Histone-specific Th0 and Th1 clones derived from systemic lupus erythematosus patients induce double-stranded DNA antibody production.

OBJECTIVE: To investigate whether histone-specific T helper (Th) cells that are able to induce anti-double-stranded DNA (anti-dsDNA) antibodies can be isolated from patients with systemic lupus erythematosus (SLE) and to characterize the cytokine secretion pattern of such Th clones. METHODS: Peripheral blood mononuclear cells from SLE patients and healthy donors were stimulated with autologous apoptotic cell material or purified histones, expanded with interleukin-2 (IL-2), and cloned by limiting dilution. Histone reactivity of clones was examined by histone-specific proliferation and cytokine release. Cytokines were determined by enzyme-linked immunosorbent assay (ELISA) and CTLL-2 bioassay. Induction of anti-dsDNA antibodies was measured in cocultures of autologous B cells and Th clones by ELISA: RESULTS: Numerous histone-specific T cell receptor (TCR) alpha/beta+ Th clones were established from 2 of 3 patients with active SLE and from 1 of 2 healthy individuals. Most Th clones secreted IL-2, interferon-gamma (IFNgamma), and IL-4, whereas some produced predominantly IL-2 and IFNgamma. Th clones that could stimulate the production of anti-dsDNA antibodies were derived from SLE patients and from a healthy individual. CONCLUSION: Th cells specific for histones may play an important role in the pathogenesis of SLE by inducing autoantibodies to dsDNA. Both Th1 and Th2 cytokines may be involved in the pathogenesis of SLE. The presence of histone-specific Th cells in a healthy individual indicates the importance of peripheral tolerance for preventing autoimmunity to nuclear antigens.

Wallstents versus plastic stents in malignant biliary obstruction: effects of stent patency of the first and second stent on patient compliance and survival.

OBJECTIVES: In prospective trials in patients with malignant biliary obstruction, it has been reported that Wallstents prolong stent patency, but this does not translate into a significant survival benefit. Compared with prospective trials, however, survival may be different in clinical practice because of differences in patient compliance. We report on a retrospective, long term analysis comparing Wallstents versus plastic stents. METHODS: Plastic endoprostheses (70 patients) and endoscopic Wallstents (95 patients) were placed in 165 consecutive patients with irresectable, malignant biliary obstruction in a first (1990-91) and second (1992-93) time period. Stent occlusion was treated by plastic stent placement. RESULTS: Patient characteristics were quite comparable in both stent groups. Initial placement of a Wallstent resulted in an increase of median stent patency of the first (10 vs 4 months, p < 0.001) and second (8 vs 3 months, p < 0.05) stent, a decrease of additional endoscopic procedures (20 vs 58%, p < 0.005), an increase of patient compliance reflected by a decrease of patients dying with untreated stent occlusion (9 vs 30%, p < 0.001), and an increase of survival time (6.5 vs 4 months, p < 0.05). CONCLUSIONS: Initial placement of a Wallstent results in an increase of stent patency of the first and second stent. Duration of stent patency appears to have a determinant effect on patient compliance. Increased stent patency and patient compliance seem to improve survival in clinical practice.

Preferential recognition of specific DNA motifs by anti-double-stranded DNA autoantibodies.

Although antibodies (Ab) specific for double-stranded (ds) DNA are thought to be involved in the etiopathogenesis of systemic lupus erythematosus (SLE), the fine structure of their DNA targets remains elusive. We have adapted a polymerase chain reaction (PCR)-assisted immunoprecipitation method to define the binding sites in DNA sequences recognized by high affinity anti-dsDNA Ab of SLE patients. SLE sera were used to bind templates from a pool of double-stranded oligonucleotides (ON). A central part of 20 base-pair random sequence was flanked by restriction endonuclease recognition sites and sequences complementary to predefined PCR primers. Immunoselected ON were precipitated, isolated from the immune complexes and then subjected to a further immunoprecipitation step after amplification by PCR. After five cycles of immunoprecipitation and PCR, the resulting ON were cloned. Sequence analysis revealed that sera from SLE patients and two human monoclonal anti-dsDNA Ab obtained from SLE patients preferentially select sequences expected to form non-B-DNA structures. Inhibition studies of the Farr assay confirmed the increased affinity of the selected epitopes for anti-DNA Ab as compared to random B-DNA.

