Synovial membrane in experimentally-produced chronic haemarthrosis

A cross-sectional study of complementary and alternative medicine use in patients with coagulation disorders in Southern Iran

OBJECTIVE

Complementary and alternative medicine (CAM) use has an increasing trend around the world. Despite the wild application of CAM in patients with coagulation disorders, its efficacy is still questioned by many studies. The aim of this study was to determine the frequency and types of CAM usage, and the factors affecting CAM use among patients with bleeding disorders.

METHODS

This cross-sectional study investigated the usage of CAM with a standard validated questionnaire in coagulopathic patients who were referred to Dastgheib Hospital, an educational therapeutic center affiliated to the Shiraz University of Medical Sciences in Shiraz, Southern Iran.

RESULTS

Between December 2015 and May 2016, 75 patients were included in this survey. Severe hemophilia A and rare bleeding disorders were the most frequent among our participants. Overall, nearly half of the studied population (49.3%) used at least one CAM product or practices. The most common products were multivitamin (29.3%), followed by folic acid (21.3%) and chamomile (12%). 32% of the patients resorted to faith healing. The main reasons of using CAM were reported to be increased general health, correction of anemia and thrombocytopenia and control of bleeding tendency.

CONCLUSION

CAM is being used frequently in patients with coagulation disorders like many other chronic illnesses all around the world. Due to emerging concern regarding the safety and possible interaction with the conventional medicine, it is necessary to develop basic data about the hematologic effects of these methods in order to use them more safely.

Blood-Induced Joint Damage: The Devastating Effects of Acute Joint Bleeds versus Micro-Bleeds

OBJECTIVE

Four days of blood exposure leads to irreversible cartilage damage in vitro. In contrast, intermittent intra-articular blood injections twice a week during 4 weeks (mimicking micro-bleeds) in a canine model resulted in transient damage only. In this study, it was evaluated whether acute joint bleeds are more harmful than micro-bleeds in a canine model of knee arthropathy.

DESIGN

Seven dogs received 4 sequential daily intra-articular blood injections twice in 2 weeks (mimicking 2 acute 4-day joint bleeds). Seven other dogs received the same blood load but in a total of 8 injections intermittently over the 4-week period with at least 1 day in between (mimicking micro-bleeds over the same timespan). Contralateral knees served as controls. Ten weeks after the last injection cartilage matrix turnover and synovial inflammation were evaluated.

RESULTS

Only after the acute joint bleeds the release of newly formed and total (resident) cartilage matrix glycosaminoglycans were increased (P = 0.04 and P = 0.01, respectively). Furthermore, in animals with the acute joint bleeds cartilage glycosaminoglycan content was decreased (P = 0.01) and not in animals with micro-bleeds. Mild synovial inflammation was observed in both groups (both P < 0.0001) but was not different between groups.

CONCLUSIONS

In contrast to micro-bleeds, 2 acute joint bleeds lead to prolonged cartilage damage independent of the level of synovial inflammation. This model suggests that micro-bleeds are less devastating than acute joint bleeds with respect to joint damage, which might be of relevance to treatment of joint bleeds in clinical practice.

Biotribological and biomechanical changes after experimental haemarthrosis in the rabbit knee

Changes in articular cartilage after haemarthrosis have not been completely elucidated in haemophilic arthropathy. Insights into the pathophysiological mechanisms of blood-induced joint damage mainly derived from histological, inflammatory and biochemical investigations. A structure-function relationship is another reasonable way to determine the joint overall health status. Cartilage, a viscoelastic connective tissue, is at least a biphasic material that should also work under minimal friction. Pendulum friction tester measures the mechanical aspects of joint lubrication and quantifies the biotribological properties of the joint. Indentation test is an in situ method characterizing the biomechanical properties of the cartilage. Gross, biotribological and biomechanical properties were determined in a rabbit model of experimental haemarthrosis. A sample of 1 mL of fresh autologous blood was injected in the left knee of rabbit's joint twice weekly for four consecutive weeks. The right knee and animals in the control group were left untreated. After 8 days, joint perimeter, biotribological and biomechanical tests were performed. In a consistent manner, all data showed detrimental effects of the blood on the overall cartilage function under loading. Non-weight bearing and early blood aspiration seem wise to be considered after haemarthrosis.

