratory and clinical parameters related to disease activity in SS. A subset of plasma cytokines [e.g. interleukin-1beta (IL-1beta), IL-6, CXCL8 (IL-8), IL-12 p40, IL-15, tumour necrosis factor-alpha (TNF-alpha), epidermal growth factor, CCL4 (MIP-1beta), CCL2 (MCP-1), CCL11 (Eotaxin), CCL5 (RANTES), TNF-RI and TNF-RII] was found to significantly differ between patients and controls. Also, distinct populations of cytokines were found to differentiate between patients with normal versus elevated ESR or IgG levels and patients with the presence or absence of extra-glandular manifestations (EGMs). Our results support the assumption that the multiplex cytokine array system can be successfully utilized in the diagnosis and disease management of SS. Furthermore, it may provide a powerful tool in the design of individualized anticytokine therapies.

Sjögren's syndrome in an out-patient clinic: classification of patients according to the preliminary European criteria and the proposed modified European criteria

OBJECTIVES

To investigate whether out-patients with a clinical diagnosis of Sjögren's syndrome (SS) satisfied current preliminary European criteria for SS, and to determine the proportion of patients who satisfied the proposed modified European criteria for SS and thus had indication of an autoimmune process.

METHODS

Out-patients with a clinical diagnosis of SS registered between 1 January 1999 and 1 November 2000 were included in the study.

RESULTS

Of 203 patients with a clinical diagnosis of SS, 116 (57.1%) satisfied the current European criteria and 83 (40.9%) satisfied the proposed modified criteria.

CONCLUSIONS

Sicca symptoms and signs may have a variety of causes. In our study only 40.9% of the patients with a clinical diagnosis of SS satisfied the proposed modified European criteria and had evidence of SS as an autoimmune condition. Our findings indicate that for patient populations with an established diagnosis of SS according to the preliminary European criteria, approximately one-third will lose the diagnosis according to the modified criteria.

Complement activation in patients with systemic lupus erythematosus without nephritis

OBJECTIVE

To study the association between disease activity and complement activation prospectively in patients with systemic lupus erythematosus (SLE).

PATIENTS AND METHODS

Twenty-one SLE patients were examined monthly for 1 yr. Disease activity, autoantibodies, conventional complement tests and the following complement activation products were investigated: C1rs-C1inh complexes, C4bc, Bb, C3a, C3bc, C5a and the terminal SC5b-9 complement complex (TCC).

RESULTS

Modest variation in disease activity was noted. None of the patients had nephritis. Flare was observed at 27 visits. Four patients had anti-C1q antibodies in conjunction with modestly low C1q concentrations. The complement parameters were rather constant during the observation period. Slightly to moderately decreased C4 (0.05-0.10 g/l) was found in 10 patients and severely decreased C4 (<0.05 g/l) in seven patients. Decreased C4 was not associated with increased complement activation. Complement activation products were either normal or slightly elevated. TCC was the only activation product correlating significantly with score for disease activity at flare. None of the variables tested predicted flares.

CONCLUSION

Complement tests are of limited importance in routine examination of SLE without nephritis, although TCC is suggested to be one of the most sensitive markers for disease activity.

Seasonal variations in activity of systemic lupus erythematosus in a subarctic region

Photosensitivity is one of the major clinical features of Systemic Lupus Erythematosus (SLE), and is considered to be implicated in the disease pathogenesis. We studied seasonal variations of SLE disease activity at latitude 70 degrees North where there is no sunlight in the winter time, in contrast to 24 h daily sunlight in the summer (midnight sun). The associations between the level of plasma melatonin in June and December with disease manifestations were also studied. Twenty-one SLE patients were examined each month for 1 y, and disease activity was assessed by laboratory parameters as well as clinical disease activity parameters SLEDAI and doctor's global assessment. Melatonin levels were quantified by a RIA-assay. There was no significant change of clinical measures or laboratory parameters of disease activity from one month to the next during the one year, except photosensitive rashes. January was the only month without SLE-flares or arthritis, in contrast to rest of the year. The levels of plasma melatonin were highest in December for seven patients and highest in June for one patient (P < 0.005). Plasma melatonin levels did not correlate with measures of clinical disease activity. At a latitude of 70 degrees North there were no major seasonal variations in SLE disease activity during the one year. There was an accumulation of photosensitivity in the summer months, but no indications of worsening of the disease in the winter months. In contrast to the rest of the year, there was no flare in January which had only 5.6 h of sunshine. The level of p-melatonin did not correlate with measures of disease activity.

