Rationale for the potential use of calcitonin in osteoarthritis

This review provides evidence that osteoarthritis (OA) or a major subset of OA is not only a disease of cartilage but also a disorder of subchondral bone. This review also discusses the potential efficacy of a bone and cartilage active agent, calcitonin, and discusses how calcitonin might be useful in the pharmaceutical treatment of OA.

A randomised comparative study of the short term clinical and biological effects of intravenous pulse methylprednisolone and infliximab in patients with active rheumatoid arthritis despite methotrexate treatment

OBJECTIVES

To compare the short term clinical and biological effects of intravenous (i.v.) pulse methylprednisolone (MP) and infliximab (IFX) in patients with severe active rheumatoid arthritis (RA) despite methotrexate (MTX) treatment.

METHODS

Patients with active RA despite MTX treatment were randomly allocated to receive a single i.v. infusion of MP (1 g) or three i.v. infusions of IFX (3 mg/kg) on weeks 0, 2, and 6. Patients were "blindly" evaluated for disease activity measures. Quality of life (QoL) was evaluated through the SF-36 health survey. Serum matrix metalloproteinase-3 (MMP-3) titres were measured at baseline, weeks 2 and 6.

RESULTS

Compared with baseline, significant improvement was noted in all activity measures, including serum C reactive protein (CRP) titres, in the IFX group only. At week 14, 6/9 (67%) and 4/9 (44%) IFX patients met the ACR20 and 50 response criteria, while this was the case in only 1/12 (8%) and 0/12 (0%) MP patients, respectively (p<0.05). None of the QoL scales improved with MP treatment, whereas some did so in the IFX group. Serum MMP-3 titres significantly decreased (41% drop) at week 6 in the IFX group, while no changes were seen in patients given MP.

CONCLUSION

This short term randomised comparative study demonstrates that TNF blockade is better than MP pulse therapy in a subset of patients with severe refractory RA, with improvement in not only clinical parameters of disease activity but also biological inflammatory indices, such as serum CRP and MMP-3 titres.

Scintigraphy using a technetium 99m-labelled anti-E-selectin Fab fragment in rheumatoid arthritis

OBJECTIVE

We previously described a novel radiolabelled monoclonal antibody (1.2B6), which reacts with porcine E-selectin, for targeting activated endothelium as a means of imaging inflammatory disorders, and presented initial clinical work based on (111)In-labelled antibody. The aim of the present study was to evaluate a Fab fragment of 1.2B6 labelled with (99m)Tc in patients with rheumatoid arthritis (RA) by comparison with (i) (111)In-labelled 1.2B6 F(ab')(2) and (ii) conventional bone scanning.

METHODS

(99m)Tc-1.2B6-Fab ( approximately 440 MBq) and (111)In-1.2B6-F(ab')(2) ( approximately 27 MBq) were compared in 10 patients using a double-isotope protocol. Images were obtained 4 and 20-24 h after injection. Two normal volunteers were also imaged. In a separate group of 16 patients, (99m)Tc-1.2B6-Fab and (99m)Tc-oxidronate ((99m)Tc-HDP) ( approximately 740 MBq) were compared on the basis of visual and semi-quantitative analysis of joint uptake (joint/soft tissue ratios) 4 h after injection. The respective biodistributions and blood clearances of the two 1.2B6 fragments were also compared.

RESULTS

Image contrast was slightly better with (99m)Tc-Fab at 4 h but equal for the two tracers at 24 h. Diagnostic accuracy, taking joint tenderness or swelling as the clinical endpoint, was 76% for both fragments at 24 h. Plasma clearance of (99m)Tc-Fab was faster than that of (111)In-F(ab')(2) (t(1/2) 142 vs 421 min; P<0.0001). (99m)Tc-Fab appeared somewhat unstable in vivo, as shown by activity in the thyroid gland and bowel. The diagnostic accuracy of (99m)Tc-Fab was 88%, higher than that of (99m)Tc-HDP (57%) as a result of the low specificity of the latter in RA. Receiver operating characteristic (ROC) curve analysis using joint/soft tissue ratios as a variable cut-off showed that (99m)Tc-Fab discriminates better than (99m)Tc-HDP between actively inflamed and silent joints (Z=4.72; P<0.0001). No uptake of (99m)Tc-Fab was observed by inactive or normal joints, whereas (99m)Tc-HDP was taken up by all joints to a variable degree, making the decision as to whether a particular joint is actively involved or chronically damaged very difficult.

CONCLUSION

(99m)Tc-anti-E-selectin-Fab scintigraphy can be used successfully to image synovitis with better specificity than (99m)Tc-HDP bone scanning. The advantages over (111)In-1.2B6-F(ab')(2) are easier availability of the radionuclide, improved physical properties and optimal imaging 4 h after injection.

Synovial fluid levels of tumor necrosis factor alpha and oncostatin M correlate with levels of markers of the degradation of crosslinked collagen and cartilage aggrecan in rheumatoid arthritis but not in osteoarthritis

OBJECTIVE

To compare synovial fluid (SF) levels of oncostatin M (OSM), tumor necrosis factor alpha (TNFalpha), and interleukin-6 (IL-6) in patients with rheumatoid arthritis (RA) and osteoarthritis (OA) and to determine which correlate best with SF levels of antigenic keratan sulfate (Ag KS), a marker of aggrecan catabolism, and pyridinium crosslinks, markers of the degradation of mature collagen molecules.

METHODS

SF was drawn from the knee joints of patients with RA (n = 31) or OA (n = 31). Levels of Ag KS, D-pyridinoline (D-Pyr), pyridinoline (Pyr), OSM, TNFalpha, and IL-6 were measured by enzyme-linked immunosorbent assay.

