Relationships of matrix metalloproteinases and their inhibitors to cartilage proteoglycan and collagen turnover and inflammation as revealed by analyses of synovial fluids from patients with rheumatoid arthritis

OBJECTIVE

To determine interrelationships in matrix turnover in articular cartilage and joint inflammation in rheumatoid arthritis (RA).

METHODS

Synovial fluid was obtained from the knees of 63 RA patients; radiographs were evaluated to determine the RA stage. Concentrations of matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs), the 846 epitope, and the keratan sulfate (KS) epitope of aggrecan, the C-propeptide of cartilage type II procollagen (CPII; biosynthetic marker), the cleavage of type II collagen by collagenase (CIIC; generated neoepitope), and polymorphonuclear leukocyte elastase (PMNE; inflammation marker) were measured by immunoassay. Concentrations of the unsaturated disaccharides of hyaluronic acid (delta di-HA) and the proteoglycan glycosaminoglycan disaccharides of chondroitins 4 and 6 sulfate (delta di-C4S and delta di-C6S) were determined by high-performance liquid chromatography.

RESULTS

MMP-3 was markedly increased in RA compared with osteoarthritis. Increases in TIMP-1 in RA were less pronounced and were inversely correlated with MMP-3 levels. CIIC was reduced in RA, as was the release of the KS epitope and delta di-C6S. In contrast, delta di-C4S and the 846 epitope were up-regulated. PMNE levels correlated with the 846 epitope and delta di-C4S, and more strongly with TIMPs 1 and 2. The changes may signify attempts at control of proteolysis in parallel with increased aggrecan turnover, which would favor matrix assembly. PMNE also correlated with MMP-9, and MMP-9 correlated with CPII. The delta di-HA level was decreased in RA and was inversely correlated with CPII and MMP-9 as well as with MMPs 2 and 3. In contrast, delta di-HA was directly correlated with TIMP-1 and the 846 epitope. These observations suggest that HA and PMNs may be involved in the control of proteolysis and cartilage proteoglycan assembly.

CONCLUSION

Our observations provide new insights into the complex changes in cartilage turnover and PMN influx in RA joints.

Determination of cycloserine in human plasma by high-performance liquid chromatography with fluorescence detection, using derivatization with p-benzoquinone

A new method for determining cycloserine in plasma samples is described. This method is based on the derivatization of cycloserine with p-benzoquinone, a reaction that takes place at the same time as the process of plasma deproteinization due to the presence of ethanol as solvent in the solution of the derivatization reagent. Four derivatives are obtained from this reaction. The main derivative is well correlated with the cycloserine concentration. The ratio between the volumes of the plasma sample and the reagent solution is 1:2 for a p-benzoquinone concentration of 1000 microg/mL. Elution from a C18 column was isocratic, using a mobile phase containing (v/v) 85% aqueous 0.1% formic acid solution, and 15% (v/v) of a mixture of methanol and acetonitrile (1:1), with a flow-rate of 1 mL/min, at 25 degrees C. Determinations by fluorescence detection were achieved with excitation at 381 nm and emission at 450 nm, with a detection limit of 10 ng/mL for an injection volume of 5 microL. This method was validated and applied to the determination of cycloserine in blood plasma samples of several healthy volunteers.

[Liver transplantation--considerations over 8 cases operated in the year 2000]

In the year 2000, at the Department for General Surgery and Liver Transplantation from The Fundeni Clinical Institute Bucharest, seven OLTs and one living-related transplantation were performed in 6 adults and 2 children. Postoperative complications were: bile leakage, hemoperitoneum, lower gastrointestinal hemorrhage, parietoabdominal hematoma. There was only one postoperative death due to septic complications in the 18th p.o.d. and one late death due to pneumonia of unknown origin. After the results in the year 2000 there was an increased number of donors and referrals. We consider that now in Romania this is an established program that will continue depending on the number of donors and financing.

An analysis of 14 molecular markers for monitoring osteoarthritis. Relationship of the markers to clinical end-points

OBJECTIVE

To investigate whether any of 14 serum and urine molecular markers (MMs) used to monitor osteoarthritis (OA) would be associated with particular clinical end-points.

DESIGN

Thirty-nine OA patients were bled and urine collected at five time points: at baseline visit and at visits 1, 3, 6 and 12 months later. Twelve clinical measurements were made and the concentrations of each of 14 MMs were determined. Principal component analysis, stepwise linear regression with backward elimination, and logistic regression were used to determine the correlations between MMs and clinical measures.

