Age- and Sex-Different Associations between Cognitive Performance and Inflammatory Biomarkers in Community Dwelling Older Adults: towards Precision Preventive Strategies

BACKGROUND

Studies have demonstrated associations between inflammatory biomarkers and cognitive function in people with dementia or stroke, but little is known regarding these associations in healthy middle-aged and older populations.

OBJECTIVES

This study aims to examine associations between inflammatory biomarkers (both vascular and systemic) and cognitive performance in stroke- and dementia-free middle-aged and older adults without apolipoprotein E4 (ApoE ε4) allele carriers.

DESIGN

A cross-sectional study.

SETTING

Social Environment and Biomarkers of Aging Study (SEBAS) 2006.

PARTICIPANTS

A total of 983 participants aged 53 years and older.

MEASUREMENTS

Composite cognitive function assessment, including the Short Portable Mental Status Questionnaire, the Rey Auditory Verbal Learning Test, and the Wechsler Adult Intelligence Scale. Overnight venous blood sampling for 6 inflammatory biomarkers (C-reactive protein, interleukin-6, fibrinogen, homocysteine, intercellular adhesion molecule-1 and E-selectin) and ApoE genotyping.

RESULTS

Among 983 participants (mean age: 65.8±9.5 years), 808 were non-ApoE e4 allele carriers and were stroke- and dementia-free. Higher log fibrinogen was associated with poorer cognitive function after adjustment for potential confounding factors in non-ApoE e4 allele carriers and stroke- and dementia-free populations (unstandardized coefficients β= -1.553, P value= 0.003). In participants aged 65 years or older, both of elevated fibrinogen and homocysteine were associated with poorer cognitive function (β= -2.288, P value= 0.015; β= -1.331, P value= 0.012, respectively). Elevated log CRP was significantly associated with lower cognitive function only in women (β= -0.514, P value= 0.024).

CONCLUSION

Higher serum levels of fibrinogen were negatively associated with cognitive function, which was independent of ApoE genotyping and prior cerebrovascular events in dementia-free community-dwelling older adults. Further studies are needed to validate the roles of fibrinogen in the pathophysiology of dementia and elucidate the underlying mechanisms.

Physio-Cognitive Decline Syndrome as the Phenotype and Treatment Target of Unhealthy Aging

In this era of unprecedented longevity, healthy aging is an important public health priority. Avoiding or shortening the period of disability or dementia before death is critical to achieving the defining objectives of healthy aging, namely to develop and maintain functional capabilities that enable wellbeing in older age. The first step is to identify people who are at risk and then to implement effective primary interventions. Geriatricians have identified a distinct clinical phenotype of concurrent physical frailty and cognitive impairment, which predicts high risk of incident dementia and disability and is potentially reversible. Differing operational definitions for this phenotype include "cognitive frailty", "motoric cognitive risk syndrome" and the recently proposed "physio-cognitive decline syndrome (PCDS)". PCDS is defined as concurrent mobility impairment no disability (MIND: slow gait or/and weak handgrip) and cognitive impairment no dementia (CIND: ≥1.5 SD below the mean for age-, sex-, and education-matched norms in any cognitive domain but without dementia). By these criteria, PCDS has a prevalence of 10-15% among community-dwelling older persons without dementia or disability, who are at increased risk for incident disability (HR 3.9, 95% CI 3.0-5.1), incident dementia (HR 3.4, 95% CI 2.4-5.0) and all-cause mortality (HR 6.7, 95% CI 1.8-26.1). Moreover, PCDS is associated with characteristic neuroanatomic changes in the cerebellum and hippocampus, and their neurocircuitry, which are distinct from neuroimaging features in normal aging and common dementia syndromes. Basic research and longitudinal clinical studies also implicate a hypothetical muscle-brain axis in the pathoetiology of PCDS. Most important, community-dwelling elders with PCDS who participated in a multidomain intervention had significant improvements in global cognitive function, and especially in the subdomains of naming and concentration. Our proposed operational definition of PCDS successfully identifies an appreciable population of at-risk older people, establishes a distinct phenotype with an apparently unique pathoetiology, and is potentially reversible. We now need further studies to elucidate the pathophysiology of PCDS, to validate neuroimaging features and muscle-secreted microRNA biomarkers, and to evaluate the effectiveness of sustained multidomain interventions.

Tissue sodium content in patients with systemic lupus erythematosus: association with disease activity and markers of inflammation

OBJECTIVES

Sodium (Na⁺) is stored in the skin and muscle and plays an important role in immune regulation. In animal models, increased tissue Na⁺ is associated with activation of the immune system, and high salt intake exacerbates autoimmune disease and worsens hypertension. However, there is no information about tissue Na⁺ and human autoimmune disease. We hypothesized that muscle and skin Na⁺ content is (a) higher in patients with systemic lupus erythematosus (SLE) than in control subjects, and (b) associated with blood pressure, disease activity, and inflammation markers (interleukin (IL)-6, IL-10 and IL-17 A) in SLE.

METHODS

Lower-leg skin and muscle Na⁺ content was measured in 23 patients with SLE and in 28 control subjects using ²³Na⁺ magnetic resonance imaging. Demographic and clinical information was collected from interviews and chart review, and blood pressure was measured. Disease activity was assessed using the SLE Disease Activity Index (SLEDAI). Plasma inflammation markers were measured by multiplex immunoassay.

RESULTS

Muscle Na⁺ content was higher in patients with SLE (18.8 (16.7-18.3) mmol/L) than in control subjects (15.8 (14.7-18.3) mmol/L; p < 0.001). Skin Na⁺ content was also higher in SLE patients than in controls, but this difference was not statistically significant. Among patients with SLE, muscle Na⁺ was associated with SLEDAI and higher concentrations of IL-10 after adjusting for age, race, and sex. Skin Na⁺ was significantly associated with systolic blood pressure, but this was attenuated after covariate adjustment.

CONCLUSION

Patients with SLE had higher muscle Na⁺ content than control subjects. In patients with SLE, higher muscle Na⁺ content was associated with higher disease activity and IL-10 concentrations.

Increased blood pressure visit-to-visit variability in patients with systemic lupus erythematosus: association with inflammation and comorbidity burden

BACKGROUND

Blood pressure visit-to-visit variability is a novel risk factor for deleterious long-term cardiac and renal outcomes in the general population. We hypothesized that patients with systemic lupus erythematosus (SLE) have greater blood pressure visit-to-visit variability than control subjects and that blood pressure visit-to-visit variability is associated with a higher comorbidity burden.

METHODS

We studied 899 patients with SLE and 4172 matched controls using de-identified electronic health records from an academic medical center. We compared blood pressure visit-to-visit variability measures in patients with SLE and control subjects and examined the association between blood pressure visit-to-visit variability and patients' characteristics.

RESULTS

Patients with SLE had higher systolic blood pressure visit-to-visit variability 9.7% (7.8-11.8%) than the control group 9.2% (7.4-11.2%), P < 0.001 by coefficient of variation. Additional measures of systolic blood pressure visit-to-visit variability (i.e. standard deviation, average real variation, successive variation and maximum measure-to-measure change) were also significantly higher in patients with SLE than in control subjects. In patients with SLE, blood pressure visit-to-visit variability correlated significantly with age, creatinine, CRP, triglyceride concentrations and the Charlson comorbidity score (all P < 0.05). Hydroxychloroquine use was associated with reduced blood pressure visit-to-visit variability (P < 0.001), whereas the use of antihypertensives, cyclophosphamide, mycophenolate mofetil and corticosteroids was associated with increased blood pressure visit-to-visit variability (P < 0.05).

