Accuracy of synovial fluid analysis compared to histology for the identification of calcium pyrophosphate crystals: an ancillary study of the OMERACT US Working Group - CPPD subgroup.

The aim of this study was to evaluate the accuracy of synovial fluid analysis in the identification of calcium pyrophosphate dihydrate crystals compared to microscopic analysis of joint tissues as the reference standard. This is an ancillary study of an international, multicentre cross-sectional study performed by the calcium pyrophosphate deposition disease (CPPD) subgroup of the OMERACT Ultrasound working group. Consecutive patients with knee osteoarthritis (OA) waiting for total knee replacement surgery were enrolled in the study from 2 participating centres in Mexico and Romania. During the surgical procedures, synovial fluid, menisci and hyaline cartilage were collected and analysed within 48 hours from surgery under transmitted light microscopy and compensated polarised light microscopy for the presence/absence of calcium pyrophosphate crystals. All slides were analysed by expert examiners on site, blinded to other findings. A dichotomic score (absence/ presence) was used for scoring both synovial fluid and tissues. Microscopic analysis of knee tissues was considered the gold standard. Sensitivity, specificity, accuracy, positive and negative predictive values of synovial fluid analysis in the identification of calcium pyrophosphate crystals were calculated. 15 patients (53% female, mean age 68 yo ± 8.4) with OA of grade 3 or 4 according to Kellgren-Lawrence scoring were enrolled. 12 patients (80%) were positive for calcium pyrophosphate crystals at the synovial fluid analysis and 14 (93%) at the tissue microscopic analysis. The overall diagnostic accuracy of synovial fluid analysis compared with histology for CPPD was 87%, with a sensitivity of 86% and a specificity of 100%, the positive predictive value was 100% and the negative predictive value was 33%. In conclusion synovial fluid analysis proved to be an accurate test for the identification of calcium pyrophosphate dihydrate crystals in patients with advanced OA.

Spasmophilia and entrapment nerve syndrome comorbidities in fibromyalgic patients: a possible neuromuscular pain generator.

This paper is aimed at investigating whether peripheral dysfunction at the neuromuscular level may represent a pain generator in fibromyalgia. We studied the prevalence of spasmophilia (SP), carpal tunnel syndrome (CTS) and ulnar neuropathy at the elbow (UNE) in a group of 40 subjects suffering from fibromyalgia. Clinical and electrophysiological data were obtained to ascertain whether comorbid conditions were present. For subjective evaluation of symptoms severity, validated questionnaires for CTS and UNE were completed by patients. Twenty subjects were positive for SP (50%); CTS was diagnosed in 12 subjects (30%); no patient suffered from UNE; 6 subjects were affected at the same time by SP and CTS (15%); 14 subjects (35%) were affected by SP alone. The prevalence of CTS and SP was higher in fibromyalgia subjects than in the general population. The scores of the questionnaires related to CTS were significantly higher in fibromyalgia subjects positive for CTS, with respect to the other subjects. In fibromyalgia, CTS and SP may be considered clinical entities in themselves, the importance of which lies in their acting as peripheral pain generators that enhance or initiate central sensitization, thereby contributing to chronic widespread pain. The amplification of pain is indeed a correctable/misguided message that occurs inside the brain of fibromyalgia subjects and identification and local treatment of pain generators would lessen the total pain burden. The magnitude of the overlap in symptoms between fibromyalgia and CTS/SP necessitates careful investigation of these conditions.

Novelty-related behavior of young and adult dopamine transporter knockout rats: Implication for cognitive and emotional phenotypic patterns.

