Change in cartilage morphometry: a sample of the progression cohort of the Osteoarthritis Initiative.

OBJECTIVE: The performance characteristics of hyaline articular cartilage measurement on magnetic resonance imaging (MRI) need to be accurately delineated before widespread application of this technology. Our objective was to assess the rate of natural disease progression of cartilage morphometry measures from baseline to 1 year in knees with osteoarthritis (OA) from a subset of participants from the Osteoarthritis Initiative (OAI). METHODS: Subjects included for this exploratory analysis are a subset of the approximately 4700 participants in the OAI Study. Bilateral radiographs and 3T MRI (Siemans Trio) of the knees and clinical data were obtained at baseline and annually in all participants. 160 subjects from the OAI Progression subcohort all of whom had both frequent symptoms and, in the same knee, radiographic OA based on a screening reading done at the OAI clinics were eligible for this exploratory analysis. One knee from each subject was selected for analysis. 150 participants were included. Using sagittal 3D DESSwe (double echo, steady-state sequence with water excitation) MR images from the baseline and 12 follow-up month visit, a segmentation algorithm was applied to the cartilage plates of the index knee to compute the cartilage volume, normalised cartilage volume (volume normalised to bone surface interface area), and percentage denuded area (total cartilage bone interface area denuded of cartilage). RESULTS: Summary statistics of the changes (absolute and percentage) from baseline at 1 year and the standardised response mean (SRM), ie, mean change divided by the SD change were calculated. On average the subjects were 60.9 years of age and obese, with a mean body mass index of 30.3 kg/m2. The SRMs for cartilage volume of various locations are: central medial tibia -0.096; central medial femur -0.394; and patella -0.198. The SRMs for normalised cartilage volume of the various locations are central medial tibia -0.044, central medial femur -0.338 and patella -0.193. The majority of participants had a denuded area at baseline in the central medial femur (62%) and central medial tibia (60%). In general, the SRMs were small. CONCLUSIONS: These descriptive results of cartilage morphometry and its change at the 1-year time point from the first substantive MRI data release from the OAI Progression subcohort indicate that the annualised rates of change are small with the central medial femur showing the greatest consistent change.

A comparative trial of imipenem versus ceftazidime in the release of endotoxin and cytokine generation in patients with gram-negative urosepsis. Urosepsis Study Group.

Evidence from in vitro experiments and animal and human studies indicate that antibiotic therapy may induce the release of endotoxin from the outer membrane of Gram-negative bacteria. Antibiotics that bind preferentially to penicillin-binding protein-2 (PBP-2)--such as imipenem--are associated with little release of endotoxin, while antibiotics that preferentially bind to PBP-3--such as ceftazidime--are associated with far greater release of endotoxin. We conducted a randomized, multicenter, double-blind study comparing imipenem to ceftazidime in patients with urinary tract infections caused by Gram-negative bacilli associated with signs and symptoms of systemic inflammation. A total of 33 patients were randomized to receive either imipenem (n = 14) or ceftazidime (n = 19) for initial treatment for urosepsis. No differences in plasma endotoxin, interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha) or urine endotoxin, IL-6 or IL-8 levels were found between the two treatment groups within the first 8 h after antibiotic administration. We conclude that, if differences exist with respect to endotoxin release by these two antimicrobial agents, these differences are not readily demonstrable in this clinical study with carefully defined patients with Gram-negative urinary tract infections.

Quinolones and tendon ruptures.

We report two cases of tendon rupture associated with ciprofloxacin. One patient had a complete rupture of an Achilles tendon 6 months after taking the medication. The other case involved a partial rupture of the subscapularis tendon. Both ruptures occurred with minimal mechanical stress on the tendons, suggesting that the fluoroquinolone increased the susceptibility to rupture. We also review the literature describing the association between fluoroquinolones and tendon rupture and discuss the mechanisms explaining the heightened risk of tendon rupture associated with these drugs.

Comparable endotoxic properties of lipopolysaccharides are manifest in diverse clinical isolates of gram-negative bacteria.

