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The aim of this study was to study polymorphonuclear leukocyte (PMN) functions in patients with solid tumor prior to or following X-irradiation. We observed that PMNs from patients with head and neck cancer exhibited decreased chemotaxis, while phagocytosis and intracellular killing of Candida albicans were normal. In contrast, PMNs from other solid cancer exhibited decreased intracellular killing of C. albicans, while chemotaxis and phagocytosis functions were normal. Local body X-irradiation significantly decreased PMN chemotaxis and intracellular killing of Candida albicans, but had no effect on phagocytosis. The effect on PMN function was dose-dependent and observed in 46 out of 65 patients (71%) that received a dose above 1000 Rad. Patients whose PMNs exhibited normal chemotaxis after receiving a dose above 1000 Rad, had comparable numbers of granulocytes and lymphocytes than those showing significant depression. No correlation was found between chemotaxis and circulating leukocyte number. Also, no correlation was found between the effects of X-irradiation on PMN functions and circulating lymphocyte number. In summary, patients with solid tumors show selective defects in PMN functions.

Purpose: To evaluate the effectiveness of a one-day and three-day train-the-trainer HIV/AIDS program delivered to homeopathy and ayurveda practitioners and educators. Introduction: The purpose of the training was to assess (a) the change in knowledge of and attitudes regarding HIV/AIDS at three and six months following the training, and (b) the number of secondary trainees trained by the primary trainees. Methods: Participants included 202 physicians of homeopathy and ayurveda in northern India. A total of 96 physicians of homeopathy and ayurveda were trained as primary trainees in the one-day program, and 106 were trained in the three-day program. Knowledge of and attitudes toward HIV/AIDS were measured by a modified 21-item questionnaire. The one-day training program covered epidemiology of the disease, transmission, and clinical presentation with a case-study approach. The three-day training added the social, ethical, and legal impact of being HIV-infected along with health counselor and participant role plays. Results: Findings revealed that both the one-day and three-day primary trainees significantly increased their HIV/AIDS knowledge and attitude scores from pretest to immediate posttest with ongoing improvement in both groups over the three- and six-month period. A total of 26% of primary trainees in the one-day program trained secondary trainees, and 36% of primary trainees in the three-day program trained secondary trainees. Conclusions: A train-the-trainer approach can improve the knowledge and attitude scores of ayurveda and homeopathy practitioners and educators as well as increase the number of secondary trainees. Increasing the number of trained providers to reinforce HIV prevention messages has policy implications for the Indian System of Medicine, which serves nearly 2.5 million HIV-infected patients.

Objective Interleukin-2 (IL-2) is a cytokine with multiple effects on lymphocytes including induction of CD4 T-cell proliferation. IL-2 administration has been shown to increase CD4 cell counts in HIV-infected people receiving antiretroviral therapy. GB virus C (GBV-C) is an apparently nonpathogenic flavivirus that replicates in CD4 T cells and inhibits HIV replication in vitro by mechanisms including downregulation of HIV entry coreceptors (CCR5 and CXCR4) and induction of chemokines (RANTES, MIP-1alpha, MIP-1 beta, and SDF-1). GBV-C replication is significantly inhibited in vitro by activation of primary CD4 cell cultures with IL-2 and phytohemagglutinin. We sought to determine if there is an interaction between GBV-C and IL-2 in vivo. Methods GBV-C viremia status was characterized in 92 HIV-infected individuals participating in a randomized trial of IL-2 and antiretroviral therapy [AIDS Clinical Trials Group Study (ACTG) 328]. Changes in CD4 cell counts and HIV RNA levels in individuals assigned IL-2 were compared with those in individuals assigned antiretroviral therapy alone. Results Individuals lacking GBV-C viremia had a significantly greater rise in CD4 cell count with IL-2, compared with GBV-C viremic individuals (by 511 cells/microl at week 84; interaction P = 0.02): GBV-C viremic individuals assigned IL-2 did not demonstrate a significant increase in CD4 cell count compared with individuals not assigned to receive IL-2 (95% CI for difference -255 to 397 cells/microl). Conclusion GBV-C viremia was associated with a block in CD4 cell expansion following IL-2 therapy in the ACTG 328 study, and GBV-C status may be an important factor in IL-2 treatment response.

Nurses play a major role in the health care delivery system; therefore education of nurses is critical to successful prevention programs for persons with HIV. Little is known about nurses’ knowledge of HIV in India. The purpose of this study was to determine the effects of a nurse-led train-the-trainer HIV education program on improving the HIV knowledge of nurses. A group of senior nurses (N = 10), were responsible for training a cohort of 10 nurses each, totaling 100 nurses. The 2-day training program included HIV epidemiology, and etiology, infection control, psychosocial support, counseling, modes of transmission, natural history of the disease, symptoms of early and late disease, diagnostic testing, and legal and ethical issues. Pre-and post-test scores were calculated using a self-administered structured questionnaire that measured HIV-related knowledge in terms of cognitive and transmission knowledge. Paired t-tests indicated that both measures of HIV knowledge improved significantly from pre-test to post-test.

This study is designed to assess AIDS knowledge among Homeopathy educators and physicians in India, which has not been evaluated previously. India now has the largest number of HIV infected persons worldwide, with an estimated cumulative 5.1 million infections. Homeopathy is the dominant system among the nationally-recognized alternative or complementary systems of medicine, which collectively provide health care to around 600 million people in India. Homeopathy, with its holistic and patient-centered approach, has a wide reach to people at risk of contracting human immunodeficiency virus (HIV). Participants were 68 homeopathy physicians (34 educators and 34 practitioners) who completed a CDC questionnaire measuring HIV/AIDS Knowledge regarding AIDS. This study reports the current level of knowledge of, and attitudes about, HIV/AIDS among homeopathy educators and practitioners. These findings will assist in the development of an education module to equip homeopathic health care personnel to impart accurate AIDS information and prevention counseling to their patients in an efficient manner. © 2007 The Author(s).

