Bone turnover markers and the factors associated with atypical femur fractures among Japanese patients.

Many previous reports have indicated that atypical femur fractures (AFFs) are associated with the administration of bisphosphonates (BPs). A number of risk factors and hypotheses regarding the pathogenesis of AFFs have been reported to date. The purpose of the present study was to identify the factors associated with AFFs in Japanese individuals and to elucidate the association between bone metabolism and AFFs by evaluating bone turnover markers (BTMs). We prospectively reviewed all patients with femur fractures and identified the patients with AFFs and typical femur fractures (TFFs). We collected the demographic and clinical data that were relevant to the present study, namely age, gender, affected side, affected site, concomitant medical history, and comorbid conditions, and measured the levels of BTMs within 24h after trauma. Welch's test and Fisher's exact probability test were used for the statistical analyses. A total of 338 patients, including 10 patients with AFFs and 328 patients with TFFs, were analyzed under the inclusion criteria. The use of BPs (p<0.001) and collagen disease and chronic granulomatous disease (CD/CGD) (p=0.025) were more frequently observed in patients with AFFs than in patients with TFFs, while the levels of BTMs, including N-terminal propeptides of type 1 procollagen (P1NP), isoform 5b of tartrate-resistant acid phosphatase (TRACP-5b) and undercarboxylated osteocalcin (ucOC) were significantly lower in patients with AFFs than in patients with TFFs. Furthermore, the level of TRACP-5b was found to be significantly lower in patients with atypical subtrochanteric fractures than in atypical diaphyseal fractures (p=0.025). Moreover, the levels of P1NP (p=0.016) and TRACP-5b (p=0.015) were found to be significantly lower in patients with AFFs than in patients with TFFs in a subgroup analysis of BPs users. The use of BPs was considered to be a factor associated with AFFs. Our comparison of the BTMs in patients with AFFs and TFFs indicated that the severe suppression of bone turnover was associated with the pathogenesis of AFFs. The extent of the influence of suppressed turnover on the pathogenesis of AFFs may differ depending on the fracture site.

Serum levels of soluble carbonic anhydrase IX are decreased in patients with diffuse cutaneous systemic sclerosis compared to those with limited cutaneous systemic sclerosis.

Hypoxia may play an important role in the pathogenesis of systemic sclerosis (SSc). Carbonic anhydrase IX (CA IX) is one of the hypoxia markers and its extracellular domain can be released into the serum. However, the clinical significance of serum CA IX levels in SSc is still unknown. The aim of this study is to evaluate the possibility that serum CA IX levels can be a specific disease marker of SSc. Serum samples were obtained from SSc patients and healthy controls. Patients diagnosed as scleroderma spectrum disorder (SSD), who did not fulfill the ACR criteria of SSc but were thought that they might develop SSc in the future, were also included in this study. Serum CA IX levels were measured with specific enzyme-linked immunosorbent assays. SSD patients had significantly lower CA IX levels than diffuse cutaneous SSc (dcSSc), limited cuntaneous SSc (lcSSc) and healthy control groups. Also, we found a significant decrease in the values in dcSSc patients compared to those of lcSSc patients. Serum levels of CA IX may be useful for the differentiation of lcSSc from SSD. Decreased serum CA IX levels in spite of the presence of hypoxia in SSc may indicate an impaired response to hypoxia, which leads to the persistent hypoxic condition. Our results suggest that the abnormal response to hypoxia may already exist in SSD patients, and may be involved in its pathogenesis.

Serum biomarker analysis of collagen disease patients with acute-onset diffuse interstitial lung disease.

