Hypofibrinolysis, thrombophilia, osteonecrosis.

In the context of additional characterization of the pathoetiologic associations of heritable hypofibrinolysis and thrombophilia with osteonecrosis of the hip, the authors assessed 15 women and 21 men at entry to a 12-week treatment study of the amelioration of Ficat Stages I or II osteonecrosis by low molecular weight heparin (Enoxaparin). All 36 patients had osteonecrosis of the hip; four patients had unifocal osteonecrosis, 25 patients had two joints affected, five had three affected joints, and two had four affected joints. In 11 of 15 women (73%), hyperestrogenemia of pregnancy (20%) or exogenous estrogen supplementation (53%) were associated with the development of osteonecrosis. Five gene mutations affecting coagulation and nine serologic coagulation tests were studied. Compared with control subjects, patients were more likely to have heterozygosity and homozygosity for the hypofibrinolytic 4G polymorphism of the plasminogen activator inhibitor-1 gene. Moreover, the plasminogen activator inhibitor-1 gene product, plasminogen activator inhibitor activity, the major determinant of hypofibrinolysis, was 10 times more likely to be high (> 21.1 U/mL) in patients than in control subjects (31% versus 3%), with a median of 15.7 versus 6.3 U/mL. Compared with controls, patients were more likely to have the thrombophilic methylenetetrahydrofolate reductase gene mutation. In addition, the thrombophilic methylenetetrahydrofolate reductase gene product, homocysteine, was four times more likely to be high (> 13.5 umol/L) in patients than in control subjects (20% versus 5%), with a median of 9.1 versus 7 umol/L. Twenty-three percent of patients had low levels (< 65%) of the thrombophilic free protein S versus 3% of control subjects. Patients were more likely than control subjects to have hypofibrinolytic high lipoprotein (a) (> or = 35 mg/dL), 33% versus 13%. Median lipoprotein (a) was higher in patients than in control subjects, 15 versus 5 mg/dL. Heritable hypofibrinolysis and thrombophilia, often augmented in women by hyperestrogenemia, seem to be major pathoetiologies of osteonecrosis. If the association between coagulation disorders and osteonecrosis reflects cause and effect, as postulated, then anticoagulation with Enoxaparin should be a promising therapy for patients with osteonecrosis.

p21(Cip1) and p27(Kip1) regulate cell cycle reentry after hypoxic stress but are not necessary for hypoxia-induced arrest.

We investigated the role of the cyclin-dependent kinase inhibitors p21(Cip1) and p27(Kip1) in cell cycle regulation during hypoxia and reoxygenation. While moderate hypoxia (1 or 0.1% oxygen) does not significantly impair bromodeoxyuridine incorporation, at very low oxygen tensions (0.01% oxygen) DNA replication is rapidly shut down in immortalized mouse embryo fibroblasts. This S-phase arrest is intact in fibroblasts lacking the cyclin kinase inhibitors p21(Cip1) and p27(Kip1), indicating that these molecules are not essential elements of the arrest pathway. Hypoxia-induced arrest is accompanied by dephosphorylation of pRb and inhibition of cyclin-dependent kinase 2, which results in part from inhibitory phosphorylation. Interestingly, cells lacking the retinoblastoma tumor suppressor protein also display arrest under hypoxia, suggesting that pRb is not an essential mediator of this response. Upon reoxygenation, DNA synthesis resumes by 3.5 h and reaches aerobic levels by 6 h. Cells lacking p21, however, resume DNA synthesis more rapidly upon reoxygenation than wild-type cells, suggesting that this inhibitor may play a role in preventing premature reentry into the cell cycle upon cessation of the hypoxic stress. While p27 null cells did not exhibit rapid reentry into the cell cycle, cells lacking both p21 and p27 entered S phase even more aggressively than those lacking p21 alone, revealing a possible secondary role for p27 in this response. Cdk2 activity is also restored more rapidly in the double-knockout cells when returned to normoxia. These studies reveal that restoration of DNA synthesis after hypoxic stress, but not the S phase arrest itself, is regulated by p21 and p27.