This study investigated circulating natural killer (NK), CD4+ and CD8+ cells in response to acute psychological challenge among mothers of child cancer survivors with and without posttraumatic stress symptoms (PTSS). Control mothers of healthy children (n = 9) were compared to 17 cancer mothers with (PTSS: n = 9) and without PTSS (No PTSS: n = 7) under conditions of rest, after a generic stressor (MAT: mental arithmetic task) and a personalized stressor (script-driven trauma imagery), and after recovery from each stressor. Results indicate the PTSS group had higher percentage CD4+ and lower CD8+ levels than non-symptomatic women and blunted NK reactivity to generic challenge. Multiple regression analyses indicated PTSS effects were independent of self-reported distress. Contrary to expectations, cancer mothers without PTSS were not significantly different from controls on tonic or phasic immune outcomes. Also unlike predictions, reactivity to challenge was greatest to the non-social MAT stressor compared to the personalized challenge for all groups. Conclusions are constrained by study limitations (e.g., small sample size and potential phase order effects). Nonetheless, results are consistent with an emerging literature on PTSS-associated immune differences and further suggest these effects may be distinct from that associated with subjective distress more generally.

Objective To determine if inducing self-blame would lead to increases in shame and guilt as well as increases in proinflammatory cytokine activity and cortisol. Based on previous research and theory, it was hypothesized that induced shame would be specifically associated with elevations in proinflammatory cytokine activity. Materials and methods Healthy participants were randomly assigned to write about traumatic experiences in which they blamed themselves (N = 31) or neutral experiences (N = 18) during three 20-minute experimental laboratory sessions over 1 week. Tumor necrosis factor-alpha receptor levels (sTNFalphaRII), an indicator of proinflammatory cytokine activity, beta2-microglobulin, cortisol (all obtained from oral fluids), and emotion were assessed prewriting and postwriting. Results Participants in the self-blame condition showed an increase in shame and guilt as well as an increase in sTNFalphaRII activity when compared with those in the control condition. Cortisol and beta2-microglobulin levels were unaffected by the procedures. Those individuals in the self-blame condition reporting the greatest increases in shame in response to the task showed the greatest elevations in proinflammatory cytokine activity, while levels of guilt and general negative emotion were unrelated to cytokine changes. Conclusion These data suggest that inducing self-related emotions can cause changes in inflammatory products, and that shame may have specific immunological correlates.

Background. Aging is associated with decline in both cell-mediated and humoral immunity and may contribute to increased incidence and severity of infections in frail elderly. Exercise, depending on intensity, has significant effects on the immune system. We conducted a randomized, controlled clinical trial of a 32-week functionally oriented exercise program in frail elderly living in nursing homes and determined whether the exercise intervention was associated with a change in immune parameters in this frail elderly nursing home population. Methods. Nursing home residents were randomly assigned to an intervention (n ¼94) and control group (n ¼96). The intervention consisted of a functionally oriented endurance and resistance exercise training that was provided every 2 hours from 8:00 AM to 4:00 PM for 5 days a week for 8 months. Lymphocyte subpopulations, including activation markers (CD28, CD25, HLA-DR), in vitro proliferation, and soluble products of cytokine activity (neopterin and sTNF-RII) in serum were measured by taking blood samples at baseline and after 8 weeks and 32 weeks of the intervention. Results. Exercise training did not induce changes in lymphocyte subpopulations, activation markers (CD28, CD25, HLA-DR), in vitro proliferation, and soluble products of cytokine activity (neopterin and sTNF-RII) in serum. Conclusions. A 32-week exercise intervention did not bring about beneficial or detrimental effects on immune parameters in the frail elderly nursing home population and may explain why the intervention was not associated with a change in the incidence of infections in the intervention group compared with the control group.

C-reactive protein (CRP) is an acute-phase reactant whose levels increase in response to a variety of inflammatory stimuli. Elevated levels in serum are observed after trauma, tissue necrosis, infection, surgery, and myocardial infarction and are associated with an increased risk of cardiovascular disease. CRP levels are also elevated in noninflammatory states, such as obesity, sleep disturbances, depression, chronic fatigue, aging, and physical inactivity. In this study, the performance of a highly sensitive CRP enzyme immunoassay was evaluated, along with common laboratory variables (specimen type, processing time, and storage conditions) that may influence measured blood concentrations of CRP. The measurement range of the assay was from 0.4 to 50 μg/liter. Total imprecision (coefficient of variation) ranged from 8.1 to 11.4%. CRP levels obtained with the enzyme immunoassay were highly correlated with those obtained with an automated immunonephelometric assay. Comparable results were obtained for plasma (heparin and EDTA treated) and serum samples, and levels were unaffected by delays in sample processing and storage temperature. CRP levels were also unaffected by up to seven freeze-thaw cycles. The median CRP concentration in healthy adults was determined to be 0.94 mg/liter, with a 95% working reference interval of 0 to 6.9 mg/liter. In view of these data, we recommend that serial serum or plasma samples for CRP should be stored at 4 o C for short periods of time or at −70 o C for longer periods and tested within the same run to minimize interassay variability.

This study tested the hypothesis that cognitive processing about a past bereavement would produce increases in goals and priorities indicative of finding positive meaning from the loss. It was further hypothesized that increases in meaning-related goals would be associated with changes in immune function, specifically increased natural killer cell cytotoxicity (NKCC). Cognitive processing was manipulated using written emotional disclosure. Forty-three women who had lost a close relative to breast cancer wrote about the death (cognitive processing/disclosure group) or about nonemotional topics weekly for 4 weeks. Contrary to predictions, written disclosure did not induce changes in meaning-related goals or NK cell parameters. However, women in both experimental groups who reported positive changes in meaning-related goals over the study period also showed increases in NKCC. Results suggest that prioritizing goals emphasizing relationships, personal growth, and striving for meaning in life may have positive biological correlates but that solitary written disclosure may not be sufficient to induce changes in these goals in response to a past bereavement.