RESULTS

Principal component analysis was used to reduce the 12 clinical measurements into three independent clinical clusters: baseline clinical assessments, changes in clinical assessments and signal joint measurements. The 14 MMs were similarly reduced to five MM clusters. Each of the three clinical clusters was correlated with a single but different MM cluster. Baseline clinical assessments were correlated with bone markers typified by hydroxylysyl pyridinoline (HP) crosslinks, swelling of the signal joint was correlated with inflammation markers, especially CRP, and the change in clinical assessments over the 1 year evaluation was correlated with TGFbeta1. There was no correlation between any of the skeletal markers and the clinical measures, a situation which draws attention to the need for a direct assessment of cartilage damage in OA to validate the use of cartilage markers.

CONCLUSIONS

This study demonstrates statistical methodology for analysis of clinical trials using multiple MMs and clinical end-points. The patient numbers are sufficient to test hypotheses of relationships of single MMs such as CRP, TGFbeta1 and HP to clinical measures, but larger clinical trials are needed to validate hypotheses.

Use of synovial fluid markers of cartilage synthesis and turnover to study effects of repeated intra-articular administration of methylprednisolone acetate on articular cartilage in vivo

In vivo the effects of intra-articular (IA) corticosteroids on articular cartilage remain controversial. This study was designed to examine this issue using synovial fluid (SF) markers of cartilage metabolism. Paired radiocarpal joints, without clinical or radiographic signs of joint disease, were studied in 10 adult horses. Aseptic arthrocentesis was performed weekly for 13 weeks. IA injections of methylprednisolone acetate (MPA) into the treatment joint and the vehicle into the control joint were performed at weeks 3, 5 and 7. We used radioimmunoassays on SF samples which measure a keratan sulfate epitope (KS) and the 846 epitope on cartilage aggrecan (PG) and the C-propeptide (CPII) of cartilage type II procollagen which is released following synthesis of this molecule. Gel chromatography was performed on selected SF samples to evaluate the sizes of SF PG molecules. The total joint KS and the 846 epitopes were both present on a heterogeneous population of mainly molecules which, from chromotographic analysis, appeared to be mainly fragments of the articular cartilage aggrecan. They were significantly elevated in MPA joints whereas CPII was significantly reduced compared to the control during the treatment period. These results indicate that the repeated use of IA MPA leads to a potentially harmful inhibition of procollagen II synthesis and an increased release of degradation products of the PG aggrecan from articular cartilage.

[Palliative total gastrectomy in advanced malignancies of the stomach]

The diagnosis of the malignancies of the stomach is generally late (stages III and IV to a medium value of 80% of patients). Therefore it is necessary a surgical treatment in order to effectuate the extirpation of the lesions and to warn or to treat the complications in course of the neoplastic disease. The indications and the results of the palliative total gastrectomy (PTG) are analyzed in the present study. Between 1992 and 1999 there were studied retrospectively and prospectively during three successive periods of time, 217 patients (pts.) with PTG. This group of pts. represents 22.1% of the total number of pts. operated on for gastric malignancies (carcinoma particularly). The indication of PTG was established only after one complex evaluation of the every patient from the point of view of his general and biological status. 142 (65.4%/217) of the analyzed pts. presented at the admission in the hospital various complications of the malignant disease (gastric different stenosis, digestive hemorrhages, loco-regional invasion). The lymph nodes metastases and the systemic metastases (in the liver especially) as well as the invasion in the neighbouring viscera imposed sometimes the extension of the PTG with partial or total extirpation of the invaded organs. A proportion of 61% pts. were submitted to those type of enlarged surgical interventions without radical intentions; all the operated pts. remained by necessity in R1 or R2 types of operations. The reconstructive preferred anastomosis was effectuated with an Y jejunal ansa à la Roux completed or not by a "J" reservoir. Microscopically pathologic lesions were: adenocarcinoma and carcinoma (82%), followed by primitive lymphoma (11.5%), and others malignant forms of lesions (approximately 6%). The general perioperative morbidity was 32.5% divided in: 12.3% having a surgical cause (the majority anastomotic leakages +/- septically complications or precocious occlusions); 20.2% complications depending by the general status and altered biology of the patients. Perioperative mortality was 10.1% (22 pts.) comparable with other experiences published in the international literature in those forms of advanced gastric cancer operated by PTG. The average outcome of the operated followed pts. was 16-18 month (extremes 12 months and 29 months). A better quality of life and a variable disease-free period was obtained. As a conclusion we think that the PTG is a advantageous modality of surgical treatment with an acceptable rate of perioperative morbidity and mortality. The outcome of operated pts. is superior comparable with that of nonoperated pts. or with that secondary to other palliative surgical interventions. The importance of adjuvant treatment (chimeo- or radiotherapy) remain to be appreciated in the future.