Anticoagulant therapy for osteonecrosis associated with heritable hypofibrinolysis and thrombophilia.

Osteonecrosis develops as the end-result of reduced blood flow to the femoral head. We postulate that venous thrombosis leads to increased intraosseus venous pressure, reduced arterial flow and hypoxic bone death. Hypofibrinolysis (reduced ability to lyse thrombi) and thrombophilia (increased tendency to form thrombi) appear to play an important role in osteonecrosis. If coagulation disorders cause osteonecrosis, then anticoagulation might ameliorate osteonecrosis. In subjects with coagulation disorders and osteonecrosis of the hip, provided that anticoagulant therapy is started before irreversible segmental collapse of the head of the femur, osteonecrosis may be arrested or, speculatively, sometimes reversed. This has the potential of preventing femoral head collapse which usually leads to total hip replacement.

NF-kappaB determines localization and features of cell death in epidermis.

Specialized forms of physiologic cell death lacking certain characteristic morphologic features of apoptosis occur in terminally differentiating tissues, such as in the outer cell layers of epidermis. In these cell layers, NF-kappaB translocates from the cytoplasm to the nucleus and induces target gene expression. In light of its potent role in regulating apoptotic cell death in other tissues, NF-kappaB activation in these cells suggests that this transcription factor regulates cell death during terminal differentiation. Here, we show that NF-kappaB protects normal epithelial cells from apoptosis induced by both TNFalpha and Fas, whereas NF-kappaB blockade enhances susceptibility to death via both pathways. Expression of IkappaBalphaM under control of keratin promoter in transgenic mice caused a blockade of NF-kappaB function in the epidermis and provoked premature spontaneous cell death with apoptotic features. In normal tissue, expression of the known NF-kappaB-regulated antiapoptotic factors, TRAF1, TRAF2, c-IAP1, and c-IAP2, is most pronounced in outer epidermis. In transgenic mice, NF-kappaB blockade suppressed this expression, whereas NF-kappaB activation augmented it, consistent with regulation of cell death by these NF-kappaB effector proteins. These data identify a new role for NF-kappaB in preventing premature apoptosis in cells committed to undergoing physiologic cell death and indicate that, in stratified epithelium, such cell death normally proceeds via a distinct pathway that is resistant to NF-kappaB and its antiapoptotic target effector genes.

Secondhand smoke, hypofibrinolysis, and Legg-Perthes disease.

In 39 children with Legg-Perthes disease who were nonsmokers, the specific aim was to assess relationships among parental cigarette smoking during pregnancy, household smoking before diagnosis of Legg-Perthes disease, hypofibrinolysis, and thrombophilia. Fifteen (38%) children had no secondhand smoke exposure; 24 (62%) had secondhand smoke exposure before their diagnosis. Seventeen (71%) of these 24 children were exposed while in utero to smoking by a parent or live in relative and also had exposure to household smoke during childhood; seven (29%) had only household smoke exposure in childhood. In the full cohort of 39 children, secondhand smoke exposure correlated inversely with the major stimulator of fibrinolysis, stimulated tissue plasminogen activator activity. Of the children exposed to smoking, 48% had low stimulated tissue plasminogen activator activity (< 2.19 IU/ml) compared with 7% of the children without secondhand smoke exposure and 14% of 22 healthy control children. Secondhand smoke exposure had no significant effects on other measures of coagulation. Secondhand smoke exposure while in utero and during childhood appears to lower stimulated tissue plasminogen activator activity and additionally may depress heritable low stimulated tissue plasminogen activator activity, leading to hypofibrinolysis. Hypofibrinolysis may facilitate thrombotic venous occlusion in the head of the femur, leading to venous hypertension and hypoxic bone death, Legg-Perthes disease.

A model of corrective gene transfer in X-linked ichthyosis.