Attention deficit hyperactivity disorder (ADHD) is a neuropsychiatric disorder characterized by a developmentally inappropriate, pervasive and persistent pattern of severe inattention, hyperactivity and impulsivity. Despite onset in early childhood, ADHD may continue into adulthood with substantial impairment in social, academic and occupational functioning. A new animal model of this disorder was developed in rats with genetic deletion of the dopamine transporter (DAT) gene (dopamine transporter knockout rats; DAT-KO rats). We analyzed the behavior of DAT-KO rats for a deeper phenotypical characterization of this model. We first tested rats of the 3 genotypes at different ages (preadolescent, adolescent and adult), in a novelty-seeking test using a black/white box (Experiment 1). After that, we tested adult rats in a novelty-preference test using a 3-chamber apparatus with different shapes (Experiment 2). Experiment 1: as evidenced by analysis of time spent in the novel environment, adult DAT heterozygous (DAT-HET) rats show an increased curiosity-driven exploration compared with wild-type (WT) controls while DAT-KO rats did not recognize novelty. The locomotor activity data show a minimal difference between genotypes at adolescent age while the preadolescent and adult DAT-KO rats have significantly increased activity rate compared with WT and DAT-HET subjects. Experiment 2: in this case, due to more clearly evident spatial differences, time spent in novel environment was not significantly different among genotypes. During first 10 minutes, DAT-KO rats showed a decreased hyperactivity, apparently related to curiosity and attention to the new environments. In conclusion, DAT-KO rats may show some inattention while more novelty-seeking traits appear in DAT-HET rats.

Ultrasound in the diagnosis of calcium pyrophosphate dihydrate deposition disease. A systematic literature review and a meta-analysis.

OBJECTIVE: Ultrasonography (US) demonstrated to be a promising tool for the diagnosis of calcium pyrophosphate dihydrate deposition disease (CPPD). The aim of this systematic literature review (SLR) was to collect the definitions for the US elementary lesions and to summarize the available data about US diagnostic accuracy in CPPD. METHODS: We systematically reviewed all the studies that considered US as the index test for CPPD diagnosis without restrictions about the reference test or that provided definitions about US identification of CPPD. Sensitivity and specificity were calculated for each study and definitions were extrapolated. Subgroup analyses were planned by anatomical site included in the index text and different reference standards. RESULTS: Thirty-seven studies were included in this review. All the studies were eligible for the collection of US findings and all definitions were summarized. US description of elementary lesions appeared heterogeneous among the studies. Regarding US accuracy, 13 articles entered in the meta-analysis. Considering each joint structure, the sensitivity ranged between 0.77 (0.63-0.87) and 0.34 (0.16-0.58) while the specificity varies between 1.00 (0.89-1.00) and 0.92 (0.16-1.00). Considering the reference standards used, the sensibility ranged between 0.34 (0.02-0.65) and 0.87 (0.76-0.99) while specificity ranged between 0.84 (0.52-1.00) and 1.00 (0.99-1.00). CONCLUSION: US is potentially a useful tool for the diagnosis of CPPD but universally accepted definitions and further testing are necessary in order to assess the role of the technique in the diagnostic process.

Change perspective to increase diagnostic accuracy of ultrasonography in calcium pyrophosphate dehydrate deposition disease! A new approach: the axial scan of the meniscus.

Ultrasonography (US) is a relevant tool in the study of calcium pyrophosphate dihydrate (CPP) deposition disease. However, differential diagnosis of hyperechoic deposits within the fibrocartilage can be difficult; moreover, US study is limited by the need of an adequate acoustic window. We describe a US scanning technique that offers a new viewpoint in the study of knee meniscal structure: a longitudinal scan performed according to the long axis of meniscus. This technique proves to be particularly useful for the identification of CPP deposition, but could also improve the US diagnostic utility and accuracy in other meniscal pathologies.

Radiologists and rheumatologists on performing and reporting shoulder ultrasound: from disagreement to consensus.