RESULTS

RA patients had higher median SF levels of OSM, TNFalpha, IL-6, and Pyr, but a lower median level of D-Pyr, than OA patients. In both groups, IL-6 levels correlated positively with those of OSM and TNFalpha. However, the correlation between levels of OSM and TNFalpha was only significant in the RA group. Ag KS and Pyr levels correlated positively in RA but not in OA. The correlation between TNFalpha and Ag KS was positive in RA and negative in OA. Further, in RA, OSM and IL-6 levels correlated strongly with Pyr and Ag KS levels but not with D-Pyr levels, while there were no strong correlations in OA for OSM or IL-6 levels with Pyr, Ag Ks, or D-Pyr levels.

CONCLUSION

This in vivo study suggests that TNFalpha and other proinflammatory cytokines are involved in the up-regulation of the coordinated degradation of cartilage aggrecan and collagen in RA. Further, OSM may act synergistically with other proinflammatory cytokines in up-regulating the production of metalloproteinases by chondrocytes in rheumatoid joints.

Serum levels of hyaluronan, antigenic keratan sulfate, matrix metalloproteinase 3, and tissue inhibitor of metalloproteinases 1 change predictably in rheumatoid arthritis patients who have begun activity after a night of bed rest

OBJECTIVE

To evaluate whether and how moderate physical activity following a night of rest influences serum levels of matrix metalloproteinase 3 (MMP-3), tissue inhibitor of metalloproteinases 1 (TIMP-1), antigenic keratan sulfate (Ag KS), and hyaluronan (HA) in 10 normal subjects and 38 patients with rheumatoid arthritis (RA).

METHODS

Blood was obtained from 20 RA patients before they arose from a night's sleep, and again 1 and 4 hours after they had begun to perform moderate physical activity. Another 18 RA patients remained in bed and blood was sampled at the same time periods. Serum levels of MMP-3, TIMP-1, Ag KS, and HA were measured by enzyme-linked immunosorbent assay. Clinical activity was evaluated by the Lansbury index.

RESULTS

Both in normal subjects and in RA patients who did not remain in bed throughout the period of blood sampling, levels of HA, Ag KS, and MMP-3 increased significantly during the first hour after the subjects arose: the increase in HA and Ag KS correlated with the Lansbury index in the RA group. Three hours later, levels of Ag KS had dropped to baseline values in both groups of subjects. Levels of HA remained significantly and moderately elevated in the RA group but not in the control group, while levels of MMP-3 did not drop significantly in either group. In contrast, levels of HA, Ag KS, and MMP-3 did not change significantly in RA patients who had remained in bed. Unlike the other markers, the levels of TIMP-1 remained unchanged at the different time periods in all 3 groups studied.

CONCLUSION

Significant changes in serum levels of some metabolic markers occur during the first hour after one arises from a night of sleep, especially in patients with RA. Measurement of the magnitude of these changes at different times in individual patients provides very different information about metabolic changes occurring in joint tissue than does measurement of the level of the markers at a single time point, as is usually currently reported.

Treatment with calcitonin suppresses the responses of bone, cartilage, and synovium in the early stages of canine experimental osteoarthritis and significantly reduces the severity of the cartilage lesions

OBJECTIVE

To relate the rate of bone resorption to serum levels of both hyaluronan (HA) and antigenic keratan sulfate (KS) in canine experimental osteoarthritis (OA) and to evaluate the effects of calcitonin on these parameters and the OA lesions of the unstable knee.

METHODS

Twenty-two dogs underwent anterior cruciate ligament transection (ACLT) and 6 dogs underwent sham operation. Urinary pyridinium crosslinks were quantified by high-performance liquid chromatography. Immunoassays quantified hyaluronan (HA) and antigenic KS. Macroscopic and histologic OA lesions were scored. Calcitonin treatment was started on day 14 postsurgery and stopped on either day 49 or day 104 postsurgery. Control dogs and all treated dogs were killed on day 105.

RESULTS

All ACLT joints developed OA. In contrast to sham-operated animals, all operated dogs exhibited an early and sustained rise in the levels of their urinary and serum markers. Calcitonin markedly reduced the levels of these markers and the severity of OA lesions. Furthermore, the longer the period of calcitonin therapy, the lower the score of the OA lesions.

CONCLUSION

Bone, synovium, and articular cartilage all appear to be involved in the state of hypermetabolism that develops in unstable joints. Furthermore, the rate of bone resorption increases markedly in the early stages of this OA model and is likely to contribute to cartilage breakdown. Since calcitonin reduced the severity of OA changes, this form of therapy may have benefits for humans who have recently experienced a traumatic knee injury.

99mTc-labelled immunoglobulin scintigraphy in arthritis: an analysis of synovial fluid activity

The distribution of 99mTc-labelled human polyclonal non-specific immunoglobulin G (HIG) in the synovial fluid was studied in 14 patients with rheumatoid and non-rheumatoid arthritides. Analysis included the determination of the total activity per ml synovial fluid 6 h post-injection (p.i.) of the tracer as well as of the protein- and cell-bound fractions. At 6 h p.i., > 60% of the injected dose remained in plasma as protein-bound radioactivity. Values in the synovial fluid ranged between 0.001 and 0.009% of the injected dose per ml. Importantly, the synovial fluid to plasma ratio was consistently < 1 (range: 0.09-0.43), which is in the range of ratios observed for endogenous proteins in vivo. Similar values were obtained in samples of synovial tissue obtained at surgery in two patients. These data are consistent with the hypothesis that labelled HIG accumulates in the extracellular fluid (both within the synovial tissue and fluid) by non-specific mechanisms (such as increased blood pool and capillary permeability) and does not equilibrate with circulating plasma proteins in accordance with basic knowledge of synovial physiology. In addition, it was found that most of the activity remained bound to the proteins in the fluid and that cell-binding occurred to a very low degree that cannot be considered an important mechanism of uptake of this radiolabelled agent in vivo. These results provide the first evidence in an in vivo human setting that radiolabelled HIG accumulates mainly by non-specific mechanisms in inflamed joints.

