Self-reported food intolerance and mucosal reactivity after rectal food protein challenge in patients with rheumatoid arthritis

OBJECTIVES

A dietary link to rheumatoid arthritis (RA) has been suspected and an influence on arthritic symptoms by different diets has been reported. Our primary aim was to record the self-experienced adverse food reactions in patients with RA. A secondary aim was to relate self-experienced adverse reactions to dairy produce and wheat to the local mucosal reactivity observed after rectal challenge with cow's milk protein (CM) and wheat gluten.

METHODS

A questionnaire about self-experienced adverse reaction to food was sent to 347 RA patients. Rectal challenge with CM and gluten was performed in 27 of these patients and in healthy controls (n = 18). After a 15-h challenge the mucosal production of nitric oxide (NO) and the mucosal release of myeloperoxidase (MPO) and eosinophil cationic protein (ECP) were measured by using the mucosal patch technique.

RESULTS

Twenty-seven per cent of the RA patients reported food intolerance (FI) to various foods, and in particular to CM, meat, and wheat gluten. Strong mucosal reactivity to CM was observed in 11% of the patients. Moderately increased mucosal reactivity to CM and gluten was found in 22% and 33%, respectively, of the patients. No relationship was found between self-experienced adverse reactions to CM or gluten and mucosal reactivity to these proteins.

CONCLUSIONS

Perceived FI is reported frequently by RA patients, with a prevalence similar to that reported previously in the general population. Mucosal reactivity to CM and gluten is seen in a minor fraction of RA patients and is not related to the frequently perceived intolerance to these proteins.

Increased total serum IgE in alcoholics

Total serum IgE concentrations were measured in 106 male alcoholics with current alcohol abstinence of varying duration. The influence of smoking habits and clinical atopy on IgE levels was considered. The majority (91%) of the alcoholics were smokers and 26% suffered from possible clinical atopy. The geometric mean IgE in non-atopic, smoking alcoholics was 42 kU/l and significantly higher than the mean IgE level, 19 kU/l, in age-matched, smoking, non-atopic male participants in a general health survey (p less than 0.001). The IgE levels declined with the length of the alcohol abstinence period. Alcoholics, serially followed after a heavy drinking spree, showed a uniform pattern of declining IgE levels during a fortnight of abstinence (p less than 0.001). No link was noted between total IgE levels and the extent of liver affection as estimated by various serum variables (bilirubin, aminotransferases, gamma-GT, IgG, IgA and IgM) or galactose tolerance test. The increased IgE levels in alcoholics are suggested to reflect an influence of ethanol on T lymphocytes regulating the IgE synthesis. Such a proposed effect of ethanol on cellular immunity may contribute to certain organic alcohol diseases, but does not appear to influence the frequency of clinical atopy, being similar in our patient group and in the general population of the same geographic area.

Ethanol reduces myoglobin release during isokinetic muscle exercise

Changes in serum myoglobin concentrations were studied in 12 healthy males performing a standardized isokinetic 2-min exercise test. The test was performed on three separate occasions: in the habitual state, during moderate ethanol intoxication and one day after ethanol intake. Although the performed muscle work, maximal heart rate, and blood lactate levels did not differ between the three test occasions, the serum myoglobin increments after exercise were significantly reduced (p less than 0.05) in the ethanol-intoxicated state and also 10-15 hours after ethanol intake. The reduction of the exercise-induced myoglobin increment was not explained by increased elimination of the protein. The mechanism, therefore, is likely to be a reduction of myoglobin release from skeletal muscle due to an ethanol-induced alteration of the muscle cell membrane, possibly by means of adenylate cyclase activation.

Smoking and circulating IgE in bronchial carcinoma

The serum concentrations of total IgE were significantly raised in smokers compared to those who had never smoked (p less than 0.005) among male patients with bronchial carcinoma, while no differences were found between smoking and non-smoking female bronchial carcinoma patients. The total IgE levels in male and female patients with non-malignant pulmonary diseases were not correlated to smoking habits. No significant differences in the IgE levels were observed between smoking males subgrouped according to the WHO histological types of bronchial carcinoma. Males with carcinoma who had stopped smoking more than 10 years ago had significantly reduced IgE levels compared to male cancer patients continuously smoking (p less than 0.01). These data, indicating that smoking is associated with elevated IgE levels in males with bronchial carcinoma, might suggest that smoking in certain, preferably male, individuals induces an impaired cellular immunity which is reflected by an enhanced IgE synthesis and a depressed resistance to carcinogens of tobacco smoke.

Serum ferritin in alcoholics and the relation to liver damage, iron state and erythropoietic activity

Serum ferritin was measured in two groups of alcoholics; one comprised 71 individuals on ambulatory control and with varying current alcohol intake and the other 19 alcoholics followed with serial determinations during two weeks of abstinence Serum ferritin was elevated in 26 subjects in the larger group, and 22 of them had elevated ASAT and ALAT values. Low-grade but significant correlations were found between serum levels of ferritin and serum concentrations of some variables used to detect liver affection (ASAT, ALAT, bilirubin and gamma-GT). Serum ferritin and ASAT declined in a parallel fashion in the 19 patients studied longitudinally, so that the ferritin:ASAT ratio described a straight line. No correlation was found between serum ferritin or the serum ferritin:ASAT ratio and serum iron. Neither was any correlation observed between the magnitude of the changes in serum ferritin and the changes in serum iron, serum transferrin or circulating platelets or reticulocytes observed in the serially followed alcoholics. These data indicate that elevated serum ferritin in alcoholics is associated with the degree of liver affection and not with the degree of erythropoietic activity.

Indices of inflammatory cell activity and pulmonary function in different stages of sarcoidosis

The present study was carried out to compare radiological and physiological changes in sarcoidosis with biochemical markers for inflammatory cell populations. Of 53 patients with sarcoidosis, 28 had respiratory symptoms and 30 past or present bilateral hilar adenopathy without symptoms. A clinical score based on lung function tests and radiological findings correlated well with elevations of lysozyme and beta2-microglobulin in serum, indicating increased inflammatory cell activity in patients with more severe lung affection. A covariation between beta2-microglobulin and lysozyme was found, suggesting concomitant activation of macrophages and lymphocytes in sarcoidosis. Serum levels of lactoferrin were elevated in patients with a disease of short duration but did not correlate with the severity of the lung affection. The closing volume also seems to be abnormal in the early course of the disease, while elevated lysozyme and beta2-microglobulin levels rather seem to reflect the extent of the pulmonary affection.

Serum and urinary myoglobin in alcoholics

The serum levels of myoglobin were measured in 106 male alcoholics. Subnormal levels were found in 31% of the alcoholics with no alcohol consumption for the last 2--4 weeks, while none of them had elevated levels. Of the alcoholics on ambulatory control and with varying current alcohol intake. 18% had increased levels compared to healthy controls. Serial myoglobin levels were determined in 19 patients following the cessation of heavy drinking sprees. Despite the fact that none of the patients had clinical evidence of acute myopathy, marked myoglobin elevations were noted in five patients; their serum levels gradually declined and normalized with 4--7 days. Comparing the three groups, similar frequencies of subnormal or elevated serum CK levels were observed. Myoglobin levels were not raised due to impaired glomerular filtration rates. No correlation was found between serum myoglobin and laboratory signs of liver affection. Although hypophosphatemia, hypomagnesemia and hypokalemia were occasionally noted, decreased serum electrolytes did not have any relation to elevated serum myoglobin. A transient, slightly increased urinary excretion of myoglobin parallel with increased excretion of beta 2-microglobulin was observed in 2/17 alcoholics, suggesting that instances of myoglobinuria in alcoholics with heavy recent drinking may be due to a transient minor tubular dysfunction.