Shoulder pain is a common condition in the rheumatologist's practice, yet there are no guidelines on how to report shoulder ultrasound (US) examinations. The aim of this study was to compare scanning and reporting techniques performed by radiologists and rheumatologists and identify any discrepancies between the two. The participants in this study were five rheumatologists and two radiologists specialized in musculoskeletal US. The study was divided in 2 phases. In the first phase, each participant performed an US of 3 patients and reported the findings without knowing the patient diagnosis and the findings reported by the other operators. Other three investigators reported the US technique of each operator. Reports and images were subsequently compared to identify any discrepancies and reach consensus on a common approach. In the second phase, a US scan was performed on a fourth patient in a plenary session to assess feasibility and efficacy of the common approach The US scanning technique was similar for all operators. The differences in reporting emerged in the description of the rotator cuff disease. Radiologists provided a detailed description of lesions (measurements along 2 axis and scoring of lesions), whereas rheumatologists described carefully the inflammatory changes. The experts concluded that lesions should be measured along 2 axes and the grade of degeneration and the age of the lesion should be reported. Another difference emerged in the description of the irregularities of the bone surface. The experts concluded that the term erosion should be used only when an inflammatory joint disease is suspected. This study led to the clarification of some inconsistencies in US reporting, and represented an interesting collaborative experience between radiologists and rheumatologists.

Prevalence of Baker's cyst in patients with knee pain: an ultrasonographic study.

The objectives of this study are to investigate the prevalence of Baker's cyst (BC) in patients with knee pain, and to assess the correlation between BC and severity of osteophytes and joint effusion. A retrospective study was conducted on a group of patients with knee pain referred to our outpatient clinic for ultrasonography of the knee between January 2010 and February 2011. Patients underwent an ultrasonographic exam of the knees to assess the presence of marginal femorotibial osteophytosis, joint effusion and BC. A dichotomous score was assigned to each item (1 present, 0 absent) and severity of US signs of osteoarthritis and joint effusion were also graded semiquantitatively. Collected data were processed using logistic regression analysis to evaluate the correlation between degree of osteophytosis and joint effusion and BC. Patients affected by inflammatory joint conditions or with history of joint surgery or recent trauma were excluded. A total of 399 patients with knee pain were studied (299 women), in the age range 18-89 years (mean 56.2, SD 16.3 years). 293 patients (73.4%) showed sonographic features of osteoarthritis and 251 (62.9%) joint effusion. BC was found in 102 patients (25.8%) together with a positive association with sonographic features of osteoarthritis and joint effusion. Our data show a prevalence of BC of 25.8% in a population of patients with knee pain, and suggest that BC is positively related to osteoarthritis and joint effusion. Ultrasonographic examination of knee is worthwhile in patients with painful osteoarthritis or evidence of effusion.

Treatment of anemia in patients with HIV infection, Part 1: The need for adequate guidelines.

Anemia in HIV-infected individuals, still a common hematologic complication in the highly active antiretroviral therapy (HAART) era, is associated with shortened survival, increases in the rate of disease progression, and reduction in quality of life. Based on a thorough review of the literature, guidelines were developed for the assessment, diagnosis, monitoring, and treatment of anemia in patients with HIV/AIDS by a consensus committee consisting of nurses from academia and clinical practice. A major goal of this committee is to increase awareness within the nursing community of the prevalence of anemia in HIV-infected patients and its impact on their lives. Anemia developed in close to 90% of HIV-infected patients before the introduction of HAART, and it is still found in up to 46% of patients in the HAART era. Another goal is to encourage screening for anemia and the adaptation of a proposed classification system of anemia based on a graded decrease in hemoglobin levels.

Assessment and treatment of HIV-related fatigue.

Fatigue, a common presenting complaint in primary care, is described as a lack of energy, sleepiness, tiredness, exhaustion, an inability to get enough rest, or weakness. Thus, fatigue affects quality of life. The prevalence rate of fatigue among patients with HIV infection is estimated to be 20% to 60%, and as the disease worsens, fatigue may become even more prevalent. The causes of HIV-related fatigue may be multifactorial and may include lack of rest or exercise, or improper or inadequate diet; psychological stress including depression and anxiety; the use of recreational substances; anemia; abnormalities of the thyroid gland and hypogonadism; infections; side effects of medications; sleep disturbances; and fever. This article reviews the common causes of HIV-related fatigue and briefly discusses options for reducing fatigue.

The need for national guidelines to manage fatigue in HIV-positive patients.