Objective Fatigue is a common problem among cancer patients and survivors, yet the mechanisms underlying the occurrence and persistence of this symptom are not known. Activation of the immune system may evoke feelings of fatigue, which are mediated by proinflammatory cytokines. We examined whether fatigued breast cancer survivors would show elevations in proinflammatory cytokines and markers of cytokine activity compared with nonfatigued survivors. Differences in lymphocyte subsets, cortisol, and behavioral symptoms associated with proinflammatory cytokines were also assessed. Methods Forty breast cancer survivors (20 fatigued, 20 nonfatigued) provided blood samples at visits scheduled to control for diurnal variability. Cytokines, soluble markers of cytokine activity, and cortisol were measured by immunoassay and lymphocyte subsets by flow cytometry. Participants also completed questionnaires measuring demographic, medical, and behavioral variables. Results Fatigued breast cancer survivors had significantly higher serum levels of several markers associated with proinflammatory cytokine activity than nonfatigued survivors, including interleukin-1 receptor antagonist (IL-1ra), soluble tumor necrosis factor receptor type II (sTNF-RII), and neopterin. They were also more likely to report behavioral problems that co-occur with fatigue in the context of immune activation. Fatigued survivors had significantly lower serum levels of cortisol than the nonfatigued group as well as differences in two lymphocyte populations. Conclusions Fatigued breast cancer survivors showed elevations in serum markers associated with proinflammatory cytokine activity an average of 5 years after diagnosis. Results suggest mechanisms through which enduring immune activation may occur, including alterations in cortisol and in lymphocyte subsets.

Background: Exceptionally robust cell preparations are needed for quality assessment programs (QAPs) such as the International Program for Quality Assessment and Standardization for Immunological Measures (QASI) relevant to HIV/AIDS. A suitable product must withstand environmental stress related to transportation for a minimum of 6 days. The two objectives of this study are (1) to evaluate the performance of various commercial preparations with multicenter participation and (2) to evaluate the robustness of stabilized blood cell products. Methods: Phase 1: The performance of stabilized blood cell products was evaluated in a multicenter QAP utilizing various staining procedures and flow cytometers. Absolute cell enumeration was achieved using single-platform T-cell subset methodology. Phase 2: The robustness of stabilized blood cell products was evaluated by monitoring T-cell subset values from samples stored at 4°C, 22°C, and 37°C for up to 10 days. Results: The largest interlaboratory variation in both absolute and relative T-cell values was 16% in samples with CD4 levels >400 cells per microliter and 21% in samples with CD4 levels

Measurements of CD4 T-cell levels are essential for the assessment of human immunodeficiency virus (HIV) disease course, clinical staging, epidemiological studies, and decisions regarding prophylactic therapies against opportunistic infection. Until now, only in the industrialized countries was T-cell subset monitoring considered a practical option to assess disease progression. The Quality Assessment and Standardization for Immunological Measures Relevant to HIV/AIDS (QASI) program was established in 1997 to meet performance assessment for immunophenotyping laboratories in countries where such service is not available. The QASI program is provided at no cost to any laboratory in a resource-poor setting that wishes to participate. This report describes the beneficial impact of participation in the QASI program. Carefully selected commercial stabilized whole blood preparations were sent regularly to participating laboratories. Participants reported the T-cell subset values they obtained by flow cytometry. Once the aggregate mean values for the T-cell subsets were established for the shipment, a comprehensive and confidential report was sent to each laboratory. The results from five consecutive shipments were analyzed. The coefficient of variation decreased from 7.2% to 4.7% and from 14.2% to 8.8% for percent and absolute CD4 T-cell counts, respectively. With the implementation of the QASI program using commercial stabilized whole blood specimens, it is possible to reduce interlaboratory error. This study illustrates that a quality assessment program can improve the overall performance of laboratories. Reducing interlaboratory variation can enhance significantly the effectiveness of multicenter HIV vaccine or drug trial evaluation.

Objective: This study examines whether there may be an immune component that protects a relatively rare group of HIV-infected people with very low CD4 cell counts (≤ 50 × 10 6 /l) \) who have prolonged asymptomatic periods. Design/methods: Three groups were recruited in Miami: (i) healthy low CD4 cell count patients (HLC; n = 30) who, for 9 months had < 50 x 10 6 CD4 cells/l, were asymptomatic and were not on protease inhibitors during that time; (ii) HIV comparison group (Comp; n = 60) who had CD4 cell counts predominantly 150 × 10 6 to 400 x 10 6 /l and never had AIDS Category C symptoms; this group was also followed for CD4 cell count and viral load change over 6 months; and (iii) healthy community controls (n = 33). The study was replicated at the University of California at Los Angeles (UCLA) with HLC (n = 31) versus HIV-negative laboratory controls (n = 28). Results: The HLC patients were significantly higher than the Comp group on natural killer cell cytotoxicity (NKCC) and natural killer cell number (NK#) despite their lower CD4 cell numbers and higher viral loads. In fact, there was no difference between the HLC group and the healthy community control group in NK# or NKCC. The NK findings were replicated at UCLA. A retrospective analysis showing that higher NKCC was related to fewer prior symptoms in the HLC group, and prospective analysis in the Comp group showing that NK# predicted a lower increase in viral load over 6 months further supported the importance of NK# and NKCC. Conclusions: Non-specific cellular immunity may be a factor protecting the health of HIV sero-positive individuals with very low CD4 cell counts.

Idiopathic CD4+ T cell lymphocytopenia was unexpectedly detected in a 33-year-old, otherwise healthy young woman with no HIV or other viral infection, autoimmune, or neoplastic disease or increased susceptibility to infection. CD4+ T cell levels were 60–140/μl over a 3.5-year period. Following an uneventful pregnancy, the patient developed anemia and interstitial nephritis associated with a plasma cell dyscrasia with a monoclonal IgA gammopathy and a shifting immunoglobulin pattern that included IgG and IgA monoclonal proteins and increased urinary light chains. Osteolytic lesions were never detected and bone marrow aspirations revealed up to 10% atypical plasma cells. Various therapies often used in treating multiple myeloma only temporarily controlled the increasing renal damage. IL-2 therapy of 600,000 to 1 million units subcutaneously daily resulted in increased CD4+ T cells to normal levels, a decrease in the gammopathy, a return of renal function, energy, and weight gain, and apparently normal health status sustained for 2 years. The findings are compatible with a potentially fatal but nonmalignant immunoregulatory disorder that can be controlled by IL-2 administration.