Single gene recessive genetic skin disorders offer attractive prototypes for the development of therapeutic cutaneous gene delivery. We have utilized X-linked ichthyosis (XLI), characterized by loss of function of the steroid sulfatase arylsulfatase C (STS), to develop a model of corrective gene delivery to human skin in vivo. A new retroviral expression vector was produced and utilized to effect STS gene transfer to primary keratinocytes from XLI patients. Transduction was associated with restoration of full-length STS protein expression as well as steroid sulfatase enzymatic activity in proportion to the number of proviral integrations in XLI cells. Transduced and uncorrected XLI keratinocytes, along with normal controls, were then grafted onto immunodeficient mice to regenerate full thickness human epidermis. Unmodified XLI keratinocytes regenerated a hyperkeratotic epidermis lacking STS expression with defective skin barrier function, effectively recapitulating the human disease in vivo. Transduced XLI keratinocytes from the same patients, however, regenerated epidermis histologically indistinguishable from that formed by keratinocytes from patients with normal skin. Transduced XLI epidermis demonstrated STS expression in vivo by immunostaining as well as a normalization of histologic appearance at 5 weeks post-grafting. In addition, transduced XLI epidermis demonstrated a return of barrier function parameters to normal. These findings demonstrate corrective gene delivery in human XLI patient skin tissue at both molecular and functional levels and provide a model of human cutaneous gene therapy.

Transcriptional control in keratinocytes and fibroblasts using synthetic ligands.

The skin is an attractive tissue for regulated target gene expression by virtue of its accessibility to topical regulating stimuli. We have used synthetic ligand-driven intracellular oligomerization to accomplish specific target gene regulation in human skin keratinocytes and fibroblasts. GAL4 DNA binding domains and VP16 transactivation domains, each linked to the FK506 binding protein, were expressed in normal human skin keratinocytes and fibroblasts. These hybrid proteins underwent heterodimerization via the novel intracellular dimerizing agent FK1012 to generate a heterodimeric activator of target gene expression in vitro. Dimeric FK1012, but not monomeric FK506M induced target gene expression in a dose-dependent fashion. FK1012 exerted no detectable nonspecific effects on expression of cutaneous genes and did not alter cellular proliferation kinetics. Controlled oligomerization of hybrid transcription activators offers a potential approach to target gene regulation in cells of normal human skin.

Fas signal transduction triggers either proliferation or apoptosis in human fibroblasts.

Although shown to be highly expressed by the epidermis in inflammatory skin disease, the ability of the Fas protein to trigger apoptosis in the distinct cell subpopulations of cutaneous tissue, particularly with regard to receptor density and the degree of crosslinking, has not been fully characterized. We therefore determined the effect of Fas cross-linking in primary human dermal fibroblasts at both high and low levels of Fas receptor expression. First, we examined the effects of the anti-Fas monoclonal antibody, CH-11, on fibroblasts expressing low basal levels of Fas. In these cells Fas aggregation stimulated proliferation by 160 +/- 10% over untreated controls. In contrast, the same concentration of CH-11 had an inhibitory effect on epidermal keratinocyte growth. Because Fas is upregulated in inflamed skin, we next examined the effects of Fas cross-linking on fibroblasts expressing augmented levels ofFas. Fibroblasts were either transfected with plasmids for overexpression of full length or bioengineered Fas receptors or were transduced with a retroviral Fas expression vector. In these cells Fas oligomerization triggered the morphologic changes indicative of apoptosis regardless of whether or not the Fas-signaling domain was tethered to the plasma membrane. These studies indicate that Fas oligomerization in dermal fibroblasts may initiate dual signaling programs, either proliferation or apoptosis, and that the chosen outcome may depend upon the magnitude of Fas aggregation.

Specific triggering of the Fas signal transduction pathway in normal human keratinocytes.