CONCLUSION

Patients with SLE had higher blood pressure visit-to-visit variability than controls, and this increased blood pressure visit-to-visit variability was associated with greater Charlson comorbidity scores, several clinical characteristics and immunosuppressant medications. In particular, hydroxychloroquine prescription was associated with lower blood pressure visit-to-visit variability.

Real-world electronic health record identifies antimalarial underprescribing in patients with lupus nephritis

Antimalarials (AMs) reduce disease activity and improve survival in patients with systemic lupus erythematosus (SLE), but studies have reported low AM prescribing frequencies. Using a real-world electronic health record cohort, we examined if patient or provider characteristics impacted AM prescribing. We identified 977 SLE cases, 94% of whom were ever prescribed an AM. Older patients and patients with SLE nephritis were less likely to be on AMs. Current age (odds ratio = 0.97, p < 0.01) and nephritis (odds ratio = 0.16, p < 0.01) were both significantly associated with ever AM use after adjustment for sex and race. Of the 244 SLE nephritis cases, only 63% were currently on AMs. SLE nephritis subjects who were currently prescribed AMs were more likely to be followed by a rheumatologist than a nephrologist and less likely to have undergone dialysis or renal transplant (both p < 0.001). Non-current versus current SLE nephritis AM users had higher serum creatinine (p < 0.001), higher urine protein (p = 0.05), and lower hemoglobin levels (p < 0.01). As AMs reduce disease damage and improve survival in patients with SLE, our results demonstrate an opportunity to target future efforts to improve prescribing rates among multi-specialty providers.

Association of estimated sodium and potassium intake with blood pressure in patients with systemic lupus erythematosus

Sodium and potassium intake are modifiable determinants of hypertension in the general population but have not been studied in patients with systemic lupus erythematosus (SLE). We examined the relationship between urinary excretion of sodium and potassium, as an estimate of intake, and blood pressure in patients with SLE. We studied 178 SLE patients and 86 controls, matched for age, sex, and race. Urine sodium (Na⁺) and potassium (K⁺) were measured by flame photometry. Blood pressure was the average of two resting measurements. The associations between systolic (SBP) and diastolic blood pressures (DBP) and estimated 24-hour urinary Na⁺, K⁺, and Na⁺:K⁺ ratio were tested. The estimated mean 24-hour urinary K⁺ excretion was lower, and the Na⁺:K⁺ ratio was higher in patients with SLE than controls. There were no significant differences in the estimated 24-hour urinary Na⁺. In patients with SLE, a higher urinary Na⁺:K⁺ ratio was associated with higher SBP (β coefficient = 4.01, p = 0.023) and DBP (β coefficient = 4.41, p = 0.002) after adjusting for age, sex, and race. SLE patients had significantly lower estimated 24-hour urinary K⁺ and higher estimated 24-hour urinary Na⁺: K⁺ ratio than controls. The urinary Na⁺:K⁺ ratio was significantly associated with SBP and DBP.

GlycA, a novel marker of inflammation, is elevated in systemic lupus erythematosus

BACKGROUND

GlycA is a novel marker of systemic inflammation detected by nuclear magnetic resonance (NMR) spectroscopy. In the general population, GlycA is correlated with inflammatory markers such as C-reactive protein (CRP) and associated with coronary heart disease and diabetes. The utility of GlycA in patients with systemic lupus erythematosus (SLE) has not been defined. Therefore, we tested the hypothesis that GlycA concentrations are elevated in patients with SLE and associated with other markers of inflammation and coronary atherosclerosis.

METHODS

We compared concentrations of GlycA, detected by NMR, in 116 patients with SLE and 84 control subjects frequency-matched for age, sex, and race. SLE disease activity index (SLEDAI) and the SLE Collaborating Clinics damage index (SLICC) were calculated. Acute phase reactants, a panel of cytokines, and a lipid panel were measured. Electron beam computer tomography (EBCT) was used to quantify coronary artery calcification, a measure of coronary artery atherosclerosis.

RESULTS

Patients with SLE had higher concentrations of GlycA (398 (350-445)) than control subjects (339 (299-391)) µmol/L, p < 0.001. In patients with SLE, concentrations of GlycA were significantly associated with sedimentation rate (rho = 0.43), C-reactive protein (rho = 0.59), e-selectin (rho = 0.28), intracellular adhesion molecule-1 (rho = 0.30), triglycerides (rho = 0.45), all p < 0.0023 to account for multiple comparisons, but not with creatinine, SLEDAI, SLICC, or coronary calcium scores.

CONCLUSIONS

Concentrations of GlycA are higher in patients with SLE than control subjects and associated with markers of inflammation but not with SLE disease activity or chronicity scores or coronary artery calcification.

Genetic variation and coronary atherosclerosis in patients with systemic lupus erythematosus

Coronary artery disease is the major cause of mortality in patients with systemic lupus erythematosus (SLE). Increased cardiovascular risk in SLE is not explained by traditional risk factors. We examined the hypothesis that genetic variation contributes to the presence of coronary atherosclerosis in patients with SLE. The genotypes of single-nucleotide polymorphisms (SNP) in 152 candidate genes linked with autoimmune or cardiovascular risk were determined in 125 patients with SLE. Coronary artery calcium (CAC), a measure of coronary atherosclerosis, was detected in 32 patients (26%) by electron-beam computed tomography. Polymorphism in 20 of the candidate genes (ADAM33, ADIPOQ, CCL5, CCR7, CDKN2B, CSF1, IL4, IL12A, IL23R, INS, IRF5, MIF, MS4A1, PTGS1, PTPN22, RETN, SELE, TNFSF4, TNFRSF11B, and VCAM1) were nominally associated with the presence of CAC (p-values = 0.001-0.047 after adjustment for age, sex and race). Some of these are known susceptibility genes for SLE and others have been implicated in cardiovascular disease in other populations. No association withstood false discovery rate adjustment. Replication studies in additional cohorts of patients with SLE may be informative.

A cell-permeable fusion protein for the mineralization of human dental pulp stem cells

Human dental pulp stem cells (hDPSCs) are the only mesenchymal stem cells in pulp tissue that can differentiate into osteoblasts, odontoblasts, and adipose cells. The transcriptional co-activator with PDZ-binding motif (TAZ) protein has been reported to modulate osteogenic differentiation in mouse MSCs. Therefore, we examined whether the TAZ protein plays the same role in human pulp stem cells. In this study, TAZ was applied to cells directly with low-molecular-weight protamine (LMWP) as a cell-penetrating peptide (CPP). The LMWP-TAZ fusion proteins were expressed in an E. coli system with a pET-21b vector and efficiently transferred into hDPSCs without producing toxicity in the cells. The efficient uptake of TAZ was shown by Western blot with an anti-TAZ antibody, fluorescence-activated cell sorting, and confocal microscopy in live cells. The delivered TAZ protein increased osteogenic differentiation, as confirmed by alkaline phosphatase (ALP) staining, RT-PCR, and Western blotting. In addition, TAZ also inhibited adipogenic differentiation, regulating peroxisome proliferator-activated receptor-γ (PPAR-γ), lipoprotein lipase (LPL), and adipocyte fatty acid-binding protein (aP2) mRNA levels. These in vitro studies suggest that cell-permeable TAZ may be used as a specific regulator of hard-tissue differentiation.