In general there is a poor correlation between serum lipopolysaccharide (LPS; the biologically active constituent of endotoxin) levels and mortality in septic patients. The objective of this study was to determine if chemical, structural, or biological differences among LPS from different clinical isolates of gram-negative bacteria might explain this discrepancy. LPS preparations were made using the hot phenol-water extraction method from eight clinical isolates of gram-negative bacteria. As a percentage of the total weight of the LPS, the phosphate content ranged from 3.0 to 13.8% (average, 6.7 +/- 3.6%), and the 2-keto-3-deoxyoctonate content ranged from 1.9 to 27.4% (average, 8.9 +/- 8.5%). These values were not dissimilar to those obtained for a reference endotoxin. In a standard measure of LPS activity, the Limulus amoebocyte lysate assay, there was approximately a twofold difference between the least and most active preparations. The two preparations with the greatest difference in their ability to elicit the secretion of tumor necrosis factor alpha from a mouse peritoneal macrophage cell line were similar in lethality when administered to mice sensitized to the effects of LPS by D(+)-galactosamine. These relatively minor differences in LPS activity seem unlikely to explain the generally observed discrepancy between serum endotoxin levels and mortality in patients with gram-negative sepsis.

Preparation of endotoxin from pathogenic gram-negative bacteria.

Endotoxins have been recognized for decades as important structural components of the outer cell wall/cell membrane complex of Gram-negative microorganisms. These chemically heterogeneous macromolecular structures were recognized very early on to consist of lipid, polysaccharide, and protein, and to have the capacity to induce deleterious pathophysiological changes when administered either systemically or locally to a wide variety of experimental laboratory animals. The recognition of the very significant disease-causing potential of these interesting microbial constituents provided a sound conceptual basis for studies directed at the isolation, purification, and detailed chemical characterization of the active constituent(s). It is perhaps not particularly surprising, therefore, that there are now numerous methods and modifications of methods, that have been published in the scientific literature describing various approaches that have been employed for the extraction and purification of endotoxin from bacteria. It would be beyond the scope of this chapter to describe in detail all of these various methods. Therefore, we shall provide only a brief historical perspective of the evolution of different methodologies. We will then focus upon a more detailed discussion of those that will ultimately serve the investigative purposes of most researchers interested in isolating and purifying endotoxins.

Structure-function relationships of bacterial endotoxins. Contribution to microbial sepsis.

A substantial body of knowledge has emerged over the past several decades concerning the primary and tertiary, and quaternary structure of endotoxic LPS and their contribution to the pathogenesis of gram-negative sepsis; however, important questions remain. Among them are the precise three-dimensional configuration of the LPS macromolecule and the contribution of the quaternary structure to the ability of these potent microbial factors to interact with host humoral and cellular inflammatory mediator systems. Also remaining to be sufficiently addressed is the relative contribution of endotoxin interactions with the host to the overall manifestation of disease and conditions under which such contributions serve as the pivotal event in determining outcome. The answers to these questions can be expected to provide valuable insights into potential novel therapeutic intervention strategies and approaches that will ultimately reduce both morbidity and mortality in infection from gram-negative microbes.

Transient visual loss due to severe anemia in a patient with AIDS.

We present a case of a patient with AIDS who developed a profound anemia caused by zidovudine, an important antiretroviral drug. In the setting of concurrent cytomegalovirus retinitis, the anemia produced transient visual loss that resolved with transfusion of red blood cells. Withdrawal of zidovudine resulted in a stable hemoglobin. This case describes an unusual manifestation of severe anemia. Anemia itself is a very common complication of treatment with zidovudine, one of the most commonly used agents in the treatment of AIDS. The relationship of profound anemia to transient visual loss and the role played by zidovudine in anemia in AIDS patients are discussed.

Case report of long-term survival in a patient with acquired immunodeficiency syndrome and cryptococcal meningitis.

In the era before protease inhibitors were available, the great majority of patients with AIDS died within five years of the diagnosis. This grim reputation may cause both physician and patient to give up hope prematurely when antiretroviral therapy fails. We report a patient who survived five years after the diagnosis of cryptococcal meningitis and AIDS. Although there are now combinations of antiretroviral drugs available that can delay disease progression and extend the lives of AIDS patients, these are associated with a significant failure rate. It is thus important to be aware of the potential to extend life in patients even when antiretroviral therapy is not effective.

Carcinoma of the colon: an unusual cause of prolonged fever.

Solid tumors rarely present with fever. Among those that do, carcinoma of the colon has been infrequently reported as a primary cause of fever. This patient had carcinoma of the right colon with prolonged fever, but no evidence of infection or gastrointestinal symptoms. At surgical resection, a caecal adenocarcinoma was found with metastases to the mesentery and 10 of 40 lymph nodes. The patient's fever resolved after 3 days. The patient remained healthy during 8 years of follow-up. Right-sided colon cancer is not often considered in the complete evaluation of fever of undetermined cause.