Haemophilic arthropathy resembles degenerative rather than inflammatory joint disease

AIMS

To investigate the pathogenetic mechanisms of haemophilic arthropathy (HA) by comparing end-stage arthropathy with osteoarthritis (OA; a degenerative joint disorder) and rheumatoid arthritis (RA; an inflammation-mediated joint disease).

METHODS AND RESULTS

Cartilage and synovium from patients with HA (n=10), RA (n=8), OA (n=14) and normal control subjects (n=6) were examined morphologically, biochemically and histochemically. Cartilage in HA exhibited characteristics of degenerative joint disease (OA), as evidenced by morphological, histochemical (Safranin-O fast green-iron haematoxylin, Mankin grade) and biochemical (proteoglycan synthesis, glycosaminoglycan content and DNA content) changes, whereas synovium in HA showed characteristics of inflammation-mediated joint disease (RA), as evidenced by histochemical (inflammation, haematoxylin and eosin (H&E) and iron deposition, Perls' blue) and biochemical changes (interleukin (IL)-1, IL-6, tumour necrosis factor (TNF)alpha and catabolic properties).

CONCLUSION

Haemophilic arthropathy shows characteristics of both inflammatory and degenerative joint disease. On the basis of these results and published information, it appears that degenerative cartilage changes have a dominant role in HA and are augmented by relatively mild inflammation of the synovium.

Synovium in haemophilic arthropathy

Synovium is an essential component of the joint and plays a critical role in maintaining a balance between physiological processes and pathological changes in the joint. Recurrent intra-articular bleeding as occur in haemophilia induce pathological synovial changes in the joint. From a certain point on, synovitis inevitably plays a major role in joint destruction, although in the early phase of haemophilic arthropathy its role may be secondary to cartilage damage as a result of the direct effects of blood on cartilage. The changed haemosiderotic, synovial tissue produces catabolic cytokines and enzymes harmful for cartilage.

Experimental haemarthrosis in rhesus monkeys: morphometric, biochemical and metabolic analyses

The effects of a single episode of massive haemarthrosis in rhesus monkeys were studied. Autologous whole blood was injected into a femorotibial joint of 16 anaesthetized monkeys, equally divided into four groups and killed 7 days, 2, 3 and 6 months post-injection (PI). Synovial membrane and femoral articular cartilage were analysed morphometrically and articular cartilage was further analysed biochemically and metabolically. At 7 days PI, morphometric evaluation revealed a significant increase (P less than 0.05) in synovial membrane cellularity and synovial intimal thickness of injected joints versus control joints. This change was no longer evident 2 months PI. There was also an overall (n = 16) significant increase (P less than 0.05) in femoral articular cartilage cellularity in injected joints. The average chondrocyte lacuna area of injected joints was not statistically different from the control joints. Biochemical analyses of femoral articular cartilage revealed a significant decrease in hexosamine concentration (P less than 0.05) of injected joints. There was no significant difference between the injected and control joints in hydroxyproline or total protein concentration. Metabolic analyses revealed a significant increase (P less than 0.05) in cartilage collagenous protein production by injected joints compared with control joints. There were no significant differences in cartilage or secreted total protein production between injected and control joints. There were also no significant differences in cartilage or secreted proteoglycan production between joints. Morphometric evaluation of articular tissues following massive haemarthrosis has quantified a temporary hyperplastic reaction. A significant decrease in cartilage hexosamine concentration in haemarthrotic joints suggests this is a crucial biochemical event in the pathogenesis of blood-induced cartilage destruction.