Adipocytokines in systemic lupus erythematosus: relationship to inflammation, insulin resistance and coronary atherosclerosis

We tested the hypothesis that concentrations of adipocytokines are altered in SLE and associated with coronary atherosclerosis, insulin resistance and inflammation. Concentrations of resistin, leptin, adiponectin and visfatin were measured in 109 patients with SLE and 78 control subjects. Coronary calcification was measured using electron beam-computed tomography, and insulin resistance was defined by the homeostasis model assessment index. Concentrations of adiponectin (28.7 +/- 17.9 vs 22.0 +/- 15.3 microg/mL, P = 0.003), leptin (41.1 +/- 49.9 vs 19.8 +/- 24.6 ng/mL, P < 0.001) and visfatin (7.5 +/- 10.5 vs 4.5 +/- 2.8 ng/mL, P < 0.001) were higher in patients with SLE than in controls. These differences remained significant after adjustment for age, race, sex and body mass index (BMI; all P values < 0.02). Concentrations of resistin (10.7 +/- 7.6 vs 9.1 +/- 5.1 ng/mL, P = 0.41) did not differ in patients and controls. In patients with SLE, leptin was positively associated with BMI (rho = 0.80, P < 0.001), insulin resistance (rho = 0.46, P < 0.001) and C-reactive protein (CRP) (rho = 0.30, P = 0.002), whereas adiponectin was negatively associated with the same factors (rho = -0.40, P < 0.001; rho = -0.38, P < 0.001; rho = -0.22, P = 0.02, respectively). None of the adipocytokines were associated with coronary atherosclerosis in SLE. In conclusion, patients with SLE have increased concentrations of adiponectin, leptin and visfatin. Lower concentrations of adiponectin and higher concentrations of leptin are associated with insulin resistance, BMI and CRP in patients with SLE.

Changing patterns of medication use in patients with rheumatoid arthritis in a Medicaid population

OBJECTIVE

To examine changes in patterns of medication utilization in patients with RA.

METHODS

Data from Tennessee Medicaid (TennCare) databases (1995-2004) were used to identify adults with both a diagnosis of RA and at least one DMARD prescription each year. Annual age-specific utilization of DMARDs, glucocorticoids, NSAIDs and narcotics was measured on the last day of each year to determine the point prevalence of use of these agents.

RESULTS

Records from 23 342 patients with treated RA were analysed. Most patients were females (78%) and white (74%). The median age was 57 yrs (interquartile range: 48-65). The proportion of patients who had a current DMARD prescription on the index date increased from 62% in 1995 to 71% in 2004 (P < 0.001). MTX was the most commonly used DMARD. By the end of 2004, 22% of patients had a current prescription for a biologic, and etanercept represented 51% of all biologic therapies. During the study period, the overall utilization of glucocorticoids decreased from 46% to 38% (P < 0.001), whereas NSAID utilization increased from 33% to 38% (P < 0.001), and use of narcotics increased from 38% to 55% (P < 0.001). A secondary analysis that identified RA patients based on diagnosis codes alone, showed similar patterns, but lower DMARD utilization which increased from 33% to 52% overall and from 0% to 16% for biologics.

CONCLUSIONS

The utilization of DMARDs increased in TennCare patients with RA, and by 2004, use of biologics was substantial. Although glucocorticoid utilization decreased, use of both NSAIDs and narcotics increased.

Oxidative stress in systemic lupus erythematosus: relationship to disease activity and symptoms

Oxidative stress may play a role in the pathogenesis of systemic lupus erythematosus (SLE). We examined the hypothesis that oxidative stress was associated with indices of lupus disease activity and severity of symptoms. Urinary F2 isoprostane excretion, a validated marker of oxidative stress, was measured in 95 patients with SLE and 103 healthy controls. Outcome measures included SLEDAI and SLICC scores, the modified health assessment questionnaire, the fatigue severity scale (FSS), and visual analogue scales (VAS) for fatigue, pain and overall disease activity. F2 isoprostane excretion was compared in patients and controls, and its relationship with clinical variables in SLE examined. F2 isoprostane excretion did not differ significantly among patients with lupus (2.7 +/- 2.3 ng/mg Cr) and control subjects (2.2 +/- 1.4 ng/mg Cr) (P = 0.70). In patients with lupus, F2 isoprostane concentrations were independently associated with higher patient reported disease activity (VAS) (OR = 1.52, P = 0.01), fatigue (FSS, OR = 1.52, P = 0.03) and lower quality of life (OR = 0.73, P = 0.05), but not with objective markers or inflammation or disease activity. In conclusion, F2 isoprostane excretion is associated with patient-reported symptoms in SLE but not with measures of inflammation, SLEDAI or SLICC. Oxidative stress may contribute to debilitating symptoms such as fatigue in SLE.

A 2-year open-label study of galantamine therapy in Chinese Alzheimer's disease patients in Hong Kong

There was no long-term clinical study on galantamine in Alzheimer's disease (AD) in the Asian population. The objectives of this study were to evaluate the efficacy of galantamine on cognitive function, daily functioning, behavioural symptoms and its safety in Chinese AD patients. This was a 2-year open-label clinical trial. The inclusion criteria were patients with probable AD by the NINCDS-ADRDA criteria. A historical control group (n = 19) of AD patients with no galantamine or other cholinesterase inhibitor therapy was employed. In the galantamine group, 33 and 32 subjects had completed a 1-year and 2-year follow up, respectively. Within the galantamine group and at a 6-month follow up, the Alzheimer's Disease Assessment Scale Cognitive Subscale (ADAS-cog score) showed an improvement of 2.9 +/- 1.18 (p = 0.019, paired t-test) but remained the same at 1 and 2 years. The Alzheimer's Disease Cooperative Study-Activities of Daily Living Inventory (ADCS-ADL) deteriorated by 4.31 +/- 2.06 (p = 0.044, paired t-test) at 6 months but showed no significant decline at 1 and 2 years vs. baseline. The Neuropsychiatric Inventory (NPI) score also showed a significant deterioration of 5 +/- 1.99 (p = 0.017, paired t-test) at 6 months, 8.06 +/- 1.97 (p < 0.001, paired t-test) at 1 year and 7.31 +/- 1.76 at 2 years. Comparison between the two groups showed a statistically significant improvement in the 1-year ADAS-cog score but decline in the NPI score in the galantamine vs. control groups. Adverse effects were commonly mild. In Chinese mild-moderate AD patients, galantamine showed beneficial effects mainly on the cognitive function.