Fatal Cytomegalovirus pneumonia in a patient receiving corticosteroids and methotrexate for mixed connective tissue disease.

Cytomegalovirus (CMV) pneumonia is a serious illness that may occur in severely immunocompromised patients such as those with bone marrow transplants. A strong association between this condition and immunosuppressive therapy for collagen vascular diseases has not been described. We describe a patient who had CMV pneumonia while receiving methotrexate and corticosteroids for mixed connective tissue disease.

Soluble urate in sera and synovial fluids from patients with different joint disorders.

OBJECTIVE: To evaluate simultaneous serum and synovial fluid (SF) urate levels in various inflammatory and noninflammatory joint disorders and to correlate SF white blood cell (WBC) counts with serum and joint fluid urate levels. METHODS: Sixty-three paired samples of sera and SF from 58 patients including 25 patients with inflammatory arthropathies, 18 patients with gout and 15 patients with noninflammatory joint disorders, were measured for urate concentrations by a UV enzymatic method. RESULTS: In inflammatory arthropathies other than gout, urate concentrations in SF were significantly lower than in paired sera (p < 0.0001). There was no difference between the SF and serum urate levels in noninflammatory arthropathies and in gout. In gout, however, SF urate occasionally were found to be considerably higher than in sera. This phenomenon was observed in fluids with massive amounts of monosodium urate crystals. There was no correlation between SF WBC counts and serum of SF urate levels in any of the disease groups studied. CONCLUSIONS: Serum and synovial fluid levels vary more than previously recognized. SF urate levels tend to reflect serum levels in gout and noninflammatory arthropathies but not in inflammatory joint disorders. Disturbed purine metabolism in inflammatory arthropathies may reflect a component in the pathophysiology of inflammation. The elevations of SF urate levels seen in gout are unique for this disease and most likely reflect crystal dissolution in joints.

Blindness in a woman with human immunodeficiency virus infection and syphilis.

BACKGROUND: A concomitant infection with human immunodeficiency virus (HIV) may alter the natural history of other infections. Several reports indicate that syphilis may behave more aggressively when HIV infection is present. CASE: A woman presented with a rash involving her hands and feet and progressive loss of the vision in her right eye. Her serologic tests for syphilis and HIV infection were positive. A diagnosis of neurosyphilis was confirmed by an analysis of cerebrospinal fluid (CSF). She was treated with high-dose intravenous (IV) penicillin. Her skin lesions resolved, but her vision did not improve. CONCLUSION: The incidence of HIV infection among women is rising. A patient with HIV and syphilis may develop neurosyphilis in a much shorter time than a patient without HIV infection.

Detection of T cell receptors in early rheumatoid arthritis synovial tissue.

Synovial tissue is rarely available from patients with early synovitis, with the exception of synovial biopsies. However, T cell populations early in the development of synovitis may be enriched in antigen-specific cells and critical to disease pathogenesis. To investigate the T cell repertoire in early synovitis, we utilized a PCR protocol for detection of T cell receptor (TCR) transcripts present in small amounts of synovial tissue. To expand the substrate for PCR, preamplification of cDNA was performed with a 3' constant region primer plus either a mixture of variable region primers or random hexanucleotides. Utilizing this method improved the sensitivity of detection. This technique is applied here to the analysis of TCR transcripts in synovial biopsies from individuals with early rheumatoid arthritis (RA) and non-RA synovitis. TCR alpha-chain transcripts were detectable in 5/5 RA and 4/4 non-RA specimens evaluated, with beta-chain transcripts detected in 4/5 early RA and 4/4 non-RA specimens evaluated. Confirmation of transcripts by sequencing of cloned PCR products verified the specificity of amplification. The most frequently expressed TCR V region families in early RA synovitis were V alpha 11, V alpha 14, V alpha 28, V beta 7, V beta 9 and V beta 17. Several of these V regions have previously been implicated in studies of chronic RA synovitis. J alpha and J beta region usage was similar to that seen in chronic RA, and conserved N region motifs were apparent. We conclude that it is possible to detect TCR transcripts in small synovial biopsies from individuals with early arthritis.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunotherapeutic strategies targeting rheumatoid synovial T-cell receptors by DNA inoculation.