[Pyogenic liver abscess]

The objective of this study was to investigate and report changes in presentation, management and outcome of patients with pyogenic liver abscess (PLA). Between 01.01.1995-31.12.1999, 27 patients with PLA were treated in the General Surgical Service of the Fundeni Clinical Hospital. The incidence of cryptogenic abscesses was dominant (55.5%). The symptoms and the biological status are frequently nonspecific. The CT scan and echographic examination sensibility in the diagnosis of the PLA was 89.5% and 78.3%. The aerobe germs are most involved. All patients received antibiotic treatment in preoperative as in postoperative period. The surgical treatment was performed in 24 patients: in 9 patients (33.3%), the abscess was surgically evacuated and drained and in 15 patients (55.5%), a liver resection was performed. Percutaneous catheter drainage under CT or echo-guidance was performed in three patients (11.1%). The clinical evolution was good in 21 patients (77.7%). There was four complications (14.8%) and two death (7.4%). Although with a better prognostic, the PLA remains an important pathology.

Selective assembly and remodelling of collagens II and IX associated with expression of the chondrocyte hypertrophic phenotype

The assembly and resorption of the extracellular matrix in the physis of the growth plate are poorly understood. By examining isolated fetal growth plate chondrocytes in culture and using immunochemical methods we show that type II collagen, proteoglycan aggrecan, and type IX collagen are assembled into a matrix that is initially enriched in type II collagen over proteoglycan and type IX collagen. When compared to the content of the COL2 domain in the alpha(1)(IX) chain it is evident that the majority ( 90%) of type IX molecules lack the NC4 domain unlike in articular cartilage. During matrix assembly the molar ratio of type II/COL2 of alpha(1)(IX) varied from 25:1 to 2.5:1. Following expression of the hypertrophic phenotype (initiation of type X collagen synthesis) there are parallel changes in both collagen and proteoglycan contents (inversely related to collagenase cleavage of type II collagen). The NC4 domain is then selectively, rapidly and irreversibly removed as mineralization is initiated, leaving the alpha(1)(IX) chain COL2 domain. Subsequently as mineralization progresses type II and type IX collagen (COL2 domain), but not the proteoglycan aggrecan, are resorbed coincident with a markedly increased cleavage of type II collagen by collagenase as mineral is deposited in the matrix. This study, therefore reveals a carefully orchestrated series of events in matrix assembly and resorption that prepares the extracellular matrix for mineralization.

Mature full-thickness articular cartilage explants attached to bone are physiologically stable over long-term culture in serum-free media

Mature tissue explants containing the entire depth of articular cartilage, calcified and uncalcified, attached to a thin layer of subchondral bone were isolated from bovine humeral heads of 1-2-year-old steers. These explants were placed in defined serum-free culture medium for a period of 3 weeks to investigate their biological and mechanical stability and thus to determine their potential utility in studies of cartilage physiology. Tissue mass remained constant over the culture period and no evident tissue swelling or distortion was observed. Chondrocytes were viable in all zones at the time of tissue isolation and throughout the culture period, with the exception of a thin layer of cells at the articular surface and the cut radial edge of the disks. Proteoglycan metabolism attained a steady state after 5 days of culture when the rate of loss of proteoglycan to culture media was compensated by new synthesis to maintain a stable proteoglycan content. Collagen metabolism was also stable with a constant content of type II collagen and a constant content of denatured collagen II throughout culture; the content of the C-propeptide of type II procollagen as a measure of procollagen synthesis, dropped slightly during the first week to attain a steady state after that time. Dynamic and equilibrium mechanical properties of these explant disks were also stable confirming maintenance of these tissue properties during long-term culture. In addition, the disk geometry of the system, with the cut surface in the bone parallel to the intact articular surface, is well-suited to study tissue regulation by mechanical load. Taken together, the stability of these indicators of tissue physiology indicates the maintenance in serum-free conditions of normal metabolism for organ cultures containing full-depth mature articular cartilage attached to bone.

An analysis of 14 molecular markers for monitoring osteoarthritis: segregation of the markers into clusters and distinguishing osteoarthritis at baseline

OBJECTIVE

To investigate the relationships between serum and urinary molecular markers (MM) used to monitor osteoarthritis.