BACKGROUND: Interstitial lung disease (ILD) is frequently associated with collagen diseases. The prognosis of acute-onset diffuse ILD (AoDILD) occurring in collagen disease patients is very poor. Here, we investigated serum biomarker profiles of AoDILD to find markers predicting outcome in patients with collagen diseases. METHODS: A solid-phase antibody array was used for screening 274 biomarkers in pooled sera from collagen disease patients in the AoDILD state and in the stable state. Biomarkers in individual sera were detected without pooling by bead-based immunoassay. RESULTS: The serum levels of matrix metalloproteinase (MMP)-1, tissue inhibitor of metalloproteinase (TIMP)-1, osteopontin, interleukin (IL)-2 receptor α (IL-2Rα), and IL-1 receptor antagonist were significantly increased in AoDILD, but TIMP-2, MMP-3, and eotaxin 2 levels were decreased. The MMP-3 to MMP-1 ratio was reduced in AoDILD state. This tendency was also observed in RA patients with AoDILD. Moreover, serum IL-6 level was significantly increased in the AoDILD state in patients with acute exacerbation of ILD (AE-ILD). Serum TIMP-1 and IL-2Rα levels were significantly increased in the AoDILD state in patients with drug-induced ILD (DI-ILD), whereas TIMP-2, MMP-3, and eotaxin 2 levels were decreased. The MMP-3 to MMP-1 ratio was reduced in AoDILD state in patients with DI-ILD. The serum TIMP-3, MMP-9, osteopontin, IL-2Rα, MMP-1, and MMP-8 levels were significantly increased in the AoDILD state in patients who subsequently died, whereas TIMP-2 and MMP-3 levels were decreased in those who survived. The MMP-3 to MMP-1 ratio was reduced in AoDILD state in patients who died, but not in those who survived. CONCLUSIONS: Serum biomarker profiles could represent prognosis markers for AoDILD in collagen diseases.

Serum levels of soluble vascular endothelial growth factor receptor-2 in patients with systemic sclerosis.

BACKGROUND: Although vascular endothelial growth factor (VEGF)-A/VEGF receptor 2 (KDR) signalling may play a major role in the microangiopathy of systemic sclerosis (SSc), serum levels of soluble KDR (sKDR) in this disease have not yet been determined. OBJECTIVES: To evaluate the possibility that serum sKDR levels can be a specific disease marker of SSc. METHODS: Serum sKDR levels of 42 patients with SSc, 10 patients with Raynaud's phenomenon (RP) and 22 healthy controls were measured with specific enzyme-linked immunosorbent assays. Quantitative real-time polymerase chain reaction (PCR) was performed to determine KDR mRNA levels. RESULTS: In females, the serum sKDR levels were significantly higher in patients with SSc, especially limited cutaneous SSc, than in patients with RP or healthy controls. Quantitative real-time PCR with RNA from skin sections revealed that KDR mRNA levels were also increased in the skin of patients with SSc with elevated serum sKDR levels. A significantly lower prevalence of pulmonary fibrosis, higher percentage vital capacity, and a higher incidence of telangiectasia were seen in female patients with SSc with elevated serum sKDR levels than those with normal levels. CONCLUSIONS: These results suggest that the skin can be one of the sources of elevated serum sKDR levels, and that serum sKDR levels are useful for diagnosis and may be a marker of microangiopathy in patients with SSc, especially females. The VEGF-A/KDR signalling system may be involved in the pathogenesis of the disease.

Degradation of collagen by metalloproteinase 2 in patients with abdominal hernias.

BACKGROUND: The groin hernia is a significant social and economic problem of our times. The pathogenesis of the disease is not clear. The metalloproteinases (MMP) are the group of proteolytic enzymes responsible for the degradation of extracellular matrix proteins and the basic membrane of blood vessels. THE AIMS OF OUR STUDY WERE: (1) to estimate the MMP-2 levels in the blood and tissues of patients with a groin hernia; (2) to answer the question of whether changes in MMP-2 activity correlate with the occurrence of inguinal hernias. METHOD: The study was performed on a group of 90 male patients suffering from inguinal hernias, aged 28-70 years (mean: 49 years). The control group was made up of 10 healthy (free from hernia) males, aged 30-68 years (mean: 46 years). RESULTS: We noticed increased levels of MMP-2 in patients with all types of hernia and across all age groups. The MMP-2 mean serum levels were statistically higher in patients with a groin hernia when compared to the control group. The highest blood levels of MMP-2 were observed in young men with a direct hernia. CONCLUSIONS: This study confirmed the important role of MMP-2 in the pathogenesis of inguinal hernia. The increased activity may lead to dysfunctions in collagen fiber, which is responsible for forming fascial structures, and as a result weaken their durability.

[Could the screening of autoimmune diseases be simplified?]. / Dépistage d'une vascuuite ou d'une collagénose: tentative de simplification.