Glucose intolerance in patients with chronic inflammatory diseases is normalized by glucocorticoids

Nine of 16 patients with inflammatory connective tissue diseases (rheumatoid arthritis, polymyalgia rheumatica, scleroderma and mixed connective tissue disease) had glucose intolerance defined a a K-rate less than one but a normal early insulin response to intravenous glucose loading. The degree of the impaired glucose handling was related to the degree of inflammatory activity as defined by acute phase reactants. Glucocorticoid therapy induced within three days an improved and normalized glucose tolerance and an augmented early insulin response (p less than 0.001). The glucocorticoid effect was still present up to six months of ongoing therapy. It is suggested that glucose intolerance in chronic inflammation is a consequence of a peripheral insulin antagonism and an inhibition of insulin secretion. This inhibition may be mediated directly or indirectly by inflammatory cell products and may be sensitive to glucocorticoids.

Serum ferritin during inflammation. A study on myocardial infarction

The ferritin level in serum was investigated in 9 patients with myocardial infarction, all with a history of chest pain of less than 4 hours before admission. A significant rise in serum ferritin level was found in 8 patients. The rise was generally smaller than that seen in acute infection and not significantly correlated to the size of infarction, as estimated from changes in serum levels of myoglobin, ASAT and LDH. The rise started after a mean of 30 hours, the peak being reached within a week (M 4.3 days). Serum ferritin then fell to 120--300% (M 190) of the initial level, where it remained. An initial rise in serum iron levels was unexpectedly seen within 12 hours in 7 patients.

Cow's milk protein sensitivity assessed by the mucosal patch technique is related to irritable bowel syndrome in patients with primary Sjögren's syndrome

Introduction

Patients with primary Sjögren's syndrome (pSS) are reported to have a variety of gastrointestinal symptoms partly attributed to an overrepresentation of celiac disease. We have observed that irritable bowel syndrome (IBS)-like symptoms are frequent complaints in this patient group. Allergic manifestations to various drugs are also common in pSS. A role of food allergy in IBS has been proposed.

Objective

This study is aimed at evaluating the mucosal response to rectal challenge with cow's milk protein (CM) in patients with pSS and relates possible CM reactivity to their intestinal symptoms.

Methods

A rectal challenge with CM was performed in 21 patients with pSS and 18 healthy controls. Fifteen hours after challenge the mucosal production of nitric oxide (NO) and the release of myeloperoxidase (MPO) as signs of mucosal inflammatory reaction were measured using the mucosal patch technique.

Results

Eight out of 21 patients with pSS had a definite increase of mucosal NO synthesis and the luminal release of MPO after rectal CM challenge. This sign of milk sensitivity was not linked to IgG/IgA antibodies to milk proteins. The symptoms for IBS according to Rome III criteria were fulfilled in 13 patients. All patients who were CM sensitive suffered from IBS. In a small open study, patients reactive to CM reported an improvement of intestinal symptoms on a CM-free diet.

Conclusion

A rectal mucosal inflammatory response after CM challenge is seen in 38% of patients with pSS as a sign of CM sensitivity. IBS-like symptoms were common in pSS, linked to CM sensitivity.

Mucosal reactivity to cow's milk protein in coeliac disease

Patients with coeliac disease (CD) on a gluten-free diet may still have gastrointestinal symptoms. On clinical grounds cow's milk (CM) protein sensitivity may be suspected. Here, using rectal protein challenge, we investigated the local inflammatory reaction to gluten and CM protein in adult patients with CD in remission. Rectal challenges with wheat gluten and dried CM powder were performed in 20 patients with CD and 15 healthy controls. Fifteen hours after challenge the mucosal reaction was recorded by the mucosal patch technique with measurements of local release of neutrophil and eosinophil granule constituents; myeloperoxidase (MPO) and eosinophil cationic protein (ECP). We measured the mucosal production of nitric oxide (NO) simultaneously. Six of the patients who reacted to CM were also challenged with alpha-lactalbumin and casein. In 18 of 20 patients gluten challenge induced neutrophil activation defined as increased MPO release and increased NO synthesis. Ten of these 20 patients showed a similarly strong inflammatory reaction to CM challenge. Six of the CM sensitive patients were challenged with specific CM proteins: casein and alpha-lactalbumin. Casein, in contrast to alpha-lactalbumin, induced an inflammatory response similar to that produced by CM. A mucosal inflammatory response similar to that elicited by gluten was produced by CM protein in about 50% of the patients with coeliac disease. Casein, in particular, seems to be involved in this reaction.

The gut-joint axis: cross reactive food antibodies in rheumatoid arthritis

BACKGROUND AND AIMS

Patients with rheumatoid arthritis (RA) often feel there is an association between food intake and rheumatoid disease severity. To investigate a putative immunological link between gut immunity and RA, food antibodies were measured in serum and perfusion fluid from the jejunum of RA patients and healthy controls to determine the systemic and mucosal immune response.

METHODS

IgG, IgA, and IgM antibodies to dietary antigens were measured in serum and jejunal perfusion fluid from 14 RA patients and 20 healthy subjects. The antigens originated from cow's milk (alpha-lactalbumin, beta-lactoglobulin, casein), cereals, hen's egg (ovalbumin), cod fish, and pork meat.

RESULTS

In intestinal fluid of many RA patients, all three immunoglobulin classes showed increased food specific activities. Except for IgM activity against beta-lactoglobulin, all other IgM activities were significantly increased irrespective of the total IgM level. The RA associated serum IgM antibody responses were relatively much less pronounced. Compared with IgM, the intestinal IgA activities were less consistently raised, with no significant increase against gliadin and casein. Considerable cross reactivity of IgM and IgA antibodies was documented by absorption tests. Although intestinal IgG activity to food was quite low, it was nevertheless significantly increased against many antigens in RA patients. Three of the five RA patients treated with sulfasalazine for 16 weeks had initially raised levels of intestinal food antibodies; these became normalised after treatment, but clinical improvement was better reflected in a reduced erythrocyte sedimentation rate.

CONCLUSIONS

The production of cross reactive antibodies is strikingly increased in the gut of many RA patients. Their food related problems might reflect an adverse additive effect of multiple modest hypersensitivity reactions mediated, for instance, by immune complexes promoting autoimmune reactions in the joints.

Gut mucosal granulocyte activation precedes nitric oxide production: studies in coeliac patients challenged with gluten and corn

BACKGROUND AND AIMS

To elucidate the dynamics of nitric oxide (NO) production induced by rectal gluten challenge and the relation between NO production and mucosal granulocyte activation.

SUBJECTS AND METHODS

Release of rectal NO was measured in 13 patients with coeliac disease and in 18 controls before and after rectal wheat gluten challenge. Rectal gas was collected with a rectal balloon using a newly developed instrument/technique, the "mucosal patch technique". The instrument allows simultaneous measurements of concentrations of granulocyte mediators in the rectal mucosa. We measured myeloperoxidase (MPO), eosinophil cationic protein (ECP), and histamine. For comparison, we made similar measurements after corn (maize) gluten challenge.

