Biochemical markers of joint tissue damage increase shortly after a joint bleed; an explorative human and canine in vivo study.

OBJECTIVE: Evaluation whether biomarkers of joint damage are sensitive to change shortly after a joint bleed in hemophilia patients and in a canine model of blood-induced joint damage. METHODS: Blood and urine samples were collected from 10 hemophilia patients after they reported a joint bleed: within 2 days, after 3-5 days, and 12-14 days. Additionally, 90 days after the bleed a blood and urine sample was taken and considered to represent baseline condition. Commercial serum and urine biomarker assays were performed: urinary C-terminal telopeptide of type II collagen (uCTX-II), serum cartilage oligomeric matrix protein (sCOMP), serum cartilage cleavage product C1,2C, and serum chondroitin sulfate 846 (sCS846). The same panel of biomarkers was explored in dogs (n = 7) after induction of a first joint bleed by intra-articular blood injections. Biosamples were collected at baseline, day 2, 1 and 2 weeks later. RESULTS: In hemophilia patients, levels of uCTX-II and sCS846 increased 5 days after joint bleeding when compared with baseline (+52%; P = 0.021 and +14%; P = 0.011, respectively). In dogs, uCTX-II increased statistically significant from day 2 to day 7 (from 75% to 155% of baseline; P = 0.018), and sCOMP from baseline to day 2 (+46%; P = 0.028). CONCLUSIONS: This study demonstrates that biochemical markers of joint tissue damage increase shortly after a single joint bleed, both in humans with established hemophilic arthropathy (HA) and in an animal model of joint damage upon a first joint bleed. Biomarkers might be useful in monitoring the impact of a joint bleed and in evaluation of treatment of such bleeds.

Molecular serum and urine marker repertoire supporting clinical research on joint diseases.

The need for improved analytical techniques in the study of slow, degenerative diseases such as rheumatoid arthritis and osteoarthritis has driven major efforts aimed at identifying biochemical markers of pathological processes in both diseases. A series of novel biochemical markers has surfaced and their careful validation has become a critical requirement for further use in clinical research. This report aims at providing a critical review of biochemical markers applied in clinical research of joint diseases, in particular those markers reflecting the turnover of cartilage tissue.

Detection of unsaturated disaccharides, pyridinoline, and hydroxyproline in urine of patients with Kashin-Beck disease: comparison with controls in an endemic area.

OBJECTIVE: To investigate the pathologic status of adult patients with Kashin-Beck disease (KBD) in an endemic area of China through detection of 5 biochemical markers in their urine, and to study the correlations between these markers and KBD. METHODS: A total of 55 patients with KBD over age 40 years were recruited and divided into groups, Grade 1 and Grade 2, according to clinical diagnosis criteria for KBD and our inclusion criteria; 25 healthy persons were enrolled into a control group. The first-time urine of the 80 participants was collected in the morning. Three unsaturated disaccharides, pyridinoline (PYD), and hydroxyproline (HYP) were detected in urine samples with high performance liquid chromatography, ELISA, and a chemical kit. Mean levels of these markers were compared in the 3 groups. RESULTS: The mean concentrations of 3 unsaturated disaccharides and PYD in the Grade 2 group were significantly higher than levels in the Grade 1 group and controls (p<0.05). There was no significant difference between findings in the Grade 1 group and controls. Levels of 3 unsaturated disaccharides correlated with each other (p<0.01). The correlation coefficient between PYD and HYP was 0.470 (p<0.01). Except for HYP, the other markers all correlated with grade of KBD, rather than age or sex of subjects. CONCLUSION: The cartilage degradation of patients with Grade 2 KBD was more severe than that of Grade 1 patients and controls. The pathologic condition of Grade 1 patients was mild. Except for HYP, the markers we investigated specifically reflected the pathologic bone metabolism of adult patients with KBD. Trial registration number ChiCTR-TRC-00000140.

Manipulation with prolonged epidural analgesia for treatment of TKA complicated by arthrofibrosis.