Macroscopic, microscopic and ultrastructural findings in experimental haemarthrosis of rhesus monkeys

The effects of a single episode of massive haemarthrosis in rhesus monkeys were studied morphologically. Autologous whole blood was injected into a femorotibial joint of 16 anaesthetized monkeys, equally divided into four groups and killed 7 days, 2, 3 and 6 months post injection (PI). Synovial membrane and articular cartilage were examined for macroscopic, microscopic and ultrastructural changes. Haemarthrosis was only evident in one monkey by 7 days PI. Slight yellow-brown discoloration of synovium and cartilage was evident in groups killed early after injection. Histologically, a hyperplastic and inflammatory reaction was present in the synovium at 7 days PI. Ultrastructural examination of synoviocytes in this group revealed numerous cytoplasmic vacuoles and prominent microplicae compatible with increased phagocytic activity. Erythrophagocytosis by synoviocytes was observed by light microscopy and confirmed by transmission EM. Results of scanning EM suggested that red cells might also pass through the synovial intima. Transmission EM also revealed mild degenerative changes in superficial chondrocytes. Rhesus monkeys reacted morphologically to haemarthrosis in the same way as dogs and rabbits, with mild morphological changes that resolved by 2 months PI.

Mechanisms of joint damage in an experimental model of hemophilic arthritis

Autologous whole blood was injected into the knee joints of rabbits 3 times each week for 12 weeks. The resulting destructive arthritis showed macroscopic and microscopic changes similar to those described in hemophilic arthritis in humans. Immunofluorescence studies indicated that a specific immune response is probably not involved in the pathogenesis of hemophilic arthritis. Detailed histopathologic examinations of knee joints in both the early and the late phase of arthritis revealed an obvious synovial and cartilage iron load, in the absence of inflammatory changes. The implications of these findings in the pathogenesis of destructive cartilage changes are discussed.

Mechanical and histological studies of acute joint hemorrhage

In this study, a simple animal model has been used to gather data on the mechanical and histologic changes in cartilage and the histologic changes in synovium attendant to acute joint hemorrhage. The continuous presence of autologous blood in the experimental joints for 10 days results in cartilage which is significantly more compliant than normal. These changes are attributed to loss of proteoglycan. Further, the study demonstrates a consistent pathology of the synovial tissues. Elaboration of degenerative enzymes from iron-laden synovial or subsynovial macrophages must be considered a primary mechanism of cartilage damage.

Macrophage ferritin and iron deposition in the rat air pouch model of inflammatory synovitis

Using a rat air pouch model of red cell promoted allergic inflammation, we have investigated the relation between ferritin synthesis and iron deposition in pouch wall lining cells. These cells have structural and immunohistochemical similarities to human synovial intimal cells and studies of them are pertinent to the clinical situation. In control air pouch wall tissue after single or double antigenic challenge the (apo)ferritin containing macrophages are most numerous seven days after antigenic challenge when there is active connective tissue proliferation and a generalised mononuclear cell response in the pouch wall, suggesting that (apo)ferritin is produced in macrophages as part of the tissue inflammatory response. In contrast with control tissue, where there is a steady decrease in positive cells over the ensuing weeks, injection of blood into both single and double challenge air pouches produces a significant (p less than 0.001) and continuing rise in the numbers of ferritin containing macrophages after day 7. Also, after 14 days Perls' positive ferric iron is detectable in increasing numbers of ferritin containing macrophages, a trend which is more marked in double challenge, blood injected air pouches. The histological data clearly show that there is a close relation between the presence of Perls' iron and proliferation of vascular and connective tissue elements in the pouch wall. We propose that this proinflammatory role of iron is the result of its ability to promote oxidative damage in tissues, and discuss ways in which this may take place.

The nature of iron deposits in haemophilic synovitis. An immunohistochemical, ultrastructural and X-ray microanalytical study

Using a computerized electron-probe X-ray microanalytical technique to measure phosphorus/iron ratios we have defined the iron saturation of ferritin in vitro from prepared ferritin standards of known iron loading. This technique has been applied to the study of 5 haemophilic synovial membranes. At light microscope level the distribution and relationship of iron/ferritin were defined using Perls' reaction and an immunoperoxidase technique respectively. The synovia from all cases contained intra and extra-cellular deposits of Perls' positive material which were granular in nature in the most superficial synovial cells. There were increasing numbers of pheomorphic (1-12 micron diameter ovate bodies in the deeper synovial layers. Immunoperoxidase ferritin staining produced a strongly positive reaction in the granular material but the ovate bodies were negative with the exception of some peripheral staining. X-ray microanalysis showed the granular material to be highly iron saturated ferritin and the ovate bodies to be almost pure iron. We suggest that iron saturated ferritin in the synovial membrane could increase/perpetuate inflammation by promoting lipid peroxidation.

