Efficacy and safety of intraarticular sodium hyaluronate in knee osteoarthritis. ORTHOVISC Study Group.

A prospective, multicenter, randomized, double-blind, controlled trial was conducted in 226 patients with knee osteoarthritis to evaluate the safety and efficacy of intraarticular injections of sodium hyaluronate. Patients were randomized to three weekly injections of 30 mg sodium hyaluronate or physiologic saline (control) and were observed for an additional 25 weeks. In comparison with the control group, among patients who completed at least 15 weeks of the study and whose Western Ontario and McMaster Universities Osteoarthritis Index pain score for the contralateral knee was less than 12 at baseline, sodium hyaluronate injection resulted in improvement in Western Ontario and McMaster Universities Osteoarthritis Index pain score, patient and investigator global assessments, and pain on standing from Weeks 7 to 27. Fifty-eight percent of patients treated with sodium hyaluronate achieved a 5-unit or greater improvement in mean pain score from Weeks 7 through 27, compared with 40% of control patients. In addition, nearly twice as many patients treated with sodium hyaluronate as with saline (30% versus 17%, respectively) achieved a net improvement of at least 7 units. In contrast to treatment with saline, Western Ontario and McMaster Universities Osteoarthritis Index pain score for the contralateral knee was inversely related to the magnitude of improvement after treatment with sodium hyaluronate. Few side effects were attributed to treatment, and no differences between treatment groups were seen in this respect (sodium hyaluronate, nine [8%]; saline, 11 [10%]). The incidence of injection site reactions was low (sodium hyaluronate, 1.2 %; saline, 1.5%). The results indicate that sodium hyaluronate treatment is well tolerated and produces statistically and clinically significant improvement of symptoms in patients with mild to moderate knee osteoarthritis in whom pain in the contralateral knee is relatively modest.

Systemic lupus erythematosus and dementia.

Comparison of Trail-making Parts A and B and the Shipley Conceptual Quotient of 18 index patients (M age = 29 years) and 18 controls indicated no dementia for the index patients.

Explantation of silicone breast implants.

Silicone gel-filled breast implants have been employed clinically for decades for aesthetic augmentation or postmastectomy reconstruction. Most patients and surgeons attest to the efficacy and safety of these devices. However, more recently in the medical literature and popular media, silicone gel-filled breast implants have been claimed to incite an array of clinical sequelae such as capsular formation, granulomatous disease, arthritis, arthralgia, fibromyalgia, autoimmune collagen vascular disease, human adjuvant disease, siliconosis, silicone-related disease, and silicone implant-associated syndrome. During a recent 24-month period, 25 referred patients underwent explantation of bilateral silicone gel-filled prostheses at the University of South Alabama. Patient-reported symptoms and signs included mastodynia, arthralgia, fibromyalgia, xerophthalmia, xerostomia, hypesthesia, and amblyopia. Clinical examination and mammography were reliable in diagnosing implant rupture, but only re-exploration reliably detected implant leakage. Most patients underwent concurrent replacement with saline-filled devices. Histopathologic analyses of all tissue samples revealed chronic inflammation. Subjective improvement of patient-reported symptoms and signs occurred over the course of months postoperatively. There was no mortality associated with explantation, with or without replacement, but an overall morbidity incidence of 20 per cent (5 of 25) was observed. Predicated upon review of the available scientific literature and analysis of this modest number of patients, the following perspectives are germane. 1) A small cohort of patients of status postimplantation of silicone gel-filled devices will manifest chronic morbidity. Identifying such patients prospectively remains problematic. 2) Whether or not silicone gel incites adverse systemic phenomena is unproven, although it has been implicated. 3) Symptomatic patients with silicone gel-filled implants in place should be considered for removal, with full knowledge of the morbidity associated with revisional procedures. 4) Patients currently undergoing breast augmentation or reconstruction employing prosthetics are perhaps best served by insertion of saline-filled devices. 5) Patient-physician dialogue regarding the risk-benefit analysis of prosthetic implantation is imperative. Patients consenting to such procedures must be willing to assume risks.