Immunohistochemical characterization of the cellular infiltrates in Sjögren's syndrome, rheumatoid arthritis and osteoarthritis with special reference to calprotectin-producing cells

The aim of this study was to analyse the nature of infiltrating cells in minor salivary glands of patients with Sjögren's syndrome (SS). Furthermore, we wanted to characterize the tissue distribution of calprotectin-producing cells in inflamed salivary gland tissue of SS and in synovial tissue of patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Cryostat sections of labial salivary gland tissue from patients with SS and synovial tissue from RA and OA patients were stained (ABC-immunoperoxidase technique) using monoclonal antibodies (MoAbs) to T cells (CD3), monocytes/macrophages (CD14, CD68), and calprotectin. Monocytes and macrophages were widely distributed in focal infiltrates of salivary gland tissue from SS patients. Calprotectin markers showed a distinct staining of infiltrating macrophages and around blood vessel walls. In synovial tissue samples, calprotectin was expressed in a high percentage of cells in the synovial lining, the subsynovium, and vessel walls. The percentages of cells stained for calprotectin were significantly higher in RA than in OA and SS tissues. Antibodies to the calprotectin complex stained cells with a similar distribution as antibodies against the separate polypeptide chains of calprotectin. The localization and differentiated expression of calprotectin in these chronic inflammatory conditions indicate a role in the inflammatory process and may be an additional marker of macrophages/granulocytes in SS, RA and OA.

Pristane-induced arthritis in rats: a new model for rheumatoid arthritis with a chronic disease course influenced by both major histocompatibility complex and non-major histocompatibility complex genes

We present a novel animal model for rheumatoid arthritis induced with a well defined synthetic adjuvant oil, pristane. Two weeks after a single intradermal injection of 150 microliters of pristane, the rats developed severe and chronic arthritis. The inflammation was restricted to the joints and involved pannus formation, major histocompatibility complex (MHC) class II expression, and T lymphocyte infiltration. The initial development as well as the chronic stage of pristane-induced arthritis was ameliorated by treatment with antibodies to the alpha beta-T-cell receptor showing that the disease is T cell dependent. Increased levels of interleukin in serum was seen after pristane injection but not during the chronic stage of arthritis. Joint erosions were accompanied by elevated serum levels of cartilage oligomeric matrix protein. Comparison of MHC congenic LEW strains showed that the severity and chronicity of arthritis varied among the different MHC haplotypes. Rats with RT1f haplotype showed a significantly higher susceptibility to pristane-induced arthritis. A strong influence of non-MHC genes was also suggested by the variability of arthritis susceptibility among different strains with the same MHC haplotype; the most susceptible background was the DA and the least susceptible was the E3. Arthritis induced with a well defined nonimmunogenic adjuvant, with a disease course that closely resembles that of rheumatoid arthritis, makes a suitable animal model for future studies of the pathology and genetics of rheumatoid arthritis.

Breast feeding, other reproductive factors and rheumatoid arthritis. A prospective study

The evidence regarding reproductive events as risk factors for rheumatoid arthritis (RA) is not conclusive. In the present study a population-based cohort consisting of 63,090 women were followed from 1961 to 1989. Detailed data on reproductive factors were collected through personal interviews in the period 1956-9. The endpoint used was mention of RA on the death certificate. Mortality rate ratios were estimated by Poisson regression, controlling for various demographic variables. During 1,485,400 person-yr of observation, a total of 355 cases with RA mentioned on the death certificate were identified. Total time of lactation was associated with a decreased mortality of RA, with an approximate dose-response relationship. The results did not support a role of parity, age at first and last birth, or age at menarche and menopause in the development of RA. This protective effect of lactation on the development of RA has not previously been described, and since a definite biological explanation is lacking, the association should be confirmed in other populations.