RESULTS

In all coeliac patients rectal NO concentration increased after gluten challenge and reached a peak after 15 hours (mean 9464 (SEM 2393) parts per billion (ppb); range 250-24982). The maximum MPO and ECP increase occurred five hours after challenge. A correlation was found between mucosal MPO and NO production at 15 hours. Six of the patients showed an increase in NO production 15 hours after rectal corn gluten challenge but this was much smaller than after gluten challenge. No increases were seen in the control group after either challenge.

CONCLUSION

Mucosal activation of neutrophils and eosinophils precedes pronounced enhancement of mucosal NO production after rectal wheat gluten challenge in patients with coeliac disease. Some of our coeliac patients displayed signs of an inflammatory reaction, as measured by NO and granulocyte markers, after rectal corn gluten challenge.

Clinical and subclinical intestinal inflammation assessed by the mucosal patch technique: studies of mucosal neutrophil and eosinophil activation in inflammatory bowel diseases and irritable bowel syndrome

BACKGROUND AND AIMS

There is a clear need for a rapid, simple, safe, and sensitive method of determining the type and intensity of inflammation in the gut mucosa in clinical practice. In this study, we have evaluated the potential of a new method, the mucosal patch technique, in patients with and without apparent gut inflammation, as assessed by conventional diagnostic procedures.

SUBJECTS AND METHODS

The technique tested is based on the idea that inflammatory mediators released from the rectal mucosa can be absorbed by and then extracted from cellulose patches brought into contact with the mucosa by use of an instrument with an inflatable balloon. Measurements were performed in healthy controls (n = 16) and in patients with active (n = 19) and inactive ulcerative colitis (UC, n = 8), collagen colitis (CC, n = 12), coeliac disease (n = 13), and irritable bowel syndrome (IBS, n = 13).

RESULTS

Inflammatory mediators from neutrophils (myeloperoxidase (MPO)) and eosinophils (eosinophil cationic protein (ECP)) were increased on average 300- and 10-fold, respectively, in patients with active UC compared with healthy controls and were correlated with the endoscopic score. Patients with inactive UC, CC, coeliac disease, and IBS exhibited no endoscopic signs of inflammation. These patient groups had significantly lower levels of MPO and ECP than the active UC group but showed on average a four- to sevenfold increase in MPO compared with healthy controls.

CONCLUSION

The mucosal patch technique was well tolerated by patients and easily applied by the investigator. Pronounced neutrophil and eosinophil involvement in UC was demonstrated. With the high sensitivity of the technique, low degree mucosal neutrophil activation could also be quantified in patients with CC and UC in clinical remission. The finding of increased neutrophil involvement in patients with IBS contributes to the pathophysiological ideas of this disease.

A randomised placebo controlled 12 week trial of budesonide and prednisolone in rheumatoid arthritis

OBJECTIVES

To compare budesonide, a locally acting glucocorticoid with minimal systemic exposure, with conventional glucocorticoid treatment and placebo in rheumatoid arthritis.

METHODS

A double blind, randomised, controlled trial over 12 weeks in 143 patients with active rheumatoid arthritis, comparing budesonide 3 mg daily, budesonide 9 mg daily, prednisolone 7.5 mg daily, and placebo. Particular attention was paid to the pattern of clinical response and to changes in the four week period following discontinuation of treatment.

RESULTS

There were improvements in tender joint count and swollen joint count on budesonide 9 mg compared with placebo (28% for tender and 34% for swollen joint counts, p<0.05). Prednisolone 7.5 mg gave similar results, while budesonide 3 mg was less effective. ACR20 response criteria were met by 25% of patients on placebo, 22% on budesonide 3 mg, 42% on budesonide 9 mg, and 56% on prednisolone 7.5 mg. A rapid and significant reduction in symptoms and signs in response to budesonide 9 mg and prednisolone 7.5 mg was evident by two weeks and maximal at eight weeks. There was no evidence that budesonide provided a different pattern of symptom control from prednisolone, or that symptoms became worse than placebo treatment levels after discontinuation of glucocorticoid treatment. Adverse effects attributable to glucocorticoids were equally common in all groups.

CONCLUSIONS

The symptomatic benefits of budesonide 9 mg and prednisolone 7.5 mg are achieved within a short time of initiating treatment, are maintained for three months, and are not associated with any rebound in symptoms after stopping treatment.

Hyaluronic acid accumulation; the mechanism behind graft rejection edema

Hyaluronic acid (HA) is an important stabilizing consistuent of the loose connective tissue and regulates water homeostasis. Thus, excessive accumulation of HA in interstitial tissue immobilizes water and may thereby contribute to interstitial tissue edema. By the use of biotin labelled core protein and an avidin-enzyme system, we visualized HA in grafted rat kidney, rat heart, rat small bowel and also in human kidneys. By an extraction procedure the tissue amounts of HA were measured in the experimental grafts. Simple techniques for measuring water content were also employed. The extracellular amounts of HA increased between 100% and 350% in rejecting tissues as compared to syngeneic controls. The relative water content also increased and correlated well with the HA accumulation. The clinical value of these experimental observations was confirmed in human transplantation where rejecting kidney allografts demonstrated a highly significant increase in HA staining in the interstitium as compared to non-rejecting biopsy specimens. We therefore concluded that transplantation edema--a key features of graft rejection--is regulated by the accumulation of HA not only under experimental conditions but also in the clinical setting.

Human neutrophil lipocalin is a unique marker of neutrophil inflammation in ulcerative colitis and proctitis

BACKGROUND AND AIM

Accumulation and infiltration by neutrophil granulocytes is a prominent feature in the local inflammatory process in ulcerative colitis (UC). The present study was performed to evaluate human neutrophil lipocalin (HNL) as a specific neutrophil marker in the inflamed lesions of the colon and rectum in patients with colitis and proctitis.

METHODS

The activity of intestinal neutrophils with respect to release of granule proteins was studied in 18 patients with UC (10 with colitis and eight with isolated proctitis) and in 18 healthy controls using perfusion fluid and biopsies from the sigmoid colon and rectum. The released amounts of the neutrophil granule proteins HNL and myeloperoxidase (MPO) were determined by radioimmunoassays, and the location of HNL and MPO in biopsies from colonic mucosa was examined by immunohistochemistry.

RESULTS

Mucosal release of HNL and MPO was increased 10-55-fold in patients with colitis and proctitis compared with controls. Their bowel biopsies demonstrated that only neutrophils were stained with anti-HNL. We also found correlations between HNL and levels of granulocyte/macrophage-colony stimulating factor (GM-CSF) and interleukin 8 (IL-8) in perfusion fluids from the sigmoidal segments of patients with proctitis, between HNL and GM-CSF in rectal segments in patients with proctitis, and in sigmoidal segments in patients with colitis.

CONCLUSION

We conclude that the increased release of HNL and MPO in colorectal perfusion fluids indicates neutrophil involvement in the local inflammatory process, and suggest that HNL may serve as a specific marker of intestinal neutrophil activation in UC. GM-CSF, and to some extent IL-8, may play a role in neutrophil accumulation and priming in this disease.

