Early cathepsin K degradation of type II collagen in vitro and in vivo in articular cartilage.

OBJECTIVE: To characterize the initial events in the cleavage of type II collagen mediated by cathepsin K and demonstrate the presence of the resulting products in human and equine articular osteoarthritic cartilage. DESIGN: Equine type II collagen was digested with cathepsin K and the cleavage products characterized by mass spectrometry. Anti-neoepitope antibodies were raised against the most N-terminal cleavage products and used to investigate the progress of collagen cleavage, in vitro, and the presence of cathepsin K-derived products in equine and human osteoarthritic cartilage. RESULTS: Six cathepsin K cleavage sites distributed throughout the triple helical region were identified in equine type II collagen. Most of the cleavages occurred following a hydroxyproline residue. The most N-terminal site was within three residues of the previously identified site in bovine type II collagen. Western blotting using anti-neoepitope antibodies showed that the initial cleavages occurred at the N-terminal sites and this was followed by more extensive degradation resulting in products too small to be resolved by SDS gel electrophoresis. Immunohistochemical staining of cartilage sections from equine or human osteoarthritic joints showed staining in lesional areas which was not observed in non-arthritic sites. CONCLUSIONS: Cathepsin K cleaves triple helical collagen by erosion from the N-terminus and with subsequent progressive cleavages. The liberated fragments can be detected in osteoarthritic cartilage and may represent useful biomarkers for disease activity.

Extended venous thromboembolism prophylaxis in patients undergoing hip fracture surgery - the SAVE-HIP3 study.

There is currently limited information available on the benefits and risks of extended thromboprophylaxis after hip fracture surgery. SAVE-HIP3 was a randomised, double-blind study conducted to evaluate the efficacy and safety of extended thromboprophylaxis with the ultra-low molecular-weight heparin semuloparin compared with placebo in patients undergoing hip fracture surgery. After a seven- to ten-day open-label run-in phase with semuloparin (20 mg once daily subcutaneously, initiated post-operatively), patients were randomised to once-daily semuloparin (20 mg subcutaneously) or placebo for 19 to 23 additional days. The primary efficacy endpoint was a composite of any venous thromboembolism (VTE; any deep-vein thrombosis and non-fatal pulmonary embolism) or all-cause death until day 24 of the double-blind period. Safety parameters included major and clinically relevant non-major bleeding, laboratory data, and treatment-emergent adverse events (TEAEs). Extended thromboprophylaxis with semuloparin demonstrated a relative risk reduction of 79% in the rate of any VTE or all-cause death compared with placebo (3.9% vs 18.6%, respectively; odds ratio 0.18 (95% confidence interval 0.07 to 0.45), p < 0.001). Two patients in the semuloparin group and none in the placebo group experienced clinically relevant bleeding. TEAE rates were similar in both groups. In conclusion, the SAVE-HIP3 study results demonstrate that patients undergoing hip fracture surgery benefit from extended thromboprophylaxis.

Orthopaedic thromboprophylaxis: limitations of current guidelines.

Thromboprophylaxis remains a controversial subject. A vast amount of epidemiological and trial data about venous thromboembolism has been published over the past 40 years. These data have been distilled and synthesised into guidelines designed to help the practitioner translate this extensive research into 'evidence-based' advice. Guidelines should, in theory, benefit patient care by ensuring that every patient routinely receives the best prophylaxis; without guidelines, it is argued, patients may fail to receive treatment or be exposed to protocols which are ineffective, dangerous or expensive. Guidelines, however, have not been welcomed or applied universally. In the United States, orthopaedic surgeons have published their concerns about the thromboprophylaxis guidelines prepared by the American College of Chest Physicians. In Britain, controversy persists with many surgeons unconvinced of the risk/benefit, cost/benefit or practicality of thromboprophylaxis. The extended remit of the recent National Institute of Clinical Excellence thromboprophylaxis guidelines has been challenged. The reasons for this disquiet are addressed in this paper and particular emphasis is placed on how clinically-acceptable guidelines could be developed and applied.

The cleavage of biglycan by aggrecanases.