DESIGN

Forty osteoarthritis patients had blood and urine collected at baseline and 1, 3, 6 and 12 months later. Specimens from 20 controls were obtained twice at a one month interval. The concentration of 14 different markers was determined at each time point and the data were analyzed by statistical methodology.

RESULTS

The markers could be divided by the method of principal components analysis into five clusters of related markers: inflammation markers (C-reactive protein, tumor necrosis receptor type I and tumor necrosis receptor type II, interleukin 6, eosinophilic cationic protein), bone markers (bone sialoprotein, hydroxylysyl pyridinoline, lysyl pyridinoline), putative markers of cartilage anabolism (carboxypropeptide of type II procollagen, hyaluronan, epitope 846) and catabolism (keratan sulfate, cartilage oligomeric matrix protein), and transforming growth factor beta. Three markers (tumor necrosis factor receptor II, cartilage oligomeric matrix protein and epitope 846) from independent clusters discriminated osteoarthritis patients from controls. Inflammation was not a confounding factor in measurement, but a recognizable distinguishing factor in osteoarthritis.

CONCLUSIONS

The markers separated into rational groups on the basis of their covariance, a finding with independent biochemical support. The covariance of markers from the same cluster suggests the use of a representative marker from the cluster to reflect changes in osteoarthritis. If multiple markers are being measured within a single cluster, then the use of a weighted cluster 'factor' may be preferable to the separate use of individual markers.

Alterations in cartilage type-II procollagen and aggrecan contents in synovial fluid in equine osteochondrosis

The etiology and pathophysiology of osteochondrosis remain poorly understood because it is difficult to obtain material from lesions in the early stage of this disease and because there is no satisfactory experimental animal model. We wished to determine whether there are changes in articular cartilage turnover in equine osteochondrosis, which closely resembles the human disease, by assaying cartilage matrix molecules in synovial fluids. We used immunoassays that measure a keratan sulfate epitope and the epitope 846 on the cartilage proteoglycan aggrecan and the C-propeptide of cartilage type-II procollagen, which is released following the synthesis of this molecule, to analyse synovial fluids from equine tarsocrural joints with and without osteochondrosis. In young horses with osteochondrosis, there was a significant increase of C-propeptide of type-II procollagen accompanied by a decrease in the 846 and keratan sulfate epitopes. The results identify differential alterations in aggrecan and type-II collagen turnover in the cartilage matrix in young animals with osteochondrosis that may contribute to the pathological degeneration of articular cartilage in this disease.

Comparison of the degradation of type II collagen and proteoglycan in nasal and articular cartilages induced by interleukin-1 and the selective inhibition of type II collagen cleavage by collagenase

OBJECTIVE

To compare interleukin-1alpha (IL-1alpha)-induced degradation of nasal and articular cartilages in terms of proteoglycan loss and type II collagen cleavage, denaturation, and release; to examine the temporal relationship of these changes; and to investigate the effects of an inhibitor of collagenase 2 and collagenase 3 on these catabolic processes.

METHODS

Discs of mature bovine nasal and articular cartilages were cultured with or without human IL-1alpha (5 ng/ml) with or without RS102,481, a selective synthetic inhibitor of collagenase 2 and collagenase 3 (matrix metalloproteinase 8 [MMP-8] and MMP-13, respectively) but not of collagenase 1 (MMP-1). Immunoassays were used to measure collagenase-generated type II collagen cleavage neoepitope (antibody COL2-3/4C(short)) and denaturation (antibody COL2-3/4m), as well as total type II collagen content (antibody COL2-3/4m) in articular cartilage and culture media. A colorimetric assay was used to measure total proteoglycan concentration (principally of aggrecan) as sulfated glycosaminoglycans (sGAG).

RESULTS

IL-1alpha initially induced a decrease in tissue proteoglycan content in nasal cartilage. A progressive loss of proteoglycan was noted during culture in articular cartilages, irrespective of the presence of IL-1alpha. In both cartilages, proteoglycan loss was followed by IL-1alpha-induced cleavage of type II collagen by collagenase, which was often reflected by increased denaturation. The inhibitor RS102,481 had no clear effect on the reduction in proteoglycan content (measured by sGAG) and collagen denaturation in either cartilage, but at 10 nM it inhibited the enhanced cleavage of type II collagen, partially in nasal cartilage and completely in articular cartilage.