Evaluation of cytokine gene expression following in vitro stimulation is one means of examining the dysregulation of the immune system in human immunodeficiency virus (HIV) infection. We have assessed differences in the immune status of non-HIV-infected (HIV−) and HIV-infected (HIV+) individuals by evaluating the kinetics of the expression of cytokine genes. We compared detailed time courses of cytokine mRNA expression in HIV− and HIV+ peripheral blood mononuclear cells (PBMC) and found that there is a significant shift (P< 0.01) for all cytokines examined (interleukin 2 [IL-2], IL-6, IL-10, gamma interferon, and tumor necrosis factor alpha [TNF-α]) to an earlier time of mean peak mRNA expression by HIV+ PBMC (between 4 and 8 h) compared to HIV− PBMC (8 h) in response to either phytohemagglutinin (PHA) or anti-CD3 stimulation. Additional studies showed that although PHA-stimulated HIV+ PBMC showed decreased median IL-2, IL-4, and TNF-α mRNA levels, they typically demonstrated more rapid kinetics (increased mean 4-h/24-h cytokine mRNA ratios), with significant differences for IL-4 (P< 0.05) and TNF-α (P< 0.005), compared to HIV− PBMC. The use of fresh or frozen cells gave comparable cytokine mRNA data; however, the secretion of some cytokine proteins (IL-2 receptor, IL-10, and TNF-α) appeared to be reduced in HIV+ PBMC that had been frozen and thawed. Our studies demonstrate that the kinetics of cytokine gene expression can reveal additional dysregulation of the immune system in HIV infection, suggesting that PBMC of HIV-infected persons exist in an activated state in vivo that permits them to express cytokine genes more rapidly than a normal PBMC.

Background In patients with advanced human immunodeficiency virus (HIV) infection, aphthous ulceration of the mouth and oropharynx can become extensive and debilitating. Preliminary reports suggest that thalidomide may promote the healing of oral aphthous ulcers. Methods We performed a double-blind, randomized, placebo-controlled study of thalidomide as therapy for oral aphthous ulcers in HIV-infected patients. The patients received a four-week course of either 200 mg of thalidomide or placebo orally once per day. They were evaluated weekly for the condition of the ulcers, their quality of life, and evidence of toxicity. Assays were performed for plasma tumor necrosis factor α (TNF-α), soluble TNF-α receptors, and HIV RNA. Results Sixteen of 29 patients in the thalidomide group (55 percent) had complete healing of their aphthous ulcers after four weeks, as compared with only 2 of 28 patients in the placebo group (7 percent; odds ratio, 15; 95 percent confidence interval after adjustment for group sequenti...

Worry, the cognitive enumeration and anticipation of potential future negative events, is associated with autonomic dysregulation, which may in turn have implications for the immune system. People endorsing high (n = 7) and normal levels of trait worry (n = 8) were briefly exposed to a phobic stimulus and the autonomic and immune responses and recovery were assessed. A time-matched control group (n = 6) was not exposed to any stimulus. Both worry groups showed increased heart rate and skin conductance in response to phobic fear. However, only the normal worry group showed a concomitant increase in natural killer cells in peripheral blood. Patterns of change during the follow-up period suggested that phobic fear had disrupted a normal circadian increase in natural killer cells. Adrenergic and hypothalamus-pituitary-adrenal mechanisms may be responsible for the differences between high and normal worry groups in their natural killer cell response to and recovery from phobic fear.

This study examined how specific emotions relate to autonomic nervous and immune system parameters and whether cynical hostility moderates this relationship. Forty-one married couples participated in a 15-min discussion about a marital problem. Observers recorded spouses' emotional expressions during the discussion, and cardiovascular, neuroendocrine, and immunologic parameters were assessed throughout the laboratory session. Among men high in cynical hostility, anger displayed during the conflict was associated with greater elevations in systolic and diastolic blood pressure, cortisol, and increases in natural killer cell numbers and cytotoxicity. Among men low in cynical hostility, anger was associated with smaller increases in heart rate and natural killer cell cytotoxicity. These findings suggest that models describing the impact of stress on physiology should be refined to reflect the joint contribution of situational and dispositional variables.

Cytokines and soluble immune activation markers that reflect cytokine activities in vivo are increasingly being measured in plasma, serum, and other body fluids. They provide useful diagnostic and prognostic information as well as insight into disease pathogenesis. Assays of neopterin, β2-microglobulin, soluble interleukin-2 receptor, and soluble tumor necrosis factor receptor type II as well as of the cytokines tumor necrosis factor alpha and gamma interferon (IFN-γ) were evaluated by using serum and plasma samples of human immunodeficiency virus (HIV)-positive and HIV-negative subjects. Many factors were found to influence the outcomes of these assays. Substantial differences in apparent levels of analytes were frequently found when enzyme-linked immunosorbent assay (ELISA) kits from different manufacturers were used. In some cases, differences were found in the standards provided by separate manufacturers. Furthermore, the analytic results from different lots of ELISA kits supplied by single manufacturers differed by as much as 50%. The need for uniformity in the standards for quantitative assays was clearly illustrated. International reference standards are available for cytokines but not for soluble cytokine receptors or soluble activation markers. Marker levels in serum or in plasma were similar except those for IFN-γ. Most of the analytes were stable under several storage conditions. Thus, batch testing of frozen stored samples is feasible. The findings indicate that for longitudinal studies, the levels of cytokines and immune activation markers in plasma or serum should be measured by using preverified reagents from one manufacturer. The quality of laboratory performance can have an impact on clinical relevance. Proficiency testing and external quality assurance programs can help to develop the needed consensus.

This study investigated whether finding meaning in response to an HIV-related stressor was associated with changes in immune status and health. Forty HIV-seropositive men who had recently experienced an AIDS-related bereavement completed interviews assessing cognitive processing and rinding meaning after the loss and provided blood samples for a 2- to 3-year follow-up. AIDS-related mortality over an extended follow-up was determined from death certificates. As predicted, men who engaged in cognitive processing were more likely to find meaning from the loss. Furthermore, men who found meaning showed less rapid declines in CD4 T cell levels and lower rates of AIDS-related mortality (all ps < .05), independent of health status at baseline, health behaviors, and other potential confounds. These results suggest that positive responses to stressful events, specifically the discovery of meaning, may be linked to positive immunologic and health outcomes. The ways in which individuals respond to stressful life events may influence their immune status and, potentially, their physical health. A growing number of studies in the field of psychoneuroimmunology have found that exposure to stressful experiences is associated with changes in the human immune system (for review, see Cohen & Herbert, 1996; Kemeny, Solomon, Morley, & Herbert, 1992). It has been hypothesized that these immune changes are related to cognitive and emotional responses elicited by the stressor (e.g., Cohen & Herbert, 1996). However, studies have generally failed to assess the associations between particular ways of responding to a stressor, both positive and negative, and immune outcomes. In addition, few studies have examined the health consequences of immune changes associated with stressful experiences and the psychological responses they provoke. One important way of responding to a stressful experience