OBJECTIVE: Aggrecanase-1 [a disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS)-4] and aggrecanase-2 (ADAMTS-5) have been named for their ability to degrade the proteoglycan aggrecan. While this may be the preferred substrate for these enzymes, they are also able to degrade other proteins. The aim of this work was to determine whether the aggrecanases could degrade biglycan and decorin. METHODS: Biglycan, decorin and aggrecan were purified from human and bovine cartilage and subjected to degradation by recombinant aggrecanase-1 or aggrecanase-2. In vitro degradation was assessed by sodium dodecyl sulfate/polyacrylamide gel electrophoresis (SDS/PAGE) and immunoblotting, and the cleavage site in biglycan was determined by N-terminal amino acid sequencing. SDS/PAGE and immunoblotting were also used to assess in situ degradation in both normal and arthritic human articular cartilage. RESULTS: Both aggrecanase-1 and aggrecanase-2 are able to cleave bovine and human biglycan at a site within their central leucine-rich repeat regions. Cleavage occurs at an asparagine-cysteine bond within the fifth leucine-rich repeat. In contrast, the closely related proteoglycan decorin is not a substrate for the aggrecanases. Analysis of human articular cartilage from osteoarthritic (OA) and rheumatoid arthritic (RA) joints showed that a biglycan degradation product of equivalent size is present in the extracellular matrix. No equivalent degradation product was, however, detectable in normal adult human articular cartilage. CONCLUSION: Biglycan, which is structurally unrelated to aggrecan, can act as a substrate for aggrecanase-1 and aggrecanase-2, and these proteinases may account for at least part of the biglycan degradation that is present in arthritic cartilage.

BAY 59-7939: an oral, direct factor Xa inhibitor for the prevention of venous thromboembolism in patients after total knee replacement. A phase II dose-ranging study.

BACKGROUND: BAY 59-7939, a novel, oral, direct factor Xa inhibitor, is in clinical development for the prevention of venous thromboembolism (VTE), a frequent complication following orthopaedic surgery. METHODS: In a multicenter, parallel-group, double-blind, double-dummy study, 621 patients undergoing elective total knee replacement were randomly assigned to oral BAY 59-7939 (2.5, 5, 10, 20, and 30 mg b.i.d., initiated 6-8 h postsurgery), or subcutaneous enoxaparin (30 mg b.i.d., initiated 12-24 h postsurgery). Treatment was continued until mandatory bilateral venography 5-9 days after surgery. The primary efficacy endpoint was a composite of any deep vein thrombosis (proximal and/or distal), confirmed non-fatal pulmonary embolism and all-cause mortality during treatment. The primary safety endpoint was major, postoperative bleeding during treatment. RESULTS: Of the 613 patients treated, 366 (59.7%) were evaluable for the primary efficacy analysis. The primary efficacy endpoint occurred in 31.7%, 40.4%, 23.3%, 35.1%, and 25.4% of patients receiving 2.5, 5, 10, 20 and 30 mg b.i.d. doses of BAY 59-7939, respectively (test for trend, P = 0.29), compared with 44.3% in the enoxaparin group. The frequency of major, postoperative bleeding increased with increasing doses of BAY 59-7939 (test for trend, P = 0.0007), with no significant difference between any dose group compared with enoxaparin. Bleeding endpoints were lower for the 2.5-10 mg b.i.d. doses compared with higher doses of BAY 59-7939. CONCLUSIONS: Oral administration of 2.5-10 mg b.i.d. of BAY 59-7939, early in the postoperative period, showed potential efficacy and an acceptable safety profile, similar to enoxaparin, for the prevention of VTE in patients undergoing elective total knee replacement.

An evaluation of cognitive-behavioral therapy for training resistance to visually-induced motion sickness.

This investigation examined the techniques for reducing visually-induced motion sickness. On the basis of their responses to a motion sickness history questionnaire, 32 subjects were selected and assigned to 1 of 4 groups such that the groups were matched on the basis of their ability to tolerate visually-induced apparent motion (VM). One group received 10 sessions of desensitization training only (DT); a second group received 10 sessions of cognitive therapy only (CT); a third group received 10 sessions of combined desensitization and cognitive therapy treatment (CG); and a fourth group received no treatment (C). (There are many speculations about why and how an individual's response changes with repeated stimulation. We have arbitrarily selected the term desensitization to connote the decrease in sensitivity over time with repeated exposures). The results indicated that only the groups which received cognitive therapy (i.e., CT and CG) exhibited significant increases in tolerance to VM when pretreatment measures were compared to posttreatment measures. No significant differences in pre- vs. posttreatment measures were observed in the desensitization only or control groups (i.e., DT and C). A similar pattern of results was obtained with the symptomatology data.