Inability to achieve adequate range of motion (ROM) after total knee arthroplasty (TKA) represents a frustrating complication for both patient and surgeon. Manipulation under anesthesia is indicated in TKA having less than 90 degrees ROM after six weeks, with no progression or regression in ROM. A modified technique has evolved for patients with chronic regional pain syndrome (CRPS) symptoms or persistent stiffness after standard manipulation. A retrospective review was conducted to determine the efficacy of the modified technique, which uses epidural anesthesia continued for postoperative analgesia, hospital stay of one to three days, continuous passive motion (CPM) for two to three days, and daily physical therapy (PT). Between 1997 and 2003, 5714 TKAs were performed in 4106 patients. Manipulation using a standard technique was performed on 334 (5.8%) knees in 273 patients. Manipulation using a modified technique was performed on 65 (1%) knees in 60 patients. Age averaged 58 years and body mass index (BMI) averaged 34.39. Follow up averaged 18.4 months. ROM improved significantly from 71 degrees to 102 degrees (p < 0.0001). Knee Society pain, function, and total clinical scores all improved significantly (all p < 0.0001). Successful results were observed in 48 (74%) knees. Four (6%) additional knees achieved a successful result after a subsequent manipulation. Nine (14%) knees required component revision for treatment of persistent arthrofibrosis, which included one full revision, five polyethylene exchanges, and three revisions of femoral component and polyethylene. Two significant complications occurred: one subdural hematoma and one death due to pulmonary embolism. Although not without complications, manipulation under epidural anesthesia represents a viable option for treatment of persistent stiffness after TKA; 80% of these difficult cases achieved successful results.

Urine cartilage oligomeric matrix protein (COMP) measurement is useful in discriminating the osteoarthritic Thoroughbreds.

OBJECTIVE: To quantify the urinary concentration of cartilage oligomeric matrix protein (COMP), and to evaluate the relationship between urinary COMP concentration and the catabolic activity of synovial fluid (SF) in diseased horses. METHODS: COMP in horse urine was detected by immunoblotting with a monoclonal antibody (mAb; 14G4) raised against equine COMP from articular cartilage. Urine and serum samples were obtained from 83 Thoroughbred horses with aseptic joint diseases (AJD, 79 horses) or septic joint diseases (SJD, four horses) at the time of anesthesia induction, and samples of SF were obtained during surgery. Control samples of urine (n=111) were collected from normal horses free of any orthopedic diseases after they had been racing. COMP concentration was determined in all samples using inhibition enzyme-linked immunosorbent assay (ELISA) with mAb 14G4. SF samples were also used for the quantification of gelatinase activity. RESULTS: Positive bands of COMP fragments were determined on the immunoblots with mAb 14G4. The urinary COMP concentrations in AJD and SJD horses (1.02+/-0.75 and 1.55+/-1.17 microg/100mg creatinine, respectively) were significantly higher than normal (0.57+/-0.29 microg/100mg creatinine). In 55 horses with fractures in the AJD group there was a logarithmic relationship (r=-0.45, P<0.001) between the urinary and SF COMP measurements, while the urinary COMP level was positively correlated with matrix metalloproteinase (MMP)-2 and -9 activities (r=0.30, P<0.05 and r=0.51, P<0.001, respectively) in SF. CONCLUSIONS: The urinary COMP assay with mAb 14G4 is useful for discriminating horses with osteoarthritis. The higher COMP levels in urine from such horses would be indicative of enhanced proteolytic activity, in addition to the increased COMP levels in the diseased joints.

It's on the tip of my tongue.

A 48-year-old white woman was admitted to the hospital with low-grade fever, night sweats, fatigue, nonproductive cough with dyspnea, bilateral knee pain, and swelling that progressed slowly over 6 weeks. She was a 30-pack-year smoker, and had received outpatient antibiotic therapy with clarithromycin and then cephalexin without improvement. The admission chest radiograph showed bilateral interstitial infiltrates, and an effusion was seen on knee radiographs. She was treated with levofloxacin, cefepime, and methylprednisolone with some improvement, but fevers persisted up to 104 degrees F/40 degrees C. She also developed multiple painful skin nodules (Figure 1) and an enlarging painful tongue ulcer (Figure 2). Her bilateral knee swelling and pain also worsened, and a bone scan showed increased activity. Skin biopsy showed acute and chronic inflammation with an abscess that contained "yeast" (Figure 3). Fungal culture from the skin lesion and joint fluid aspirate grew Blastomyces dermatitidis. Urine antigen and blood antigen enzyme-linked immunoassays for B. dermatitidis were positive. The patient was started on a 6-month course of itraconazole oral solution with slow resolution of her joint inflammation and skin lesions over the next several weeks.