An autosomal screen for genes that predispose to celiac disease in the western counties of Ireland.

Celiac disease is a strongly heritable gastrointestinal illness that is an especially important model of the genetically complex multifactorial immune mediated diseases. The HLA component of celiac disease (a specific HLA-DQ heterodimer)is largely established and is relatively uncomplicated, and the environmental component (gluten and related grain storage proteins in the diet) is remarkably well understood. Previous family studies of celiac disease suggested that there is at least one important non-HLA locus. This locus may be a stronger genetic factor than HLA, and it apparently has a recessive mode of inheritance. We used a three step genome screening protocol to identify loci that contribute to celiac disease in the western counties of ireland, a region with the highest prevalence of celiac disease in the world. The most significant of several possible non-HLA loci that we found was on chromosome 6p about 30 cM telomeric from HLA. It has a multipoint maximum lod score of 4.66 (compared with 4.44 for HLA-DQ) and appears to have a recessive mode of inheritance. Our study localizes and provides strong evidence for linkage of at least one non-HLA locus to celiac disease and may serve as a prototype for an efficient approach to screening the human genome for loci that contribute to complex diseases.

HLA-DR, DQ genotypes of celiac disease patients and healthy subjects from the West of Ireland.

Celiac disease (CD) has one of the strongest class II HLA associations of any human illness. We used DNA-RFLP typing to study the class II HLA genotypes of celiac disease patients from the West of Ireland, the geographic area with the highest rate of celiac disease in the world. We confirmed the high frequency of HLA-DR3 in this population, and we were also able to demonstrate the additional risk of developing celiac disease imparted by HLA-DR7. This was done by clearly distinguishing DR7,DQ2 haplotypes from DR7,DQ9 haplotypes, and by "subtraction analysis" of haplotype frequencies. As reported in other populations, most of the patients without DR3 were heterozygous for DR7 and DR11 or 12 (DR5), or had DR4. We used PCR-RFLP and direct sequencing of amplified DNA to examine HLA-DR4 subtypes. The frequency of HLA-DR4 was markedly decreased in patients compared with controls (p = 0.000001) and there was a significant alteration of DR4 subtypes of the patients compared with controls (p = 0.0227). Moreover, all of the CD patients (5 of 5) with DR4 had a haplotype associated with the DQB1*0302 allele compared with only 11 of 23 control subjects with DR4. Our results in this population with exceptionally high risk of CD strongly support the DQ heterodimer hypothesis and suggest that the recently described sequence difference between the DQB1*02 alleles of DR3 and DR7 may contribute to a synergistic increased risk when these haplotypes are inherited together. In addition, our findings suggest a role for HLA-DQ in DR4-associated CD.

T cell receptor gamma gene polymorphisms and class II human lymphocyte antigen genotypes in patients with celiac disease from the west of Ireland.

Although celiac disease has one of the strongest human lymphocyte antigen (HLA) class II associations of any human illness, it is clear that at least one gene that is not linked to the HLA region also is required for its pathogenesis. The occurrence of large numbers of gamma delta T cells in the bowel mucosa of patients and the recent description of T cell receptor (TCR) gamma chain polymorphic variants identified by restriction fragment length polymorphism analysis led the authors to examine TCR gamma genotypes in relation to HLA-DR, DQ genotypes in 89 patients with celiac disease and 55 control subjects from the West of Ireland. The overall frequency of TCR gamma genotypes in patients and control subjects was comparable. However, most of the patients had 1 of 3 HLA-DR3 genotypes (DR3/15, 3/7, or 3/3), and there was a significant alteration of the expected frequency of TCR gamma genotypes among patients with these three genotypes. The major differences were an increased association of HLA-DR3 homozygosity, with TCR gamma genotypes having a 16.0 kb fragment and an increased frequency of DR3/7 heterozygosity and decreased frequency of DR3/15 heterozygosity, respectively, in association with the TCR gamma 13.0/11.3 kb genotype. Based on their results, there is the possibility that an interaction between the products of two polymorphic and unlinked gene regions contributes to the pathogenesis of celiac disease.