Rate of mortality for elderly patients after fracture of the hip in the 1980's.

At an average follow-up of 2.1 years, we reviewed the records of 241 patients who had had a fracture of the hip. The average age of the patients was 75.4 years. The rate of mortality one year after the fracture was 21.6 per cent for the total group, 8.0 per cent for the low-risk group, and 49.4 per cent for the high-risk group. The standard mortality ratio was six times higher for the high-risk group than for the general population (individuals who did not have a fracture), matched for age. It was highest for patients who were less than seventy years old and lowest for those who were older than eighty. However, in the second year after the fracture, the standard mortality ratio approached unity--that is, the rate of mortality approached that of the general population. The results suggest that there is an inverse relationship between mortality and advanced age and that the impact of a fracture of the hip on mortality is seen primarily in the first year after injury.

Neer total shoulder replacement in rheumatoid arthritis.

Forty-two shoulders in 37 patients with polyarthritis were treated with Neer total shoulder replacements and reviewed 12 to 66 months afterwards. There was good pain relief and improvement in function, but the range of movement was less than that seen after replacements for osteoarthritis; this may have been related to the fact that 34 shoulders had abnormal rotator cuff tendons. Although there was a high incidence of radiolucent lines around the glenoid component, there was no clinical evidence of loosening. There were a few complications, but on the whole we feel that the Neer total shoulder arthroplasty is a valuable procedure for a patient with polyarthritis.

Surgical stabilisation of the rheumatoid cervical spine. A review of indications and results.

We have reviewed 32 patients with rheumatoid disease of the cervical spine who underwent a total of 40 operations aimed at correcting instability and improving any associated neurovascular deficit. Apart from four patients with intractable pain, the main indication for surgery was progressive neurological impairment. Of the 32 primary operations, 19 (60%) were successful; the remainder failed to achieve their objective and there were two deaths in the immediate postoperative period. Of eight secondary operations performed for recurrence of symptoms or failure to relieve cervical myelopathy, only four were successful. Of nine operations for bony decompression to relieve cord compression from irreducible subluxation, only four were successful. The overall results show a success rate of 57% and a failure rate of 35% with early operative mortality in 8%. Indications for operation are discussed and earlier diagnosis is considered to be the key to improved results.

Mast cells at sites of cartilage erosion in the rheumatoid joint.

Cartilage-pannus junctions of the rheumatoid lesion have been examined by histochemical and ultrastructural techniques in an attempt to identify the cells responsible for cartilage degradation. Mast cells have been identified at sites of cartilage erosion in 3 specimens of rheumatoid joint. It is known that mast cells participate in immunological reactions, produce the vasoactive and proteinase-modulating agents histamine and heparin as well as their own degradative proteinases. The close association of mast cells with sites of cartilage erosion suggests they may play an important role in the pathophysiology of joint destruction in rheumatoid arthritis.

A bacteriologically occlusive clothing system for use in the operating room.

A comparison was made in a laminar-flow operating room between total-body exhaust gowns and a clothing system made from Fabric 450. This disposable clothing was found to be much more comfortable and convenient than the total-body exhaust gowns. The average airborne bacterial counts obtained during total hip replacement operations from each of the clothing systems were identical when the downflow method of ventilation was used (0.7 per cubic metre) and no significant difference could be demonstrated when the crossflow system was used (2.2 per cubic metre with the total-body exhaust gowns and 3.1 per cubic metre with the disposable clothing). Tests in a dispersal chamber were carried out to find the effectiveness of each item of the disposable clothing in reducing bacterial dispersion. These tests demonstrated the relative ineffectiveness of wearing a surgical gown as compared with wearing the complete system. It was confirmed bacteriologically that the downflow system of ventilation was more efficient than the crossflow type; the importance of this observation with respect to clothing and sepsis is discussed in this paper.

Stimulation of collagenase secretion from rheumatoid synovial tissue by human collagen peptides.