A comparison between 111In-anti-E-selectin mAb and 99Tcm-labelled human non-specific immunoglobulin in radionuclide imaging of rheumatoid arthritis

We have developed and validated a method for imaging inflammation using a monoclonal antibody (1.2B6) against E-selectin, an endothelial-cell specific adhesion molecule. This study was undertaken to compare 111In-1.2B6 with 99Tcm-labelled non-specific IgG (99Tcm-HIG) in the detection of synovitis in 11 patients with rheumatoid arthritis (RA). Imaging was performed 4 h and 20-24 h post-injection (pi) of 555 MBq 99Tcm-HIG and 15 MBq 111In-1.2B6. Scintigraphic results were compared with clinical scores of joint involvement. Joint uptake was semiquantitated. The scintigraphic appearances with both tracers correlated well, although 111In-1.2B6 at 24 h showed the highest detection rate. Taking joint tenderness or swelling as evidence of clinical activity, the sensitivity of 111In-1.2B6 at 4 h and 24 h was 69% and 82%, respectively, compared with 69% and 62% for 99Tcm-HIG. 111In-1.2B6 also displayed abnormal activity over a number of joints that appeared silent on clinical examination. Joint-to-soft tissue ratios were higher for 111In-1.2B6 at 24 h (4.0 +/- 1.9; p < 0.0001 vs all) than at 4 h (2.4 +/- 1.4) or than for 99Tcm-HIG at 4 h and 24 h (1.6 +/- 0.5 and 2.3 +/- 0.7, respectively). Net 111In counts over joints increased significantly between 4 h and 24 h (mean change: 54 +/- 40%). This study demonstrates that 111In-1.2B6 scintigraphy is a sensitive method by which to assess RA activity and that targeting is more intense and specific than using 99Tcm-HIG. However, the optimum time for 111In-1.2B6 scintigraphy is 24 h whereas good results are already obtained with 99Tc-HIG at 4 h pi. Current efforts are directed at developing 99Tcm-labelled 1.2B6 for imaging endothelial activation.

Levels of circulating collagenase, stromelysin-1, and tissue inhibitor of matrix metalloproteinases 1 in patients with rheumatoid arthritis. Relationship to serum levels of antigenic keratan sulfate and systemic parameters of inflammation

OBJECTIVE

To measure serum levels of matrix metalloproteinase-1 (MMP-1), matrix metalloproteinase-3 (MMP-3), and tissue inhibitor of MMP-1 (TIMP-1) in patients with rheumatoid arthritis (RA) and in age-matched control subjects, and to determine how these correlate with serum levels of antigenic keratan sulfate (KS) and other biochemical and clinical indicators of disease activity.

METHODS

Immunoassays were used to measure levels of MMP-1, MMP-3, TIMP-1, and antigenic KS. Radiologic and functional joint scores were based upon Steinbrocker's criteria. Erythrocyte sedimentation rates (ESR) and levels of C-reactive proteins (CRP) were measured.

RESULTS

In RA patients, levels of MMP-3 and TIMP-1 were significantly increased, and strongly correlated with the ESR and CRP levels but not with radiologic or functional joint scores. Levels of antigenic KS were significantly lower in RA patients and correlated negatively with systemic parameters of inflammation and serum levels of TIMP-1.

CONCLUSIONS

The increase in serum levels of MMP-3 and TIMP-1 appears to reflect systemic inflammation in RA. The inverse correlation between serum levels of TIMP-1 and antigenic KS suggests that an upregulation of TIMP-1 synthesis might be responsible for the apparent suppression of cartilage aggrecan catabolism in patients with severe inflammatory changes.

Evaluation of disease activity in rheumatoid arthritis and other arthritides using 99mtechnetium labeled nonspecific human immunoglobulin

OBJECTIVE

To determine the usefulness of 99mtechnetium (99mTc) immunoglobulin scintigraphy (99mTc IgG) in rheumatoid arthritis (RA) and in other arthritides.

METHODS

Scintigraphic scores were compared with the Ritchie index and biochemical variables of disease activity.

RESULTS

In RA, scintigraphic scores were reproducible and seemed to perform better than clinical scores. Moreover, the scores of synovial uptake correlated significantly with systemic variables of inflammation. Other inflammatory arthritides also disclosed uptake of 99mTc IgG but noninflammatory joints did not.

CONCLUSION

Although nonspecific for RA, 99mTc IgG scintigraphy is a reliable tool to evaluate the degree and extent of joint inflammation.

Rapid and sustained rise in the serum level of hyaluronan after anterior cruciate ligament transection in the dog knee joint

OBJECTIVE

To monitor changes in serum levels of hyaluronan (HA) in experimental canine osteoarthritis (OA), and to relate these changes to the level of HA in synovial fluid (SF) and/or to the rate of HA synthesis by synovium.