Familial anticardiolipin antibodies and C4 deficiency genotypes that coexist with MHC DQB1 risk factors.

OBJECTIVE: To investigate the familial basis of antiphospholipid antibodies by studying putative risk factors at the C4 and MHC class II loci. METHODS: Autoimmune diseases, anticardiolipin (aCL) and other autoantibodies were studied in 38 first and 2nd degree family members of 3 index cases selected for primary antiphospholipid syndrome (APS) and 33 controls. C4 protein phenotyping and restriction fragment length polymorphism analysis of C4 and MHC class II loci were performed. RESULTS: Nineteen family members (46%) had autoimmune diseases or autoantibodies; aCL were present in 10 family members, 4 of whom had primary APS. Each family had 2 or more subjects with aCL. Among 22 independent haplotypes in family members, there was a high frequency of C4A and C4B deficiency alleles (0.41 vs 0.18 in 66 controls, p = 0.03) and a strong trend toward an increase in MHC DQB1 putative risk factors that share the TRAELDT structural domain. This DQB1 structural domain was present in 4/5 different haplotypes that contained a C4B deficiency genotype; however, neither of 2 different haplotypes with a C4A deletion (one being a common ancestral haplotype) contained this DQB1 putative risk factor. Among the 10 family members who had aCL, 10/20 haplotypes contained a C4 deficiency genotype; moreover, the DQB1 putative risk factor was present in all 16 MHC haplotypes that did not contain a C4A deletion. CONCLUSION: In these families, expression of an autoimmunity trait as aCL antibody appears to be associated with the coexistence of C4 deficiency alleles with DQB1 alleles that contain the TRAELDT structural domain.

Celiac disease: clinical features and pathogenesis.

Celiac disease is a fascinating illness, from both a clinical and research perspective. Most clinicians consider a diagnosis of celiac disease when a young patient has classic signs and symptoms of steatorrhea and severe malabsorption. However, the typical gastrointestinal symptoms often are absent. The patient may only have subtle signs of chronic malnutrition or nonspecific gastrointestinal complaints. Celiac disease is not diagnosed commonly in the United States, at least in part because of a low clinical index of suspicion. A diagnosis of celiac disease is confirmed by a small bowel mucosa biopsy. A dramatic clinical response to a gluten-free diet verifies the diagnosis, and provides a cost-effective treatment free of significant side effects. Strict adherence to the prescribed diet usually results in a complete resolution of the symptoms and mucosal histopathologic changes. The serious, long-term complication of intestinal lymphoma also may be prevented. To the clinical investigator, celiac disease is an important model of the HLA-associated immune-mediated illnesses. A specific HLA-DQ heterodimer is found in 95% of patients, representing perhaps the strongest association of any illness with a specific class II HLA molecule. In addition, an important environmental trigger (gluten) has been identified, providing a unique opportunity to study the interaction of gene products and environmental factors in the pathogenesis of an immune-mediated disease.

Evidence for an ongoing role of class I histocompatibility molecules for the production of interleukin-2 in response to suboptimal concentrations of phytohaemagglutinin.