Autoimmune diseases (AD) represent usually a big challenge for the general physician (GP) and are often under diagnosed because of their rarity and their complex clinical symptoms. Even though AD are rapidly suspected, the GP is often exposed to the difficulty of screening and the complexity of the various biological tests at his disposal. This article propose the way to simplify the primary diagnostic approach of AD which often need a further specialized counseling necessary to determine the therapy.

Angiogenic activity of sera from patients with systemic autoimmune diseases in relation to clinical, radiological, and functional pulmonary status.

Systemic autoimmune diseases, such as vasculitis and collagen diseases, are characterized by chronic inflammation. Mutual interrelationship between angiogenesis and chronic inflammation has already been demonstrated. The aim of the study was to examine the effect of sera from patients with systemic autoimmune diseases on angiogenesis induced by human mononuclear cells. The study population consisted of 43 patients with a systemic autoimmune disease associated with pulmonary manifestations, divided into three groups: 14 with Wegener's granulomatosis (WG), 13 with systemic sclerosis (SS), and 16 with collagen vascular diseases (CVD) such as rheumatoid arthritis, systemic lupus erythematosus, and dermatomyositis. The control group consisted of 15 healthy volunteers. Clinical status was evaluated using a questionnaire. Standard chest radiographs were performed in all patients. Pulmonary function tests were performed according to the ERS standards. An animal model of a leukocyte-induced angiogenesis assay was used as an angiogenic test. Sera from WG and CVD patients significantly stimulated angiogenesis compared with healthy subjects (P<0.001). On the other hand, sera from healthy donors exerted a proangiogenic effect compared with PBS. In contrast, sera from SS patients significantly (P<0.001) inhibited angiogenesis compared with sera from healthy subjects and PBS. Proangiogenic effect of sera from systemic diseases patients depended on radiological changes. No significant correlation between a degree of dyspnea or functional pulmonary tests and the number of new vessels or angiogenesis index was found. Sera from patients with systemic autoimmune diseases and healthy people constitute the source of mediators modulating angiogenesis. These modulatory effects differ depending on the disease entity.

Serum levels of CA19-9 in patients with nonmalignant respiratory diseases.

CA19-9 is a specific tumor marker in patients with gastrointestinal cancer; however, some patients with respiratory disease can have elevated serum levels of CA19-9 as well. In this study we evaluated serum CA19-9 levels of patients with nonmalignant respiratory diseases. We also estimated the prognostic significance of elevated serum levels of CA19-9 in patients with interstitial lung diseases. The study included 554 patients who had been diagnosed at our hospital during the period of 1984-2005. Serum CA19-9 levels in these patients were measured with a commercially available kit. Elevated levels (>37 U/mL) of CA19-9 were observed in 30.7% of patients with lung cancer. Furthermore, 38.9% of patients with idiopathic interstitial pneumonia (IIP), collagen disease-associated pulmonary fibrosis (CDPF), diffuse panbronchiolitis (DPB), and bronchiectasis had elevated serum CA19-9 levels. Survival rates were significantly lower in patients with interstitial lung diseases (IIP and CDPF) and elevated serum CA19-9 levels than in those with levels in the normal range (P=0.0065). Serum CA19-9 was elevated in some patients with nonmalignant diffuse lung diseases. Therefore, clinicians should pay attention to the evidence that increased serum CA19-9 levels can be found in nonmalignant respiratory disease patients. In patients with IIP and CDPF, elevated serum CA19-9 levels may be related to poor prognosis.

Incidence and clinical features of cytomegalovirus infection diagnosed by cytomegalovirus pp65 antigenemia assay during high dose corticosteroid therapy for collagen vascular diseases.