METHODS

OA was induced in 16 dogs by anterior cruciate ligament transection; 7 dogs were sham operated. An immunoassay was used to measure HA levels in serum at various times postsurgery and in SF from OA knees at sacrifice (Week 13 postsurgery). The rate of HA synthesis by synovium from both knees of 9 OA dogs and 5 sham operated dogs was measured at 13 weeks.

RESULTS

The serum level of HA showed a minor transient rise postsurgery in sham operated dogs. In all OA dogs, this rise was marked and sustained and correlated with the SF level of HA. Further, in OA dogs, the rate of HA synthesis by synovium was elevated in both the operated OA knee and the nonoperated knee.

CONCLUSION

The sustained rise in the serum level of HA in OA dogs appears to be the result of increases in the rate of HA synthesis by synovium in both the operated and nonoperated knees, and possibly in other synovial joints.

Serum markers of systemic disease processes in osteoarthritis

Serum levels of several molecules originating from joints and cartilages have been shown to rise during the preradiological stages of osteoarthritis (OA). Using a dog model of posttraumatic OA, we have shown that serum levels of markers of aggrecan degradation (antigenic keratan sulfate) and synovial proliferation/metabolism (hyaluronan) rise within 1-2 weeks after the injury and remain elevated for at least 13 weeks. These changes, which precede the development of OA lesions, are consistent with the view that traumatic injury to a single synovial joint gives rise to a state of hypermetabolism that is local at first but becomes systemic with time.

Effects of tenoxicam and aspirin on the metabolism of proteoglycans and hyaluronan in normal and osteoarthritic human articular cartilage

1. As nonsteroidal anti-inflammatory drugs may impair the ability of the chondrocyte to repair its damaged extracellular matrix, we explored the changes in the metabolism of newly synthesized proteoglycan (PG) and hyaluronan (HA) molecules produced by tenoxicam and aspirin in human normal cartilage explants and in osteoarthritic (OA) cartilage from age-matched donors. 2. Explants were sampled from the medial femoral condyle and were classified by use of Mankin's histological-histochemical grading system. Cartilage specimens were normal in 10 subjects, exhibited moderate OA (MOA) in 10 and had severe OA (SOA) in 10. 3. Cartilage explants were pulsed with [3H]-glucosamine and chased in the absence and in the presence of either aspirin (190 micrograms ml-1) or tenoxicam (4-16 micrograms ml-1). After papain digestion, the labelled chondroitin sulphate ([3H]-PGs) and HA([3H]-HA) molecules present in the tissue and media were purified by anion-exchange chromatography. 4. In normal cartilage as well as in explants with MOA and SOA aspirin reduced more strongly PG and HA synthesis than the loss of [3H]-HA and [3H]-PGs. 5. In normal cartilage, tenoxicam did not affect PG metabolism whereas it reduced HA synthesis in a dose-dependent manner and did not change or even increased the net loss of [3H]-HA. In contrast, in OA cartilage, tenoxicam produced a stronger reduction in the loss of [3H]-PGs than in PG synthesis and this decrease occurred at lower concentrations in cartilage with SOA (4-8 micrograms ml-1) than in cartilage with MOA (8-16 micrograms ml-1). In cartilage with MOA, the metabolic balance of HA was unaffected by tenoxicam whereas in cartilage with SOA, the drug decreased the loss of [3H]-HA and concomitantly did not change or even increased HA synthesis.6. The data obtained in short-term in vitro cultures indicate that aspirin may produce OA-like changes in normal cartilage and is likely to worsen the disease process in OA tissue. On the other hand, although tenoxicam may reduce the HA content of normal cartilage, and, in so doing, may produce OA-like lesions, this drug should not per se accelerate joint failure in OA.

Serum levels of collagenase, stromelysin-1, and TIMP-1. Age- and sex-related differences in normal subjects and relationship to the extent of joint involvement and serum levels of antigenic keratan sulfate in patients with osteoarthritis

OBJECTIVE

To measure serum levels of collagenase (MMP-1), stromelysin-1 (MMP-3), and tissue inhibitor of matrix metalloproteinases-1 (TIMP-1) in normal subjects and in patients with osteoarthritis (OA), and to assess how these correlate with biochemical and clinical indicators of disease activity in OA.

METHODS

Specific immunoassays were used to measure MMPs, TIMP-1, and antigenic keratan sulfate (KS). The total area of cartilage affected by the disease was measured (expressed as an articular index).

RESULTS

In the normal population (n = 118), the serum concentration of MMP-3, but not of MMP-1 or TIMP-1, increased with age and was approximately 2 times higher in males than in females. In the OA patients (n = 33), the serum levels of MMP-3, but not of MMP-1 or TIMP-1, were significantly elevated and correlated strongly with the articular index but poorly with objective and subjective functional capacity scores as well as with serum levels of antigenic KS and systemic parameters of inflammation.

CONCLUSION

These findings illustrate the importance of matching patients and normal controls for age and sex in further studies of MMP-3 and are consistent with the hypothesis that MMP-3 might play an important role in the degradation of joint cartilage in OA. Further, serum levels of MMP-3 may prove useful for monitoring therapy for OA.

[Biological markers of osteoarthritis]

The degradation of proteoglycans, collagens and proteins in the articular cartilage matrix produces fragments which diffuse out of the tissue and into the joint fluid. These fragments subsequently appear in the blood circulation and are eventually eliminated by the liver or the kidney. Recent studies have shown that the joint fluid and blood levels of these biological markers of degradation can be used to monitor abnormal metabolic processes in cartilages. The joint fluid level of a cartilage-derived marker provides information about the metabolism of that molecule in that joint. In blood, levels of specific markers have been shown to be helpful in identifying systemic changes affecting the metabolism of matrix constituents in all or most cartilages in the body. Measurement of different biological markers in body fluids have proved useful in identifying increased catabolic activities in articular cartilage during the preradiological stages of osteoarthritis. These markers have great potential for monitoring disease activity, assessing disease progression, examining responses to drug therapy and evaluating long-term prognosis. In addition, markers should prove most useful in prospective studies at identifying early changes in cartilage metabolism in humans at high risk of developing post-traumatic osteoarthritis.