CONCLUSION

IL-1alpha-induced cleavage and denaturation of type II collagen is observed in both hyaline cartilages and is secondary to proteoglycan loss. It probably involves different collagenases, since there is no evidence of a rate-limiting role for collagenase 1 in articular cartilage, unlike the case for nasal cartilage. Inhibitors of this kind may be of value in the treatment of cartilage damage in arthritis. Also, the ability to detect the release of type II collagen collagenase-generated fragments from degraded cartilage offers the potential to monitor cartilage collagen damage and its control in vivo.

Selective enhancement of collagenase-mediated cleavage of resident type II collagen in cultured osteoarthritic cartilage and arrest with a synthetic inhibitor that spares collagenase 1 (matrix metalloproteinase 1)

OBJECTIVE

To examine whether type II collagen cleavage by collagenase and loss of proteoglycan are excessive in human osteoarthritic (OA) articular cartilage compared with nonarthritic articular cartilage, and whether this can be inhibited by a selective synthetic inhibitor that spares collagenase 1 (matrix metalloproteinase 1 [MMP-1]).

METHODS

Articular cartilage samples were obtained during surgery from 11 patients with OA and at autopsy from 5 adults without arthritis. The articular cartilage samples were cultured in serum-free medium. A collagenase-generated neoepitope, which reflects cleavage of type II collagen, and proteoglycan glycosaminoglycan (GAG), which predominantly reflects aggrecan release, were assayed in culture media. In addition, cultures were performed using either of 2 synthetic MMP inhibitors, both of which inhibited collagenase 2 (MMP-8) and collagenase 3 (MMP-13), but one of which spared collagenase 1. Cultures were also biolabeled with 3H-proline in the presence and absence of these inhibitors to measure collagen synthesis (as tritiated hydroxyproline) and incorporation in articular cartilage.

RESULTS

As a group, cleavage of type II collagen by collagenase was significantly increased in OA cartilage samples. In contrast, proteoglycan (GAG) release was not increased. This release of a collagenase-generated epitope was inhibited by both MMP inhibitors in 2 of 5 nonarthritic samples and in 9 of 11 OA cartilage samples. The inhibitor that spared collagenase 1 was generally more effective and inhibited release from 4 of 5 nonarthritic cartilage samples and the same OA cartilage samples. Group analyses revealed that the inhibition of collagenase neoepitope release by both inhibitors was significant in the OA patient cartilage, but not in the nonarthritic cartilage. Proteoglycan loss was unaffected by either inhibitor. Newly synthesized collagen (predominantly, type II) exhibited increased incorporation in OA cartilage, but only in the presence of the inhibitor that arrested collagenase 1 activity.

CONCLUSION

These results further indicate that the digestion of type II collagen by collagenase is selectively increased in OA cartilage, and that this can be inhibited in the majority of cases by a synthetic inhibitor that can inhibit collagenases 2 and 3, but not collagenase 1. The results also suggest that in OA, newly synthesized collagen is digested, but in a different manner than that of resident molecules. Proteoglycan release was not increased in OA cartilage and was unaffected by these inhibitors. Inhibitors of this kind may be of value in preventing damage to type II collagen in human arthritic articular cartilage.

[Post-caustic esophageal stenosis]

This study treats the last 13-year experience of the Surgical Department from the Fundeni Hospital Bucharest (Romania) regarding the surgery of the postcaustical esophageal stenoses. The series is composed of 25 patients (10 males and 15 women), with ages between 19 and 58 years. The patients were admitted in our unit at an interval between 2 months and 20 years from the caustical ingestion. In 20 cases we preferred seriate procedures (gastrostomy or jejunostomy as a first operation, followed after 2 months to 20 years by a reconstructive procedure). The reconstructive operation was accompanied by resection of the stenotic esophagus in 15 cases (60%); in 10 cases we performed a bypassing (without resection) presternal esophagoplasty. Resection of the esophagus implied a combined abdomino-thoracic approach in 10 cases and an cervico-thoraco-abdominal approach in 5 (depending upon the extent of the lesions). The early postoperative course was complicated by anastomotic leakage's in 5 patients (20%) and by pulmonary complications in another 5 (20%) cases. There were no postoperative deaths. The late follow-up showed a good functional result in 24 patients with medium weight gain of 2.6 kilograms and a normal social reintegration. In conclusion, we consider that the esophagus resection in postcaustical stenoses is indicated when there are no counterindications, with a low morbidity when it is performed in specialized surgical services.