Cardiovascular risk scores and the presence of subclinical coronary artery atherosclerosis in women with systemic lupus erythematosus

The Framingham risk score is widely used to identify patients at increased cardiovascular risk, and women with systemic lupus erythematosus (SLE) have a marked increased prevalence of cardiovascular events. Thus, we examined the hypothesis that cardiovascular risk scores would identify women with SLE who had asymptomatic coronary atherosclerosis. Ninety-three women with SLE and 65 control subjects were studied. The Framingham score and a score for younger populations developed from the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study were compared in both groups. Coronary atherosclerosis was ascertained by electron beam computed tomography. There were no significant differences in the median (interquartile range) Framingham [5 (2-10) compared to 7 (0-10), P = 0.88] and PDAY [15 (14-18) compared to 16 (13-18), P = 0.99] scores in patients with SLE and controls, respectively. Coronary atherosclerosis was associated with higher Framingham [12 (3-15) compared to 4 (1-8), P = 0.008] and PDAY [17 (15-19 compared to 15 (12-18), P = 0.03)] scores in patients with SLE; however, 99% of patients were classified as low-risk with a 10-year predicted risk of 1% (<1-3%). Our data indicate that cardiovascular risk scores are not adequate for risk stratification in women with SLE. Measurement of coronary calcification may add information to identify asymptomatic women with lupus who might benefit from aggressive preventive measures.

Declines in number of tender and swollen joints in patients with rheumatoid arthritis seen in standard care in 1985 versus 2001: possible considerations for revision of inclusion criteria for clinical trials

OBJECTIVE

To analyse tender and swollen joint counts in three cohorts of patients with rheumatoid arthritis (RA), with a focus on the proportions of patients who had fewer than 6-12 tender or swollen joints, as possible evidence based information toward more generalisable inclusion criteria for current and future RA clinical trials.

METHODS

Tender and swollen joint counts were analysed in three cohorts of patients with RA: 125 in 1985, 138 in 2000, and 232 with early RA in 2001.

RESULTS

The median numbers of tender joints were 11, 2, and 4 in 1985, 2000, and in early RA in 2001, respectively. The median numbers of swollen joints were 12, 6, and 5 in 1985, 2000, and 2001, respectively. The numbers of tender joints among 28 assessed were >or=12, >or=6, >or=4, and >or=3 in 47%, 80%, 85%, and 90% of patients in 1985; 20%, 37%, 44%, and 49% in 2000; and 17%, 37%, 50%, and 58% in early RA in 2001. The numbers of swollen joints among 28 assessed were >or=12, >or=6, >or=4, and >or=3 in 51%, 78%, 86%, and 90% of patients in 1985; 20%, 50%, 64%, and 67% in 2000; and 14%, 46%, 58%, and 72% in 2001. The number of patients with >or=6 tender or swollen joints in 1985 was greater than the number with >or=3 joints in 2000 and in early RA in 2001.

CONCLUSION

Contemporary cohorts of patients seen in standard care have smaller numbers of tender and swollen joints than in previous times. These findings suggest that revision of inclusion criteria for numbers of tender and swollen joints in contemporary RA clinical trials might improve generalisability.

Detection of intracranial venous reflux in patients of transient global amnesia

BACKGROUND

The mechanism of transient global amnesia (TGA) is not clear. Attempting to support the hypothesis that retrograde venous hypertension causing cerebral venous ischemia plays a role in the pathogenesis of TGA, the authors used cranial three-dimensional time-of-flight (TOF) MR angiography (MRA) to detect a possible intracranial retrograde venous flow in TGA patients.

METHODS

The frequency of abnormal venous signals on cranial three-dimensional TOF MRA was compared in 10 TGA patients with the signals in 50 age- and gender-matched normal individuals. In TGA patients with abnormal venous signals, other examinations (cerebral digital subtraction angiography, upper extremity digital subtraction venography [DSV], and thoracic inlet MRI) were performed to elucidate the etiology of these abnormal intracranial venous flow patterns.

RESULTS

Abnormal venous signals on three-dimensional TOF MRA were found in five (50%) of the TGA patients and none of the control subjects (p < 0.001). Compression leading to occlusion of the left brachiocephalic vein by the sternum and aorta during regular breathing, as depicted by upper extremity DSV and thoracic inlet MRI, occurred consistently among these five TGA patients with abnormal venous signals.

CONCLUSIONS

Retrograde intracranial venous flow caused by left brachiocephalic vein occlusion was found only in patients with transient global amnesia (TGA). This result suggests that TGA patients may have an underlying impairment of cerebral venous outflow that increases their vulnerability to TGA attack.

Work disability in early rheumatoid arthritis: higher rates but better clinical status in Finland compared with the US

OBJECTIVE

To analyse and compare work disability attributed to rheumatoid arthritis in two cohorts of patients with early disease: one in the US and the other in Finland.

PATIENTS AND METHODS

Two cohorts of patients who were working and aged <65 years at the time of their first symptom of rheumatoid arthritis were studied: 269 patients in Nashville, TN, USA (median age 46 years, 72.5% females), and 364 patients from Jyväskylä, Finland, (median age 47.1 years, 70.9% females). The cohorts were analysed and compared for measures of clinical status and work disability status over a median (interquartile range) of 38.9 months in Nashville and 48.4 months in Jyväskylä.

RESULTS

The probability of working at 36 months was 0.89 (0.84-0.92) for patients from Nashville and 0.84 (0.80-0.88) for patients from Jyväskylä (p = 0.02). These rates were lower than in earlier decades. Patients from Jyväskylä had significantly higher rates of work disability (p = 0.02) than those from Nashville, but better scores for self-report physical function (p<0.001), pain (p<0.001) and global status (p<0.001) at last observation. The likelihood of being disabled from work was 2.6-fold higher in Jyväskylä compared to Nashville (95% confidence interval 1.44 to 4.59, p = 0.001), after adjustment for demographic and disease-specific variables.

CONCLUSION

Rates of work disability in both early rheumatoid arthritis cohorts were improved from earlier decades, but differed significantly in two different social systems. Higher work disability rates with better clinical status was seen in the Finnish early rheumatoid arthritis cohort than in the US cohort.

Are American College of Rheumatology 50% response criteria superior to 20% criteria in distinguishing active aggressive treatment in rheumatoid arthritis clinical trials reported since 1997? A meta-analysis of discriminant capacities

OBJECTIVE

To carry out a meta-analysis designed to compare the discriminant capacities of American College of Rheumatology 50% (ACR50) with 20% (ACR20) responses in clinical trials on rheumatoid arthritis reported after 1997 and to analyse whether ACR50 can be as informative as ACR20 in distinguishing active from control treatments in more recent trials.

METHODS

Clinical trials on rheumatoid arthritis reported since 1997 were identified, which included aggressive combinations of disease-modifying antirheumatic drugs and glucocorticoids, as well as powerful new agents-leflunomide, etanercept, infliximab, anakinra, adalimumab, abatacept, tacrolimus and rituximab. A meta-analysis of ACR20 compared with ACR50 responses for 21 clinical trials was carried out on differences in proportions of responders for active and control treatments and corresponding odds ratios (ORs).

RESULTS

In all but one clinical trial on rheumatoid arthritis published since 1997 with data available on ACR20 and ACR50, more than 50% of patients who were ACR20 responders among those randomised to active treatment were also ACR50 responders. This phenomenon was seen for control groups in 38% of trials, many of which included treatment with methotrexate. A meta-analysis of the clinical trials indicated a slight advantage to ACR50 for quantifying treatment comparisons, not significant for differences in proportions but significant for ORs.

CONCLUSION

ACR20 and ACR50 seem to be similar in distinguishing active from control treatments in clinical trials on rheumatoid arthritis reported since 1997. As ACR50 represents a considerably stronger clinical response, ACR50 may be a preferred end point for contemporary clinical trials on rheumatoid arthritis.