To examine the role of cellular interactions involving class I histocompatibility antigens in the response to low concentrations of phytohaemagglutinin, we studied the effect of antibodies to components of these antigens on proliferative responses, interleukin-1 and interleukin-2 production, and IL-2 receptor expression. Antibody to human beta 2-microglobulin (beta 2m) had an inhibitory effect both on IL-2 accumulation at 48 h of culture and on the proliferative response 24 h later. Exogenous IL-2 completely reconstituted the inhibited proliferative responses, and also restored the modest decrease in IL-2 receptor expression that was induced by anti-beta 2m. Pretreatment of either purified monocytes or T cells with anti-beta 2m had a similar inhibitory effect both on proliferation and on interleukin-2 production. By contrast, IL-1 production by LPS- or silica-stimulated monocytes was not affected by this antibody. Kinetic experiments demonstrated that anti-beta 2m was equally inhibitory when added at the initiation of culture or after 24h, and significant inhibition occurred when the antibody was added as late as 48 h. Our results are consistent with an ongoing role for class I antigens in the cellular interactions between lymphocytes and accessory cells required for the production of IL-2.

Mechanism of calcium ionophore and phorbol ester-induced T-cell activation. Accessory cell requirement for T-cell activation.

We examined the role of monocytes in T-cell activation induced by phorbol myristate acetate (PMA) and calcium ionophore ionomycin. Depletion of monocytes from peripheral blood mononuclear cells (PBMC) was associated with the loss of interleukin-2 (IL-2) production, IL-2 receptor (IL-2R) expression and proliferation, in response to either PMA or ionomycin. Addition of monocytes to highly purified T cells resulted in the complete reconstitution of IL-2 production, IL-2R expression and proliferation by PMA-stimulated lymphocytes. Exogenous IL-2, but not interleukin-1 (IL-1), could reconstitute the T-cell responsiveness. Addition of monocytes to highly purified T cells stimulated with ionomycin resulted in partial reconstitution of IL-2 production, IL-2R expression and proliferation. Similarly, the addition of exogenous IL-2 to ionomycin-stimulated T cells only partially reconstituted the response compared with PBMC. These results suggest that monocyte-T-cell interactions contribute to IL-2 production and IL-2R expression and are crucial events for PMA-induced T-cell proliferation. With ionomycin, monocytes play a role, in part, in inducing IL-2 production, IL-2R expression and proliferation. However, IL-2 is not a sufficient signal to induce T-cell proliferative response to ionomycin, suggesting that an IL-2-independent mechanism may exist in ionomycin-induced T-cell proliferation.

Evidence for a dominant gene mechanism underlying coeliac disease in the west of Ireland.

Although coeliac disease (CD) is strongly associated with the HLA alleles B8 and DR3, the genetic basis of this illness remains obscure. Recent studies show that at least two unlinked loci are involved. Most studies agree on recessivity at the HLA-unlinked locus but differ with respect to dominance or recessivity at the HLA-linked disease susceptibility locus. To address this controversy, we examined the association of CD with HLA in 39 families from the West of Ireland. Previous studies have shown that the prevalence of CD and the frequencies of the HLA antigens associated with it are higher in this population than in most others. Analysis of the data revealed a significant excess of concordant sib-pairs with two HLA haplotypes in common and an excess of discordant pairs with no haplotype in common. Chi-square tests confirmed a highly significant association between HLA-B8 and CD. Both heterozygotes and homozygotes for B8 had a significantly increased risk of CD. The risk for homozygotes was slightly higher than for heterozygotes, although not significantly so. The segregation ratio for disease occurrence among sibs of probands was estimated to be 0.185 when neither parent is affected. We estimated a gene frequency of 0.003 for the disease allele (C) at the HLA-linked locus and of 0.648 for the disease allele (d) at the HLA-unlinked locus. Assuming that CCdd homozygotes are always affected and that only carriers of C who are homozygous dd can be affected, the disease was found to be completely penetrant in Ccdd heterozygotes. These results support dominance at the HLA-linked locus conferring susceptibility to CD. Possible reasons for the discrepancy between the West of Ireland and other populations are discussed.

Inhibition of polyamine synthesis suppresses human lymphocyte proliferation without decreasing cytokine production or interleukin 2 receptor expression.