Changes in collagen turnover in early acute respiratory distress syndrome

Pulmonary fibrosis is a well-recognized feature of acute respiratory distress syndrome (ARDS). Using immunoassays of bronchoalveolar lavage (BAL), fluid we investigated the synthesis of type I procollagen (PICP) and type I/II collagen degradation products (COL2-3/4C(short) neoepitope) in patients with ARDS, acute lung injury (ALI), subjects with risk factors for ARDS (At Risk), and healthy/ventilated control subjects. PICP was measured by ELISA as a marker of type I procollagen synthesis. COL2-3/4C(short) neoepitope was measured by an inhibition ELISA as a marker of collagenase degradation of type I/II collagen. BAL was performed initially within 48 h of ventilation (Day 1) and then subsequently on Day 4. Dilution of epithelial lining fluid (ELF) was corrected for by plasma urea comparison. Increased PICP levels were observed in the ELF from ARDS and ALI subjects on Day 1 compared with subjects At Risk (median values, 124.9 and 95.0 ng/ml versus 38.0 ng/ml, respectively, p < 0.0005). By contrast, the levels of COL2-3/4C(short) neoepitope were significantly reduced in the subjects with ARDS versus the At Risk subjects (13.22 ng/ml versus 32.33 ng/ml, p < 0.0005). This translated into a greatly increased PICP:COL2-3/4C(short) ratio in the subjects with ARDS (p < 0.0001). There was a significant decline in the PICP level in the subjects with ARDS between Days 1 and 4 (n = 15, p < 0.05). Linear regression analysis showed a significant association between PICP and lung injury score in the subjects with ARDS (p = 0.01). Our data suggests an early shift in balance between type I collagen synthesis and degradation by collagenase. The resultant increase in type I collagen would favor matrix deposition and the development of pulmonary fibrosis in the lungs of subjects with ARDS.

Measurement of synovial fluid and serum concentrations of the 846 epitope of chondroitin sulfate and of carboxy propeptides of type II procollagen for diagnosis of osteochondral fragmentation in horses

OBJECTIVE

To determine whether serum or synovial fluid concentrations of chondroitin sulfate epitope 846 and carboxy propeptides of type II collagen (CPII) can be used to diagnose osteochondral fragmentation (OC) in horses.

ANIMALS

38 horses with unilateral OC of the radiocarpal (n = 31) or intercarpal (33) joints and 8 clinically and radiographically normal horses. Procedures-For horses with OC, serum and synovial fluid concentrations of epitope 846, CPII, and keratan sulfate (KS) were determined, along with synovial fluid WBC counts and total protein concentrations. Serum epitope 846, CPII, and KS concentrations were measured in control horses.

RESULTS

Synovial fluid epitope 846 and total protein concentrations were significantly higher in the joints with OC than in unaffected joints, but CPII and KS concentrations and WBC counts were not. Synovial fluid total protein and 846 epitope concentrations were linearly related to grade of OC. Serum epitope 846 and CPII concentrations were significantly higher in horses with OC than in control horses. Discriminant analysis allowed 27 of 34 (79%) horses to be correctly classified as having or not having OC on the basis of serum epitope 846 and CPII concentrations.

CONCLUSIONS

Results suggest that serum and synovial fluid concentrations of epitope 846 and CPII are associated with OC. Increases in concentrations of epitope 846 and CPII suggest that increased synthesis of cartilage aggrecan and type II procollagen may be associated with OC.

CLINICAL RELEVANCE

Measurement of serum epitope 846 and CPII concentrations may be useful in the diagnosis of OC in horses.

Changes in joint cartilage aggrecan after knee injury and in osteoarthritis

OBJECTIVE

To determine the concentrations of aggrecan fragments in synovial fluid from patients with knee joint injury, osteoarthritis (OA), or acute pyrophosphate arthritis (PPA; pseudogout), and to test their relative reactivity with the 846 epitope, a putative marker of cartilage aggrecan synthesis.

METHODS

Samples of knee joint fluid from 385 patients and 9 healthy-knee volunteers were obtained in a cross-sectional study. Study groups were acute PPA/ pseudogout (n = 60), anterior cruciate ligament (ACL) rupture (n = 159), meniscus lesion (n = 129), and primary knee OA (n = 37). The 846 epitope on aggrecan was assayed by competitive solution-phase radioimmunoassay. Aggrecan fragments were assayed by enzyme-linked immunosorbent assay using a monoclonal antibody (1-F21). Cartilage oligomeric matrix protein (COMP), C-propeptide of type II collagen (CPII), bone sialoprotein, matrix metalloproteinases 1 and 3, and tissue inhibitor of metalloproteinases 1 were previously quantified by immunoassays.