[Endoscopic, biopsy and functional results in irradiated esophageal carcinoma]. / Endoskopische, bioptische und funktionelle Ergebnisse bestrahlter Osophaguskarzinome.

83 patients of average age 64 (36-86) years with esophageal cancer were irradiated according to a prospectively defined treatment concept. After 60 Gy, re-endoscopy with biopsy was scheduled. If the tumor was still macro- or microscopically described, a boost to 70 Gy was given. During consistent weekly monitoring particular attention was focused on patients' ability to feed themselves. While initially only 7.2% could swallow solid food, by the end 84% of patients with a radiation dose of 60 Gy or more reported normal daily eating. Patients in whom the tumor was no longer present endoscopically or histologically survived four times longer (13.5 months) than those with persistent malignoma.

Cholylsarcosine, a new bile acid analogue: metabolism and effect on biliary secretion in humans.

BACKGROUND: Cholylsarcosine, the synthetic conjugate of cholic acid and sarcosine, is resistant to deconjugation-dehydroxylation during enterohepatic cycling in rodents and improves lipid absorption in a canine model of intestinal bile acid deficiency caused by distal intestinal resection. Experiments were performed to define its metabolism and effect on biliary secretion in humans. METHODS: The circulating bile acid pool was labeled with [14C]cholylsarcosine, and its turnover rate and biotransformation were determined by sampling bile daily. Cholylsarcosine (or cholyltaurine) was infused into the duodenum for 8 hours to define its effect on bile flow and biliary lipid secretion. RESULTS: Cholylsarcosine was lost rapidly from the enterohepatic circulation with a t1/2 of 0.5 days. The compound was not biotransformed by hepatic or bacterial enzymes. Cholylsarcosine had choleretic activity similar to that of cholyltaurine but induced more phospholipid and cholesterol secretion than cholyltaurine in four or five subjects. Infusion of cholylsarcosine (or cholyltaurine) at a rate averaging 0.6 mumol.min-1.kg-1 gave a biliary recovery of 0.2 mumol.min-1.kg-1; this value is the Tmax for active ileal transport of conjugated bile acids in humans. Laboratory tests for liver injury remained within normal limits. CONCLUSIONS: In humans, cholylsarcosine is not metabolized, is nontoxic, and has similar effects on biliary secretion as cholyltaurine. It appears safe to test in long-term studies the effect of cholylsarcosine on bile acid-deficiency states in humans.

[Osteosynthesis in dislocated femoral neck fracture (Garden 3 and 4). Long-term results and treatment concept]. / Osteosynthese bei der dislozierten Schenkelhalsfraktur (Garden 3 und 4). Langzeitresultate und Behandlungskonzept.

The dislocated fracture of the femoral neck (Garden type 3 and 4) in the young patient is preferably treated by open reduction and internal fixation. In the period 1980-1989 we fixed 49 fractures with a dynamic hip screw, a 130 degrees-angled plate, screws alone, or by a valgisation osteotomy fixed with a 120 degrees-plate (Pauwels osteotomy). 30 fractures were reviewed after 66 months in average. We observed radiological signs of femoral neck necrosis in 9 patients, thereof 7 with symptoms, and radiological signs of osteoarthritis in 3 patients, two with symptoms. The possible factors causing these late complications are discussed. We advocate the immediate open reduction to evacuate the intracapsular hematoma into a slight valgus over-correction for stability. For the fixation we use 3 screws in good bone quality, the dynamic hip screw and the angled plate in osteoporotic bone often combined with an accessory screw for rotational stability. The functional long-term result was good or excellent in 70%. By avoiding technical errors this rate can be improved.