Ultrastructural and x-ray microanalytical observations of minocycline-related hyperpigmentation of the skin

In order to elucidate the nature and distribution of the pigment responsible for the circumscribed blue-black cutaneous hyperpigmentation occurring after administration of minocycline hydrochloride, transmission electron microscopy and energy-dispersive electron x-ray microanalysis were performed on lesional skin. Ultrastructural observations demonstrated electron-dense iron-containing particles either incorporated into a variety of siderosomes, within dermal histiocytes, free within the cytoplasm, or, rarely, scattered among dermal collagen fibers. Electron x-ray microanalysis confirmed iron content present within these particles. Although siderosomal inclusions contained occasional melanosome complexes, the degree of deposition of electron-dense iron-containing particles in dermal histiocytes seemed to be primarily responsible for the blue-black discoloration of the skin. The present study is an investigation of the structure and composition of the pigment responsible for minocycline-related cutaneous hyperpigmentation.

Clearance of calcium pyrophosphate dihydrate crystals in vivo. III. Effects of synovial hemosiderosis

Synthetic triclinic calcium pyrophosphate dihydrate crystals, uniformly labeled with 85Sr and 45Ca, were injected into the knee joints of 2 normal adult rabbits and 2 rabbits previously injected repeatedly with autologous blood. The "half clearance time" of the injected crystal mass was 20.4 and 19 days from control joints, nearly identical to previously reported values in 6 rabbits (19.1 +/- 1.4), and 28.8 and 34 days from the joints injected with blood, a significant difference (P less than 0.05). Iron stains showed hemosiderin granules in the superficial synovium in these joints. Electron microscopy showed crystals with a molar calcium/phosphorus ratio of 1.0 and particles containing iron within synovial cells. We hypothesize that the decreased clearance rate from hemosiderotic synovium is due to inhibition of one or more intracellular pyrophosphatases by iron.

Final stages of erythrophagocytosis in the sheep placenta

In trophoblastic epithelial cells of the sheep placenta the final stages of erythrocyte breakdown within the lysosomal apparatus were studied at the ultrastructural level. As a result of hemoglobin digestion lysosomes containing hemoglobin-derived pigments (HDP) were formed. The HDP-lysosomes were acid phosphatase-positive, highly electron-dense bodies of round to irregular shape containing whorled membranous formations. The accumulation of these lysosomes in epithelial cells led to fusion resulting in the formation of conglomerates. At the end of the gestation period the amount of HDP-lysosomes and their conglomerates markedly increased. In addition to erythrocytes the trophoblastic epithelial cells in the erythrophagocytic regions phagocytosed maternal leukocytes and neighbouring epithelial cells and giant cells. By gradual accumulation of HDP-lysosomes and remnants of phagocytosed cells, highly electron-dense acid phosphatase-positive residual bodies of variable appearance were formed within the epithelial cells. At the end of pregnancy the spaces between juxtaposed villi of the trophoblastic epithelium in the erythrophagocytic zones were occluded by apposition of the epithelial cells. In these occluded regions an increase in highly electron-dense large-sized residual bodies (15-22 micrometer of dimension) occurred as a result of multiple cell phagocytosis in combination with fusion. In these residual bodies the numerous incorporated HDP-lysosomes and the remnants of phagocytosed cells could still be recognized.

Reaction of superficial bursae in response to specific disease stimuli

Although microscopic studies have shown similarities between bursal and joint membranes, little is known about bursae and their response to disease states. Eighty-six cases of superficial bursitis due to trauma, bacterial infection, or gout were reviewed and compared with cases of joint inflammation due to the same etiologies. In traumatic bursitis the bursal fluid mucin test was more abnormal and the viscosity lower than that of joint fluid in traumatic arthritis. The bursal fluid total leukocyte count of septic bursitis was less than 20,000/mm3 in 8 of 13 cases but in only 1 of 21 synovial fluids from cases of septic arthritis (P = 0.005). In gouty bursitis the mean total leukocyte count of bursal fluid was 2800/mm3, compared with a mean synovial fluid total leukocyte count of 28,700 in gouty arthritis (P less than 0.02). These findings indicate that superficial bursae react less intensely than diarthrodial joints to specific disease stimuli and that a relatively low bursal fluid leukocyte count is often present in cases of septic and gouty bursitis.