There are currently no guidelines available for clinicians who treat HIV-infected patients experiencing fatigue. Fatigue in this population is overlooked and undertreated. Guidelines need to be developed. A model developed by Rousswurm and Larrabee can be used to develop such guidelines. The steps to develop guidelines include the following: (a) assess the need for change in practice, (b) link the problem interventions and outcomes, (c) synthesize the best evidence, (d) design the practice change, (e) implement and evaluate the change in practice that has occurred since the guidelines were set up, and (f) integrate and maintain the changes that has come about in practice. By using evidence-based guidelines, the diagnosis and treatment of fatigue in HIV-positive patients experiencing fatigue can be approached in a standardized way, assuring the best treatment to those patients and assisting the health care providers manage patients with guidelines to standardize care.

Hypoxic inhibition of breathing in fetal sheep: relationship to brain adenosine concentrations.

Because hypoxic inhibition of fetal breathing may be caused by a rise in central adenosine levels, the effects of O2 deficiency on fetal brain adenosine concentrations were determined at levels of hypoxia that inhibited fetal breathing. Under halothane anesthesia, the brains of fetal sheep (0.8 term) were implanted with guide cannulas exteriorized through a Silastic rubber window in the uterus and flank of the ewe. At least 4 days after surgery, a microdialysis probe was inserted into a cannula with the membrane tip placed in the rostral brain stem. During 1 h of isocapnic hypoxia, mean fetal arterial PO2 was reduced from 24.0 +/- 0.9 Torr (control) to 13 +/- 0.6 Torr and arterial pH fell progressively from 7.354 +/- 0.007 to 7.273 +/- 0.023. Hypoxia decreased the incidence of fetal breathing movements from 33 +/- 5.2 to 5 +/- 2.2 min/h, with a normal incidence (29 +/- 3.5 min/h) during the hour after arterial PO2 returned to control values. Adenosine concentrations in microdialysis perfusate under control conditions averaged approximately 35 nM, increased up to 2.3-fold during the hour of O2 deficiency, and fell toward control values when normoxia was restored. We conclude that fetal brain adenosine levels are increased at levels of O2 deficiency that inhibit fetal breathing, which are results consistent with a role for adenosine in hypoxic inhibition of fetal breathing.

Characterisation of an epitope recognised by a monoclonal antibody against horse alcohol dehydrogenase using peptides synthesised on solid support.

Immunological analysis, using the Pepscan technique, of the tetradecapeptide, Pro344-Glu357 (PLITHVLPFEKINE), from horse liver alcohol dehydrogenase has identified a five amino acid sequence, HVLPF, which binds a monoclonal antibody. The epitope seems to be rather flexible with only two of the amino acids, Pro and Phe, having the characteristics of contact residues. However, the presence of the adjacent glutamic acid residue as part of the Pepscan peptide has a dramatic negative neighbourhood effect and inhibits binding. This highlights the potential risk of missing an epitope altogether when using the Pepscan procedure for epitope mapping.

A monoclonal antibody to alcohol dehydrogenase cross-reacts with human complement component C3.

A monoclonal antibody (mHADH1) against alcohol dehydrogenase was found to cross-react with an abundant protein in human serum. This cross-reacting material was identified unambiguously as the third component of complement (C3), probably part of the alpha-chain, by immunoblotting and immunoprecipitation experiments. The known ADH epitope, HVLPF, recognized by the monoclonal antibody is not, however, present in the C3 sequence.

Age-dependent changes in cat masseter nerve: an electrophysiological and morphological study.

The present study was undertaken to determine the manner in which aging affects the function and structure of the masseter nerve in old cats. Electrophysiological data demonstrated a significant decrease in the conduction velocity of the action potential in old cats compared with that observed in adult cats. Light microscopic analyses revealed an age-dependent decrease in axon diameter. Electron microscopic observations of the masseter nerve in the aged cats revealed a disruption of the myelin sheaths and a pronounced increase in collagen fibers in the endoneurium and perineurium. These morphological changes are discussed and then related to the decrease in conduction velocity which was observed in the electrophysiological portion of this study.

Molecular organization and dynamics of the outer membrane of Salmonella thyphimurium mutant strains detected by frequency domain fluorometry.