Risk factors, co-medication, and concomitant diseases: their influence on the outcome of therapy with cisapride.

In a 28-day non-blinded study of 1071 patients with functional dyspeptic symptoms in a general practice setting, 666 presented with mainly typical symptoms of functional dyspepsia and received 5 mg cisapride three times daily, while 405 with predominating symptoms indicative of gastroesophageal reflux received 10 mg cisapride three times daily. On the basis of an anamnestic risk factor analysis for organic lesions, 'low-risk' patients were to be treated directly with cisapride, while for 'high-risk' patients a more thorough gastrointestinal examination was recommended before starting cisapride. Of patients in the dyspepsia group 75% reported a good or excellent response; the corresponding rate was 80% in the reflux group. Low-risk patients in both groups tended to respond better than high-risk patients (mean difference, 11%). Patients and investigators reached identical assessments of response. Concomitant antacids, calcium antagonists, beta-blockers and sedatives did not affect the results, but concomitant NSAIDs reduced the mean improvement rate by 14% (p < 0.01). Adverse effects such as abdominal cramps and loose stools were uncommon (< or = 3.4%).

A new approach to the molecular characterization of the c-ANCA antigen in Wegener's granulomatosis.

Classic anti-neutrophil cytoplasmic antibodies (c-ANCA) specific for constituents of neutrophil primary granules and monocyte lysosomes have been implicated in the pathogenesis of Wegener's Granulomatosis (WG). The revised amino-terminal sequence of Proteinase 3 (PR-3) as ANCA antigen, suggested that PR-3 is identical to myeloblastin (MBN). As it has been proposed that autoantibodies recognize a conformational epitope on c-ANCA, prokaryotic expressed protein might not be recognized by the patients sera. Therefore we set up an in vitro translation in an eukaryotic cell-free system using an internal ATG (amino acid 15 of the mature protein).

Recurrent bleeding after variceal hemorrhage: predictive value of portal venous duplex sonography.

OBJECTIVE: Risk assessment of recurrent variceal bleeding is essential for therapeutic decisions and is usually performed by endoscopy of the upper gastrointestinal tract. We studied the value of portal venous duplex sonography in predicting subsequent variceal bleeding in patients with cirrhosis. SUBJECTS AND METHODS: Thirty patients with cirrhosis who received sclerotherapy because of acute variceal hemorrhage for the first time (hemorrhage group), 30 patients with cirrhosis who had no previous hemorrhage (nonhemorrhage group), and 30 control subjects were examined prospectively. With the use of portal duplex and color Doppler sonography, flow direction, flow velocity, vein diameter, and response to respiration of portal vein vessels were measured and portosystemic collaterals and thrombosis of portal vessels were visualized. The results of these measurements and imaging findings were combined into a Doppler sonoscore. At entry into the study, all patients were classified on the basis of a sonoscore as having a low (sonoscore, < 4) or a high (sonoscore, > or = 4) risk for subsequent hemorrhage. During a mean follow-up period of 2 years (range, 15-36 months), the predictive value of this Doppler sonoscore was studied. RESULTS: In the hemorrhage group, the prevalence of recurrent hemorrhage was 40%, despite sclerotherapy, and the mortality rate was 60%. In patients with a Doppler sonoscore of 4 or more, the prevalence of recurrent hemorrhage was 67%, whereas in patients with a score less than 4, the prevalence was only 22% (p < .02). After sclerotherapy, endoscopic criteria showed no significant correlation with the prevalence of bleeding. In the nonhemorrhage group, the prevalence of variceal hemorrhage occurring was 13%, and Doppler sonographic criteria showed no significant correlation with the prevalence of subsequent hemorrhage. CONCLUSION: We conclude that Doppler sonography, performed after the first occurrence of variceal hemorrhage, provides useful prognostic information regarding the risk of recurrent hemorrhage. If these results are confirmed, Doppler sonography may be used to select the best method of treatment.