Centrifugal and biochemical comparison of proteoglycan aggregates from articular cartilage in experimental joint disuse and joint instability

Two models involving altered joint loading were compared with regard to their effects on the biochemical composition and proteoglycan aggregate structure of articular cartilage. Disuse atrophy was created in greyhound dogs by nonrigid immobilization of the right knee in 90 degrees of flexion, and joint instability was created by transection of the anterior cruciate ligament. Similarities and differences between the two experimental groups at two different time periods were examined to investigate why joint instability induces progressive and irreversible changes to the articular cartilage, whereas joint disuse induces changes that may be reversible when the joint is remobilized. The following studies were performed on the cartilage from all experimental and control groups: (a) compositional analyses to determine water, uronate, and hydroxyproline contents; (b) high performance liquid chromatography for detection of hyaluronan and chondroitin sulfates; and (c) centrifugation analyses of nondissociatively extracted and purified proteoglycans to isolate and quantify the populations of monomers and slow and fast-sedimenting families of aggregates. In general, all cartilage was found to have a decreased ratio of proteoglycan to collagen after 4 weeks of disuse, and this ratio returned to control values at 8 weeks. In contrast, cartilage had an elevated ratio of proteoglycan to collagen as well as increased hydration at 12 weeks after transection of the anterior cruciate ligament. The most striking contrast between the two models was the finding of an approximately 80% decrease in the content of hyaluronan at both time periods after transection of the anterior cruciate ligament, with no evidence of a change after disuse. The results of centrifugation analyses indicated a significant decrease in the quantity of proteoglycan aggregates in both models. However, this decrease was associated primarily with a loss of slow-sedimenting aggregates after disuse and a loss of both slow and fast-sedimenting aggregates after transection of the anterior cruciate ligament. Furthermore, the population of fast-sedimenting aggregates was depleted to a greater extent than that of the slow-sedimenting aggregates. The preservation of fast-sedimenting aggregates as well as hyaluronan after periods of joint disuse but not joint instability suggests a possible mechanism for the reversibility of cartilage changes. Although the proteoglycan aggregates were depleted after disuse atrophy, it is possible that an aggregate-depleted matrix could recover when normal proteoglycan synthesis is resumed. In contrast, although synthesis may be maintained or elevated after transection of the anterior cruciate ligament, the matrix may not be repopulated with aggregates because there is an insufficient amount of hyaluronan.

[Semi-quantitative analysis of 3-phase bone scintigraphy data in algodystrophy of the limbs]

Three-phase bone scanning of the extremities (foot or hand) was performed in 40 normal subjects and in 56 patients with an unequivocal clinical diagnosis of reflex sympathetic dystrophy. Ten patients were in the "cold" or atrophic stage of the disease process, whereas 46 were in the "hot" or acute phase. The scintigraphic parameters studied were the ratios of tracer activity in the affected side over the healthy side established for blood flow (BF), blood pool (BP), early vasculo-tissular fixation (EF), and late bone fixation (LF). In the controls, blood flow, blood pool, and early fixation showed considerable interindividual variation and only the variation of late fixation remained within narrow limits. Among the patients, those at the hot stage of the disease had significantly higher values for all four parameters than those at the cold stage. The group at the cold stage did not differ from the controls except for a significantly higher late fixation value. Furthermore, among hot stage patients, 15% to 25% had normal or diminished blood flow, blood pool and early fixation values. At the cold stage of the disease, radionuclide parameters were similar in affected feet and hands, whereas at the hot stage values at the feet were double those at the hands. Finally, statistical analysis revealed that late fixation was most closely correlated with early fixation, which in turn was most close correlated with blood pool. The clinical and pathophysiological significance of these data is discussed.

An assay for matrix metalloproteinases and other proteases acting on proteoglycans, casein, or gelatin

We have set up a quantitative and sensitive enzymatic assay for proteases of different classes acting on proteoglycans, casein, or gelatin. Radiolabeled substrates were covalently attached to insoluble microcarriers and assays were performed in 96-well plates. Protease activities were determined by the release of labeled degradation products. Time- and dose-response curves were linear when the solubilization of labeled substrates did not exceed 15-20% of the initially bound molecules. Results were compared to those from zymographic analyses on proteoglycan-, gelatin-, and casein-polyacrylamide gels, as well as to the results obtained with conventional assays using soluble [3H]-casein and [3H]gelatin. Our assay procedure was more sensitive than other available methods: it detected picogram amounts of trypsin as well as picogram or nanogram amounts of the purified human matrix metalloproteinases, MMP-1, MMP-2, MMP-3, and MMP-9, depending on the specific activities of these MMPs on the different substrates. Our new procedure was appropriate for assaying the MMPs present in crude culture media conditioned by chondrocytes cultivated under various conditions.

Levels of circulating tumor necrosis factor alpha and interleukin-6 in patients with rheumatoid arthritis. Relationship to serum levels of hyaluronan and antigenic keratan sulfate

OBJECTIVE

To measure serum levels of tumor necrosis factor alpha (TNF alpha) and interleukin-6 (IL-6) in patients with rheumatoid arthritis (RA) and age-matched control subjects and to study how these correlate with serum levels of hyaluronan (HA) and antigenic keratan sulfate (KS) and other biochemical as well as clinical indicators of disease activity.