Immunotherapy against autoreactive T-cell receptors (TCRs) has been reported to have promise in several animal models of autoimmune diseases. Facilitated DNA inoculation has many potential advantages as a modality for development of specific immune responses. Specifically, this technology is able to deliver exogenous antigens for processing via both the endogenous pathway, with subsequent presentation by class-I major histocompatibility (MHC) antigens, and the exogenous pathway, with subsequent presentation by class-II MHC antigens. This allows for induction of both arms of the cellular immune system. These cellular immune responses may be particularly important in targeting and controlling pathogenic cell populations. The application of this technology to the treatment of human autoimmune diseases depends on the availability of readily manipulated systems for the evaluation of specific interventions. Here we report the full length cloning and expression of TCRs from rheumatoid arthritis synovial tissue. These were developed by recombinant polymerase chain reaction, cloning and retroviral transduction into a TCR-alpha/beta-negative murine T-cell hybridoma. Reconstitution of CD3 expression was confirmed by flow cytometry. Similar constructs have been developed for TCR-based immunotherapy by facilitated inoculation of DNA intramuscularly. Preliminary analysis of immune responses in mice indicates that these constructs elicit anti-TCR responses. These studies indicate the ability to reconstitute expression of potentially autoreactive human TCRs in a model system wherein specific immune responses elicited against these TCRs by various immunogens can be evaluated.

Binding, internalization, and deacylation of bacterial lipopolysaccharide by human neutrophils.

Bacterial LPS is a potent agonist for priming and stimulating neutrophils (PMN). Although much has recently been learned about the binding receptors for LPS on these and other cells, little is known about the subsequent fate of LPS that has bound to the cell surface. In these studies, we evaluated three events in the interaction of Escherichia coli [3H]LPS with human PMN: 1) binding to the plasma membrane; 2) translocation to an intracellular compartment; and 3) enzymatic deacylation. Our results suggest that PMN bind LPS by at least two mechanisms: when serum is present, LPS binds almost entirely to CD14, whereas in the absence of serum, other binding mechanisms predominate. Serum thus augments CD14-mediated LPS binding, although the total amount of cell-associated LPS increases only by a factor of two, on average, when serum is added. Binding outpaces intracellular movement of the LPS, yet at least 1%/min of the cell-associated LPS is translocated to an intracellular compartment. In the absence of serum, LPS internalization occurs in the presence of a mAb that blocks LPS-CD14 binding, suggesting that an interaction with CD14 is not essential for LPS to traffic beyond the plasma membrane. LPS deacylation, which occurs over several hours, is inhibited by agents that reduce lysosomal (endosomal) acidification. This finding is consistent with a deacylating role for acyloxyacyl hydrolase, which has an acid pH optimum, and suggests that LPS moves at least transiently into an acidic intracellular compartment. These experiments provide a new temporal framework for evaluating LPS-neutrophil interactions.

Primary idiopathic pulmonary hypertension complicated by pulmonary arterial thrombosis. Association with antiphospholipid antibodies.

OBJECTIVE: We report an unusual case of primary pulmonary hypertension and review the pertinent literature. METHODS: A 25-year-old Caucasian woman presented with progressive dyspnea and was found to have pulmonary hypertension. Antiphospholipid antibodies were present. The patient had a prolonged hospital course, was unresponsive to therapy, and died suddenly. RESULTS: Postmortem examination revealed a large thrombus affecting the right main pulmonary artery, with plexogenic arteriopathy bilaterally. CONCLUSION: This appears to be the first reported case of primary pulmonary hypertension complicated by thrombosis of a main pulmonary artery in association with antiphospholipid antibodies.

Metastatic tumors to the female breast. An autopsy study of 12 cases.

Twelve cases of metastatic tumors to the female breast are reported. Ten of them were incidentally discovered at autopsy; two cases were diagnosed ante mortem but one was misinterpreted as primary. The patients' mean age was 58 years. The metastasizing tumors included cutaneous malignant melanoma (four cases); ovarian, renal and gastric adenocarcinoma (two cases each); and individual cases of pulmonary and pancreatic carcinoma. The patients with melanoma were younger than the others (49.7 vs. 62.7 years). The results of the present study indicate that breast metastases, although rare, are not exceptional especially in large autopsy series. Their recognition in surgical material would result in more adequate treatment against the primary tumor, thereby avoiding unnecessary radical surgery to the breast.