Low serum dehydroepiandrosterone sulfate in women with primary Sjögren's syndrome as an isolated sign of impaired HPA axis function

OBJECTIVE

To assess the hypothalamic-pituitary-adrenal (HPA) and thyroid axes in women with primary Sjögren's syndrome (pSS).

METHODS

In 10 women with pSS and 10 age matched female controls, we evaluated serum dehydroepiandrosterone sulfate (DHEA-S), testosterone, androstenedione, follicle stimulating hormone, luteinizing hormone, thyroid stimulating hormone, prolactin, growth hormone, sex hormone binding globulin, cortisol, and adrenocorticotropin hormone (ACTH), in both basal condition and after stimulation with corticotropin releasing hormone, thyrotropin releasing hormone, and luteinizing hormone releasing hormone intravenously. Patients had not previously been treated with glucocorticoids.

RESULTS

Patients with pSS had significantly lower basal mean DHEA-S values compared with healthy controls (2.4 +/- 0.4 vs 3.9 +/- 0.3 mumol/l; p < 0.05) and significantly lower DHEA-S values after stimulation. The cortisol/DHEA-S ratio in the patient group was higher than in controls (171 +/- 39 vs 76 +/- 5; p < 0.05). A correlation was found between basal ACTH and DHEA-S values in the patients (r = 0.650; p = 0.05). No correlation was seen between disease activity or age and the serum concentration of DHEA-S. The levels of other hormones both at baseline and after stimulation were similar in patients and controls.

CONCLUSION

The results show that women with pSS have intact cortisol synthesis but decreased serum concentrations of DHEA-S and increased cortisol/DHEA-S ratio compared with healthy controls. The findings may reflect a constitutional or disease mediated influence on adrenal steroid synthesis. The thyroid axis and gonadotropin secretion were similar in patients and controls.

Renomedullary interstitial cells in culture; the osmolality and oxygen tension influence the extracellular amounts of hyaluronan and cellular expression of CD44

Our previous studies have suggested a role for renomedullary interstitial cells (RMICs) and renal medullary hyaluronan (HA) in water homeostasis. In the present study, cultured rat RMICs were used to examine the relationship of osmolality and oxygen tension on the extracellular amount of HA in the culture and to the cellular immunoreactivity to CD44, a HA binding protein. Under isotonic (330 mOsm(.)kg(-1) H(2)O), normoxic (20% O(2)) conditions, supernatant from sub-confluent RMICs contained 120+/-37 pg 10(4) cells(-1) 24 h(-1) of HA. Under hyperosmotic conditions (630 mOsm kg(-1) H(2)O), HA in the supernatant was decreased by 42% and under hypoosmotic conditions (230 mOsm kg(-1) H(2)O) it was doubled. Under hypoxic, iso-osmolar conditions (5% and 1% O(2), 330 mOsm kg(-1) H(2)O) this HA content was decreased by 56 and 48%, respectively, compared with normoxic, iso-osmolal conditions. Expression of CD44 on sub-confluent cells increased with increasing osmolality, as shown by immunostaining and flow cytometric analysis. The increases in CD44 from 330 to 630, 930 and 1230 mOsm kg(-1) H(2)O amounted to 5, 142 and 212%, respectively. Low oxygen tension (5% O(2)) decreased the intensity of CD44 immunofluorescence by 31%. Cell viability was similar at all conditions studied. In summary, these data indicate that cultured RMICs produce HA and are immunoreactive to CD44. In the supernatant of RMICs, the HA content decreases under hyperosmotic, hypoxic conditions. Conversely, CD44 immunoreactivity increases under hyperosmotic conditions. These results may explain our previous in vivo findings of a decreased renal papillary HA content during anti-diuresis and an increased content during water diuresis. The results support the concept that RMICs play an important role in renal water handling.

Monitoring of intragraft pressure of rejecting organs: increased tissue pressure can be reduced by hyaluronidase therapy

BACKGROUND

The present study was undertaken in order to: (a) develop a new technique for measurement of interstitial pressure, (b) study the intragraft pressure of rejecting and non-rejecting organs, and (c) study the effect of treatment with the hyaluronan-degrading enzyme hyaluronidase on intragraft pressure. Treatment with hyaluronidase has previously been demonstrated to result not only in reduction of tissue hyaluronan but also in ameliorated interstitial edema, and we suggested that the diminished edema would lead to a reduced interstitial pressure as well.

METHODS

At day 5 after syngeneic or allogeneic rat heterotopic heart transplantation, the interstitial pressure of the cardiac grafts was measured using a microtip pressure sensor. Subsequently, the allogeneically grafted animals received a continuous intravenous infusion of either hyaluronidase (total dose: 60,000 U/kg) or vehicle during 2 hr; meanwhile, the interstitial pressure was monitored.

RESULTS

The intragraft pressure measurement technique was found to give reproducible results. The interstitial pressure of the rejecting (allogeneic) grafts was considerably higher than that of the non-rejecting (syngeneic), i.e., 12.3+/-1.6 mmHg vs. 1.1+/-0.6 mmHg (P<0.001). Hyaluronidase infusion effectively reduced the interstitial pressure as compared with vehicle treatment. By 20 min, the pressure had been reduced by 28% (P<0.01 compared with vehicle treatment); after 1 hr, by 49% (P<0.001); and after 2 hr, by 68% (P<0.01).

CONCLUSIONS

By using modern technology for tissue pressure measurements, we found that the strongly increased interstitial pressure of rejecting organs can be instantly reduced by intravenous administration of the hyaluronan-degrading enzyme hyaluronidase.

Hyaluronan content in the kidney in different states of body hydration

BACKGROUND

Growing evidence suggests that the interstitial hyaluronan (HA) content is a determinant of the fluid exchange barrier in tissues through its high resistance to water flow. This study addressed the possible involvement of renal papillary HA in water balance regulation.

METHODS

In anesthetized rats during different states of renal water handling (euvolemia, water diuresis, antidiuresis), in desert rodents, and in Brattleboro rats (diabetes insipidus) with a hereditary difference in water handling, regional renal HA and water contents were measured.

RESULTS

The intrarenal HA distribution is heterogeneous, with 100 times larger amounts in the papilla than in the cortex. Compared with control rats, two hours of water diuresis increased the papillary HA content by 48% and that in the outer medulla by 52%, leaving the cortex unaffected. After 24 hours of water deprivation, papillary HA was decreased by 17%, while outer medullary HA remained unchanged. In gerbils, papillary and outer medullary HA contents were only 25 and 13%, respectively, of those in normal rats, while the cortical content was similar. In Brattleboro rats, the outer medullary HA content was significantly higher (285%) than in the normal rat, while the papillary content was similar. Generally, papillary HA was positively correlated to water content but was inversely related to urine osmolality.

CONCLUSIONS

The amount of renal papillary HA changes in response to water balance of the organism. When excess water needs to be excreted, increased papillary interstitial HA could antagonize water reabsorption. The opposite occurs during water conservation. HA may play a role in renal water handling by affecting physicochemical characteristics of the papillary interstitial matrix and influencing the interstitial hydrostatic pressure, thereby determining interstitial water diffusion.