METHODS

Immunoassays were used to measure levels of TNF alpha, IL-6, HA, and antigenic KS in the serum of 35 patients with RA and a group of age- and sex-matched control subjects. Clinical disease activity in the RA group was assessed using the Lansbury index. Drug intake was recorded and the erythrocyte sedimentation rate, and levels of fibrinogen, creatinine, bilirubin, alkaline phosphatase, lactate dehydrogenase, and aminotransferase were measured.

RESULTS

Serum levels of TNF alpha, IL-6, and HA were significantly higher in the RA population than in the control group. In patients with RA, serum levels of HA correlated positively with serum levels of TNF alpha and with clinical joint scores, but only weakly with other laboratory parameters of inflammation. Serum levels of antigenic KS correlated negatively with levels of circulating TNF alpha, but much more weakly with other clinical and biochemical parameters of disease activity.

CONCLUSION

These in vivo data support in vitro studies which have shown that TNF alpha is a potent stimulator of HA synthesis by synovial lining cells. The results strengthen the contention that serum HA may be a unique marker of synovial involvement and inflammation, rather than of only inflammation, in RA.

Levels of serum keratan sulfate rise rapidly and remain elevated following anterior cruciate ligament transection in the dog

The levels of serum keratan sulfate (KS) were measured in 9 dogs who underwent anterior cruciate ligament transection. They rose in some animals as early as 7 days after surgery, long before any decrease in the articular cartilage content of KS containing proteoglycans could be measured; and they reached their maximum in most dogs by Day 21 and remained elevated for at least 13 weeks. In contrast, the serum levels of the KS epitope showed no increase in sham operated control animals. Analysis of synovial fluid suggested an increase in the catabolism of cartilage proteoglycans in the operated joint contributed significantly to the increased levels of serum KS.

Treatment of osteoarthritis with tiaprofenic acid: biochemical and histological protection against cartilage breakdown in the Pond-Nuki canine model

Experimental and cage matched control animals were sacrificed 12 weeks after production of ligamentous instability in the right knee, and biochemical studies were performed on eroded OA and normal articular cartilage. Significant protection was afforded by tiaprofenic acid administered orally at 15 mg/kg body weight. Chondroprotection was manifested by reduction of fast sedimenting proteoglycan aggregates, as well as retention of hyaluronate content, and favorable proteoglycan aggregate S value levels. This agent showed significant chondroprotective action under the conditions of these studies.

Proteoglycans nondissociatively extracted from different zones of canine normal articular cartilage: variations in the sedimentation profile of aggregates with degree of physiological stress

Proteoglycans were extracted and purified without dissociation (a-A1 preparations) from superficial and deeper layers of high weight-bearing (HWA) and low weight-bearing (LWA) areas of dog normal articular cartilage. These proteoglycans were then characterized by velocity gradient centrifugation. In each of the 4 different topographical regions, the weight average sedimentation coefficients related strongly with total hexuronate content of the tissue. In the superficial layers, almost all aggregates had low sedimentation coefficients: the aggregates were smaller and less abundant in LWA than in HWA. The deeper layers contained an additional population of faster sedimenting aggregates which appeared smaller and less abundant in LWA than in HWA. Quantification and functional characterization of aggregates as well as in vitro aggregating studies showed that the topographical differences in size and content of aggregates were related to differences in content of hyaluronate and link protein in the a-A1 preparations. Superficial a-A1 specimens contained twice as much hyaluronate as deeper a-A1 preparations and their hyaluronate content increased with degree of physiological stress. Deeper a-A1 specimens from weight-bearing areas did not differ in their hyaluronate content but experiments assessing the saturation with link protein of these different a-A1 preparations suggested that specimens from HWA contained more active link than those from LWA. In contrast, the capacity of aggregation of a-A1D1D1 proteoglycan monomers as well as the molecular weight (Mr = 5 x 10(5) and aggregating capacity of hyluronate molecules appeared very similar in all a-A1 preparations from areas of articular cartilage. It is hypothesized that the synthesis of the three constituents necessary for aggregate formation (i.e. proteoglycan monomers as well as hyaluronate and link protein molecules) increases with degree of physiological load and that aggregation helps to maintain within cartilage the high concentration of proteoglycans that are essential for its biomechanical functions. The reported topographical variations in the distribution of proteoglycan aggregates reflect probably a maximal adaptation of the physiologic and biomechanical properties of the matrix to meet the high stress levels experienced by the articular cartilage in vivo.

Centrifugal characterization of proteoglycans from various depth layers and weight-bearing areas of normal and abnormal human articular cartilage

Ultracentrifugal polydispersity differential [g(S)] distributions were determined for the proteoglycans of various postmortem human articular cartilage samples extracted from six lateral patellar grooves in nondissociative conditions after mild collagenase digestion of the tissue. The samples consisted of 53 slices (250 microns thick), from normal, mildly fibrillated, and extensively ulcerated knee joints. When statistically analyzed in various subgroupings, the obtained average sedimentation coefficients and polydispersity profiles supported the following conclusions: (a) loss of proteoglycan aggregation and sedimentability is confirmed to be a primary sign of cartilage matrix degradation; (b) higher S values for proteoglycans of the high weight (HW)-bearing areas and lower values for those of the low weight (LW)-bearing areas were a typical finding in normal cartilage samples; (c) inversion of this pattern was indicative of matrix degradation, suggesting that the HW regions are more affected than the LW-bearing areas; (d) the average S value distribution across cartilage thickness tended to resemble the corresponding proteoglycan content versus distance from articular surface; and (e) the deepest cartilage layer had, in most cases, the smallest amount of aggregates while the highest average sedimentability was observed at the middle zone of the normal samples. In the discussion, a role of proteoglycan aggregation for providing a means to "pack" more proteoglycans within the collagen meshwork and to control the generation of osmotic pressure gradients is suggested.