Biochemical markers of types I and III collagen and limited joint mobility in type 1 diabetic patients.

Limited joint mobility (LJM), a long-term complication of diabetes, has been shown to be associated with microvascular complications of diabetes. Connective tissue alterations may contribute to the development of LJM and other diabetic complications. We tested whether biochemical markers of types I and III collagen metabolism are associated with LJM in type 1 diabetes. We studied 28 male patients of mean age 43.4 years (SD=9.5) and with a duration of diabetes of 25.2 years (SD=9.7) years. LJM assessment included goniometric measurements of the joints and classification by Rosenbloom's method. We measured serum concentrations of aminoterminal propeptide of type III procollagen (PIIINP), carboxyterminal propeptide of type I procollagen (PICP) and carboxyterminal crosslinked telopeptide of type I collagen (ICTP); urinary excretion of crosslinked N-telopeptides of type I collagen (NTX) and deoxypyridinoline crosslinks (DPyr) was also measured. Although average serum PIIINP tended to be higher in subjects with moderate-severe LJM (3.1 +/- 1.3 microg/l) than in subjects with mild LJM (2.5 +/- 0.7 microg/l) or without LJM (2.6 +/- 0.4 microg/l), no significant association was found (p<0.27). Concentrations of the other collagen markers were not different in subjects with or without LJM. We conclude that synthesis and degradation of types I and III collagen in diabetic subjects with LJM did not differ from those without LJM to reflect changes in the biochemical markers of these proteins.

Molecular markers of bone and cartilage metabolism.

Molecular markers of bone and cartilage metabolism are increasingly used as helpful tools in the diagnosis and early detection of joint disease. Their quantification may help to improve the ability for therapeutic monitoring and follow-up of patients affected with rheumatic or degenerative cartilage disorders. The biochemical background and the functional properties of markers of bone, cartilage, and synovial tissue turnover are described. Current clinical applications and the diagnostic and prognostic validity of these metabolites are presented with special emphasis on recent research activities. Finally, molecular aspects of bone and joint diseases are discussed, highlighting genetic contributions to the development of joint disease.

Increased urinary excretion of glycosaminoglycans in insulin-dependent diabetic patients with limited joint mobility.

Urinary excretion of glycosaminoglycans (GAG) was measured in 24-h specimens collected from 27 insulin-dependent male diabetic patients and 22 healthy males of similar ages. Excretion relative to creatinine was increased by 35% in the diabetic group as a whole (p less than 0.02). Twelve patients with limited joint mobility (cheiroarthropathy) formed a subgroup with high excretion (69% above controls), those without limited joint mobility being similar to controls. There was no correlation of retinopathy with GAG excretion.

Methylprednisolone pulses and urine electrolyte excretion.

The mineralocorticoid activity of methylprednisolone pulses was assessed by measurement of urine electrolyte excretion prior to and during alternate day pulsing in patients with skin or joint disease. Two groups were studied: the first receiving pulses, but no other steroid; the second having taken oral prednisolone prior to and during pulsing. Urine sodium excretion in 24 hr urine specimens from both groups was suppressed, with no rebound between pulses, but a gradual "escape" occurred from the effects of continued pulsing. Four hour urine collections demonstrated suppression of urinary sodium excretion for up to 32 hr after pulsing with gradual recovery. The peak recovery in sodium excretion coincided with the subsequent pulse and was insufficient to compensate for the preceding sodium retention. Alternate day pulsing does not, therefore, reduce the risk of sodium retention from large doses of methylprednisolone.

Urinary neopterin index as a measure of rheumatoid activity.

The urinary neopterin index (U-NEOPT-I), expressed as micro-moles of neopterin/moles of creatinine) of 67 patients with definite or classical rheumatoid arthritis was significantly higher than that of sex- and age-matched persons or of 24 non-matched patients suffering from osteoarthrosis or arthralgia (2p less than 0.001). Furthermore, the patients with active disease had statistically significantly increased U-NEOPT-I when compared with patients with a clinically less active disease. In this study, the U-NEOPT-I value was the equal of CRP as a measure of rheumatoid activity. We suggest that neopterin might be involved in the pathogenesis of rheumatoid arthritis.