Effects of calprotectin in avridine-induced arthritis

Plasma levels of calprotectin correlate with disease activity and clinical assessments of arthritis in various rheumatic diseases, and high levels have been demonstrated in the synovial fluid of patients with rheumatoid arthritis. However, the role of calprotectin in rheumatic inflammation is unclear. The purpose of the present study was to investigate potential intra-articular effects of calprotectin. Calprotectin was injected into joints of healthy male Lewis rats and into joints of rats in the latency period before onset of avridine-induced arthritis. In addition, a group of animals had IgG antibodies to rat calprotectin injected into joints before onset of avridine-induced arthritis. Injection of 0.2 or 10 micrograms calprotectin into the ankles of healthy male Lewis rats resulted in histologically minor and reversible inflammatory changes, but without any circulating antibodies to calprotectin. Furthermore, animals with 40 micrograms calprotectin injected into ankles before the expected onset of avridine-induced arthritis had lower scores for cellular infiltration than were seen in control joints. This difference did not quite reach statistical significance in the two-sided test used. However, the induced arthritis increased in joints injected with IgG antibodies to calprotectin. These findings may indicate that increased local concentrations of calprotectin are partially protective against avridine-induced arthritis. In contrast, reduced local concentrations appear to exacerbate the severity of arthritis. Calprotectin may thus be involved in the regulation of inflammatory processes in joints.

Calprotectin levels in oral fluids: the importance of collection site

Calprotectin is a major protein of granulocytes and monocytes with antimicrobial properties, and is released during activation or cell death. In the present study the levels of calprotectin in various oral fluids were analyzed in 12 healthy adults using different collection devices. Parotid saliva, stimulated whole saliva and "mucosal transudate" were collected and analyzed by enzyme-linked immunosorbent assay (ELISA). The results showed mean concentrations of 3.2, 22.0 and 40.9 mg/l in the respective oral fluids, illustrating great variation of calprotectin levels between different oral fluids. The results are in accordance with the composition of these saliva samples; the lowest calprotectin level was obtained in parotid saliva, which contains the purest secretion. These findings illustrate the importance of careful sampling procedures. The levels of salivary calprotectin are markedly influenced by the site of collection.

Effects of human calprotectin (L1) on in vitro immunoglobulin synthesis

Calprotectin (L1) is a major cytoplasmic protein of neutrophilic granulocytes and monocytes/macrophages which is released from leucocytes during activation or cell death. Apart from in vitro antimicrobial and antiproliferative activity little is known about the biological function of the protein. Since previous investigations have shown that calprotectin plasma levels are elevated in various inflammatory rheumatic diseases, we wanted to investigate if calprotectin has an effect on immune cell functions. Peripheral blood mononuclear cells, either unstimulated or polyclonally stimulated with mitogen, were incubated with calprotectin and effects were assessed by enumeration of immunoglobulin secreting cells (ELISPOT). The results indicate that incubation with high concentrations of calprotectin (> 64 micrograms/ml) inhibit the production of the three classes of immunoglobulins investigated (IgG, IgM and IgA), both for mitogen stimulated and unstimulated lymphocytes. Except for the highest concentration of calprotectin (500 micrograms/ml), it seems plausible that the observed inhibitory effect of calprotectin on Ig production is not a result of a direct toxic effect of calprotection on B lymphocytes. Altogether, these effects of high calprotectin levels might be of importance in the immunoregulation of inflammatory conditions.

Use of a sicca symptoms questionnaire for the identification of patients with Sjögren's syndrome in a heterogeneous hospital population with various rheumatic diseases

OBJECTIVE

A six-item questionnaire regarding sicca symptoms recently validated for primary Sjögren's syndrome (SS) was tested on 154 in-patients with a wide range of inflammatory rheumatic diseases. Patients with one or more positive responses underwent objective ocular and oral diagnostic procedures. Of 27 patients thus investigated, 19 could be classified as having SS.

RESULTS

The positive answers obtained were mainly in response to 4 of the 6 questions: dry eyes, sensation of sand or gravel in the eyes, dry mouth, and drinking of liquids to aid in swallowing dry foods. Among the 19 patients found with SS, most had had earlier diagnoses of various connective tissue diseases (rheumatoid arthritis included) and most were female.