Procedures for quality control (QC) in a laboratory that concentrates on cytokine and soluble marker measurements in biological fluids are outlined. Intra-assay, interassay, and interlaboratory experiences are presented. Plasma and serum β2-microglobulin (β2M) and neopterin test data are presented in greatest detail, along with substantial tumor necrosis factor alpha (TNF-α), gamma interferon, soluble interleukin-2 receptor-α (sIL-2Rα), sTNF-RII, IL-4, and IL-6 data. Recommended QC procedures for cytokine and soluble-marker testing include replicate testing of two or more reference samples provided by the kit manufacturer, replicate testing of in-house frozen reference QC samples that represent normal and abnormal analyte contents, retesting 15 to 20% of randomly selected samples, and comparing normal reference ranges each year. Also, eight cytokines and soluble markers were evaluated in human immunodeficiency virus (HIV)-seronegative and HIV-seropositive individuals stratified on the basis of CD4 T-cell numbers. Levels of some but not all cytokines in serum increased in HIV infection. There was a tendency for cytokines to increase with more advanced disease, defined by reduced CD4 T-cell numbers. Cytokine changes did not relate closely to CD4 level, indicating that separate information was provided by the measurements of TNF-α, sTNF-RII, sIL-2Rα, β2M, and neopterin. Serum IL-4 and TNF-α levels were not increased. The quality of laboratory data can impact on clinical relevance. Interlaboratory comparisons revealed substantial differences at some sites and documented the need for external proficiency-testing quality assurance programs.

Laboratory surrogate markers of human immunodeficiency virus (HIV) infection are needed to provide information about the stages and course of disease, especially in the years prior to the development of clinical signs and symptoms of immune disorder, e.g., opportunistic infections or neoplasia.

Objective: To evaluate the prognostic significance for AIDS occurrence of plasma levels of immune activation markers in comparison with and in conjunction with HIV viral load and CD4 T-cell measurements. Design: A retrospective analysis was conducted of three plasma activation markers, the soluble tumor necrosis factor (TNF) receptor Il (TNF-RII), neopterin and soluble interleukin-2 receptor levels, and of CD4 T-cell levels and plasma HIV viral load. Subjects: The participants were 659 men taking part in the University of California Los Angeles Multicenter AIDS Cohort Study who were HIV-seropositive but AIDS-free in 1985. Main outcome measure: Clinically defined AIDS within 3 years. Failure time statistical regression models for the time to development of AIDS were used to assess prognostic capacity of the parameters alone and in combination. Results: All the markers had prognostic capability. The levels of the three plasma activation markers correlated well with each other (median r = 0.61). They related less well with HIV RNA plasma levels (median r = 0.50) and least well with CD4 cell levels (median r = 0.36). Furthermore, plasma marker levels were shown to be able to stratify patients for prognosis within all the major categories of CD4 T-cell and HIV RNA levels. Conclusions: Plasma levels of soluble TNF-RII and other soluble markers of immune activation have prognostic capabilities which are different from HIV and CD4 T-cell levels. Combination of a single plasma activation marker measurement (such as soluble TNF-RII) with CD4 T-cell levels improved the prognostic capability of each. A new graphic technique for presenting prognostic capability indicated that plasma soluble TNF-RII and CD4 cell levels are better prognostic factors than HIV plasma level with CD4 cells < 200 x 10 6 /l. Inexpensive tests for one of the plasma activation markers, such as soluble TNF-RII or neopterin, can be useful for evaluations of HIV disease course, especially when expensive equipment, technical expertise and funding required for flow cytometry and for HIV load measurements are not readily available.

To explore the role of sympathetic nervous system activation in HIV pathogenesis, we examined the effect of the neuroeffector molecule norepinephrine (NE) on HIV-1 replication in quiescently infected PBMCs that were subsequently activated with Abs to CD3 and CD28. NE accelerated HIV-1 replication at concentrations ranging from 10−8 to 10−5 M. This effect could be mimicked by protein kinase A (PKA) activators (forskolin or dibutyryl-cAMP) and abrogated by β-adrenoreceptor antagonists or the PKA inhibitor rp-cAMP, indicating transduction via the adrenoreceptor signaling pathway. NE reduced cellular activation and altered the production of several HIV-modulating cytokines: IL-10 and IFN-γ were markedly suppressed; TNF-α, IL-1β, IL-2, IL-4, and IL-6 were mildly suppressed; and levels of IL-12 were not significantly altered. The addition of either exogenous IFN-γ or IL-10 abrogated the effect of NE on virus production. Thus PKA-dependent suppression of cytokine production appears to mediate the enhancement of HIV-1 replication by NE.

Oral fluids are convenient alternatives to blood sampling for evaluating significant metabolic components. Two forms of oral fluids, oral mucosal transudates (OMT) and saliva, were collected and compared for content of soluble products of immune activation. The data confirm that OMT and saliva represent distinct body fluids. The concentrations, outputs, and analyte/protein ratios of β-2-microglobulin (β2M), soluble tumor necrosis factor alpha receptor II (sTNFαRII), and neopterin were measured. Both the OMT and the saliva of most of the individuals in the control healthy populations had measurable levels of all three activation markers. When the immune system is activated, as in human immunodeficiency virus (HIV) infection, the levels of β2M and sTNFαRII are increased in both OMT and saliva compared to those in a healthy control population. OMT levels correlated better with levels in serum than did saliva and appear to reflect systemic immune activation in HIV infection. Because acquisition of oral fluids is noninvasive and easily repeatable, measurement of β2M and/or sTNFαRII content in OMT could be useful in the assessment of disease activity in patients with HIV infection or chronic inflammatory diseases.