Changes in the sedimentation profile of proteoglycan aggregates in early experimental canine osteoarthritis

Osteoarthritis was induced in 12 normal dogs by severing of the anterior cruciate ligament of the right knees, the left knees serving as sham operated controls. The animals were killed at 7 and 14 weeks postsurgery. The total hexuronate, and thus proteoglycan, content of the articular cartilage of operated knees remained unaltered during the period of study. After pretreatment with a highly purified collagenase and in the presence of selected protease inhibitors, a higher proportion of the tissue hexuronate could be extracted from the different topographical areas of osteoarthritic joints under non dissociative conditions (70-75% versus 55-65% for control knees). The nondissociatively recovered osteoarthritic proteoglycans (a-A1 preparations) displayed progressive and consistent changes in their sedimentation profile. First, the size of the fast sedimenting or more saturated aggregates appeared to be reduced in the different regions of osteoarthritic joints at 7 weeks postoperatively. The disappearance of the faster sedimenting mode as well as a dramatic increase in the proportion of monomers were only detected in the topographical zones exhibiting the most severe surface damage and histologic abnormalities at 14 weeks postsurgery. The proteoglycan molecules present as "free" or "nonaggregated" monomers in a-A1 preparations recovered from normal and osteoarthritic cartilage at different time periods after surgery were separated from their corresponding aggregates by rate zonal centrifugation in isokinetic cesium sulfate gradient. Although they were severely depleted in keratan sulfate, the purified "free" and "aggregated" osteoarthritic monomers appeared to be normal in terms of aggregating capacity and size distribution, and were therefore not degraded. This progressive changes in size distribution of proteoglycan aggregates in the early stages of experimental canine osteoarthritis could contribute significantly to the biochemical and biomechanical alterations of osteoarthritic cartilage.

Superficial and deeper layers of dog normal articular cartilage. Role of hyaluronate and link protein in determining the sedimentation coefficients distribution of the nondissociatively extracted proteoglycans

Proteoglycans were extracted under nondissociative conditions from superficial and deeper layers of dog normal articular cartilage. The purified a-A1 preparations were characterized by velocity gradient centrifugation. Superficial specimens exhibited an abundant population of slow sedimenting aggregates whereas the aggregates of deeper preparations sedimented as two well-defined families of molecules. These dissimilarities in the size distribution of the aggregates observed between superficial and deeper a-A1 preparations derived most of all from differences in their content of hyaluronate and link proteins: (a) superficial preparations contained twice as much hyaluronate as deeper specimens; (b) superficial aggregates were link-free and unstable at pH 5.0 whereas deeper preparations contained link-proteins and their faster sedimenting aggregates were stabilized against dissociation at pH 5.0. In these proteoglycan preparations from different cartilage layers, the monomers exhibited an identical capacity for aggregation and the hyaluronate molecules displayed quite similar molecular weight (Mr = 5 x 10(5] and aggregating capacity. These observations as well as aggregating studies conducted with highly purified link protein and purified hyaluronate specimens of different molecular weights support the following conclusions: (a) link protein not only stabilizes proteoglycan aggregates but also enhances the aggregating capacity of hyaluronate; (b) for all practical purposes, the slow sedimenting aggregates represent a secondary complex of hyaluronate and proteoglycan monomers whereas the fast sedimenting aggregates may be considered as a ternary complex wherein link protein stabilizes the hyaluronate-proteoglycans interaction; (c) the distinctive heterogeneity of articular cartilage can be related to structurally different proteoglycan aggregates. The structural dissimilarities observed between superficial and deeper aggregates could reflect the different macromolecular organization of the proteoglycan molecules in the territorial and interterritorial matrices, respectively.

Progressive depletion of hyaluronic acid in early experimental osteoarthritis in dogs

The hyaluronic acid (HA) content of articular cartilage was studied in early experimental osteoarthritis (OA) in 16 normal dogs. The anterior cruciate ligament in the right knees of the dogs was transected; their left knees served as sham operated controls. The animals were killed at 7 and 14 weeks postsurgery. Although their total hexuronate, and thus proteoglycan, content remained unaltered during the period of study, the different weight-bearing areas of the OA knees displayed a progressive and significant decrease in HA content. We found no differences in the molecular weight and in vitro aggregating capacity of the HA molecules from OA cartilage versus those from control cartilage. This early relative depletion of HA could contribute significantly to the biochemical alterations of OA cartilage. Furthermore, it appears to be a good parameter for the differentiation of changes related to OA and changes related to aging.

Quantification and characterization of hyaluronic acid in different topographical areas of normal articular cartilage from dogs

Normal articular cartilage from adult dogs was analyzed for hyaluronate, hexuronate and hydroxyproline. The low weight-bearing areas of both tibial plateaus and femoral condyles displayed a higher collagen content and a lower proteoglycan content than the regions of maximum contact. Both superficial and deeper layers contained more hyaluronate in areas of maximum than of minimum contact. On the other hand, in each weight-bearing area, the proportion of hyaluronate relative to total proteoglycan content appeared twice as much in the superficial layers than in their corresponding underlying zones. The molecular weight and in vitro aggregating capacity of the hyaluronate molecules were however quite similar in the different topographical areas of the articular tissue.