CONCLUSION

In conclusion, this study indicates that the sicca symptom questionnaire may be useful when deciding which patients with inflammatory rheumatic diseases should be subjected to special investigations with regard to SS.

Measurement of plasma calprotectin as an indicator of arthritis and disease activity in patients with inflammatory rheumatic diseases

OBJECTIVE

To investigate if the plasma level of the granulocyte protein calprotectin is a useful indicator of severity of arthritis in patients with inflammatory rheumatic diseases, and to analyze which factors contribute to the raised plasma calprotectin levels.

METHODS

Plasma calprotectin levels were measured by ELISA: In a cross sectional study of 154 patients with various inflammatory rheumatic diseases, calprotectin levels were correlated with laboratory and clinical variables.

RESULTS

The plasma levels of calprotectin and C-reactive protein (CRP) correlated significantly with the clinical evaluation of swollen joints (r = 0.51, p < or = 0.01 and r = 0.29, p < or = 0.01, respectively). Calprotectin levels, but not CRP levels or erythrocyte sedimentation rate, were significantly lower in patients with no swollen joints than in patients with one or more swollen joints (2613.6 micrograms/l vs 6287.0 micrograms/l, p < 0.001). A significant correlation between calprotectin and number of neutrophils was demonstrated (r = 0.43, p < or = 0.01), indicating that circulating neutrophils contribute to plasma calprotectin levels.

CONCLUSION

The plasma calprotectin level may be a useful indicator of arthritis in inflammatory rheumatic diseases.

Sjögren's syndrome in inflammatory rheumatic diseases: analysis of the leukocyte protein calprotectin in plasma and saliva

In a hospital population of 154 patients with a wide range of inflammatory rheumatic diseases, patients with sicca symptoms were subjected to objective ocular and oral tests to establish cases with Sjögren's syndrome (SS). The plasma level of the leukocyte protein calprotectin has been shown to be a good indicator of disease activity and inflammation in various rheumatic diseases. In the present study, calprotectin levels in plasma and whole saliva were analysed and evaluated as potential markers of SS and salivary gland disease activity. Plasma calprotectin levels did not differ significantly between patients with SS and patients with no sicca symptoms. However, salivary calprotectin levels correlated significantly with the plasma calprotectin levels and with several ocular variables, weakly with salivary flow and serum rheumatoid factor, but not with focal sialadenitis. In conclusion, this study shows that salivary calprotectin levels seem to be associated with several variables of SS glandular pathology, indicating the need for further and more comprehensive studies on calprotectin in various oral fluids and in lacrimal fluid in relation to SS glandular disease activity.

Calprotectin in patients with systemic lupus erythematosus: relation to clinical and laboratory parameters of disease activity

Calprotectin (L1) is a granulocyte and monocyte cytosolic protein released during activation of these cells. The plasma level of L1 has been shown to be a good marker of disease activity in rheumatoid arthritis. In this cross-sectional study of 100 patients with systemic lupus erythematosus (SLE), the serum level of L1 was found to be higher in patients than in matched controls (3661 micrograms/l versus 1051 micrograms/l; P < 0.001). The serum level of L1 was the only laboratory parameter with significant association to the disease activity index SLEDAI (r = 0.28; P < 0.01). Furthermore, the serum level of L1 was significantly higher in SLE patients with anti-DNA antibodies compared to patients without anti-DNA antibodies (4501 micrograms/l versus 3279 micrograms/l; P = 0.01). SLE patients with arthritis had higher serum levels of L1 than patients without arthritis (7652 micrograms/l versus 2811 micrograms/l; P < 0.01), indicating that the serum level of L1 also reflects arthritis activity in SLE.