Measures of immune function have become increasingly important as endpoints in AIDS clinical trials, with respect to both modulation and reconstitution of immunity by experimental therapies. Measurement of immune function in this setting requires the development of robust analytic approaches suitable for the clinical laboratory. Experiments were performed to evaluate the suitability of using cultured heparinized (“whole”) blood for induction of tumor necrosis factor alpha (TNF-α) and gamma interferon (IFN-γ), two cytokines critical in AIDS pathogenesis. TNF-α expression ranged from 229 to 769 pg/ml in lipopolysaccharide (LPS)-stimulated cultures and was not detected in unstimulated cultures. IFN-γ expression ranged from 0 to 112,000 pg/ml in phytohemagglutinin A (PHA)-stimulated cultures and from 0 to 789 pg/ml in antigen-stimulated cultures. The mean coefficient of variation observed in three weekly determinations was 0.47 for TNF-α and ranged from 0.12 to 1.73 for IFN-γ. These values indicate that sample sizes of 8, 24, and 29 subjects would be sufficient to detect twofold changes in LPS-induced TNF-α and in PHA- and antigen-induced IFN-γ, respectively, if two baseline and two treatment determinations were obtained, and if the interpatient variability of changes in true levels from baseline to follow-up is negligible compared to the variability in the three weekly measurements. Measurement of LPS-induced TNF-α and mitogen- or antigen-induced IFN-γ can be performed simply and reproducibly in human immunodeficiency virus-infected persons by the whole-blood culture method. Further studies are warranted to determine the effect of overnight shipping on assay reproducibility and to determine the extent to which responses can be reliably detected in subjects with low CD4 cell numbers.

Changes in the patterns of cytokine expression are thought to be of central importance in human infectious and inflammatory diseases. As such, there is a need for precise, reproducible assays for quantification of cytokine mRNA that are amenable to routine use in a clinical setting. In this report, we describe the design and performance of a branched DNA (bDNA) assay for the direct quantification of multiple cytokine mRNA levels in peripheral blood mononuclear cells (PBMCs). Oligonucleotide target probe sets were designed for several human cytokines, including TNFalpha, IL-2, IL-4, IL-6, IL-10, and IFNgamma. The bDNA assay yielded highly reproducible quantification of cytokine mRNAs, exhibited a broad linear dynamic range of over 3-log10, and showed a sensitivity sufficient to measure at least 3000 molecules. The potential clinical utility of the bDNA assay was explored by measuring cytokine mRNA levels in PBMCs from healthy and immunocompromised individuals. Cytokine expression levels in PBMCs from healthy blood donors were found to remain relatively stable over a one-month period of time. Elevated levels of IFNgamma mRNA were detected in PBMCs from HIV-1 seropositive individuals, but no differences in mean levels of TNFalpha or IL-6 mRNA were detected between seropositive and seronegative individuals. By providing a reproducible method for quantification of low abundance transcripts in clinical specimens, the bDNA assay may be useful for studies addressing the role of cytokine expression in disease.

This study explored prospectively the effects of dispositional and situational optimism on mood (N = 90) and immune changes (N = 50) among law students in their first semester of study. Optimism was associated with better mood, higher numbers of helper T cells, and higher natural killer cell cytotoxicity. Avoidance coping partially accounted for the relationship between optimism and mood. Among the immune parameters, mood partially accounted for the optimism—helper T cell relationship, and perceived stress partially accounted for the optimism-cytotoxicity relationship. Individual differences in expectancies, appraisals, and mood may be important in understanding psychological and immune responses to stress.

Worry is a cognitive activity in which potential problems are anticipated and enumerated in an attempt to control the future. Worry has been associated with dysregulation of the autonomic nervous system, which may extend to the immune system. The relationship between trait worry and immune parameters was investigated at three follow-up points after the Northridge earthquake in a sample of 47 hospital employees. Participants with scores above the median on a trait worry measure had fewer natural killer cells than participants with worry scores below the median and controls. This effect was not mediated by intrusive thoughts, avoidance, anxious mood, or health behavior. These results suggest that worry may have a detrimental effect on the regulation of natural killer cells during stress. This effect may be due to differences in autonomic responsiveness associated with worry.

The goal of this study was to determine the relationship between plasma human immunodeficiency virus (HIV) load and cytokine expression. HIV-RNA plasma levels were determined in 34 HIV-seropositive (HIV+) asymptomatic subjects [range: 0.5 to 211 kiloequivalents (kEq)/ml HIV-RNAJ, by a modified branched-DNA (bDNA) assay. Plasma HIV-RNA levels were positively correlated with increased plasma levels of TNF-alpha, soluble TNF receptor type II, soluble IL-2 receptor, beta 2-microglobulin, and neopterin, but not with plasma IL-6 levels. In contrast, increased viral load and diminished CD4 counts correlated weakly. TNF-alpha mRNA levels, as determined by bDNA technology, were not significantly increased in peripheral blood mononuclear cells (PBMC) isolated from HIV-infected subjects, compared to HIV-seronegative (HIV-) subjects, and were not correlated with plasma levels of HIV-RNA, cytokines, or activation markers. These results are consistent with the hypothesis that a self-reinforcing mechanism exists between TNF-alpha production and generalized immune activation on one hand with HIV replication on the other.

BACKGROUND In patients with advanced human immunodeficiency virus (HIV) infection, aphthous ulceration of the mouth and oropharynx can become extensive and debilitating. Preliminary reports suggest that thalidomide may promote the healing of oral aphthous ulcers. METHODS We performed a double-blind, randomized, placebo-controlled study of thalidomide as therapy for oral aphthous ulcers in HIV-infected patients. The patients received a four-week course of either 200 mg of thalidomide or placebo orally once per day. They were evaluated weekly for the condition of the ulcers, their quality of life, and evidence of toxicity. Assays were performed for plasma tumor necrosis factor alpha (TNF-alpha), soluble TNF-alpha receptors, and HIV RNA. RESULTS Sixteen of 29 patients in the thalidomide group (55 percent) had complete healing of their aphthous ulcers after four weeks, as compared with only 2 of 28 patients in the placebo group (7 percent; odds ratio, 15; 95 percent confidence interval after adjustment for group sequential testing, 1.8 to 499; unadjusted P