Ultrastructural localization and in situ analysis of iron, bismuth, and gold inclusions

The purpose of this article is to review ultrastructural and electron probe X-ray analytical studies on metallic deposits in cells. The metals that will be dealt with are iron, bismuth, and gold, mainly because they have been extensively studied in recent years. The nature and chemical composition of endogenously (e.g., from breakdown of autologous blood) and exogenously (e.g., after a transfusion or injection of iron compounds) produced hemosiderin (i.e., iron deposits) has been the subject of time-hallowed controversies. Quite a few of these have now been resolved by ultrastructural studies and the atomic composition of such deposits has been determined by electron probe X-ray analysis. The interest in bismuth centers around the fact that this is one of the two metals (the other being lead) that produces quite large intranuclear inclusions. Here again much has been learned by ultrastructural and X-ray analytical studies. The interest in gold stems from the fact that soluble salts of this metal are used for the treatment of rheumatoid arthritis and current studies with the above-mentioned techniques indicates how gold produces its beneficial and toxic effects.

Ultrastructure of intramuscular haematomas and electron-probe x-ray analysis of extracellular and intracellular iron deposits

Haematomas were produced in rabbits by intramuscular injections of autologous blood. Clotting and marked lysis of erythrocytes was noted in these haematomas but there was no evidence of fragmentation of erythrocytes, prior to, during, or after ingestion by macrophages as has been reported in other sites such as spleen, peritoneal cavity or joint cavity. The phagocytosis of intact erythrocytes, lysed erythrocytes and haemoglobin led to the formation of three main types of lysosomal bodies, (1) myelinosomes, (2) siderosomes and (3) myelinosidersomes. Electron-probe X-ray analysis of siderosomes has yielded further data supporting the idea that haemosiderin is essentially an inorganic iron compound; presumably a hydrated ferric oxide. An unusual and hitherto unreported finding was the occurrence of electron-dense granules in the connective tissue matrix in two animals. The granules were shown to contain iron, calcium, potassium and phosphorus. It is thought they might represent an attempt at pathological calcification in damaged tissue.

Proliferative synovitis in hemophilia: biochemical and morphologic observations

The synovium removed from the knee of a 10-year-old with hemophilia A was characterized morphologically and biochemically. The specimen showed villous hypertrophy with hyperplasia of synovial lining cells which contained abundant intracytoplasmic granules of hemosiderin. Monolayer cultures prepared from enzymatically dispersed tissue were characterized by pigment-laden fibroblast-like cells and round cells. Both explants of synovium and adherent cells secreted a large amount of latent collagenase and neutral proteinase into the culture medium. The secretion of these enzymes dropped sharply and intracellular pigment decreased with passage of these cultures. Lysozyme was secreted by the explants but was not detected in the monolayer culture medium. These data establish the degradative potential of the synovitis found in hemophilia and support the concept that recurrent hemarthrosis without inflammation is sufficient in and of itself to produce proliferative synovitis.

Ultrastructure of experimentally produced subcutaneous haematomas in the rabbit

Haematomas were produced in rabbits by subcutaneous injection of autologous blood. Clotting and marked lysis of erythrocytes was noted in these haematomas, but there was no evidence of fragmentation of erythrocytes prior to or after ingestion by macrophages as has been reported in other sites such as the peritoneal cavity and the joint cavity. The phagocytosis of intact erythrocytes, lysed erythrocytes and haemoglobin led to the formation of three main types of lysosomal bodies; (1) myelinosomes containing whorled osmiophilic membranes, (2) siderosomes containing haemosiderin, and (3) myelinosiderosomes containing a mixture of osmiophilic membranes and haemosiderin.