Psychological well-being in patients with primary Sjögren's syndrome

OBJECTIVES

To evaluate quality of life and psychological symptoms in patients with primary Sjögren's syndrome and to compare this with patients with rheumatoid arthritis.

METHODS

A standardised questionnaire, the Psychological General Well-Being Index (PGWB), was used to examine the quality of life and psychological symptoms in patients with primary Sjögren's syndrome (pSS; n = 34). Patients with rheumatoid arthritis (RA; n = 32) were used as patient controls.

RESULTS

The total mean score +/- SD for PGWB was 84.9 +/- 16.2 in pSS patients and significantly lower (p = 0.001) than in RA patients (97.7 +/- 17.5). Patients with pSS had an increased propensity for depressed mood (p = 0.0009), and suffered from reduced well-being (p = 0.002) and impaired vitality (p = 0.003).

CONCLUSION

The results suggest that patients with pSS have a reduced quality of life, a higher degree of distress and a lower sense of well-being than patients with RA.

Hyaluronidase can be used to reduce interstitial edema in the presence of heparin

BACKGROUND

Treatment with the hyaluronan-degrading enzyme, hyaluronidase, reduces rejection-induced interstitial edema of transplanted organs. Hyaluronidase has also been demonstrated to reduce tissue necrosis after experimentally induced myocardial infarction, but its clinical use has been limited by an observed interaction between heparin and hyaluronan. In the present work, we investigated whether it is also possible to retain the effect of the enzyme in heparinized animals.

METHODS

Day 5 after heterotopic heart transplantation, recipient rats received a 2-hour intravenous infusion of hyaluronidase, either of ovine or of bovine origin. Concomitantly, the animals received intravenous heparin, either as 2 bolus doses or as a constant infusion.

RESULTS

Both hyaluronidase preparations effective reduced the hyaluronan content as well as the water content of the rejecting cardiac grafts. The concomitant use of heparin did not hamper the positive results, neither when heparin was administered intermittently nor when it was given continuously.

CONCLUSIONS

Our results in the transplantation model clearly demonstrate that hyaluronidase can be successfully used in heparinized individuals, provided that sufficient doses of the enzyme are given.

Role of hyaluronan in acute pancreatitis

BACKGROUND

The connective tissue component hyaluronan is accumulated locally in the damaged tissue during various inflammatory conditions. Owing to the strong water-binding capacity of this glycosaminoglycan, increased tissue content of hyaluronan is paralleled by the development of interstitial edema. The aim with the current experiment was to investigate whether hyaluronan is accumulated in acute pancreatitis and if increased levels of hyaluronan can be correlated to the inflammation of the pancreatic tissue.

METHODS

Acute pancreatitis was induced in Sprague-Dawley rats by the administration of supramaximal doses of the cholecystokinin analogue caerulein. The animals were followed for 5 hours (n = 4), 24 hours (n = 6), or 48 hours (n = 5), and the pancreata were then investigated for hyaluronan and water content, hyaluronan distribution, general morphology and the presence of CD44-positive cells, macrophages, and T lymphocytes.

RESULTS

Hyaluronan accumulated in the edematous interstitium during acute pancreatitis. Twenty-four hours after the induction of pancreatitis, the hyaluronan content of the pancreata had increased by more than 100%. Simultaneously, CD44-positive cells infiltrated the tissue. However, no correlation between hyaluronan and water was seen at any time point.

CONCLUSIONS

This study shows that acute pancreatitis is associated with a strong but transient increase in interstitial hyaluronan and an infiltration of CD44-positive cells located mainly in the same region as the accumulated hyaluronan.

Intestinal mucosal secretion of basic fibroblast growth factor in patients with ulcerative colitis

BACKGROUND

Basic fibroblast growth factor (bFGF) promotes angiogenesis and several other biologic processes, including proliferation of mesenchymal cells and tumor progression. We investigated whether bFGF could be detected in the intraluminal secretion of the small intestine, sigmoid colon, and rectum in healthy individuals and in patients with ulcerative colitis.

METHODS

We used endoscopic perfusion techniques to obtain samples from well-defined intestinal segments. The perfusion fluid concentrations of bFGF, biochemical markers of inflammation, myeloperoxidase (MPO), interleukin-6 (IL-6), and permeability (albumin) were determined with immunochemical methods.

RESULTS

In the perfusion fluids the albumin concentration, which reflects passive diffusion, was less than 1% of the plasma concentration, whereas the intestinal concentration of bFGF was similar to that in plasma. Among healthy subjects the concentration of bFGF was eightfold higher in the jejunum and twofold higher in the rectum than in the sigmoid colon. The perfusion fluid from colorectal segments in patients with ulcerative colitis had a significantly higher mean concentration of bFGF than that from healthy individuals; an almost 10-fold difference was found in rectal segments. There were strong correlations between the concentration of bFGF and the concentrations of MPO and IL-6.

CONCLUSIONS

The high concentrations of bFGF in the intestinal perfusion fluid reflect either a local synthesis or an active secretion of bFGF within the mucosa. The bFGF concentration differs in intestinal anatomic location and increases significantly in patients with ulcerative colitis in close relationship with biochemical markers of inflammation and permeability.

Anxiety and depression in patients with primary Sjögren's syndrome

OBJECTIVE

To examine the degree of anxiety and depression and to assess well being and general symptoms in patients with primary Sjögren's syndrome (SS).

METHODS

A standardized questionnaire, the Hospital Anxiety and Depression Scale, was used to examine the degree of anxiety and depression in patients with primary SS (n = 62) and in age matched healthy female controls. The Gothenburg quality of life instrument (GQOL) was used to assess well being and general symptoms. Patients with rheumatoid arthritis (RA; n = 38) were used as patient controls.

RESULTS

The patients with primary SS had significantly higher scoring rate for "possible" clinical anxiety (48%) and for "possible" clinical depression (32%) compared with reference groups (p<0.05). The physical and mental well being of the patients with primary SS were significantly reduced compared with controls. Furthermore, patients with primary SS complained more commonly of low mood, irritability, headache, gastrointestinal symptoms, and impaired concentration and memory than the patients with RA.

CONCLUSION

The results indicate that patients with primary SS often have psychiatric symptoms and worse well being, which may affect their quality of life.

Serum lysozyme: a potential marker of monocyte/macrophage activity in rheumatoid arthritis

OBJECTIVE

Estimate the contribution of monocytes/macrophages to the disease process in rheumatoid arthritis (RA), by measuring the serum levels of the leucocyte-derived granular proteins: lysozyme, myeloperoxidase (MPO), lactoferrin and human neutrophil lipocalin (HNL).

METHODS

Serum levels of these granular proteins were measured in patients with RA (n=23) and in healthy controls (n=27), and in 10 patients with RA after treatment with low-dose prednisolone. The serum levels of the granular proteins were also measured before and after treatment with metyrapone, a substance that inhibits the synthesis of cortisol in the adrenals.

RESULTS

The serum levels of lysozyme and MPO were elevated in patients with RA, while the concentrations of lactoferrin and HNL were similar in both groups. Prednisolone treatment decreased the serum concentration of lysozyme and MPO. Metyrapone did not influence the level of the granular proteins measured.