OBJECTIVE The 1994 Northridge earthquake created life disruption and psychological distress for employees of the nearby Sepulveda VA Medical Center. We were interested in the immunologic correlates of disruption and distress under these stressful circumstances. METHOD Sixty-eight employees were examined beginning 11 days post-earthquake and were observed until about 4 months after the earthquake, during which time three psychological and immunologic assessments were done. Subjects experienced life disruption from the earthquake itself, damage to home and possessions, injury to self and others, and damage to and functional disruption of workplace. Questionnaires assessed degree of life disruption (personal and work-related), mood, earthquake-specific distress, and repression (alexithymia, coping style or "Type C", and "immunosuppression-prone" traits). Immune measures included lymphocyte subsets-total T (CD3+), helper T (CD4+), cytotoxic T (CD3 + CD8+), B (CD19+), and natural killer (NK; CD3 - CD16 + CD56+)-as well as lymphoid cell mitogenesis (PHA and PWM), and NK cell cytotoxicity. RESULTS Along with a lessening degree of distress over time, a number of immunologic measures declined over the assessment period (CD3+, CD8+, CD16 + 56+ cells. T cell blastogenesis, and NK cell cytotoxicity). Furthermore, subjects reporting low distress had higher numbers of CD3+ and CD8+ cells and a higher proliferative response to PHA. Those with distress corresponding to life disruption had highest levels of CD3+ and CD8+ cells. Measures of repression did not relate directly to immunity. CONCLUSION These results suggest that appropriateness of psychological reaction to the realistic degree of life stress was least disruptive of an aspect of immunity.

Reduced CD4 T cell level and increased serum neopterin and β2-microglobulin levels, which reflect immunological activation and dysregulation, are three important markers of HIV disease. The aim in this study is to delineate more clearly the relation of activation to future CD4 values and disease progression. By analyzing a cohort of 198 seroconverters from the Multicenter AIDS Cohort Study with 9 years' follow-up, the dynamic changes and levels of these three markers and their interrelationships are explored. We observed that the levels of markers in the first year after seroconversion have a much stronger impact on the progression of the disease than the preseroconversion marker levels. The actual change during the year after seroconversion is not as important as the final level reached during that year. The early levels of markers after seroconversion appear to be good indicators of the subsequent course of disease as defined by CD4 level and slightly better than the quantitative changes following seroconversion or the changes in the period 1 to 2.5 years after seroconversion. To investigate the variation between subjects, the 198 seroconverters were stratified into three approximately equal-sized groups in 12 ways based on their pre- and postseroconversion levels and changes in the three markers. The group with the highest CD4 level within a year after seroconversion maintains the highest CD4 level 8 years after seroconversion. The group with the lowest level of neopterin or β2-microglobulin in this period has much higher future CD4 counts than the other two groups. The level of markers during the first year after seroconversion has a high predictive power for AIDS onset. Substantial differences in the hazards of AIDS are found between the groups with the highest and lowest CD4 count, neopterin, and β2-microglobulin following seroconversion. The three markers are generally correlated throughout the postseroconversion period but can provide distinct information. High current levels of neopterin or β2-microglobulin tend to be associated with low future CD4 count, while current levels of CD4 count have less association with future neopterin and β2-microglobulin levels.

Immune-based therapies are being explored on the presumption that host response to HIV is central to the pathogenesis and progression of HIV infection. Specific immune responses in most individuals serve to limit the acute stage of infection and induce a more chronic form of viral infection. Thus, immune response to HIV appears to be critical to virus control. On the other hand, HIV infection induces widespread activation of immune cells, which in turn contributes to further HIV production. Also, immune dysfunction contributes to the development of a number of clinical disorders of AIDS, including opportunistic infections, wasting syndrome, AIDS dementia complex, Kaposi’s sarcoma and lymphoproliferative disorders.

Recent laboratory studies have shown several immune system changes consistently associated with brief stress including increases in circulating natural killer (NK) cell numbers, increases in NK cell cytotoxicity (NKCC), increases in suppressor cytotoxic (CD8) T cell numbers, and decreases in the in vitro proliferative response to mitogen stimulation. In the present study, we use a confrontational role-play, which brings out responses varying from assertion to capitulation and examine the psychological, behavioral, physiological, and immune system responses to this task compared to a resting control task. Compared to the control condition, the brief confrontational role-play led to significant subjective and physiological arousal and increases in circulating NK (CD16, CD56) as well as large granular lymphocyte (CD57) cells and suppressor/cytotoxic T cells (CD8). There were also significant relationships between stress-related increases in the cardiovascular measures and the numbers of circulating NK cells. These findings support sympathetic nervous system activation as a primary mechanism for increases in NK cell numbers under challenge. These role-play results are generally consistent with those from other laboratory tasks such as mental arithmetic. However, in contrast to previously examined brief stressors, the role-play led to decreased NKCC adjusted for percentage of NK cells. This apparent differential change in NK cytotoxicity across different types of activating experimental tasks points to the importance of examining dimensions of the behavioral and emotional response to challenge or threat in addition to that of autonomic arousal.

Tumor necrosis factor-alpha (TNF) may activate human immunodeficiency virus (HIV), antagonize zidovudine activity, and contribute to AIDS wasting syndrome. Pentoxifylline decreases TNF production. In cell culture, pentoxifylline decreases HIV replication and gene expression. Since an AIDS Clinical Trial Group study suggested that pentoxifylline (400 mg thrice daily) is safe in AIDS patients and decreases TNF mRNA levels in peripheral blood mononuclear cells (PBMC), a second cohort received 800 mg thrice daily for 8 weeks. During treatment, the median decrease in TNF production by PBMC cultured with 0.1 microgram/mL lipopolysaccharide (LPS) was 40%. The median change in TNF mRNA was a 34% decrease. Pentoxifylline did not affect HIV levels as detected by quantitative microculture or serum p24 antigen measurements, nor did it alter zidovudine pharmacokinetics. The most common toxicity was gastrointestinal. Pentoxifylline at dosages of less than thrice-daily 800 mg is well tolerated and may decrease TNF mRNA levels and LPS-induced TNF production.

This study investigated subjective, cardiovascular, and cellular immune system responses in 20 healthy young men during brief mental arithmetic stress compared with a video-watching control task. The role of endogenous opioids in mediating the immunological change to stress was examined by pre-task administration of the opiate antagonist naloxone. Immune changes were followed over a 1 hr post-task period. The results indicate significant physiological arousal and subjective distress as well as increases in NK cell cytotoxicity, numbers of circulating CD8 suppressor/cytotoxic T cells and NK lymphocytes following mental arithmetic but not the control task. Immune measures generally returned to baseline by 1 hr after the stress. Naloxone did not block the increase in NK cell activity or cell numbers following the stressor and had no effect on the other physiological or subjective measures. Thus, the results do not support endogenous opioids as a primary mechanism for immune changes to this type of acute stress. Naloxone did, however, increase NK cell cytotoxicity during the video task without effecting NK cell numbers, suggesting naloxone itself can increase per-cell NK cytotoxicity. Affective ratings for the week preceding testing were inversely related to the increase in NK cell numbers during mental arithmetic. If the increase in NK cell numbers under brief stress is part of an adaptive response to potential injury, then our data suggest that increases in general distress may impede normal immune system adaptation. Acute stress paradigms may be used as potential probes for investigations of individual differences in immune system responsivity.