Analysis of immunoglobulin variable region genes from human IgG anti-DNA hybridomas.

The molecular mechanisms leading to anti-double-stranded (ds) DNA antibody production in systemic lupus erythematosus (SLE) are poorly understood. We describe here the immunoglobulin variable region genes of six human hybridomas secreting IgG anti-dsDNA antibodies derived from three SLE patients. The monoclonal IgG anti-dsDNA antibodies have been shown to be of high affinity and no multireactivity was observed (Winkler et al., Clin. Exp. Immunol., 1991. 85: 379). The comparison of the variable region genes expressed in the hybridomas with known germ-line genes as well as with the germ-line counterparts from one patient shows that the VH and VL sequences are somatically mutated. The pattern and extent of the observed somatic mutations are suggestive for an antigen-driven selection of at least four of these B cell clones. Several VH and VL genes used by the hybridomas were found to be expressed in the natural antibody repertoire, in the restricted fetal repertoire and in B cell malignancies expressing the CD5 antigen.

[Cisapride: clinical experience in 1071 patients with non-ulcer dyspepsia or reflux symptoms]. / Cisaprid: Erfahrung in der Praxis bei 1071 Patienten mit Non-Ulcer-Dyspepsie (NUD) oder Refluxsymptomatik.

Controlled studies showed that cisapride is effective in non-ulcer dyspepsia. Its prokinetic properties are not complicated by dopamine inhibition. In our study the dose of 5 mg t.i.d. was adequate for the treatment of patients with gastric symptoms, while for patients with reflux symptoms the preferred dose is 10 mg t.i.d. cisapride. The average improvement after 1 month of treatment was 68%. Additional medication with antacids was not of benefit. Side effects such as abdominal cramps or diarrhea were minimal (less than 4%). 1071 patients were selected according to the principles described by Talley et al. in 1987. This method was well accepted by investigators and patients and is recommended for similar studies.

Activation of macrophages for ADCC in vitro: effects of IL-4, TNF, interferons-alpha/beta, interferon-gamma, and GM-CSF.

Macrophages in varying states of activation differ in their ability to perform antibody-dependent cellular cytotoxicity (ADCC) and antibody-independent macrophage-mediated tumor cytotoxicity (MTC). To define further the activation requirements for macrophages to perform various cytolytic functions, we stimulated peptone-elicited peritoneal macrophages, which are only poorly cytolytic, with one of a panel of cytokines and then quantified three distinct cytolytic capacities. The peptone-elicited macrophages, after stimulation with IFN-alpha/beta, IL-4, or TNF, had increased ability to perform both the rapid and slow variants of ADCC but not to perform MTC. Stimulation with high doses of IFN-gamma, however, increased the macrophages' ability to perform all three cytolytic functions. GM-CSF had no effects on any cytolytic capacity. The effects of IL-4, TNF, IFN-gamma, and IFN-alpha/beta on the macrophages' capacity for both forms of ADCC were dose-dependent. IFN-gamma and IFN-alpha/beta increased the macrophages' capacity for both variants of ADCC within 4 hr of treatment, whereas IL-4 and TNF did so only after prolonged treatment. These results suggest that three forms of macrophage cytolytic capacity can be enhanced by cytokine treatment but that the requirements for enhancing each of the three forms of macrophage cytolytic capacity differ.

Cytokine stimulation of antibody-dependent cellular cytotoxicity (ADCC) enhances cytolytic but not binding capacity of peritoneal macrophages.

Macrophages in varying states of activation differ in their ability to perform antibody-dependent cellular cytotoxicity (ADCC). To define further the activation requirements for macrophages to perform cytolytic functions, we stimulated peptone-elicited peritoneal macrophages, which exhibit only a low level of ADCC, with a panel of cytokines and then assayed for the macrophages capacity to effect the rapid and slow forms of ADCC, to bind antibody-coated tumor cells, and to secrete H2O2 in response to immune complex or PMA. All four cytokine preparations, at optimal conditions, enhanced both forms of ADCC, but did not appreciably increase tumor cell binding. Three of the four cytokine preparations (Il-4, TNF and IFN-alpha/beta), however, increased the macrophages capacity to secrete H2O2 in response to either immune complex or PMA, IFN-gamma alone did not affect H2O2 secretion.