The relationship between non-cognitive symptoms and functional impairment in Alzheimer's disease

OBJECTIVE

Cognitive impairment is an important determinant for functional impairment in Alzheimer's disease. The role of non-cognitive symptom is uncertain. The objective of this study was to investigate the role of non-cognitive symptoms as predictive factors for functional outcome in A.D.

METHODS

This was a retrospective study. Subjects were recruited from the Memory Clinic in Queen Mary Hospital over a two years period. Patients with diagnosis of probable A.D. by NINCDS-ADRDA were identified. Demographic data, Folstein Mini-Mental Status Examination (MMSE), Clinical Dementia Rating (CDR), Neuropsychiatric inventory (NPI), Barthel activities of daily living (ADL) as well as Lawton's Instrumental activities of daily living (IADL) were retrieved.

RESULTS

100 patients were identified. Univariate analysis identified statistically significant correlation between hallucination and disinhibition score with Barthel Index (r=-0.43, p <0.001; r=-0.30, p=0.002 respectively); hallucination and aberrant motor act score with Lawton's IADL (r=-0.21, p=0.038; r=-0.21, p=0.038). MMSE was statistical significantly correlated with the above two functional scores. NPI was not statistical significantly correlated with any one of the functional measures. Multivariate regression analyses showed that hallucination score was an independent predictive factors for the Barthel index but not for the Lawton's IADL. MMSE score was identified to be independent predictive factor for all functional measures.

CONCLUSIONS

Global cognitive impairment and hallucination was an important independent predictive factor for functional outcomes. Screening hallucination during the course of A.D. would be helpful. Further studies are needed to show the benefit of treatment of hallucination on the improvement of functional outcomes.

Molded porous poly (L-lactide) membranes for guided bone regeneration with enhanced effects by controlled growth factor release

The aim of this study was to develop platelet-derived growth factor (PDGF-BB) loaded moldable porous poly (L-lactide) (PLLA)-tricalcium phosphate (TCP) membranes for guided bone regeneration (GBR) therapy. The membranes were designed to fit various types of bone defect sites. PDGF-BB-dissolved PLLA-TCP in methylene chloride-ethyl acetate solution was cast on a dome shaped metallic mold to fabricate a model membrane. The release rate of PDGF-BB, the osteoblast attachment test, and guided bone regeneration potential were evaluated with PDGF-BB-loaded PLLA-TCP membranes. Regular pores were generated throughout the membrane mainly due to phase inversion of PLLA-methylene chloride-ethyl acetate solution. A therapeutic amount of PDGF-BB was released from the membrane. The release rate could be controlled by varying the initial loading content of PDGF-BB. A significant amount of cells attached onto the PDGF-BB-loaded membrane rather than onto the unloaded membrane. Dome shaped bone formation was achieved in rabbit calvaria at 4 weeks. This indicated that restoration of bone defects to the bone's original shape can be made possible by using molded membranes, which guide bone regeneration along with providing sufficient spaces. Bone forming efficiency was increased remarkably due to PDGF-BB release from PLLA-TCP membranes. These results suggested that the PDGF-BB releasing molded PLLA-TCP membrane may potentially improve GBR efficiency in various types of bone defects.

Tissue-engineered growth of bone by marrow cell transplantation using porous calcium metaphosphate matrices

In this study we investigated not only osteoblastic cell proliferation and differentiation on the surface of calcium metaphosphate (CMP) matrices in vitro but also bone formation by ectopic implantation of these cell-matrix constructs in athymic mice in vivo. Interconnected porous CMP matrices with pores 200 microm in size were prepared to use as scaffolds for rat-marrow stromal-cell attachment. Cell-matrix constructs were cultured in vitro, and cell proliferation and ALPase activities were monitored for 56 days. In addition to their being cultured in vitro, cell-matrix constructs were implanted into subcutaneous sites of athymic mice. In vitro these porous CMP matrices supported the proliferation of osteoblastic cells as well as their differentiation, as indicated by high ALPase activity. In vivo the transplanted marrow cells gave rise to bone tissues in the pores of the CMP matrices. A small amount of woven bone formation was detected first at 4 weeks; osteogenesis progressed vigorously with time, and thick lamellar bones that had been remodeled were observed at 12 weeks. These findings demonstrate the potential for using a porous CMP matrix as a biodegradable scaffold ex vivo along with attached marrow-derived mesenchymal cells for transplantation into a site for bone regeneration in vivo.

Cataract formation after pars plana vitrectomy

To investigate the duration and pattern of cataract formation after pars plana vitrectomy, thirty-three eyes from 33 patients with complete data from March 1995 to January 2000 were collected in this study. The time and pattern of cataract formation was analyzed according to Lens Opacities Classification System III (LOCS III). The correlation between the mean cataract progression and follow-up time was determined by simple regression and correlation analysis. Diabetes mellitus and hypertension were the main causes of patients with vitreoretinopathy who underwent pars plana vitrectomy procedure. Twenty-one patients (63.6%) had diabetes mellitus and 11 patients (33.3%) had hypertension. Four eyes (13.8%) received intravitreal gas injection after pars plana vitrectomy. The correlation between cataract progression and follow-up time was clinically significant (p < 0.05). Thirty-one patients (94%) were nuclear cataract, the mean time of cataract formation being 9.1 months; 15 patients (46.9%) were cortical cataract, the mean time of formation being 8 months; and 24 patients (72.7%) were posterior subcapsular cataract, the mean time of formation being 13.3 months. Cataract formation after pars plana vitrectomy is not infrequent. Nuclear cataract is the most common type in this study. Vitreous microenvironmental changes, post-vitrectomy uveitis, intravitreal gas, and patient age may be the key points of cataract formation after surgery. The mechanism of longer-term effect of pars plana vitrectomy on lens status is still unknown and merits further study.

Enhanced guided bone regeneration by controlled tetracycline release from poly(L-lactide) barrier membranes

With the aim of providing effective periodontal therapeutic modality, drug-releasing membranes for guided tissue regeneration (GTR) were developed. As GTR membranes, biodegradable barrier membranes composed of porous poly(L-lactide) (PLLA) films cast on poly(glycolide) (PGA) meshes were fabricated using an in-air drying phase inversion technique. PLLA was dissolved in methylene chloride-ethylacetate mixtures, cast on knitted PGA mesh, and then air-dried. Tetracycline, which is used in periodontal therapy because of its antibacterial activity and tissue regenerating effects, including osteoblast chemotactic effect and anti-collagenolytic activity, was incorporated into the membranes by adding it to PLLA solutions. The guided bone regenerating potential of tetracycline-loaded membranes was evaluated using release kinetics both in vitro and in vivo, biodegradation tests, and cell attachment tests. Homogeneous pores were generated both at the surface and in a sublayer of the membranes. The release kinetics of tetracycline depended mainly upon the hydrophilicity of tetracycline and the porosity of the membrane. The release rate further could be controlled by loaded drug contents. The release of tetracycline was appropriate for maintaining anti-microbial activity and for its tissue-regenerating potential. The membranes retained a proper degradation property, maintaining their mechanical integrity for the barrier function for 4 weeks. Tetracycline-loaded membranes induced increased cell attachment levels compared with those of unloaded membranes. Tetracycline-loaded membranes markedly increased new bone formation in rat calvarial defects and induced bony reunion after 2 weeks of implantation. These results suggest that tetracycline-loaded PLLA membranes potentially enhance guided tissue regenerative efficacy.