Objective: Quantify and study cofactors of long-term survival without AIDS in HIV-1-infected individuals with CD4 + cell counts

The objectives of this study were to determine 1) whether immune changes relevant to HIV progression occurred in HIV-seropositive men after the death of their intimate partner, and 2) whether depressed mood was associated with these immune changes. The bereaved group consisted of 39 gay men whose intimate partners had died of AIDS over the past year; the nonbereaved group consisted of 39 age- and HIV serostatus-matched nonbereaved men. Immunological parameters were assayed from blood samples drawn before and within 1 year after the death of the partner (bereaved group) or over an equivalent time period (nonbereaved group). In the HIV-seropositive bereaved men only, a significant increase in immune activation and a significant decrease in the proliferative response to phytohemagglutinin occurred after the death of the partner. These immunological changes were not explained by the use of recreational drugs, alcohol, cigarettes, or AZT. These data indicate that the death of an intimate partner in HIV-positive men is associated with immune changes that are relevant to HIV progression.

When zidovudine and dideoxycytidine (ddC) were given on schedules of 1 week on drug and 1 week off, results differed substantially in effects on HIV (human immunodeficiency virus type 1)-induced immune activation. Zidovudine (200 mg every 4 h) caused marked lowering toward normal of serum neopterin and beta 2-microglobulin within 1 week. This effect was lost within 1 week off zidovudine. Intermittent ddC (0.03 mg/kg every 4 h) had a smaller 1-week effect but had a delayed cumulative suppressive effect on HIV-associated immune activation that was not seen with intermittent zidovudine therapy. Zidovudine and ddC given in alternating weeks had synergistic effects in the first 10 weeks (e.g., early and rapid reduction followed by cumulatively greater effects on immune cell activation). The identical sawtooth effect of intermittent zidovudine was also evident in serum HIV p24 antigen levels. This is consistent with the hypothesis that the increased serum levels of the immune activation markers seen in HIV infection reflect stimulatory effects of HIV viral components on immune system cells.

The Clinical Immunology Society (CIS) developed in two broad contexts: (1) as a component of immunology research and education with human relevance, and (2) as a component of clinical medicine, i.e., disease identification, pathogenesis, treatment, and prevention. Indeed, a purpose of the CIS was to bring these two areas closer together. Initial goals included uniting the clinical investigators from the wide array of clinical fields and providing information on scientific and clinical advances. There was also the intent to enhance the framing and scope of immune-based therapies. Conversations were initiated in 1984 to develop a society for bringing together the leadership of the many clinical and laboratory contexts of clinical immunology. From 1979 to 1984, I had been on the National Advisory Council for Allergy and Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), the senior advisory group to the NIAID, which met three times each year to review recommendations for research grant awards. In those years, I became acquainted, at least by name and field of interest, with almost all of the leading immunologists in the USA. Many I knew from my own research defining human andmurine immunoglobulins in the 1960s, immunology and cancer studies in the 1970s, and description and characterization of AIDS in the 1980s. The discussions from 1984 to 1986 involved more than 50 immunologists in the USA (Table I) and with a dozen more from other countries. The leading relevant organizations were consulted. These included the American Association of Immunology (AAI), the NIH, especially the NIAID, and other health-related organizations. Initial discussions identified several individuals who became major partners in advancing this enterprise: Noel Rose, Gary Fathman, Max Cooper, and Bernard Janicki. Noel Rose made special contributions and was a cofounder. His experience included AAI committees, advocacy of the American Board of Medical Laboratory Immunology within the American Society of Microbiology, as editorin-chief of the Manual of Clinical Laboratory Immunology, and as editor of the journal, Clinical Immunology and Immunopathology. He shared administrative responsibilities in the first years and has recounted some of the early events (Noel Rose, The inception of the Clinical Immunology Society—see http://www.clinimmsoc.org/about/history. php). Gary Fathman was prominent with his knowledge of the emergence of immunology in many clinical subspecialties and his own contributions at this interface. Max Cooper was a leader in both pediatric and fundamental immunology and was en route to becoming president of the AAI. Bernard Janicki was central to immunology communication at the NIH and communication with NIAID leadership.

Proliferation of normal T lymphocytes is impaired by human immunodeficiency virus (HIV) proteins. In this paper, we demonstrate important parts of this mechanism. Initially, HIV-induced impairment of proliferation was shown to be an active process involving induction of protein tyrosine kinases in both CD4 and CD8 T cells. Furthermore, the impairment of cell proliferation was demonstrated to be linked to induction of the inhibitory protein kinase A (PKA) pathway by HIV proteins. This induction of PKA was accompanied by an increase in intracellular cAMP, which is necessary for the activation of PKA. Finally, increases in cAMP/PKA activity were shown to induce biochemical changes that impaired proliferation when cells were stimulated with phytohemagglutinin. This was demonstrated by showing that (i) agents, other than HIV proteins, that increase cAMP/PKA activity (cholera toxoid and 8-bromo-cAMP) also decreased T-lymphocyte proliferation; (ii) exposure of lymphocytes to HIV or cholera toxoid led to decreased membrane activity of the proliferation promoter protein kinase C upon stimulation; and (iii) agents that reduced cAMP generation neutralized the effect of HIV proteins and restored lymphocyte proliferation. These studies show that the HIV-induced augmentation of cAMP/PKA activity may be a key part of the mechanism responsible for all or part of the HIV-induced anergy of T lymphocytes.

SYNOPSISFunctional and phenotypic immunological parameters were examined immediately before, after, and 30 minutes after experimentally-induced short-term positive (happiness) and negative (anxiety, depression) affective states and a neutral state, in five healthy subjects. Results indicated that all affective states induced more immune fluctuations (regardless of the direction) than the neutral state. Furthermore, among the affective states, anxiety induced the most immunological variability and depression the least.