Characterization of the proteoglycans recovered under nondissociative conditions from normal articular cartilage of rabbits and dogs

Pretreatment of articular cartilage with a highly purified collagenase in the presence of selected protease inhibitors allowed the extraction under nondissociative conditions of 65% of the tissue hexuronate. Extracted proteoglycans were purified by two successive equilibrium centrifugations in Cs2SO4 and CsCl, respectively, and then characterized by their sedimentation properties. The use of labeled proteoglycan preparations demonstrated that no detectable degradation was introduced by the new extraction procedure. When applied to growth cartilage of rachitic rats the sedimentation profile of the purified proteoglycans was practically identical to that of the proteoglycan molecules recovered by micropuncture-aspiration. Proteoglycans were extracted from normal articular cartilage of rabbits and dogs with either the new procedure or 4.0 M guanidine HCl. The purified aA1 and A1 preparations were characterized by their sedimentation properties. The aA1 contained a higher proportion of aggregates which sedimented as two distinctive populations of molecules. This bimodal distribution of the aggregates was never observed in the A1 preparations even when the dissociative extraction was performed after collagenase pretreatment of cartilages. The two extraction procedures, however, extracted the same proteoglycan monomers since the aA1-D1 and A1-D1 preparations had similar biochemical composition and g(s) distribution functions. These observations and additional in vitro aggregation studies suggested that the differences in the size and proportion of aggregates between the aA1 and A1 preparations result from a more efficient recovery of link glycoproteins in nondissociative extractions that could have determined two structurally different hyaluronate molecules.

Tensile properties of human knee joint cartilage: I. Influence of ionic conditions, weight bearing, and fibrillation on the tensile modulus

The flow-independent (intrinsic) tensile modulus of the extracellular matrix of human knee joint cartilage has been measured for normal, fibrillated, and osteoarthritic (removed from total knee joint replacements) cartilage. The modulus was determined in our isometric tensile apparatus and measured at equilibrium. We found a linear equilibrium stress-strain behavior up to approximately 15% strain. The modulus was measured for tissues from the high and low weight-bearing areas of the joint surfaces, the medial femoral condyle and lateral patello femoral groove, and from different zones (surface, subsurface, middle, and middle-deep) within the tissue. For all specimens, the intrinsic tensile modulus was always less than 30 MPa. Tissues from low weight-bearing areas (LWA) are stiffer than those from high weight-bearing areas (HWA). The tensile modulus of the ECM correlates strongly with the collagen/proteoglycan ratio; it is higher for LWA than for HWA. Osteoarthritic cartilage from total knee replacement procedures has a tensile stiffness less than 2 MPa.

Gonococcal arthritis-dermatitis syndrome. Study of serum and synovial fluid immune complex levels

Immune complexes from serum and synovial fluid were detected by the C1q binding assay in 12 patients with disseminated gonococcal infection. Since immune complexes were regularly higher in synovial fluids than in paired sera and were not detected by the monoclonal rheumatoid factor radioimmunoassay, we suggest that IgM may be present in these complexes and that this represents a primary immune response. In contrast, only 2 of 10 patients with local gonococcal infection were slightly positive both with the C1q assay and the monoclonal rheumatoid factor assay. In patients with disseminated gonococcal infection, immune complexes closely paralleled the disease activity and negatively correlated with complement levels. Synovial fluid immune complexes seem to occur in the early and aseptic phase of polyarthritis and to aid the entrance of circulating gonococcal organisms. From the results of our study, it seems that immunologic processes initiate and/or sustain inflammation in disseminated gonococcal infections that appear, at least in part, as a form of reactive arthritis.

Immune complexes in polyarthritis after Salmonella gastroenteritis

In a case of polyarthritis after salmonella gastroenteritis the levels of circulating immune complexes (CIC) (C1q-binding assay) correlated closely with disease activity. This observation suggests that systematically absorbed salmonella antigens may lead or contribute to the formation of CIC. CIC activate both the classical and alternate complement pathway and may be important in the pathogenesis of the arthritis associated with salmonella infection.

Bone mineral content of the radius: good correlations with physicochemical determinations in iliac crest trabecular bone of normal and osteoporotic subjects

Specific gravity, porosity index (physical parameters), hydroxyproline, calcium, magnesium, and phosphorus (chemical parameters) were determined in iliac crest trabecular bone of normal and osteoporotic subjects. These physical and chemical parameters were compared to bone mineral contents (BMC) measurements by x-ray photodensitometry of the radius. BMC values correlated negatively with porosity index, specific gravity, and degree of mineralization of trabecular bone matrix, which all increase with osteoporosis. There was a negative correlation between calcium and magnesium contents per net bone volume. "Distal" scans of the radius reflected better the axial skeleton mass than "proximal" scans, and physicochemical data correlated better with bone mineral content values than with bone mineral mass (BMM) values.

Osteomalacia complicating a blind loop syndrome from congenital megaesophagus-megaduodenum

A young female with osteomalacia complicating a blind loop syndrome associated with congenital megaduodenum is described. In this case, the correction of vitamin D malabsorption by administration of antibiotics highlights the role of massive intraluminal bacterial overgrowth from destruction of vitamin D, or decreased unicellar solubilization due to deconjugation of biliary acids. The importance of cutaneous vitamin D synthesis in patients with osteomalacia of gastrointestinal origin is emphasized. The detection of megaduodenum and megaesophagus in the patient's father may be the first report of a familial association of these gastrointestinal abnormalities.