CONCLUSIONS

The increased serum levels of lysozyme and MPO, but not of HNL and lactoferrin in RA could indicate a stimulated secretory activity of mononuclear phagocytes. The measurement of serum lysozyme, as an indicator of monocyte/macrophage activity, might be used to study disease activity in RA.

Edema treatment during cardiac allograft rejection

BACKGROUND

Interstitial edema of rejecting organs can be correlated with the accumulation of hyaluronan in the transplant; since hyaluronan has strong water-binding capacity, treatment with the hyaluronan-degrading enzyme hyaluronidase reduces not only the hyaluronan content but also the water content of the graft. The aim of the present study was to investigate whether a further reduction of the water content would be the result if hyaluronidase was used in conjunction with classic diuretic substances.

METHODS

Five days after heterotopic heart transplantation (PVG to Wistar/Kyoto), recipient rats received hyaluronidase as a continuous intravenous infusion over 2 hours together with either a loop-diuretic (furosemide) or an osmotic diuretic (mannitol).

RESULTS

Hyaluronidase was found to reduce the hyaluronan contents of the grafts from 586+/-52 microg/g in control animals receiving vehicle infusion to 161+/-48 microg/g (p < 0.001) and the water contents from 81.3+/-0.4 x 10(-2) U to 79.7+/-0.4 x 10(-2) U (p < 0.05). Combined treatment with furosemide or mannitol did not affect the results and neither furosemide nor mannitol had any intrinsic capacity to affect the water or hyaluronan contents of the cardiac grafts.

CONCLUSION

This experiment confirms our previous findings of hyaluronidase as an effective edema-reducing drug and indicate that no additive effect is obtained by a combined therapy with diuretics and hyaluronidase.

Enhanced expression of integrins and CD66b on peripheral blood neutrophils and eosinophils in patients with rheumatoid arthritis, and the effect of glucocorticoids

The aim of this study was to elucidate signs of granulocyte activation by studying adhesion and phagocytosis receptors on peripheral blood granulocytes from patients with rheumatoid arthritis (RA), and to observe the effect of glucocorticoids. Analyses by flow cytometry showed elevation of the neutrophil and eosinophil expression of the alpha- and beta-chains of the beta2-integrin Mac-1 (CD11b/CD18) and of the CEA-gene family member 6 (CGM6, CD66b). Expression of the adhesion receptor antigens CD11a, CD29, CD49d, CD49f and CD44, and the Fcgamma receptors II and III, was unaffected. Treatment with low-dose prednisolone reduced the expression of CD11b on neutrophils and of CD11b, CD18 and CD66b on eosinophils to the same level as that found in healthy controls. Metyrapone treatment increased the surface expression of CD35 and CD49f on eosinophils, but did not affect surface expression on neutrophils. Activation of blood granulocytes may be important for the increased recruitment of neutrophils and eosinophils to the synovial cavity in RA. Treatment with low doses of glucocorticoids in RA normalizes the enhanced expression of the studied adhesion molecules in eosinophils but has minor impact on neutrophil activation. Endogenous glucocorticoid production seems to have minimal or no effect on the expression of adhesion and phagocytosis receptors on circulating granulocytes.

Hyaluronidase ameliorates rejection-induced edema

Hyaluronan, a glucosaminoglycan with unique water-binding capacity, is accumulated in the interstitial edematous tissue in rejecting organs. We here investigated whether the increased tissue content of water and hyaluronan seen during allograft rejection can be prevented by treatment with the hyaluronan-degrading enzyme hyaluronidase. Heterotopic heart transplantations between PVG and Wistar/Kyoto rats were performed. Recipient rats were treated with hyaluronidase prophylactically or therapeutically, either alone or in combination with cyclosporine. Daily intravenous injections of hyaluronidase induced a significant reduction of the cardiac content of both hyaluronan and water, as evaluated on day six after transplantation. Morphological examination revealed grafts with better preserved morphology and fewer infiltrating mononuclear cells, compared to untreated controls. Hyaluronidase therapy, alone or combined with cyclosporine, resulted in prolonged graft survival times. Hyaluronidase infusion for two hours also reduced already established edema five days after transplantation. This study confirms the hypothesis that hyaluronan accumulation plays a critical role in edema formation, and that hyaluronidase therapy can be used to reduce edema after organ transplantation.

Increased intraluminal release of eosinophil granule proteins EPO, ECP, EPX, and cytokines in ulcerative colitis and proctitis in segmental perfusion

OBJECTIVE

The role of the eosinophil granulocyte in bowel mucosa in inflammatory bowel disease still remains obscure. The present study was performed in order to elucidate the local eosinophil activity and activating cytokines in the inflamed lesions of colon and rectum in patients with ulcerative colitis and proctitis.

METHODS

The activity of intestinal eosinophils with respect to the release of granule proteins was studied in 18 patients (10 with colitis and 8 with isolated proctitis) and 18 healthy controls, using intraluminal segmental perfusion of the sigmoid colon and rectum. The released amounts of eosinophil granule proteins: eosinophil cationic protein (ECP), eosinophil peroxidase (EPO), and eosinophil protein X (EPX) to perfusion fluid were determined by radioimmunoassays. The intraluminal release of possible eosinophil priming cytokines granulocyte/macrophage-colony stimulating factor (GM-CSF) and interleukin 8 (IL-8), were analyzed by immunoassays.

RESULTS

The mucosal release of ECP, EPO, and EPX was increased 10- to 20-fold in patients with colitis and proctitis compared with controls. The intraluminal release of GM-CSF and IL-8, was several-fold enhanced in patients with colitis and proctitis. We also found a correlation between all three eosinophil granule proteins and the levels of IL-8/GM-CSF in the sigmoidal segments of patients with colitis.

CONCLUSIONS

We conclude that the increased release of ECP, EPO, and EPX to colorectal perfusion fluid indicate eosinophil involvement in the local disease in patients with colitis and proctitis. IL-8 and GM-CSF may play a role in eosinophil accumulation and priming in colitis.

Monocyte activation in rheumatoid arthritis (RA): increased integrin, Fc gamma and complement receptor expression and the effect of glucocorticoids

The aim of this work was to study the expression of beta 1- and beta 2-integrins, CR1, CD44 and Fc gamma receptors on peripheral blood monocytes in RA. The expression of these receptors was measured by flow cytometry, before and after treatment with low-dose prednisolone. Expression of the same receptors was also measured before and after treatment with metyrapone, a substance that inhibits the synthesis of cortisol in the adrenals. The expression of the beta 2-integrins CD11a, CD11b and CD18, of CD35 (CR1), and of Fc gamma RII and Fc gamma RI (CD32 and CD64) on monocytes was elevated in the RA patients compared with healthy controls, while the expression of the beta 1-integrins (CD29, CD49d, CD49f) was unaffected. A significant correlation between monocyte expression of CD64 and C-reactive protein (CRP), and blood platelet count, respectively, was found in the group of patients with RA. After 4-6 weeks of treatment with low-dose prednisolone, the expression on the monocytes of CD11a, CD11b, CD18, CD35, CD32 and CD64 was normalized. A significant correlation (r = 0.64, P = 0.02) was found between the decrease in expression of CD11b and clinical improvement after prednisolone treatment. Two days of metyrapone treatment, which significantly lowered the serum cortisol levels, elevated the expression of CD35 and CD49f. Priming of peripheral monocytes seems to be one of the mechanisms behind the recruitment of monocytes to the rheumatoid synovium. One reason for the good clinical effects of prednisolone in RA could be a down-regulation of adhesion and phagocytosis receptors on monocytes.