RESULTS

Reactivity of the 846 epitope was increased in all study groups compared with the reference group, and was highest in patients with primary OA. The median levels (in microg fetal aggrecan equivalents/ml) of the epitope were 0.28 (range 0.24-0.47) in the reference group, 0.48 (range 0.26-1.32) in PPA/pseudogout, 0.61 (range 0.12-2.87) in ACL rupture, 0.53 (range 0.22-3.02) in meniscus lesion, and 0.68 (range 0.31-4.31) in primary OA. The 846 epitope reactivity per microg aggrecan fragments in the joint fluid was higher in late-stage OA than in early-stage OA. Epitope 846 reactivity correlated positively with several markers of matrix turnover, particularly with COMP (r(s) = 0.421) and CPII (r(s) = 0.307).

CONCLUSION

The observed differences in 846 epitope reactivity in synovial fluid, and its concentration in relation to aggrecan and other markers of matrix turnover, were consistent with marked ongoing changes in aggrecan turnover after joint injury and in the development of OA. OA is thus a disease characterized by dynamic changes in tissue macromolecule turnover, which is reflected by measurable changes in aggrecan epitopes in the synovial fluid.

Changes in serum cartilage marker levels indicate altered cartilage metabolism in families with the osteoarthritis-related type II collagen gene COL2A1 mutation

OBJECTIVE

The Arg5l9-Cys mutation in type II collagen results in severe, precocious familial osteoarthritis (OA) in 100% of carriers within the first 3 decades of life. The carrier population provided a well-defined patient population for the study of serum markers of familial OA with respect to pathogenesis, diagnosis, and prognosis.

METHODS

Serum was obtained from 31 mutation-positive individuals and 16 mutation-negative individuals. OA severity was determined by clinical and radiologic assessments. Levels of serum cartilage oligomeric matrix protein (COMP), keratan sulfate (KS) epitope, the 846 epitope of aggrecan, and the C propeptide of type II collagen (CPII) were measured and were correlated with the radiologic findings.

RESULTS

COMP and KS levels, both of which have been suggested to be indicative of disturbed cartilage turnover, were significantly elevated in mutation-positive individuals and in the individuals with OA regardless of mutation status. There was no statistically significant difference between mutation-positive, mutation-negative, OA-positive, and OA-negative individuals with respect to serum concentrations of epitope 846 or CPII, both of which are putative markers of cartilage repair.

CONCLUSION

Study of the macromolecular constituents of cartilage released into serum in subjects with familial OA revealed altered metabolism in OA, as demonstrated by elevated COMP and KS levels. Other constituents, the 846 epitope and CPII, were not altered, indicating dissociation of cartilage anabolism and breakdown. Future sequential studies will provide an opportunity to define biochemical changes as familial OA develops and to monitor therapeutic responses.

Relationship of matrix metalloproteinases and their inhibitors to cartilage proteoglycan and collagen turnover: analyses of synovial fluid from patients with osteoarthritis

OBJECTIVE

To determine the relationship between matrix metalloproteinases (MMPs), their inhibitors, and the turnover of matrix molecules in articular cartilage from patients with osteoarthritis (OA).

METHODS

Synovial fluid samples were collected from the knees of 54 patients with OA. Radiographic evaluations and magnetic resonance imaging were performed on the knees of 34 OA patients to classify the stage of the disease. Biochemical analyses and immunoassays were used to measure the concentrations of MMP-1, MMP-3, tissue inhibitor of metalloproteinases 1 (TIMP-1), TIMP-2, the disaccharide of hyaluronic acid, the proteoglycan glycosaminoglycan disaccharides of chondroitin 4-sulfate (delta di-CS4) and chondroitin 6-sulfate (delta di-CS6), the 846 epitope on chondroitin sulfate of cartilage proteoglycan aggrecan (putative biosynthetic marker), the keratan sulfate (KS) epitope of aggrecan (putative degradation marker), and the C-propeptide of cartilage type II procollagen (CPII) (biosynthetic marker).

RESULTS

The concentration of TIMP-1 was directly correlated with the levels of MMP-1 and MMP-3 (both were also correlated with each other), confirming earlier results. There was an inverse correlation between the delta di-CS6:delta di-CS4 ratio and the concentration of MMP-3. The level of delta di-CS6 was correlated with that of the KS epitope, and to a lesser degree, with that of the 846 epitope (the latter was also correlated with the level of delta di-CS4). The concentration of TIMP-1 correlated with that of the 846 epitope, whereas TIMP-2 levels correlated with those of CPII. There were significantly lower concentrations of delta di-CS6, delta di-CS4, the 846 epitope, and CPII in synovial fluid from patients with late-stage OA.

