Leukocyte infiltration and mRNA expression of IL-20, IL-8 and TNF-R P60 in psoriatic skin is driven by TNF-alpha.

Anti-TNF-alpha therapy with a chimeric monoclonal antibody (Infliximab, Remicade) has been shown to be highly effective in the treatment of skin lesions as well as arthritis in patients with psoriatic arthritis. In this study we investigated the molecular consequences of the in vivo TNF-alpha blockade with infliximab in psoriatic skin lesions of 6 patients with severe psoriatic arthritis. Biopsies from lesional and non-lesional skin were taken before and 10 weeks after the initiation of treatment. Immunohistochemistry and semiquantative RT-PCR were performed focusing on proinflammatory gene products. Immunohistochemistry, after three infusions, revealed a marked decrease in the expression of TNF-alpha, HLA-DR, CD3, CD15, ICAM-1 and LFA-1 positive cells. By semiquantitative RT-PCR, we analysed mRNA expression of IL-8, IL-20, TNF-R (TNF-R p60 and TNF-R p80), IL-1R I and IL-1R II, as well as ICAM-2. Before therapy, m-RNA for IL-8, IL-20, TNF-R p60, TNF-R p80, IL-1R II and ICAM-2 were detected in lesional skin. mRNA expression of IL-8 and IL-20 completely disappeared and mRNA expression of TNF-R p60 was reduced after therapy. This effect on IL-8 expression was paralleled by a decreased infiltration of leukocytes in psoriatic skin. These data suggest that the clinical response of anti-TNF-alpha therapy in patients with psoriasis or psoriatic arthritis may be, at least in part, caused by the inhibition of the production of proinflammatory cytokines and by the decreased expression of adhesion molecules with the consequence of an impaired migration of proinflammatory cells into the inflamed tissue. These data further support a critical role for TNF-alpha in the pathology of psoriasis.

Treatment of psoriatic arthritis with antitumour necrosis factor-alpha antibody clears skin lesions of psoriasis resistant to treatment with methotrexate.

BACKGROUND: In inflamed skin, keratinocytes and inflammatory cells both produce large amounts of tumour necrosis factor (TNF) -alpha, a cytokine with broad effects that are relevant to inflammation. Blockade of this proinflammatory cytokine by a monoclonal anti-TNF-alpha antibody might be effectively used in the treatment of inflammatory skin diseases. OBJECTIVES: To gather information about the efficacy of an anti-TNF-alpha antibody (infliximab) in the treatment of skin lesions of psoriatic arthritis. METHODS: Six patients with progressive joint disease and psoriatic skin lesions unresponsive to methotrexate therapy were treated with anti-TNF-alpha antibody. The Psoriasis Area and Severity Index was determined before and 10 weeks after initiation of therapy. RESULTS: Improvement of psoriatic skin lesions was observed in all patients. In addition, a marked improvement of the joint disease was noted. CONCLUSIONS: Therapy with anti-TNF-alpha antibody may be an effective treatment regimen for both psoriatic arthritis and psoriatic skin lesions.

Immature dendritic cells generated with low doses of GM-CSF in the absence of IL-4 are maturation resistant and prolong allograft survival in vivo.

Dendritic cells (DC) were cultured from mouse bone marrow (BM) progenitors in low concentrations of granulocyte-macrophage colony-stimulating factor (GM-CSF) (GM(lo) DC) by two different protocols. The phenotype and functional properties of these GM(lo) DC were compared to those of standard BM-DC cultures generated in high concentrations of GM-CSF (GM(hi) DC) or in low GM-CSF plus IL-4 (GM(lo)/IL-4 DC). An effect of IL-4 on maturation was observed only at low but not high doses of GM-CSF. Compared to mature DC, GM(lo) DC were phenotypically immature, weak stimulators of allogeneic and peptide-specific T cell responses, but substantially more potent in presentation of native protein. Immature GM(lo) DC were resistant to maturation by lipopolysaccharide, TNF-alpha or anti-CD40 monoclonal antibodies, as the expression of co-stimulatory molecules was not increased, and stimulatory activity in oxidative mitogenesis was not enhanced. These maturation-resistant immature GM(lo) DC induced T cell unresponsiveness in vitro and in vivo. GM(lo) DC also prolonged haplotype-specific cardiac allograft survival (from 8 days to >100 days median survival time) when they were administered 7 days (but not 3, 14 or 28 days) before transplantation. Our findings may have important implications for future studies in T cell tolerance induction in vivo.