Eosinophil activation in ulcerative colitis: studies on mucosal release and localization of eosinophil granule constituents

Activation of eosinophil granulocytes (eosinophils) seems to contribute to the pathophysiology of several inflammatory conditions. This process was evaluated in 18 patients with ulcerative colitis and in 18 healthy controls using intraluminal segmental perfusion of the sigmoid colon and rectum and immunoanalysis for eosinophil cationic protein (ECP) in the perfusate. Immunohistochemistry for eosinophils and neutrophils was made in simultaneously taken biopsies and in biopsies from surgical specimens taken from additional 10 patients. The mucosal release of ECP was increased severalfold in patients with UC. The bowel biopsies demonstrated a lamina propria infiltrated with eosinophils. The degree of eosinophil activation/degranulation was related to the intensity of the inflammatory reaction. Activated eosinophils and extracellular deposits of ECP were, in particular, seen in crypt abscesses and in areas with damaged surface epithelium. Since ECP is highly cytotoxic, its release at the site of inflammatory bowel lesions might reflect a potential pathophysiological mechanism.

Concordant message of different inflammatory markers in patients with rheumatoid arthritis

The acute phase reaction is an unspecific response to inflammatory stimuli characterized by alterations in the concentration of several plasma proteins. It is of great clinical value to monitor the inflammatory state in patients with rheumatoid arthritis. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are the assays most widely used to measure the acute phase response, but there are also several other inflammatory markers (e.g., fibrinogen, haptoglobin, alpha 1-acid glycoprotein, alpha 1-antitrypsin, interleukins (IL), serum amyloid component A (SAA)). We have studied the interrelationships between several of these markers (ESR, Haptoglobin, Fibrinogen, CRP, SAA and IL-6) in rheumatoid arthritis patients. There was a good correlation between all acute phase markers in serum (p < .01). We found especially strong correlations between S-CRP and SAA (p < .000001) and between ESR and P-fibrinogen (p = .000004). The strong correlation indicates that P-fibrinogen could be used instead of ESR in monitoring rheumatoid arthritis patients. This would increase the specificity of the examination as ESR may be influenced by several factors other than the inflammatory response. There were no significant correlations between acute phase markers in serum or plasma and clinical index.

Eosinophil cationic protein and histamine after intestinal challenge in patients with cow's milk intolerance

BACKGROUND

Mast cells and eosinophils are key cells in the development of active symptoms in allergic diseases and other inflammatory conditions, and they mediate their action through the release of very potent granule constituents.

METHODS

Five patients with milk-related gastrointestinal symptoms diagnosed by double-blind placebo-controlled milk challenges, but with negative responses to skin prick tests and RASTs with milk, and eight healthy control subjects were investigated. Repeated perfusion studies were performed with a two-balloon, six-channel tube by using milk, casein, and whey as antigens. Luminal eosinophil cationic protein, histamine, and albumin were measured by radioimmunoassay.

RESULTS

Luminal cow's milk induced a pronounced increase in intestinal secretion of histamine and eosinophil cationic protein in patients, but not control subjects, during the first 20 minutes after challenge (histamine from 123 +/- 12 to 543 +/- 175 ng/cm, hr; eosinophil cationic protein from 80 +/- 23 to 686 +/- 262 ng/cm, hr). Albumin, as a marker of plasma leakage, was also significantly increased.

CONCLUSION

These data indicate that mast cells and eosinophils are effector cells not only in patients with allergic disease but also in patients intolerant to foods and lacking circulating antibodies. The underlying mechanisms may be a reaction mediated by locally appearing antibodies or an immunologic activation resembling that found in intestinal disorders such as celiac disease.

Renal accumulation and distribution of hyaluronan after ureteral obstruction

In a unilateral ureteral obstruction model, a progressive accumulation of hyaluronan (HA) was observed in the renal papilla during the first 11 days of obstruction, after which the amount of HA decreased until the last day of observation, i.e. day 22. The initial accumulation of HA in the obstructed kidney probably reflects the attempts of the kidney to maintain osmotic balance. Consequently, when filtration ceases, HA synthesis decreases and the concentration of HA falls. In the papilla of the contralateral kidney, that had not been exposed to any mechanical damage, the HA content was found to vary in a similar way to that in the obstructed kidney. The explanation for this could be that the mesenchymal cells within the papilla increase their production of HA in order to meet the requirements of increased function necessary to also shoulder the function of the damaged kidney. In short similar variations in the HA content of the renal papilla was observed in both healthy and obstructed kidneys in a unilateral ureteral obstruction model.

Enhanced jejunal production of antibodies to Klebsiella and other Enterobacteria in patients with ankylosing spondylitis and rheumatoid arthritis

OBJECTIVE

To measure gut immunity directly in jejunal fluid in patients with ankylosing spondylitis (AS) and rheumatoid arthritis (RA).

METHODS

Antibodies against three different Enterobacterias were measured in jejunal perfusion fluids (collected by a double balloon perfusion device) of 19 patients with AS, 14 patients with RA, and 22 healthy controls using enzyme linked immunosorbent assay.

RESULTS

The AS patients had significantly increased jejunal fluid concentrations of IgM, IgG, and IgA class antibodies against Klebsiella pneumoniae, and IgM and IgA class antibodies against Escherichia coli and Proteus mirabilis compared with healthy controls. When compared with the patients with RA, the AS patients had higher concentrations of IgA and IgG class antibodies only against K pneumoniae. The RA patients had higher IgM class antibody concentrations against all three studied Enterobacterias, when compared with the healthy controls, suggesting an enhanced mucosal immune response in these patients. A three month treatment with sulphasalazine did not decrease enterobacterial antibody concentrations in the 10 patients with AS.

CONCLUSION

There is strong direct evidence for an abnormal mucosal humoral immune response particularly to K pneumoniae in patients with AS.

Dynamic role of hyaluronan (HYA) in connective tissue activation and inflammation

An increased tissue accumulation of HYA occurs in several human and experimental inflammatory conditions. Such is the case in sarcoidosis, idiopathic pulmonary fibrosis and farmer's lung in man, and experimental bleomycin-induced lung damage in rats. Graft rejection in man and rats, experimental myocarditis in mice and myocardial infarction in rats follow the same pattern. Increased amounts of HYA also appear in gut luminal perfusion fluid in human inflammatory bowel disease. A transient accumulation of HYA is seen in wound healing, which is more sustained in fetuses. An increased accumulation of water and presentation of ligands for receptors on inflammatory cells are two consequences of the HYA accumulation.

The timing of glucocorticoid administration in rheumatoid arthritis

OBJECTIVE

To test the hypothesis that the timing of prednisolone administration might be critical in determining its effect on the diurnal rheumatoid inflammatory process.

METHODS

26 patients with rheumatoid arthritis were randomly divided into two equal groups and allocated to low doses of prednisolone at either 2.00 am or 7.30 am. Because of the diurnal variation in disease activity in rheumatoid arthritis, assessments of the two study groups were performed at 7.30 am both at the start of the study (day 1) and after four doses of prednisolone (day 5). The study protocol differences in the time period from the last dose of prednisolone to assessment were 5.5 hours in the 2.00 am group and 24 hours in the 7.30 am group.