Idiopathic or traumatic olecranon bursitis. Clinical features and bursal fluid analysis

Thirty cases of idiopathic olecranon bursitis were studied. Most had previous local trauma. The process was unilateral and often associated with nontender pitting edema in cases of short duration. Ten patients exhibited a bony spur at the olecranon process, and amorphous calcific deposits were seen in 6. The bursal fluid was hemorrhagic with a xanthochromic supernatant, and the mucin clot test was poor or fair. Leukocyte count averaged 878/mm3, predominantly mononuclears. Many cells contained inclusion bodies. Glucose, total protein, and complement (C3) concentration averaged 80, 60, and 60% of the respective serum values.

Ultrastructure of the haemophilic synovial membrane and electron-probe X-ray analysis of haemosiderin

An ultrastructural study of the haemophilic synovial membrane revealed the presence of solitary siderosomes, compound siderosomes and a peppering of the cell cytoplasm with electron-dense particles. These changes were found in synovial intimal cells, subsynovial macrophages and fibroblasts. Electron-probe X-ray analysis of siderosomes revealed the presence of iron and traces of phosphorus. On the basis of previous and present studies it is postulated that haemosiderin is essentially a condensate of hydrated ferric oxide and that a variable amount of phospholipid material lies in company with it in the siderosome.

Electron probe x-ray analysis of siderosomes in the rabbit haemarthrotic synovial membrane

Electron probe x-ray analysis of siderosomes produced in the rabbit synovial membrane by repeated injections of autologous blood revealed two kinds of siderosomes; (1) those containing a small amount of phosphorus and, (2) those in which no phosphorus was detectable. On the basis of these findings and past studies it is concluded that haemosiderin is an inorganic compound of iron, probably a hydrated ferric oxide and that a variable amount of organic material (proteins, lipids, phospholipids, etc.,) probably occurs in company with the haemosiderin in the siderosome, but these variable components which decrease in amount with the passage of time cannot be considered as an integral part of haemosiderin.

Ultrastructural changes produced in rheumatoid synovial membrane by chrysotherapy

Biopsies of rheumatoid synovial membrane before and after chrysotherapy were examined with the light and electron microscopes, and subjected to electronprobe x-ray analysis. The main change noted was the occurrence of electron-dense deposits of characteristic morphology within pre-existing lysosomes. Such deposits were also seen in other varieties of lysosomal bodies. X-ray analysis showed the presence of gold, phosphorus, osmium, and calcium in these deposits. The present study shows that gold enters the pre-existing lysosomes, supporting the concept that the beneficial effects of chrysotherapy are due to its action on the lysosome.

[The ultrastructure of fibrous and histiocytic skin tumors (dermatofibroma, dermatofibrosarcoma protuberans, fibroxanthoma, and histiocytoma) (author's transl)]

A report on the ultrastructure of the following skin tumors: dermatofibroma (7 cases), histiocytoma (4 cases), dermatofibrosarcoma protuberans (1 case), and fibroxanthoma (1 case). Because of their different ultrastructural characteristics a division into two groups is possible: one group of tumors would include dermatofibroma, dermatofibrosarcoma protuberans, and fibroxanthoma, where the formation of fibers is extensive and fibroblasts are suggested for its histogenesis. These types of tumor differ from histiocytoma, the cellular character of which is determined by a very pronounced phagocytosis and storage of lipid and hemosiderin; a histogenesis from histiocytes is probable. The nuclei of dermatofibroma and histiocytoma show a simple surfacedevelopment, whereas the nuclei of dermatofibrosarcoma protuberans and fibroxanthoma show multisegmented nuclei ("labyrinth nuclei"). In the case of dermatofibrosarcoma protuberans this kind of nuclear segmentation seems to be a morphologic correlate of its semimalignancy. Based on ultrastructural analysis a classification of these fiber-producing tumors into "fibrous histiocytomas" is not justified.

The effect of Arvin on experimental immune arthritis in rabbits

The production of near total defibrination in rabbits by the use of Arvin, an extract of the venom of the Malayan pit viper (Agkistrodon rhodostoma), failed to influence the development of an experimentally induced chronic immune arthritis in these animals.