The fluorescence decay of 1,6-diphenyl-1,3,5-hexatriene (DPH) in the outer membrane bilayer of two mutant strains of Salmonella thyphimurium, i.e., SH 5014 and SH 6261, at different temperatures was analyzed in terms of continuous Lorentzian lifetime distributions. The results were compared with those obtained for the free fluorophore in an isotropic nonviscous solvent. The incorporation of DPH in the outer membrane fragments resulted in a broadening of the lifetime distribution which was attributed to the microenvironmental heterogeneity of the membrane bilayer for the extrinsic fluorophore. The differences observed between the two types of membrane bilayers were interpreted in terms of a different molecular organization and, to a lesser extent, in terms of a different fluidity. The comparison between the DPH lifetime distributions obtained using two different excitation wavelengths, i.e., 280 and 350 nm, suggested that the structural organization of the membrane domains, which are richest in proteins, is almost identical in the two examined mutant strains. This observation indicates that the different susceptibility of the two mutant strains toward phagocytosis and complement-mediated lytic action may depend on the molecular organization and dynamics of the lipid regions far from those containing proteins.

Segmental demyelination in peripheral nerves of old cats.

This study of the fine structure of sciatic nerve branches in normal old cats provides evidence indicating that segmental demyelination may account, in part, for the significant decrease with age in the mean axonal conduction velocity in these hindlimb nerves. Fibers of different diameters exhibited focal abnormalities of their myelin sheath. Lipid-like droplets and granulo-vacuolar debris were present in distended portions of the inner adaxonal rim and in the outer cytoplasmic compartment of the Schwann cell. These inclusions extended into the cytoplasm of the paranodal myelin loops and clefts of Schmidt-Lantermann. There also occurred disruption of the axoglial junctions and separation of the myelin loops from the paranodal axolemma which widens the nodes of Ranvier. Complete disruption of one or more contiguous segments of the myelin sheath was produced by interlamellar splitting and ballooning along the major dense and intraperiod lines. Axonal degeneration occurred less frequently and was not present in all hindlimb nerves.

Identification of a conserved epitope in class I alcohol dehydrogenase isoenzymes using monoclonal antibodies.

Two monoclonal antibodies raised against native horse alcohol dehydrogenase (HADH) bind preferentially to the enzyme attached to solid supports and recognize the denatured and carboxymethylated HADH subunits. Both antibodies cross-react with the human class I isoenzymes but do not recognize the class III ADH isoenzyme. Protease digestion, electrophoresis and HPLC have been used to identify the linear epitope which is contained in the sequence Pro344-Glu357 of the HADH subunit.

Transplantation of B16/C3 melanoma cells into the brains of rats and mice.

The B16/C3 mouse melanoma cell line produces L-DOPA, catecholamines and melanin in tissue culture. Growth and development of these cells after transplantation into the rat and mouse brain were studied by immunocytochemical and histological techniques. The implanted cells were localized by prelabelling the cell nuclei with bisbenzimide, a fluorescent marker which binds to DNA. Following transplantation into rats, B16/C3 melanoma cells were found to survive for at least 4-6 weeks. These cells initially expressed tyrosinase and tyrosine hydroxylase immunoreactivity and in some cases contained catecholamines. After 3 weeks, the cytoplasm of the transplanted cells began to accumulate melanin; catecholamines and tyrosinase immunoreactivity were no longer detected. Ultimately the cells became round in shape and densely pigmented. Growth of the tumor in the rats was restricted and the implant was encapsulated within a glial sheath. There was evidence of an immune reaction to the tumor in that cells with Ia antigen immunoreactivity were present surrounding the graft. The rat hosts were not adversely affected by the presence of the tumor, nor did the tumor cell grafts alter rotational behavior consequent to unilateral substantia nigra lesions. In mouse hosts, however, the melanoma grew rapidly, was not encapsulated by glia and led to death of all animals. These data suggest that the tumor was not rapidly destroyed in rats, even though its growth was controlled through immunological mechanisms. Both trophic and immunological mechanisms may therefore be involved in the regulation of survival and differentiation of intracerebral grafts of tumor cells.