Calprotectin in patients with rheumatoid arthritis: relation to clinical and laboratory variables of disease activity

Calprotectin (L1) is a major granulocyte and monocyte protein which is released during activation of these cells. The plasma level of L1 is thought to reflect disease activity in rheumatoid arthritis (RA). In our cross sectional study of 70 patients with RA, L1 had significant correlations with erythrocyte sedimentation rate (r = 0.50), C-reactive protein (r = 0.58), orosomucoid (r = 0.62), platelet count (r = 0.42), leukocyte count (r = 0.33) and IgM rheumatoid factor (r = 0.32); and with the following clinical variables: number of swollen joints (r = 0.24), grip strength (r = -0.22), PIP joint circumferences (r = 0.33) and a combined global assessment score (r = 0.24). L1 was higher in seropositive (median 14,861 micrograms/l) than seronegative patients (median 10,487 micrograms/l) (p less than 0.03).

Morning stiffness and nightime pain in ankylosing spondylitis. A comparison between enteric-coated and plain naproxen tablets

Thirty-nine patients with ankylosing spondylitis participated in a randomized, double-blind, double-dummy, multi-cross-over study with enteric-coated (ECT) and plain (PT) naproxen tablets. The duration of the study was 24 days with 6 treatment periods of 4 days. The majority of the patients were taking 750 mg naproxen daily. The mean plasma concentration of naproxen in the morning was 36% higher with ECT (p < 0.001). No significant differences regarding duration of morning stiffness and night time pain were found in this patient category. The mean duration of morning stiffness was 116 minutes (ECT) and 125 minutes (PT). We were not able to show correlation between plasma concentration of naproxen and duration of morning stiffness.

[Low back pain and instability of the pelvic ring]

Low back pain is a major cause of disability, and a large percentage of patients with low back pain have no identifiable pathology. In this review of the literature low back pain is considered from the point of view of dysfunction of the pelvic joints. The reliability of the commonly used tests, signs and procedures are considered. Inflammatory causes such as ankylosing spondylitis are well documented to cause low back pain, but mechanical factors apart from intervertebral disc protrusion are largely speculative.

[An original method of making a purse for circular mechanical anastomoses]

A simple and reliable procedure applicable to all segments of the digestive tract, except the oesophagus, is described. A series of superficial U-shaped stitches is inserted along the upper edge of a Kocher's forceps that clamps the entire width of the intestine. The intestine is then cut with a scalpel along the lower edge of the forceps, i.e. on the side opposite to the sutures. After the forceps is released, a purse about 2 mm distant from the intestinal opening is obtained. When the purse is tightened the mucosa, crushed by clamping, does not protrude and therefore does not interfere with the mechanical anastomosis.

[Fibrovascular polyp of the esophagus]

A case of large intraluminal tumour located in the cervical portion of the oesophagus and removed by thoracotomy is presented. Detailed histological study was necessary, since hypervascularization and hypercellularity made it difficult to diagnose a fibrovascular polyp and to establish its histopathological prognosis. The patient has now been followed up for 7 years and remains cured. Intraluminal tumours are reviewed. Whether fibrovascular polyps should be removed surgically or endoscopically depends on their site and on their size.

Blunt thorax oesophageal stripping: an emergency procedure for caustic ingestion

We report our experience with an original procedure which we have applied to the management of acute necrotic caustic burns of the upper gastro-intestinal tract. Blunt thorax oesophageal stripping is performed through a cervicotomy and a laparotomy, thus avoiding a wide pleural exposure and the frequent and often fatal respiratory complications of a thoracotomy. The stripping method permitted survival of 13 of 17 patients and is thus considered to be a safer and more successful technique than open thoracic oesophagectomy.

[Associated compression of the celiac trunk, superior mesenteric artery and aorta by the arcuate ligament of the diaphragm]

Simultaneous compression of the coeliac axis, superior mesenteric artery and aorta by the arcuate ligament of the diaphragm is a very rare condition. The pathogenesis of the abdominal pain observed is debatable, but the simplicity and effectiveness of vascular release fully justify surgery in such cases.

[Parathyroid adenoma disclosed by a massive subcapsular hemorrhage]

In the case reported here a parathyroid gland adenoma was revealed by the sudden occurrence of a large subcapsular haematoma compressing cervical structures and causing recurrent nerve paralysis; spontaneously regressive hypercalcaemia was present. The place of these haemorrhages among other manifestations of a hitherto silent parathyroid gland adenoma is discussed, together with the diagnostic value of thyroid gland scintigraphy and cervical ultrasonography. In view of their potentially somber prognosis, emergency surgery is mandatory in such cases.