Human monocyte derived dendritic cells express functional P2X and P2Y receptors as well as ecto-nucleotidases.

We investigated the expression and function of P2 receptors and ecto-nucleotidases on human monocyte derived dendritic cells (DC). In addition we analyzed the effect of extracellular ATP on the maturation of DC. By RT-PCR, DC were found to express mRNA for several P2X (P2X1, P2X4, P2X5, P2X7) and P2Y (P2Y1, P2Y2, P2Y4, P2Y5, P2Y6, P2Y10, P2Y11) receptors. As shown by FURA-2 measurement, triggering of P2 receptors resulted in an increase in free intracellular Ca2+. In combination with Tumor necrosis factor-alpha, ATP increased the expression of the DC surface markers CD80, CD83 and CD86 indicating a maturation promoting effect. DC expressed the ecto-apyrase CD39 and the ecto-5'-nucleotidase CD73 as demonstrated by RT-PCR. Extracellular ATP was rapidly hydrolyzed by these ecto-enzymes as shown by separation of 3H-labeled ATP metabolites using a thin layer technique. These data suggest that ATP acts as a costimulatory factor on DC maturation.

An advanced culture method for generating large quantities of highly pure dendritic cells from mouse bone marrow.

As dendritic cells (DC) are rare populations in all organs, their generation from hematopoietic precursors in large quantities has proven critical to study their biology. From murine bone marrow about 5 x 10(6) cells at 70% purity are obtained per mouse after 8 days of culture with GM-CSF. We have improved this standard method and routinely achieve a 50-fold higher yield, i.e., 1-3 x 10(8) immature and mature DC per mouse at 90-95% purity. The major modifications were: (i) the avoidance of any active depletion of bone marrow cell subpopulations to circumvent loss of precursors, (ii) a lower plating density of bone marrow cells, (iii) a prolonged culture period of 10-12 days, (iv) the reduction of the GM-CSF dose from day 8 or 10 onwards to reduce granulocyte contaminations. The final non-adherent population at day 10-12 constitutes a mixture of immature and mature DC. Further maturation of DC could be induced by high doses of LPS or TNF-alpha for the last 24 h, where 50-70% of the non-adherent fraction represented mature DC with high levels of NLDC-145, CD86 and CD40. This method allows by simple means the generation of high numbers of murine DC with very low B cell or granulocyte contaminations. It will be valuable to study DC biology notably at the molecular level.

Analysis of cytokine patterns produced by individual CD4+ lymph node cells during experimental murine leishmaniasis in resistant and susceptible mice.

The concept of subdividing CD4+ T cells into Th0, Th1 and Th2 cells is based on the cytokine pattern produced by long-term in vitro cultured T cell lines. However, there exists uncertainty whether this classification can also be applied to CD4+ T cells in vivo. Herein it was investigated whether and at which frequency Th0, Th1 and Th2 cells are induced in vivo during an infection of mice with Leishmania major. Cytokine co-production in single IFN-gamma+ or IL-4+ CD4+ T cells as well as the frequency of such cells were assessed in the lymph nodes (LN) of infected mice. For this purpose, T cells derived from the draining LN were activated by phorbol myristate acetate (PMA)/ionomycin, and the intracellular cytokines IL-2, IL-4, IL-5, IL-10 and IFN-gamma were analyzed by immunofluorescence. One week after infection, a strong, but comparable increase of IFN-gamma+ CD4+ and IL-4+ CD4+ cells (up to 7% of all CD4+ cells) in the LN was observed in resistant C57BL/6 mice and susceptible BALB/c mice. IFN-gamma and IL-4 were not co-produced by single cells ('Th0 cells'). At later stages of the infection, the number of IL-4+ CD4+ cells decreased in C57BL/6, but not in BALB/c mice. All IL-4+ CD4+ cells showed an unexpected phenotype, because at least half of these cells co-produced IL-2, and the majority of the IL-4+ CD4+ did not co-produce the Th2 cytokines IL-5 and IL-10. Similar cytokine profiles were obtained when the CD4+ T cells were stimulated by Leishmania major-antigen instead of PMA/ionomycin. This study demonstrates that 'classical' Th1 cells (IFN-gamma+IL-2+), but no 'classical' Th2 cells (IL-4+IL-5+IL-10+) and no Th0 cells (IFN-gamma+IL-4+) are generated during L. major infection of mice in vivo.