RESULTS

Administration of low doses of prednisolone (5 or 7.5 mg daily) at 2.00 am had favourable effects on the duration of morning stiffness (P < < 0.001), joint pain (P < 0.001), Lansbury index (P < < 0.001), Ritchie index (P < < 0.001), and morning serum concentrations of IL-6 (P < 0.01). The other study group showed minor but significant effects on morning stiffness (P < 0.05) and circulating concentrations of IL-6 (P < 0.05). Modest and similar improvements of C reactive protein, serum amyloid protein A, and erythrocyte sedimentation rate were seen in both study groups.

CONCLUSIONS

Administration of low doses of glucocorticoids with a rather short biological half life seems to improve acute rheumatoid arthritis symptoms if it precedes the period of circadian flare in inflammatory activity, as defined by enhanced IL-6 synthesis. Further studies are needed to test the relative merits of different timing protocols of glucocorticoid administration in rheumatoid arthritis.

Experimentally-induced warm renal ischemia induces cortical accumulation of hyaluronan in the kidney

An accumulation of the connective tissue component, hyaluronan (HA), is known to occur in both syngeneic and allogeneic kidney grafts during the early postoperative period. The presence of HA in the interstitial tissue of the grafts is paralleled by an increased water content, suggesting a role for HA in the development of the transplantation edema. In the present work, the kidney content and distribution of HA was studied in a model of warm renal ischemia in the rat to investigate whether renal ischemia is associated with HA accumulation. Seventy-two hours after a period of warm renal ischemia (30 or 60 min) significantly higher amounts of HA were observed in the left kidney that had been exposed to ischemia, than in the right, healthy kidney. The most pronounced increase was found to occur in the cortex (20 to 40 times), a structure where there normally is almost no presence of HA. In addition, there was a correlation between the relative water content of the kidney and the amount of HA possible to extract from the tissue. The renal accumulation of HA and water was prevented by daily intravenous administration of hyaluronidase. We conclude that renal ischemia induces an accumulation of HA that may increase the risk for the development of interstitial edema, a situation that may be circumvented by hyaluronidase treatment.

Early and late allergic skin reactions in T cell deficient patients

Impaired delayed type skin sensitivity is supposed to be due to abnormalities in T lymphocyte functions. Lately it has been assumed that T cells play an important part also in the development of late allergic reactions in the skin and in the lungs. Patients with sarcoidosis, lung carcinoma or with uremia were skin tested with anti IgE antibodies to challenge the hypothesis that the same sort of T cell deficiency as impaired the delayed skin sensitivity also attenuated the late allergic skin reactions. All patients obtained an early reaction and with a size similar to that of normal controls. In most of the patients late reactions were seen, but the frequency varied between 67% for patients with uremia and 100% for those with sarcoidosis. The cancer patients had significantly smaller late reactions than the normal controls while patients with uremia or sarcoidosis had a normal size of their reaction. No correlation could be found between delayed reactions to PPD and late reactions to anti IgE. It is concluded that the type of lymphocyte abnormality giving impaired delayed type reactivity in e.g. sarcoidosis patients does not affect the allergic early or late skin reactivity. Testing for late allergic reactivity may be a new tool for evaluating the immune status of, for example, cancer patients.

Intact adrenocorticotropic hormone secretion but impaired cortisol response in patients with active rheumatoid arthritis. Effect of glucocorticoids

OBJECTIVE

To study the hypothalamic-pituitary-adrenal axis in rheumatoid arthritis (RA) and the influence of glucocorticoid treatment.

METHODS

Consecutive untreated patients with RA with moderately high inflammatory activity were studied and compared with healthy subjects of similar age. Subjects were studied both at baseline and after multiple releasing hormone (MRH) stimulations. Patients were reexamined one week after starting prednisolone.

RESULTS

The baseline cortisol/adrenocorticotropic hormone (ACTH) ratio was significantly lower in patients with RA. After corticotropin releasing hormone (CRH) stimulation, their serum cortisol response was reduced during the later test phases in spite of intact ACTH response. The baseline and stimulated levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), and thyroid stimulating hormone (TSH) were normal. An impaired prolactin response was seen after MRH stimulation. After one week of prednisolone therapy the absolute response of serum cortisol to CRH was decreased and the stimulated prolactin response was normalized.

CONCLUSION

Impaired cortisol secretion in patients with RA in the presence of intact ACTH secretion is consistent with relative adrenal glucocorticoid insufficiency. Adrenal impairment may be secondary to the inflammatory disease process.

Increased mucosal synthesis of rheumatoid factor (RF) in coeliac disease

Increased serum levels of RF have been reported in patients with gluten sensitivity. The objective of this study was to investigate the in vivo secretion of different isotypes of RF in the small bowel in coeliac disease. Nineteen patients were investigated by perfusion of a defined jejunal segment, and the jejunal perfusion fluid was analysed for the presence of IgA and IgM anti-Fc (IgG). Five of the patients studied had serum IgA deficiency. Patients with partial/subtotal villous atrophy but no IgA deficiency (n = 7) had a four-fold increase of IgM-RF (P < 0.001) and a three-fold increase of IgA-RF (P < 0.001) compared with healthy controls (n = 29). Patients with normal jejunal mucosa but no IgA deficiency (n = 7) had similar IgA-RF and IgM-RF concentrations to healthy controls. Patients with serum IgA deficiency had no IgA-RF detectable in jejunal fluid but the highest IgM-RF concentrations, in particular in active disease. The coeliac patients had serum levels of IgA-RF and IgM-RF within the reference ranges. Jejunal fluid levels of IgA-RF and IgA-anti-gliadin antibodies were significantly correlated (P < 0.001). The data indicate that enhanced jejunal mucosal production of RF occurs above all in active coeliac disease. The findings suggest that the immune response to gluten induces a mucosal RF synthesis.

Subcutaneous administration of hyaluronan reduces the number of infectious exacerbations in patients with chronic bronchitis

Hyaluronan (HA) is a high molecular weight glycosaminoglycan found in large amounts in the skin, joints, and other organs. Previous studies have shown that HA stimulates neutrophil functions both in vitro and in vivo. The object of this study was to test the hypothesis that HA administration subcutaneously might reduce the number of bacterial infections in humans with an increased susceptibility to such infections. For this purpose we have studied 29 patients with chronic bronchitis and recurrent acute exacerbations of their disease. The patients were randomly separated into two groups. One group had HA for 6 mo followed by 6 mo of placebo, and the other group started with placebo treatment followed by HA. The treatment periods occurred during two consecutive winter periods. HA-treated patients had significantly fewer acute exacerbations (p = 0.01) than did placebo-treated patients. Likewise the consumption of antibiotics and other signs of bacterial infections were reduced. In the crossover study the placebo-treated patients again had much higher numbers of acute exacerbations than did the HA-treated patients (p < 0.0001). It is concluded that HA reduces the number of infectious exacerbations in patients with chronic bronchitis, possibly by enhancing cellular host defense mechanisms. HA is a new endogenous substance that can be used to stimulate host defense reactions and reduce the need of antibiotics. Before being recommended for clinical use, however, our results should be confirmed by further studies.