Screening study on excretion pattern of urinary glycosaminoglycans from orthopedic patients.

To obtain a clue for the metabolic disorder of glycosaminoglycans (GAG) in orthopedic diseases, a screening study on excretion pattern of urinary GAG from orthopedic patients was performed by the procedures of Nagatsuka et al. (1980). All the urines examined gave three regular GAG-bands. Besides the regular bands, some samples gave irregular bands. Of 123 cases examined in the present study, the numbers of cases with an abnormal excretion pattern of urinary GAG in the regular bands (A) and with the irregular band(s) (B) were as follows: 23(A) and 7(B) in 38 cases of rheumatoid arthritis (RA); 8(A) and 5(B) in 13 cases of malignant bone tumor; 11(A) and 3(B) in 12 cases of benign bone tumor; 16(A) and 3(B) in 25 cases of bone metabolic and connective tissue diseases; 6(A) and 4(B) in 9 cases of osteaorthritis; 6(A) and 3(B) in 8 cases of spine diseases; and 14(A) and 8(B) in 18 cases of other orthopedic diseases. The excretion patterns of urinary GAG suggested that the metabolic rates of chondroitin sulfates tended to elevate in most cases of (A). Also, certain metabolic disorder of dermatan sulfate and heparan sulfate was suggested in several cases of (A). In addition, the abnormal metabolism of acidic glycoprotein(s) was suggested in many cases of (B). Excretion of a large amount of dermatan sulfate was elucidated in one case (Case 20 of bone metabolic and connective tissue diseases) by digestion with chondroitinases after the screening study. Therefore, the metabolic disorder of dermatan sulfate was indicated in this patient. The low activity of alpha-L-iduronidase in her urine supported this indication. This patient was finally diagnosed as mucopolysaccharidosis I-S (Scheie syndrome).

Chemical definition of the mucopolysaccharidoses.

Glycosaminoglycans were isolated from the urines of 46 patients with mucopolysaccharidosis; 11 with Type I (Hurler), 8 with Type II (Hunter), 16 with Type III (Sanfilippo A and B), 9 with Type V (Scheie), one with Type VI (Marateaux-Lamy), and one unclassified. All 46 patients excreted in their urine excessive amounts of dermatan sulfate, heparan sulfate or both. In addition, patients of certain types excreted excessive amounts of chondroitin sulfates A and/or C. There is a trend in each type of the disease towards the same carbazole/orcinol ratio, glucosamine/galactosamine ratio and glycosaminoglycan composition. Molecular weight distribution of the urinary glycosaminoglycans by gel filtration from Sephadex G-200 is characteristic for each different type of mucopolysaccharidosis and is distinguished from normal controls and patients without mucopolysaccharidosis. Preparation of elution diagrams from Sephadex G-200 allows an estimation of the composition of the glycosamino-glycans. Practically all heparan sulfate and a sizable part of dermatan sulfate from the urinary glycosaminoglycans of all these patients have been highly degraded. In all the patients in which the specific enzyme defect was demonstrated, the assignment of the type of mucopolysaccharidosis, on the basis of the elution diagrams, was correct. Patients with mucopolysaccharidosis Type V displayed two conspicuously different types of elution patterns, suggesting heterogeneity. Indeed, only a portion of these patients showed alpha-L- iduronidase deficiency. Carriers had normal urinary glycosaminoglycan output and composition and exhibited normal elution diagrams.

Stickler's syndrome (hereditary progressive arthro-ophthalmopathy).

The clinical features of Stickler's syndrome are described in two families with a total of 22 affected members and compared with those of the three previously reported families. Progressive joint degeneration (85%), myopia (83%) and retinal detachment (61%) are the most frequent manifestations. Cleft palate (28%), micrognathia (17%) and sensorineural hearing loss (9%) are also liable to occur in affected individuals. Inheritance is autosomal dominant with virtually complete penetrance. Genetic counselling is extremely important and relatively straightforward since most of the findings are manifest in the first two decades of life and represent severe incapacities to the affected families. All six of the affected individuals tested had increased urinary hydroxyproline excretion, a feature that may lead to earlier postnatal and possibly prenatal diagnosis.