Controlled release of platelet-derived growth factor-BB from chondroitin sulfate-chitosan sponge for guided bone regeneration

Platelet-derived growth factor-BB (PDGF-BB) releasing porous chondroitin-4-sulfate (CS)-chitosan sponge was designed with an aim of controlling growth factor delivery in order to improve bone formation. Porous CS-chitosan sponge was fabricated by freeze drying and crosslinking aqueous CS-chitosan solution. PDGF-BB was incorporated into the CS-chitosan sponge by soaking CS-chitosan sponge into the PDGF-BB solution. CS-chitosan sponge retained a porous structure with a 150-200-microm pore diameter that was suitable for cellular migration and osteoid ingrowth. Release rate of PDGF-BB could be controlled by varying the composition of CS in the sponge or initial loading content of PDGF-BB. CS-chitosan sponge induced increased osteoblast migration and proliferation as compared with chitosan sponge alone. Furthermore, the release of PDGF-BB from CS-chitosan sponge significantly enhanced osteoblast proliferation. These results suggest that PDGF-BB-releasing CS-chitosan sponge may be beneficial to enhance bone cell adaptation and regenerative potential when applied in wound sites.

A randomized clinical trial comparing autologous blood clot and gelfoam in transarterial chemoembolization for inoperable hepatocellular carcinoma

BACKGROUND/AIM

Inoperable hepatocellular carcinoma is common in Asia and is usually treated with repeated transarterial chemoembolization. Gunji et al. showed better survival and fewer complications with autologous blood clot as compared with gelfoam used for embolization. Our aim was to compare the effect of blood clot versus gelfoam.

METHODS

We conducted a prospective randomized trial in 100 patients with inoperable hepatocellular carcinoma, and compared the side effects and cumulative survival in the two groups. Cox's proportional hazard model was used to study the prognostic factors.

RESULTS

The diameter of the main tumor was 7.9+/-4.6 cm. Our study did not show additional beneficial effects of blood clot. The proportion of side effects was similar and the common ones included fever, pain and vomiting. Though the hepatic artery remained patent for a longer period with blood clot (p=0.061), there was no difference in survival (p=0.129 for Okuda I disease and p=0.388 for Okuda II disease). Subgroup analysis showed longer survival in patients with vascular occlusion (p=0.034 for Okuda I and p=0.029 for Okuda II disease). The independent factors of survival were sex, Child's class, Okuda stage, tumor type and presence of metastases.

CONCLUSION

This study showed no additional benefits of blood clot in patients with inoperable hepatocellular carcinoma, in Okuda I and II disease. The longer survival in patients with vascular occlusion suggested that the damage to normal liver tissue by planned periodic transarterial chemoembolization may outweigh its benefit in later sessions of repeated TACE in certain patients.

Tissue engineered bone formation using chitosan/tricalcium phosphate sponges

BACKGROUND

Chitosan is a biodegradable natural polymer that has been shown to improve wound healing. This study aimed to develop chitosan/tricalcium phosphate (TCP) sponges as tissue engineering scaffolds for bone formation by three-dimensional osteoblast culture.

METHODS

The sponges were prepared by freeze-drying and cross-linking a mixture of chitosan solution with TCP. Fetal rat calvarial osteoblastic cells were isolated, cultured, and seeded into the sponges. The cell-sponge constructs were cultured for 56 days. Cell proliferation, alkaline phosphatase (ALPase) activity, and calcium deposition in the cell-sponge constructs were measured at 1, 7, 14, 28, and 56 days. Histologic examination was performed with light microscopy and scanning electron microscopy.

RESULTS

Chitosan/TCP sponges supported the proliferation of osteoblastic cells as well as their differentiation as indicated by high ALPase activities and deposition of mineralized matrices by the cells. Light and scanning electron microscopic examination indicated that seeded osteoblastic cells were well attached to sponge matrices and proliferated in a multi-layer fashion. Small bone-like spicules were observed on the sponge matrix at 14 days. Seeded cells appeared to be embedded in the newly formed tissue matrix, which is characteristic of the osteoblast differentiation and their progression into osteocytic cells. The amount of mineralized tissue formed in the sponge at 56 days was significant.

CONCLUSIONS

These results suggest that the chitosan/TCP sponge is a feasible tool as a scaffolding material to grow osteoblast in a three-dimensional structure for transplantation into a site for bone regeneration.

The bone regenerative effect of platelet-derived growth factor-BB delivered with a chitosan/tricalcium phosphate sponge carrier

BACKGROUND

In order to achieve optimal effects, growth factors including platelet-derived growth factor (PDGF) should be delivered with a biodegradable carrier that will release therapeutic concentrations over a sufficient length of time. The purpose of this study was to evaluate the bone regenerative effect of PDGF-BB delivered with a chitosan/tricalcium phosphate (TCP) sponge carrier in a rat calvarial defect model.

METHODS

The PDGF-BB-loaded chitosan/TCP sponge carrier was fabricated by freeze-drying a mixture of chitosan solution and TCP powder and soaking in a PDGF-BB solution. The release kinetics of PDGF-BB loaded onto the sponge were measured in vitro with 125I-labeled PDGF-BB. Chitosan/TCP sponges with and without PDGF-BB were implanted into 8 mm calvarial defects in rats. Rats were sacrificed at 2 and 4 weeks following implantation, and histologic and histomorphometrical examinations were performed.

RESULTS

In vitro evaluation demonstrated that an effective therapeutic concentration of PDGF-BB following a high initial burst release was maintained throughout the examination period. In the histologic examination, the chitosan/TCP sponge carrier promoted osseous healing of the rat calvarial defects as compared to controls. The addition of PDGF-BB to the carrier further enhanced bone regeneration. Evidence of the degraded sponge matrix was observed mingled within the newly formed bone without connective tissue encapsulation.

CONCLUSIONS

The results of this study support the use of chitosan/TCP sponges as a delivery system for growth factors and demonstrate that PDGF-BB loaded onto chitosan/TCP sponge carriers has an osteogenic effect on bone regeneration in vivo.

Platelet derived growth factor releasing chitosan sponge for periodontal bone regeneration

With an aim of improving bone regeneration, chitosan sponge containing platelet-derived growth factor-BB (PDGF-BB) were developed. For fabrication of chitosan sponge, chitosan solution was freeze-dried, crosslinked and freeze-dried again. PDGF-BB was incorporated into the chitosan sponge by soaking chitosan sponge into the PDGF-BB solution. Release kinetics of PDGF-BB, cell attachment, proliferation capacity and bony regenerative potentials of PDGF-BB-loaded chitosan sponge were investigated. Prepared chitosan sponge retained porous structure with 100 microm pore diameter that was suitable for cellular migration and growth. Release rate of PDGF-BB could be controlled by varying initial loading content of PDGF-BB to obtain optimal therapeutic efficacy. PDGF-BB-loaded chitosan sponge induced significantly high cell attachment and proliferation level, which indicated good cellular adaptability. PDGF-BB-loaded chitosan sponge demonstrated marked increase in new bone formation and rapid calcification. Degradation of the chitosan sponge was proceeded at defect site and subsequently replaced with new bone. Histomorphometric analysis confirmed that PDGF-BB-loaded chitosan sponge significantly induced new bone formation. These results suggested that chitosan sponge and PDGF-BB-loaded chitosan sponge may be beneficial to enhance periodontal bone regeneration.