The epidermis is continually exposed to genotoxic injury and requires an efficient mechanism to eliminate genetically altered cells. The membrane receptor, Fas, initiates apoptosis in many cell types, including keratinocytes. Receptor cross-linking is the vital post-ligand binding step in Fas signal transduction, and we have utilized FK1012, capable of oligomerizing proteins engineered to contain the FK506 binding protein (FKBP), to trigger Fas via FKBP-linked receptor cytoplasmic domains in human keratinocytes. An FKBP chimera containing the Fas cytoplasmic domain targeted to the plasma membrane induced an up to 89% decrease in viability of keratinocytes, as reflected by the activity of constitutive promoters, in response to FK1012. Oligomerization of Fas, either with engineered Fas.FKBP by FK1012 or via antibody cross-linking of full-length Fas-induced cellular changes consistent with apoptosis. The lpr Fas point mutation abolished this effect. A Fas.FKBP construct unlinked to the membrane was fully active in this assay. Early developmental age or pre-treatment of cells with GM-CSF, TGF-beta, EGF, KGF, IFN-gamma, or phorbol ester failed to protect against Fas effects. These findings reveal that the Fas signal transduction pathway is active in keratinocytes, requires no induction, and dominantly overrides growth stimuli.

Interleukin 10 protects mice against staphylococcal enterotoxin B-induced lethal shock.

We investigated the ability of interleukin 10 (IL-10) to protect mice against lethal shock induced by staphylococcal enterotoxin B (SEB). Treatment of mice with IL-10 prevented the death of mice injected with SEB in a dose-dependent manner. IL-10-mediated protection was apparent when administered either prior to or concurrent with SEB but was less effective when administered following SEB injection. This observation indicates that IL-10 is capable of regulating T-cell activation in vivo.

The use of aspirin to prevent heterotopic ossification after total hip arthroplasty. A preliminary report.

The reported incidence of heterotopic ossification (HO) after total hip arthroplasty (THA) ranges up to 50%. HO causes pain and restricted range of motion (ROM) in a significant number of these THA patients. From 1983 to 1988, 177 primary cemented THAs were performed in 131 consecutive patients. Six hundred fifty milligrams of buffered aspirin administered twice daily for two weeks was used as a prophylaxis for thromboembolic disease. There was an unusually low incidence of HO in this group of patients. Aspirin treatment was instituted the night before surgery and continued for two weeks, except in 13 patients (7%) who had to stop treatment because of gastrointestinal symptoms. All patients had at least one year of roentgenographic study postoperatively. According to the Brooker Classification of HO, there were 169 (96%) Grade I and Grade 0 hips, six (3%) Grade II, two (1%) Grade III, and no Grade IV. None of the patients had symptomatic restriction of ROM attributable to heterotopic bone. Aspirin is a safe and inexpensive agent for prevention of HO after THA.

Extensive localized bone resorption in the femur following total hip replacement.

Extensive localized bone resorption within the femur was observed after four total hip replacements. The amount and location of the resorption suggested the presence of infection or tumor, but there was no evidence of either condition and the roentgenographic appearance differed from that associated with a loose uncemented endoprosthesis or a grossly loose femoral component of a total hip replacement. At reoperation the femoral components were not rigidly fixed but were only slightly loose. Histologically there were sheets of macrophages, a few giant cells, and multiple small fragments of a birefringent material, but no inflammatory cells. While the exact mechanism of this serious complication is unclear, the findings suggest that a benign, non-inflammatory, adverse tissue response can occur in relation to the femoral components of total hip replacements that are not rigidly fixed. In all four hips, reimplantation of a new total hip replacement was successful after follow-up of thirteen to eighteen months.

Bilateral carpal tunnel syndrome secondary to gouty tenosynovitis: a case report.

A 30-year-old patient developed bilateral carpal tunnel syndrome secondary to gouty tenosynovitis. Relief of symptoms followed removal of the tophaceous masses from the carpal tunnel. Surgical treatment is recommended whenever there is symptomatic median nerve compression.