Swallowed button batteries: is there a consensus on management?

The optimum management of ingested button batteries was ascertained by postal questionnaire sent to 608 members of the endoscopic and paediatric sections of the British Society of Gastroenterology. Some 312 returns were suitable for analysis: 36.2% of the respondents were not concerned about ingested button batteries and gave no treatment, 6.4% used medical treatment, 48.4% removed them under certain circumstances, and 9% did not know how to manage the problem. Emetics and H2 antagonists or antacids were often used for batteries in the oesophagus, stomach, and duodenum and laxatives were commonly prescribed for batteries in the small and large bowel. Of the 48.4% who felt batteries should be removed under certain circumstances, 78%, 72%, and 48% extracted them from the oesophagus, stomach, and duodenum respectively within 24 hours of ingestion. The main reason for operative removal from the small and large bowel was failure of the battery to progress. Current management is therefore variable. Heavy metal poisoning may be occurring more frequently than is suggested in the published reports.

Abnormal cardiovascular reflexes in patients with gastro-oesophageal reflux.

Using five non-invasive tests, abnormalities of cardiovascular reflex function were found in 20 of 50 patients with gastro-oesophageal reflux. Abnormalities of pupil cycle time, an index of non-vagal parasympathetic function, were found in only a few patients, implying that the cardiovascular abnormalities observed were not part of a generalised parasympathetic defect. The findings are consistent with the hypothesis that an abnormality of vagal function may contribute to the pathogenesis of gastro-oesophageal reflux.

Lack of necessity for corrections for pyloric losses and duodenogastric reflux in the performance of gastric secretory studies.

Gastric secretory studies are subject to considerable error owing to incomplete collections and to contamination by reflux of alkaline duodenal contents. Corrections for these sources of error have been defined, and they have been extensively applied in a research setting. In order to assess their utility in the performance of routine gastric secretory studies, the value of such corrections was assessed in 56 studies in patients with duodenal ulceration (10), previous surgical vagotomy (8), reflux oesophagitis (30) and primary oesophageal motility disorders (8). The effect of such corrections was small, and there were close correlations between uncorrected and corrected acid outputs in all four groups. The status of the vagal efferent gastric fibres was assessed by comparing the acid output after insulin hypoglycaemia with the maximal acid output after pentagastrin (insulin: pentagastrin ratio). The application of the corrections did not alter the conclusion regarding the assessment of vagal status in 55 of the 56 studies performed. It is concluded that such corrections are not necessary in the routine performance of gastric secretory studies.

Vagal function in achalasia of the cardia.

Autonomic nervous function in achalasia of the cardia was assessed by measuring the response of the lower oesophageal sphincter to abdominal compression, the gastric secretory response to insulin-induced hypoglycaemia and the pulse rate variability with deep respiration. Twenty-eight patients with symptomatic achalasia and 24 age and sex-matched control subjects were studied. Rise in intra-abdominal pressure normally causes a rise in lower oesophageal pressure through a vagally-mediated mechanism. Before treatment this response was unimpaired in eight of 10 patients with achalasia. A sub-normal response was found in eight of 10 patients who had previously had pneumatic dilatation of the cardia and in three of four who had had a cardiomyotomy. These abnormalities reflected the effect of treatment in disrupting the sphincter rather than impairment of its innervation. The gastric acid secretory response to insulin-induced hypoglycaemia, expressed as a ratio of that to pentagastrin, was normal in each of the nine patients studied. Pulse rate variability with deep respiration, a test of cardiac vagal function, was normal in 22 of 25 patients studied. It is concluded that in achalasia the vagal trunks appear functionally intact and that the myenteric plexus lesion rarely affects the responsiveness of the lower oesophageal sphincter to increase in intra-abdominal pressure.

Does dimethicone increase the efficacy of antacids in the treatment of reflux oesophagitis?