OBJECTIVE: To investigate the incidence and clinical features in patients with cytomegalovirus (CMV)-positive antigenemia during high dose corticosteroid therapy for collagen vascular diseases, and risk factors associated with it. PATIENTS AND METHODS: We examined retrospectively 35 consecutive patients for the presence of CMV-positive pp65 antigenemia. The patients were admitted to Saka General Hospital from 2000 to 2003, and were administered more than 0.5 mg/kg of body weight/day of peroral prednisolone for collagen vascular diseases. Characteristics of patients with and without CMV-positive antigenemia were compared. RESULTS: CMV-positive antigenemia was detected in 14 patients (40.0%), including six with microscopic polyangitis, three with rheumatoid arthritis, and five with other conditions. Three patients (8.6%) were diagnosed as having a CMV disease: pneumonitis or encephalitis. Symptoms and laboratory findings, including slight fever and a low increase in levels of hepatic enzymes and cytopenia, were observed in 10 of the 14 patients. Two patients died of CMV diseases refractory to ganciclovir. Ages of more than 70 years old were associated with the presence of CMV-positive antigenemia (relative risk = 4.5, 95% confidence interval = 1.14-17.6). CONCLUSION: CMV infection diagnosed by CMV pp65 antigenemia assay is not rare during high dose corticosteroid therapy for collagen vascular diseases, and advanced age is considered a risk factor for it. It has a variety of symptoms and laboratory findings, which are mild and nonspecific to this type of infection, and they may not be clearly noted as clinical signs of CMV infection, even in patients with CMV diseases whose prognoses can be unsatisfactory. During high dose corticosteroid therapy for collagen vascular diseases, careful attention should be paid to CMV infection.

Sex-related differences in tuberculin reaction, free and total testosterone concentrations in patients with autoimmune disorders and controls.

Earlier studies reported the associations among testosterone hormone, autoimmunity, and left-handedness. In the present study, sex differences in tuberculin reaction, a measure of cell-mediated hypersensitivity, serum free and total testosterone levels in controls and patients with autoimmune diseases were studied. There was a sex difference in right and left tuberculin reactions in controls, but not in patients. Both right and left tuberculin reactions were smaller in male and female patients than male and female controls. Free and total testosterone levels were higher in male controls than in male patients. Total testosterone levels were higher in female controls than in female patients. These results suggest that autoimmune diseases may be associated with a decrease in the blood testosterone concentrations.

Is closer linkage between systemic lupus erythematosus and anti-double-stranded DNA antibodies a desirable and attainable goal?

The anti-double-stranded DNA (anti-dsDNA) antibody test incorporated in the 1982 revised American College of Rheumatology criteria for the classification of systemic lupus erythematosus needs updating to reflect current insights and technical achievements, including allowance for the presence of nonpathogenic anti-dsDNA antibodies. As we need to develop at least some measure of pathogenicity of anti-dsDNA antibodies, we propose that initial anti-dsDNA antibody screening is done by sensitive ELISA and supplemented by more stringent assays. Simultaneously the relevance of anti-dsDNA antibody presence needs to be restricted to clinical manifestations, thought to be caused by anti-dsDNA antibody and within an appropriate time frame.

[Prenatal diagnosis and outcome of fetal bradyarrhythmias]. / Pränatale Differentialdiagnostik und Verlauf fetaler Bradyarrhythmien.

BACKGROUND: The purpose of this study was to evaluate the clinical outcome of fetuses with bradyarrhythmias or complete heart block (CHB) in the setting of fetal structural heart disease (CHD) or of maternal collagenosis with and without treatment. METHODS: A retrospective analysis of echocardiographic studies performed in 14 fetuses (mean gestational age 25.5, range 19 - 36 weeks) referred for exclusion or diagnosis of bradyarrhytmias was performed. Maternal SS-A/Ro and SS-B/La antibodies were measured by ELISA. RESULTS: 14 fetuses showed bradyarrhythmias or complete heart block in combination with severe cardiac malformations (n = 7) or with positive maternal antibodies (n = 7). Only one of the fetuses with CHD survived infancy as opposed to 5/7 fetuses with complete atrioventricular block in the setting of maternal collagenosis. Maternal treatment with corticosteroids did not seem to influence the rhythm disorder. CONCLUSION: Fetal echography is a safe method to detect bradyarrhythmias or complete atrioventricular block. When associated with structural heart defects, fetal prognosis is poorer than in combination with maternal collagenosis.

Cytokeratin 19 fragment in patients with nonmalignant respiratory diseases.