Dayer et al. demonstrated that mononuclear cells from human peripheral blood produce a mononuclear-cell factor that stimulates collagenase secretion from adherent rheumatoid synovial cells. The production of this mononuclear-cell factor can be stimulated by phytohemagglutinin, a T-cell mitogen. We have examined immune mechanisms by which collagenase secretion may be stimulated from explants of rheumatoid synovial tissue and from primary monolayer cultures of rheumatoid synovial cells. Conditioned media from cultures of normal peripheral-blood mononuclear cells that had been activated by phytohemagglutinin stimulated collagenase secretion from most explants and from all monolayer cultures that were examined. The direct addition of phytohemagglutinin stimulated collagenase secretion in explants from eight of fourteen patients and in monolayer cultures from three of six patients. These observations indicate the presence of responsive T lymphocytes in rheumatoid synovial tissue and implicate them in the stimulation of collagenase secretion from synovial cells. The direct addition of type-II collagen peptides to rheumatoid explants also stimulated collagenase secretion in explants from six to fifteen patients. Four of five of these patients displayed moderate or severe disease activity. Other patients showed a marginal stimulation of collagenase secretion on addition of type-II collagen peptides (four of fifteen patients) and type-I collagen peptides (three of twelve patients). None of the patients with mild or inactive disease responded to type-II collagen. With one exception, the addition of collagen peptides to monolayer cultures did not stimulate collagenase secretion. An increased production of factors that enhance or inhibit the migration of polymorphonuclear leukocytes was also observed in explant cultures in response to the addition of phytohemagglutinin (in seven of twelve patients), of type-I collagen peptides (in five of ten patients), and of type-II collagen peptides (in five of eleven patients). There was no correlation between production of these factors and stimulation of collagenase secretion in rheumatoid synovial tissue.

Problems and pitfalls of compression fixation of long bone fractures: a review of results and complications.

The complications encountered in the compression fixation of 70 cortical long bone fractures are reviewed. The results represent the initial experience with the AO fixation equipment following its introduction to a centre with staff relatively untrained in the technique. Infection was the most serious complication, with a deep sepsis rate of 10.5 per cent, but fixation failure, delayed union and refracture also occurred. The various problems are discussed in detail and suggestions are made as to how they can be avoided.

Centrifugal separation of irradiated cultures of Escherichia coli cells into viable and nonviable populations.

Incubation of ultraviolet-irradiated Escherichia coli B/r cultures with 0.7% Triton X-100 resulted in a large decrease in turbidity. Under phase-contrast optics, most of the irradiated detergent-treated cells were smaller than normal and of low phase density; only a small percentage were normal or larger than normal and of normal phase density. Irradiated cells not treated with detergent showed fewer pronounced morphological changes. Irradiated cells treated with detergent lost large amounts of proteins and ribonucleic acid, but not of deoxyribonucleic acid. Such cultures could be separated by centrifugation into populations of (i) slowly sedimenting cells consisting of small, phase-light cells of low viability and (ii) large cells of normal phase density and high viability (100%). A similar separation was effected in gamma-irradiated cultures.

Pyrimidine dimer excision in surviving and nonsurviving cells of ultraviolet-irradiated cultures of Escherichia coli.

We compared dimer excision in viable and nonviable cells fractions separated from Escherichia coli B/r cultures exposed to ultraviolet (UV) irradiation. For cells grown on minimal medium with glycerol as a carbon source, both fractions from the irradiated (20 J/m2, 5% survival) culture excised 60 to 70% of the thymine dimers from prelabeled DNA within 120 min. This percentage was, within experimental error, the same as that obtained from unseparated cultures. When isolated viable and nonviable populations were given a second UV exposure (20 J/m2) both types of cells were again able to excise dimers. The UV survival curve for the isolated viable population indicates that these cells are no more sensitive to radiation than exponentially growing cells not previously exposed to UV. The extent of dimer excision after UV irradiation was also the same in viable and nonviable cells separated from cultures grown on a glucose minimal medium in which both populations excised about 85% of the dimers within 120 min. These results show that the extent of removal of pyrimidine dimer from deoxyribonucleic acid is not precisely correlated with survival of repair-competent bacterial cells after exposure to UV light.