Dimethicone is a common additive to antacids, although its value in the treatment of reflux oesophagitis is unproven. Its efficacy was assessed by comparing the effect of a dimethicone-containing antacid gel (Asilone Gel) with a simple antacid gel in a double-blind trial in 45 patients with reflux oesophagitis. Thirty-eight patients completed the eight-week course of therapy. Antacid therapy alone resulted in a significant improvement of both symptoms and oesophagitis in gastro-oesophageal reflux. The inclusion of dimethicone in the antacid gel preparation did not confer any benefit in terms of symptomatic assessment but did confer a small advantage with regard to objective markers of oesophageal inflammation, suggesting that a dimethicone-containing antacid is of value in the treatment of symptomatic gastro-oesophageal reflux.

Impairment of vagal function in reflux oesophagitis.

Autonomic nervous function in reflux oesophagitis was assessed by measuring the response of the lower oesophageal sphincter to abdominal compression, gastric secretory response to insulin-induced hypoglycaemia and pulse rate variability with respiration. Rise in intra-abdominal pressure normally causes an increase in lower oesophageal sphincter pressure through a vagally mediated mechanism. In 59 of 83 patients with reflux oesophagitis the sphincter response was subnormal, and this was commoner in older patients but was unrelated to the presence of a hiatal hernia. During oesophageal acid perfusion, the onset of pain, but not that of disordered motility, was delayed in those with an abnormal sphincter response suggesting impairment of afferent autonomic function. Efferent gastric vagal function, assessed by the gastric secretory response to insulin induced hypoglycaemia and expressed as a ratio of the maximal acid output after pentagastrin, was subnormal in 15 of 27 patients with reflux oesophagitis. Pulse rate variability with deep respiration, an indicator of one aspect of non-alimentary vagal function, was subnormal in 18 of 62 patients with reflux oesophagitis. There was no correlation between abnormalities in these three tests of vagal function or with the severity of oesophagitis. These findings suggest that vagal impairment is common in reflux oesophagitis. As impairment of vagal function is not confined to the alimentary system it is unlikely to be simply a consequence of reflux oesophagitis and may be important in the pathogenesis of gastro-oesophageal reflux.

A frequency-duration index (FDI) for the evaluation of ambulatory recordings of gastro-oesophageal reflux.

Oesophageal pH monitoring has been undertaken in 20 symptomatic patients and 20 normal subjects for periods of 24 hours at work and in the home using a pH sensitive radiotelemetry capsule and a portable receiving system. There was no correlation between symptoms and endoscopic findings in symptomatic patients. The number and duration of reflux episodes was greater in symptomatic patients than normal subjects during 24 hour ambulatory study (P less than 0.002). A frequency-duration index for the evaluation of recordings is described which was significantly greater in symptomatic patients than in normal subjects during both day (P less than 0.002) and night (P less than 0.008) periods of recording. Discrimination between the two groups was more clearly seen using the frequency-duration index compared to either the frequency of reflux episodes or the cumulative duration of acid reflux.

Influence of the vagus nerve upon the reflex control of the lower oesophageal sphincter.

In 24 control patients the lower oesophageal sphincter responded to graded increments in intra-abdominal pressure by a significant and sustained rise in tone. This response was abolished by atropine and was also absent in nine of 11 patients who had previously undergone truncal vagotomy for duodenal ulcer but not in the remaining two who had recurrent ulceration. In six patients studied after proximal gastric vagotomy a variable response was seen. Gastric efferent vagal function was assessed by a combined insulin/pentagastrin gastric secretory test and did not correlate closely with the lower oesophageal sphincteric response to increased intra-gastric pressure. These findings are explicable if it is assumed that truncal vagotomy interrupts the afferent limb of a reflex arc regulating lower oesophageal sphincteric tone.

Pneumatic dilatation in achalasia.