CONCLUSION

These observations suggest a link between proteolysis and inhibitor concentrations in OA cartilage. Production of TIMPs appears to be individually linked to the synthesis of specific cartilage molecules. The reduction in the amount of cartilage-matrix structural components suggests that there is a measurable loss of cartilage in the late stages of the disease, as suggested previously. The resultant composition of the cartilage suggests that the loss may primarily involve "resident" molecules originally present in healthy cartilage.

Changes in serum cartilage marker levels indicate altered cartilage metabolism in families with the osteoarthritis-related type II collagen gene COL2A1 mutation

OBJECTIVE

The Arg5l9-Cys mutation in type II collagen results in severe, precocious familial osteoarthritis (OA) in 100% of carriers within the first 3 decades of life. The carrier population provided a well-defined patient population for the study of serum markers of familial OA with respect to pathogenesis, diagnosis, and prognosis.

METHODS

Serum was obtained from 31 mutation-positive individuals and 16 mutation-negative individuals. OA severity was determined by clinical and radiologic assessments. Levels of serum cartilage oligomeric matrix protein (COMP), keratan sulfate (KS) epitope, the 846 epitope of aggrecan, and the C propeptide of type II collagen (CPII) were measured and were correlated with the radiologic findings.

RESULTS

COMP and KS levels, both of which have been suggested to be indicative of disturbed cartilage turnover, were significantly elevated in mutation-positive individuals and in the individuals with OA regardless of mutation status. There was no statistically significant difference between mutation-positive, mutation-negative, OA-positive, and OA-negative individuals with respect to serum concentrations of epitope 846 or CPII, both of which are putative markers of cartilage repair.

CONCLUSION

Study of the macromolecular constituents of cartilage released into serum in subjects with familial OA revealed altered metabolism in OA, as demonstrated by elevated COMP and KS levels. Other constituents, the 846 epitope and CPII, were not altered, indicating dissociation of cartilage anabolism and breakdown. Future sequential studies will provide an opportunity to define biochemical changes as familial OA develops and to monitor therapeutic responses.

Evidence for altered synthesis of type II collagen in patients with osteoarthritis

There is evidence to suggest that the synthesis of type II collagen is increased in osteoarthritis (OA). Using an immunoassay, we show that the content of the C-propeptide of type II procollagen (CPII), released extracellularly from the newly synthesized molecule, is directly related to the synthesis of this molecule in healthy and osteoarthritic articular cartilages. In OA cartilage, CPII content is often markedly elevated (mean 7.6-fold), particularly in the mid and deep zones, reaching 29.6% of the content in newborn. Synthesis is also directly related to total collagen II content in OA, suggesting its importance in maintaining collagen content and cartilage structure. The release of CPII from cartilage is correlated directly with cartilage content. However, the increase in CPII in OA cartilage is not reflected in serum, where a significant reduction is observed. Together these studies provide evidence for alterations in procollagen II synthesis in vivo in patients with OA.

The outpatient management of peripheral diabetic neuropathy

Diabetic neuropathy is a common complication of diabetes. Its commonest form is the bilateral, distal sensorimotor neuropathy and this has been associated with increased risk of disability from foot ulceration, inadvertent injury leading to gangrene as well as to amputation. The economic implications of the treatment of diabetic neuropathy and its consequences are enormous. In spite of this, there is no universally accepted method of treating it and efforts are still underway to find an adequate form of therapy. The following is a review of the outpatient management of peripheral diabetic neuropathy.

Esophageal tumor with an unusual histological appearance: a case report

An unusual esophageal tumor in a 58-year-old man complaining of dysphagia and weight loss is herein described. Esophageal radioscopy and endoscopy visualized a huge polypoid tumor which was occluding the esophagus. After esophageal resection, the histological examination revealed miscellaneous benign cells (squamous, columnar fat cells, cartilaginous cells, and glandular structures) and two different malignant areas (spindler sarcomatous cells and squamous cells). There was no malignant invasion in the stalk, in the adjacent esophageal wall, or in the periesophageal tissue, and there were no malignant adenopathies. The postoperative course was favorable for one year, until the patient developed pain in the right superior back. A sarcomatous relapse was diagnosed by fine-needle biopsy under CT guidance, and the patient subsequently received radiation therapy.