Staphylococcus lugdunensis--a potential pathogen in oral infection

OBJECTIVE

The purpose of this study was to investigate the pathogenicity of Staphylococcus lugdunensis in acute oral infection.

STUDY DESIGN

S. lugdunensis was isolated from patients with acute oral infections and from healthy control subjects. Antibiotic susceptibility, in vitro cellular toxicity, in vivo virulence, and hemolytic activity testing and dot blot analysis were performed. The statistical significance of in vitro cellular toxicity was determined by means of analysis of variance.

RESULTS

Isolated from the infected patients, S. lugdunensis showed resistance to penicillin, ampicillin, methicillin, cephalothin, and clindamycin, exhibited virulence in vivo, and showed delta-like hemolysin activity. Four of the 6 strains of S. lugdunensis gave synergistic hemolysis. In dot blot analysis, S. lugdunensis showed a positive reaction to the probe of the delta-hemolysin gene in S. aureus.

CONCLUSIONS

The results suggest that S. lugdunensis may be a potential pathogen in acute oral infection.

Controlled release of platelet-derived growth factor from porous poly(L-lactide) membranes for guided tissue regeneration

Platelet-derived growth factor-BB (PDGF-BB) was incorporated into porous poly (L-lactide) (PLLA) membranes with an aim of improving early bone healing in guided tissue regeneration (GTR) therapy. Porous PDGF-BB loaded membranes were fabricated by coating PDGF-BB-dissolved PLLA methylene chloride-ethyl acetate solutions on polyglycolic acid (PGA) meshes. Release kinetics of PDGF-BB, biologic activity, degradability and guided tissue regenerative potentials of the membranes were investigated. Release of PDGF-BB could be controlled by adding bovine serum albumin that may provide porous diffusion channels for PDGF-BB release and by varying initial loading content of PDGF-BB. Biologic activity of PDGF-BB in the membranes was ascertained by fibroblast chemotaxis. PDGF-BB loaded membranes maintained proper degradation property for periodontal application. PDGF-BB loaded membrane markedly increased new bone formation in rat calvarial defects, and completed bony reunion after 2 weeks of implantation period. These results suggested that PDGF-BB loaded PLLA membrane might potentially enhance guided tissue regenerative efficacy.

Racial tropism of a highly toxic clone of Actinobacillus actinomycetemcomitans associated with juvenile periodontitis

Actinobacillus actinomycetemcomitans strains with enhanced levels of production of leukotoxin are characterized by a 530-bp deletion from the promoter region of the leukotoxin gene operon. Previous isolates with this deletion constituted a single clone belonging to serotype b, although they displayed minor differences among each other. We have analyzed the geographic dissemination of this clone by examining 326 A. actinomycetemcomitans isolates from healthy and periodontally diseased individuals as well as from patients with different types of extraoral infections originating from countries worldwide. A total of 38 isolates, all belonging to the same clone, showed the 530-bp deletion. Comparison of a 440-bp sequence from the promoter region of the leukotoxin gene operon from 10 of these strains revealed complete identity, which indicates that the deletion originates from a single mutational event. This particular clone was exclusively associated with localized juvenile periodontitis (LJP). In at least 12 of 28 families from which the clone was isolated, more than one family member had LJP. Notably, all the subjects carrying this clone had a genetic affiliation with the African population. These observations suggest that juvenile periodontitis in some adolescents with an African origin is associated with a disseminating clone of A. actinomycetemcomitans.

Clinical and microbiological effects of minocycline-loaded microcapsules in adult periodontitis

Clinical and microbiological effects of subgingival delivery of 10% minocycline-loaded (MC), bioabsorbable microcapsules were examined in 15 adult periodontitis patients. Patients received oral hygiene instruction 2 weeks prior to the study. At baseline (day 0) all teeth received supragingival scaling (SC); 2 quadrants received no further treatment and 1 quadrant received subgingival scaling and root planning (SRP). In the fourth quadrant, the tooth with the deepest probing sites (at least 1 site > or = 5 mm) was treated with minocycline microcapsules. The sites were evaluated at baseline and weeks 1, 2, 4, and 6. Clinical indices included bleeding on probing (BOP), probing depths (PD), and attachment loss (AL). Microbiological evaluations included percent morphotypes by phase-contrast microscopy; cultivable anaerobic, aerobic, and black-pigmented Bacteroides (BPB); and percent Porphyromonas gingivalis, Prevotella intermedia, Eikenella corrodens, and Actinomyces viscosus by indirect immunofluorescence. In the SC + MC group, BOP, PD, and AL were significantly reduced from baseline for weeks 1 to 6. BOP in the SC + MC group was significantly reduced compared to the SRP group from weeks 2 to 6. In the SC + MC group the percent of spirochetes and motile rods decreased and the percent of cocci increased after 1 week. The increased cocci and decreased motile rods were statistically greater at weeks 4 and 6 in the SC + MC group compared to the SRP group. This study demonstrates that local subgingival delivery of 10% minocycline-loaded microcapsules as an adjunct to scaling results in reduction in the percent sites bleeding on probing greater than scaling and root planning alone and induces a microbial response more favorable for periodontal health than scaling and root planing.

Biological effects of drug-loaded biodegradable membranes for guided bone regeneration

The biological effects of drug-loaded biodegradable novel membrane for guided bone regeneration (GBR) was evaluated. The membranes were polyglycolic acid mesh coated with poly-L-lactic acid containing flurbiprofen, tetracycline or PDGF-BB. Porous structure was generated in the membranes by using a phase inversion method. The membrane was less toxic, nicely biodegradable and biocompatible for 8 wk after implantation in the dorsal skin of the rat. The drugs released from the membranes were shown to be effective for new bone formation. Tetracycline, flurbiprofen or PDGF-BB loaded membrane was markedly effective for osteoid tissue and new bone formation in the bony defect prepared in rat calvaria to compare with that by unloaded membrane. These results suggested that drug-loaded biodegradable barrier membrane might be a potential tool for GBR in periodontal therapy.

The subgingival microflora and gingival crevicular fluid cytokines in refractory periodontitis

Refractory periodontitis manifests as a rapid, unrelenting, progressive loss of attachment despite the type and frequency of therapy. This study examined possible relationships between cytokine levels in gingival crevicular fluid (GCF), occurrence of specific periodontopathic microflora, and disease activity in patients with refractory periodontitis. Refractory periodontitis patients (7 male and 3 female) were selected on the basis of history and longitudinal clinical observations. In each patient, 2 teeth with pocket depths greater than 6 mm were selected and individual acrylic stents were fabricated with reference grooves for each site. The sites were examined at both baseline and 3 months later. The pattern and amount of alveolar bone resorption were assayed by quantitative digital subtraction radiography. Pocket depth and attachment loss were measured with a Florida Probe. The gingival index was measured at 4 sites around each sample tooth. Sites were divided into active sites (> or = 2.1 mm loss of attachment in 3 months) or inactive sites (< or = 2.0 mm loss of attachment in 3 months). The distribution and prevalence of the predominant microflora in active and inactive sites were compared using anaerobic culture and indirect immunofluorescence. Interleukin-1 beta, 2, 4, 6 and tumor necrosis factor-alpha (TNF-alpha) levels in gingival crevicular fluid (GCF) were quantified by ELISA. Prevotella intermedia and Eikenella corrodens significantly decreased in inactive sites but remained the same in active sites after 3 months. The active sites revealed significantly higher GCF levels of IL-2 and IL-6 than inactive sites at both baseline and at 3 months. IL-1 beta was also significantly greater in active sites than in inactive sites at 3 months. Alveolar bone loss in active sites correlated with increased GCF levels of IL-1 beta and IL-2. These results suggest that GCF levels of IL-1 beta, IL-2 and IL-6 and P. intermedia and E. corrodens in subgingival plaque may serve as possible indicators of disease activity in refractory periodontitis.