To assess the value of pneumatic dilatation of the cardia, 63 patients with achalasia have undergone a total of 107 Rider-Moeller dilatations over the last six years. There was a marked improvement in swallowing immediately after dilatation in all but two patients, there were no deaths attributable to the procedure and serious complications were rare (1.6% of patients). The first 50 cases have been followed from nine to 73 months after their initial dilatation (mean follow-up 29.7 months). Twenty nine patients (58%) have not required a further dilatation, 19 patients (38%) required between one and three further dilatations and two patients (4%) required four more dilatations. Continuing need for further dilatation was significantly greater in those patients aged under 45 years than in those aged 45 or more at the time of their initial dilatation (p less than 0.001). Cardiomyotomy was necessary in five patients (10%), because of poor response to pneumatic dilatation; all five cases were under 45 years old at their initial dilatation. Pneumatic dilatation is a safe and effective treatment for achalasia, particularly in the older patient, and in our opinion should be the initial treatment for all patients with achalasia, reserving surgical cardiomyotomy for those who do not respond to several dilatations.

Type III glycogenosis presenting as liver disease in adults with atypical histological features.

Two cases of type III glycogen storage disease are reported in adults; the occurrence of cirrhosis in one case illustrates the potential development of chronic liver disease in this condition. The other was the oldest patient with this condition found in a review of published reports. Electron microscopy of peripheral blood leucocytes to demonstrate excess glycogen was found to be a quick and useful aid to diagnosis. Histology of these adult cases showed a distribution of hepatocyte vacuolation which has not been previously recorded.

Palliative intubation of oesophagogastric neoplasms at fibreoptic endoscopy.

Of one hundred and twenty-one patients with neoplastic obstruction of the oesophagus or cardia 118 underwent palliative intubation at fibreoptic endoscopy on a total of 135 occasions. Sixty had adenocarcinoma, 49 had squamous carcinoma, and in nine the oesophagus was involved by a growth arising elsewhere. Satisfactory swallowing ws restored in 112 patients. Thirteen patients died in hospital shortly after the procedure. Five fatal and 10 non-fatal perforations were sustained in 135 intubation procedures. Complications of tube function included food blockage on 26 occasions, tumour overgrowth on seven occasions, displacement on 16 occasions, disappearance of the tube in two patients, and late oesophageal perforation on nine occasions. Fifty-six patients survived for three months, 33 for six months, and 10 for a year after intubation. Comparison with series in the literature of patients who underwent surgical palliative intubation suggests that endoscopic palliation has lower mortality and morbidity, and an increased survival time, and is now the method of choice for palliation of oesophagogastric neoplasms.

Ambulatory monitoring of oesophageal pH in reflux oesophagitis using a portable radiotelemetry system.

Gastro-oesophageal reflux has been assessed in 10 symptomatic patients and 10 asymptomatic normal subjects during a study period of 24 hours at work and in the home using a newly developed pH sensitive radiotelemetry capsule and a portable receiving system. Oesophageal pH was continuously monitored by the tethered radiotelemetry capsule and recorded with a portable receiver and a 24-hour cassette recorder, allowing the patient complete freedom of movement so that ambulatory studies could be undertaken during a normal working day. The number and duration of reflux episodes was greater in symptomatic patients than normal subjects during 24-hour studies at home (p less than 0.002). In both groups, reflux occurred more during the day than at night (p less than 0.01). Patients refluxed significantly more at home than when they were in hospital (p less than 0.01). Ambulatory outpatient oesophageal pH monitoring may be useful in the management of patients with atypical symptoms and may demonstrate significant reflux when inpatient investigations and endoscopy findings show minimal abnormality.

Non-steroidal anti-inflammatory drugs and benign oesophageal stricture.

Drug histories were obtained from 76 patients at the time of initial Eder-Puestow dilatation for benign oesophageal stricture. Six patients had consumed drugs known to cause oesophageal ulceration (emepronium bromide and potassium preparations). Of the remaining 70 patients, 22 had regularly taken a non-steroidal anti-inflammatory drug before the onset of dysphagia compared with 10 patients in a control group matched for age and sex; this difference was significant (p less than 0.02). Non-steroidal anti-inflammatory drugs may have a causative role in the formation of oesophageal stricture in patients with gastro-oesophageal reflux, in whom they should be prescribed with caution.

Oesophageal stricture associated with emepronium bromide therapy.

Emepronium bromide, a drug used to control urinary frequency, has been reported as causing oesophageal ulceration but not stricture formation. This paper presents 3 cases in which the use of emepronium bromide preceded development of an oesophageal stricture and suggests that the drug played a causative role.