STUDY OBJECTIVE: Cytokeratin 19 fragment (CYFRA) is a specific tumor marker in patients with lung cancer; however, it has been reported that serum CYFRA levels are elevated in some patients with nonmalignant respiratory diseases such as interstitial pulmonary fibrosis (IPF) and collagen disease-associated pulmonary fibrosis (CDPF). To investigate the serum CYFRA levels in nonmalignant respiratory diseases in detail, we studied 413 patients with respiratory diseases. DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: Four hundred thirteen patients with nonmalignant respiratory diseases and lung cancer. MEASUREMENTS AND RESULTS: Serum CYFRA levels were measured with a commercially available enzyme immunoassay kit. Immunohistochemical study was performed using monoclonal antibody Ks 19.1 (Rosch Diagnosica; Bern, Switzerland) on surgically resected or autopsied lung specimens. Gel electrophoresis and immunoblotting was performed with serum samples. In 149 patients with nonmalignant diseases except IPF and CDPF, the ratio of patients with > 3.5 ng/mL of serum CYFRA was 13.4%. In 13 of 30 patients (43.3%) with IPF and CDPF, the serum CYFRA levels were abnormally elevated. The 95th percentile serum CYFRA level of the patients with nonmalignant respiratory diseases was 6.2 ng/mL, and none of them had CYFRA levels > 20.3 ng/mL. Survival in patients with IPF and CDPF with elevated serum CYFRA levels were significantly lower than in those with normal range (p = 0.0335). Western blotting using serum from nonmalignant lung diseases and patients with lung cancer showed no apparent difference between them. An immunohistochemical study indicated CYFRA was selectively expressed in the pulmonary epithelial cells that covered the remodeling alveolar septi in nonmalignant respiratory disease. CONCLUSION: Serum CYFRA was elevated in some nonmalignant respiratory diseases, especially in IPF and CDPF. The value of serum CYFRA would reflect the severity of lung injury in nonmalignant respiratory diseases and might be related to the prognosis in patients with IPF and CDPF.

Increased circulating levels of soluble Fas ligand are correlated with disease activity in patients with fibrosing lung diseases.

OBJECTIVE: The Fas-Fas ligand (FasL) pathway is one of the important apoptosis-signalling molecule systems. We previously determined that this pathway may be involved in the pathogenesis of fibrosing lung diseases. In the present study, we evaluated the clinical significance of the levels of soluble forms of Fas (sFas) and FasL (sFasL) in serum from patients with fibrosing lung diseases. METHODOLOGY: We measured sFas, sFasL, KL-6 (a measure of alveolar type II cell damage), surfactant protein D (SP-D), and surfactant protein A (SP-A) levels in serum from 35 patients with idiopathic pulmonary fibrosis (IPF), 17 patients with interstitial pneumonia associated with collagen vascular diseases (CVD-IP), and 13 normal healthy controls using enzyme-linked immunosorbent assays (ELISA). RESULTS: The serum levels of sFasL were significantly increased in patients with active IPF and CVD-IP, compared with those with inactive disease and controls. There was no significant difference in sFasL levels between patients with inactive disease and controls. Serum sFasL levels were significantly correlated with lactate dehydrogenase and KL-6 levels in IPF. The decrease in sFasL levels following corticosteroid therapy was not correlated with the clinical course of IPF. There was no significant difference in serum sFas levels between IPF or CVD-IP patients and controls. CONCLUSIONS: Although further studies need to be performed on a large number of patients with histologically proven IPF or CVD-IP, it would seem that serum sFasL levels may reflect the activity of IPF and CVD-IP.

Cartilage proteoglycan aggrecan as a predictor of joint damage in juvenile rheumatoid arthritis.

Aggrecan was measured in the sera of 31 children with juvenile rheumatoid arthritis and in the synovial fluid of 10 of them. Patients were evaluated at baseline and 3 months later. Radiographs were repeated also after 1 year. As comparison, 15 apparently healthy children with no disease and 10 children with arthritis due to other collagen vascular diseases were studied. Baseline serum aggrecan was significantly higher in juvenile rheumatoid arthritis patients compared to controls and other patients. On re-evaluation, a significant drop in serum aggrecan from baseline values coincided with a significant drop in clinical and laboratory indices of active inflammation. Serum aggrecan can help to assess the extent of cartilage destruction and is useful as a prognostic tool to predict joint damage in patients with juvenile rheumatoid arthritis.