Potentiation of cytostatic but not cytolytic activity of murine macrophages after running stress.

The influence of physical exercise on the tumortoxicity of peritoneal murine macrophages (PMM) was investigated. The tumortoxic activity was discriminated into cytostatic and cytolytic effects. Cytostatic activity of PMM on tumor cells in vitro was studied using the proliferation assay of S-180 sarcoma cells. Cytolytic activity was monitored using the method of the slow form of antibody-dependent cellular cytotoxicity (ADCC) on SW 707 tumor cells. After a single exhaustive running session an increased cytostatic activity of PMM was observed as compared to PMM of sedentary animals. In PMM mediated ADCC no difference was detected between trained and untrained animals. It is concluded that physical exercise is a complex stimulus for macrophages that, at least in parts, triggers their cytotoxic activity against tumor cells.

Human macrophage function and physical exercise: phagocytic and histochemical studies.

Macrophages derived from human connective tissue were assayed for their enzyme content and phagocytic activity after physical exercise. A single exhaustive endurance-running test caused increased phagocytic and enzymatic activities of the macrophages. Thus, an exercise challenge activates the functional status of the cells. This effect of physical exercise on macrophages is inconsistent with the practical experience that high performance athletes suffer more frequently from harmless infectious diseases.

The influence of physical exercise on peritoneal macrophage functions: histochemical and phagocytic studies.

Peritoneal murine macrophages were assayed for their enzyme content and phagocytic activity after physical exercise. An endurance training as well as a single exhaustive exercise bout caused increased enzyme and phagocytic activities. However, a homogeneous activation could not be observed. The exhaustively exercised animals delivered macrophages with the highest levels of activation. Therefore, physical exercise has to be listed among the stimuli with macrophage-activating function. The inconsistency between an activating effect of physical exercise on macrophages and the observation that high-performance athletes suffer more frequently from harmless infectious diseases is discussed.

[Radiotherapy of esophageal carcinoma. Results checked clinically by radiology, endoscopy, biopsy and autopsy]. / Die Strahlentherapie des Osophaguskarzinoms. Klinisch, radiologisch, endoskopisch, bioptisch und autoptisch überprüfte Ergebnisse.

Forty-four patients with histologically confirmed esophageal cancer were irradiated with 60 Gy, checked endoscopically and by biopsy, and then followed clinically or radiologically until their death. The findings confirm the local destructibility of esophageal cancer with loosely ionized radiation and a favorable effect on quality of life. Three quarters of the patients were able to take normal food at the end of the radiotherapy, while the remainder were at least able to swallow soft foods. Radiotherapy can be offered as an effective alternative to patients, especially when operation is associated with a high risk. This is also demonstrated by the fact that 23 of 32 patients who had endoscopy and biopsy again at the end of the radiotherapy had no histologically demonstrable tumor.

[Microangiopathic hemolytic anemia, erythrophagocytosis and consumption coagulopathy in vinyl chloride-induced hemangiosarcoma of the spleen and liver]. / Mikroangiopathische hämolytische Anämie, Erythrophagozytose und Verbrauchskoagulopathie bei vinylchloridinduziertem Hämangiosarkom von Milz und Leber.

A case of angiosarcoma of the liver and the spleen following vinyl chloride exposure is described. The main symptoms in clinical diagnosis were microangiopathic hemolysis, disseminated intravascular coagulation, hepatosplenomegaly and exposure to vinyl chloride thirty years ago. It is the first case in which liver and spleen are involved in angiosarcoma due to vinyl chloride exposure. The tumor cells showed angioformative and solid histiocytoid growth with erythrophagocytosis.