[Colectomy by combined resection-anastomosis using linear mechanical sutures]

In the technique described, anastomosis is started with a GIA mechanical stapler then completed with a TA stapler followed by resection of the segment involved. We prefer this technique to other mechanical procedures (triangulation, circular anastomosis) in all colectomies which do not require lower colorectal anastomosis. It is simple, economical and solves problems of incongruence. Finally--and this is the most important point in surgery of the colon--it considerably shortens the septic operative stages.

Urolithiasis in children. Presenting signs, etiology, bacteriology and localisation

Based on a personal series of 310 observations, the authors have studied the presenting signs, the etiology, the urinary bacteriology and the localization of the stone in children with urolithiasis. Urinary tract infection is the presenting sign in 55% of the cases, hematuria in 23% and abdominal pain in 20%. Urinary malformation is associated in 26% of cases, whatever the age at diagnosis. The urinary bacteria found in 55% of cases is Proteus. Localization was in the kidney in 228 cases, in the ureter in 71 cases, the bladder in 45 cases and in the urethra in 5 cases.

[Multiple lesions in primary hyperparathyroidism. Nosologic approach]

Surgical exploration identified 40 patients with several enlarged parathyroid glands (two to five) out of a retrospective series of 500 cases of primary hyperthyroidism. Complete clinicopathological correlations were available in 27 cases (19 women and 8 men). Seven patients had a history of Wermer's syndrome (type I, MEN). Final diagnosis was as follows: double adenomas, 11 cases; primary hyperplasia, 16 cases. In two cases, there was a clear-cell hyperplasia, 16 cases. In two cases, there was a clear-cell hyperplasia with massive involvement of four parathyroid glands. The fourteen other cases presented with predominantly chief-cell hyper plasia; the involvement of the parathyroid glands was frequently asymmetrical, mainly or exclusively confined to two enlarged glands in 9 cases. The authors conclude that when a patient presents with two enlarged parathyroid glands, two diagnoses are possible--double adenoma or asymmetrical hyperplasia. Since anatomical study of the two enlarged glands is not always sufficient for accurate classification of the lesions, it is advisable to make a histological examination of a third.

[Total gastrectomy. Primary esophagojejunal anastomosis, the organ in place, using linear mechanical suture staplers]

In "mechanical" surgery, continuity of the digestive tract may be re-established with either circular (E.E.A. - I.L.S.) or linear stapled anastomosis (G.I.A. - T.A.). For oesophago-jejunal anastomosis, the authors prefer the second method which provides wider anastomosis without the risk of stenosis attached to circular sutures. The stomach is kept for traction, thus facilitating the procedure, which can be performed through the abdominal incision.

[Massive retroperitoneal hematoma caused by rupture of the kidney, secondary to cortical abscess]

A massive retroperitoneal hemorrhage found to be due to a renal abscess in a previously healthy kidney was treated successfully by nephrectomy. This type of lesion occurs fairly infrequently, but it is quite exceptional to observe presenting signs as in the case reported, and recovery is not mentioned in the published literature. Therapy for renal abscess involves either urgent nephrectomy in cases of associated hemorrhagic or septic shock, or medical treatment under close supervision in the absence of major signs of severity, which may, however, develop at any moment making surgery inevitable.

[Caustic digestive stenosis involving the hypopharynx. Esophagopharyngoplasty using a right ileocolic graft]

The authors describe an oesophago-laryngoplastic technique using a retrosternal ileocolic graft and involving anterior pharyngotomy above the hyoid bone. The technique was applied to five cases of major destructive lesions of the hypopharynx with fibrotic stenosis, due to severe burns of the upper digestive tract by ingestion of caustic substances. Continuity between the oral cavity and the digestive tract was re-established in all cases.

[High ectopia of a parathyroid adenomas of the "parathymus". 2 cases]

The third brachial pouch gives rise to the thymus and antero-inferior part of the parathyroid gland (P3). A P3 gland can develop in any region of the migration pathway of the thymus from the angle of the jaw to the pericardium. Rare high ectopia of a parathyroid adenoma of the "parathymus" was detected in two patients during repeat operations for primary hyperparathyroidism.