Pharmacological effects of methanolic extract from the root of Scutellaria baicalensis and its flavonoids on human gingival fibroblast

The methanolic extract from the root of Scutellaria baicalensis Georgi and its flavonoids, wogonin, baicalein, and baicalin were evaluated for anti-inflammatory action and the activatory effect on gingival fibroblasts. In LPS-induced production of IL-1 beta, three flavonoids at 1 microgram/ml expressed a significant (> 50%) inhibitory effect, similar to that of prednisolone. Moreover, the flavonoids inhibited IL-1 beta-induced synthesis of PGE2 and LTB4 considerably, although the effect of wogonin on LTB4 synthesis was marginal. In addition, three flavonoids exerted a moderate inhibition (33-36%) of collagenolytic activity, comparable to 40% inhibition by tetracycline. Meanwhile, the cellular activity of fibroblasts was augmented remarkably (40%) by baicalein (2) and slightly by baicalin (3) or wogonin (1). Consistent with the cellular activation, flavonoids enhanced the synthesis of both collagen and total protein in fibroblasts, in contrast to growth factors which increased only the synthesis of total protein. Although the effects of the methanolic extract resembled those of the flavonoids, the extract expressed a preferential effect on the synthesis of collagen and total protein.

Longitudinal monitoring for disease progression of localized juvenile periodontitis

The present study was performed to investigate the factors associated with disease progression in localized juvenile periodontitis (LJP) patients by longitudinal monitoring of microbiological changes. Following a 9-month period, 9 LJP patients were divided into 2 groups based upon attachment loss, progressing and non-progressing. Both groups received scaling, root planing, and modified Widman flaps. Clinical and microbiological data were obtained at baseline, following the observation period, and at 6 and 12 months post-treatment. At 6 and 12 months post-treatment significantly more cocci were persistent in the non-progressing group than in the progressing group. Actinobacillus actinomycetemcomitans was also more frequently isolated in the progressing group than in the non-progressing group initially and following the 9-month observation period. Also after treatment, A. actinomycetemcomitans recolonized earlier in the progressing group than in the non-progressing group. These studies suggest that A. actinomycetemcomitans may play a role in disease progression in LJP; however, they do not eliminate the possibility that other organisms may also play a role, since A. actinomycetemcomitans was not detected in all of the patients in whom disease progressed.

Actinobacillus actinomycetemcomitans serotypes and leukotoxicity in Korean localized juvenile periodontitis

Actinobacillus actinomycetemcomitans is though to play an important role in the pathogenesis of localized juvenile periodontitis (LJP). Preliminary data suggested that the serotype distribution of A. actinomycetemcomitans in Korea and the United States differ. This study evaluated A. actinomycetemcomitans prevalence, serotype distribution, and leukotoxicity in Korean LJP patients by culture, enzyme-linked immunosorbent assay, indirect immunofluorescence, and lactate dehydrogenase release from polymorphonuclear leukocytes exposed to A. actinomycetemcomitans. A. actinomycetemcomitans occurred in 75% of LJP lesions and 6% of normal sites with approximately equal distribution of serotype a, b, and c. Single serotypes were isolated from nine patients while three patients harbored two serotypes either in the same or different disease sites. A. actinomycetemcomitans leukotoxicity occurred in 22% isolates with a 69% prevalence. Individual sites harbored both leukotoxic and non-leukotoxic strains with no serotype association. The distribution of serotypes and leukotoxic strains of A. actinomycetemcomitans in Korean LJP patients differed from those reported in the United States. This suggests that serotype b may not be more important in the pathogenesis of LJP.

Antibodies to Actinobacillus actinomycetemcomitans in a Korean population

Previous studies demonstrated that serum antibodies to Actinobacillus actinomycetemcomitans strain Y4 are significantly elevated in sera from localized juvenile periodontitis (LJP) and postlocalized juvenile periodontitis (P-LJP) patients compared to normal controls in United States populations. This study examined the age of subjects in relation to the antibody levels to A. actinomycetemcomitans in a Korean population. Seven groups were investigated including sera from newborns, infants, children, periodontally normal puberty and adult groups and LJP and P-LJP groups. Antibody levels were determined by an enzyme-linked immunosorbent assay (ELISA) to A. actinomycetemcomitans strain SNUDC 10-1 (serotype C) isolated from a Korean LJP patient. In the healthy non-LJP and non-P-LJP subjects, IgG levels decreased from the newborn group to the 5-month-old group and then gradually increased through the adult group. The IgM levels in these groups continuously increased from birth until a plateau was reached in the 2- to 6-year group. Serum IgA levels to strain SNUDC 10-1 were too low to be measured by this assay.

Bacterial IgG and IgM antibody titers in acute necrotizing ulcerative gingivitis

IgG AND IgM ANTIBODY TITERS to eight bacterial isolates were measured by indirect immunofluorescence and ELISA in sera from acute necrotizing ulcerative gingivitis (ANUG) patients during the acute phase, from ANUG patients during the convalescent phase, from patients with gingivitis and from subjects with normal gingiva. Subjects were matched with respect to age and sex. Compared to the gingivitis and healthy groups, the ANUG groups exhibited significantly higher IgG and IgM titers to intermediate-sized spirochetes and higher IgG titers to Bacteroides melaninogenicus subsp intermedius. The findings support recent studies showing that these organisms are major bacterial components in ANUG lesions. They also suggest that these bacteria proliferate above-normal levels several weeks or months prior to the clinical onset of ANUG.

Bacterial antibody titers in ligature-induced periodontitis in beagle dogs

Serum antibodies to indigenous bacteria in ten beagle dogs were examined over a 7-month period during the development of ligature-induced periodontitis. Gram-negative strains comprised approximately 75% of the cultivable periodontitis microflora with a predominance of black-pigmented Bacteroides species. A total of 44 bacterial strains representing the predominant cultivable subgingival beagle dog microflora was selected for antibody determination. The IgG and, in some cases, IgM serum antibody titers to these organisms were determined by indirect immunofluorescence. The antibody titers to most test strains remained unchanged during the experimental period. Gram-negative bacteria generally exhibited lower titers than the Gram-positive bacteria. Especially low titers were found for the black-pigmented Bacteroides. Four dogs that developed the most severe periodontitis showed about 2-fold higher IgG titers to some Gram-negative anaerobic rods in the pre-ligation period than dogs that developed a more moderate periodontitis. These data suggested a possible diagnostic value of such antibody determinations. However, the overall finding of the present study was that serum antibody titers to key periodontopathic organisms remained low throughout the experiment. This result may suggest that the rapid periodontal destruction in ligature-induced periodontitis is due in part to an inadequate antibody response against the infecting microorganisms and their pathogenic products.