Difluoromethylornithine (DFMO) irreversibly inhibits ornithine decarboxylase (ODC), a crucial enzyme in polyamine synthesis, and impairs mitogen-induced lymphocyte proliferation. To examine the mechanism of action of DFMO, we studied the effect of this ODC inhibitor on lymphokine production and interleukin 2 (IL 2) receptor expression. DFMO decreased thymidine uptake of peripheral blood mononuclear cells stimulated by the mitogens phytohemagglutinin, concanavalin A, phorbol myristate acetate and ionomycin 60-70% compared with untreated cells, and the inhibition could be completely reversed by 10 mM spermidine. DFMO had no effect on IL 1 production by monocytes exposed to silica particles. Concentrations of IL 2 increased 7-fold in DFMO-treated, PHA-stimulated PBMC cultures, compared with untreated cells; whereas IL 2 receptor expression as measured by the anti-Tac monoclonal antibody was not affected by the inhibition of ODC. Mixing experiments using cells cultured with or without DFMO indicated that the inhibition by DFMO was not mediated by suppressor cells. Our results strongly support the concept that polyamines are required for a relatively late event in lymphocyte activation occurring after the interaction of IL 2 and its receptor.

Fluorescent light decreases autoimmunity and improves immunity in B/W mice.

Fluorescent light emitted from cool white tubular fluorescent lamps covered with standard acrylic lids decreased autoimmunity and enhanced immunity in the New Zealand Black/New Zealand White F1 hybrid female (B/W) mouse model of systemic lupus erythematosus (SLE). Thirty-three weeks of daily cool white fluorescent light exposure significantly decreased anti-ds DNA antibody levels and spleen size, and increased lymphocyte responsiveness to lipopolysaccharide (LPS) in B/W mice depilated to enhance light penetration. Depilation alone had no significant effect. The immunomodulatory potential of fluorescent light in B/W mice has not been previously appreciated, and may have important implications in SLE.

Mechanism of a lymphocyte abnormality associated with HLA-B8/DR3: role of interleukin-1.

Lymphocytes from normal individuals with the histocompatibility antigens HLA-B8 and DR3 have impaired proliferative responses when stimulated with suboptimal concentrations of mitogens. We have previously shown that an important factor in the impaired response is a failure to produce normal quantities of interleukin-2 (IL-2). To examine the mechanism of decreased responsiveness further, we measured interleukin-1 (IL-1) production of low responder subjects compared with controls. The peripheral blood mononuclear cells of five low responder individuals with HLA-B8/DR3 stimulated with 0.05 micrograms/ml of phytohaemagglutinin (PHA) accumulated only 0.036 U/ml of IL-1 compared with 0.32 U/ml for normal responders. There was a highly significant correlation between the PHA-stimulated IL-1 concentration at 12 h and the subsequent IL-2 concentration at 48 h(r = 0.89, P less than 0.0001) suggesting a role of decreased IL-1 production in the impaired response. A study of unfractionated or column-fractionated culture supernatants revealed no evidence that the decreased IL-1 activity in the supernatants of low responder subjects was related to increased IL-1 inhibitor concentrations. These results suggest that impaired IL-2 production and lymphocyte proliferation in healthy subjects with HLA-B8/DR3 may be mediated at least in part by decreased IL-1 production, and implicates a defect of a very early event in lymphocyte activation.

Antibodies to beta 2-microglobulin, the light-chain component of class I histocompatibility molecules, provide an activation signal to human lymphocytes.

Antibodies to beta 2-microglobulin (beta 2m), the light-chain component of class I histocompatibility antigens, provide a strong co-stimulatory signal to human lymphocytes in the presence of phorbol ester. This activation signal requires a high concentration of antibody, whereas the effect on responses to a mitogenic lectin is exclusively inhibitory over a broad dose range. A rabbit polyclonal and a mouse monoclonal antibody to beta 2m were similarly co-stimulatory. Antibody to beta 2m was co-stimulatory with phorbol ester, but not calcium ionophore, suggesting that class I antigens play a role in the initiation of the 'first' signal of a recently described two-signal model of lymphocyte activation.