The effects of short-term, progressive exercise training on disease activity in smouldering multiple myeloma and monoclonal gammopathy of undetermined significance: a single-arm pilot study.

BACKGROUND: High levels of physical activity are associated with reduced risk of the blood cancer multiple myeloma (MM). MM is preceded by the asymptomatic stages of monoclonal gammopathy of undetermined significance (MGUS) and smouldering multiple myeloma (SMM) which are clinically managed by watchful waiting. A case study (N = 1) of a former elite athlete aged 44 years previously indicated that a multi-modal exercise programme reversed SMM disease activity. To build from this prior case study, the present pilot study firstly examined if short-term exercise training was feasible and safe for a group of MGUS and SMM patients, and secondly investigated the effects on MGUS/SMM disease activity. METHODS: In this single-arm pilot study, N = 20 participants diagnosed with MGUS or SMM were allocated to receive a 16-week progressive exercise programme. Primary outcome measures were feasibility and safety. Secondary outcomes were pre- to post-exercise training changes to blood biomarkers of MGUS and SMM disease activity- monoclonal (M)-protein and free light chains (FLC)- plus cardiorespiratory and functional fitness, body composition, quality of life, blood immunophenotype, and blood biomarkers of inflammation. RESULTS: Fifteen (3 MGUS and 12 SMM) participants completed the exercise programme. Adherence was 91 ± 11%. Compliance was 75 ± 25% overall, with a notable decline in compliance at intensities > 70% V̇O2PEAK. There were no serious adverse events. There were no changes to M-protein (0.0 ± 1.0 g/L, P =.903), involved FLC (+ 1.8 ± 16.8 mg/L, P =.839), or FLC difference (+ 0.2 ± 15.6 mg/L, P =.946) from pre- to post-exercise training. There were pre- to post-exercise training improvements to diastolic blood pressure (- 3 ± 5 mmHg, P =.033), sit-to-stand test performance (+ 5 ± 5 repetitions, P =.002), and energy/fatigue scores (+ 10 ± 15%, P =.026). Other secondary outcomes were unchanged. CONCLUSIONS: A 16-week progressive exercise programme was feasible and safe, but did not reverse MGUS/SMM disease activity, contrasting a prior case study showing that five years of exercise training reversed SMM in a 44-year-old former athlete. Longer exercise interventions should be explored in a group of MGUS/SMM patients, with measurements of disease biomarkers, along with rates of disease progression (i.e., MGUS/SMM to MM). REGISTRATION: https://www.isrctn.com/ISRCTN65527208 (14/05/2018).

In situ analysis of mineral content and crystallinity in bone using infrared micro-spectroscopy of the nu(4) PO(4)(3-) vibration.

Measurements of bone mineral content and composition in situ provide insight into the chemistry of bone mineral deposition. Infrared (IR) micro-spectroscopy is well suited for this purpose. To date, IR microscopic (including imaging) analyses of bone apatite have centered on the nu(1),nu(3) PO(4)(3-) contour. The nu(4) PO(4)(3-) contour (500-650 cm(-1)), which has been extensively used to monitor the crystallinity of hydroxyapatite in homogenized bone samples, falls in a frequency region below the cutoff of the mercury-cadmium-telluride detectors used in commercial IR microscopes, thereby rendering this vibration inaccessible for imaging studies. The current study reports the first IR micro-spectroscopy spectra of human iliac crest cross sections in the nu(4) PO(4)(3-) spectral regions, obtained with a synchrotron radiation source and a Cu-doped Ge detector coupled to an IR microscope. The acid phosphate (HPO(4)(2-)) content and mineral crystallite perfection (crystallinity) of a human osteon were mapped. To develop spectra-structure correlations, a combination of X-ray powder diffraction data and conventional Fourier transform IR spectra have been obtained from a series of synthetic hydroxyapatite crystals and natural bone powders of various species and ages. X-ray powder diffraction data demonstrate that there is an increase in average crystal size as bone matures, which correlates with an increase in the nu(4) PO(4)(3-) FTIR absorption peak ratio of two peaks (603/563 cm(-1)) within the nu(4) PO(4)(3-) contour. Additionally, the IR results reveal that a band near 540 cm(-1) may be assigned to acid phosphate. This band is present at high concentrations in new bone, and decreases as bone matures. Correlation of the nu(4) PO(4)(3-) contour with the nu(2) CO (3)(2-) contour also reveals that when acid phosphate content is high, type A carbonate content (i.e., carbonate occupying OH(-) sites in the hydroxyapatite lattice) is high. As crystallinity increases and acid phosphate content decreases, carbonate substitution shifts toward occupation of PO(4)(3-) sites in the hydroxyapatite lattice. Thus, IR microscopic analysis of the nu(4) PO(4)(3-) contour provides a straightforward index of both relative mineral crystallinity and acid phosphate concentration that can be applied to in situ IR micro-spectroscopic analysis of bone samples, which are of interest for understanding the chemical mechanisms of bone deposition in normal and pathological states.

Post-irradiation aging of ultra-high molecular weight polyethylene.

A study was performed to determine the time-course of oxidative degradation and the extent to which the degradation proceeded through the bulk of ultra-high molecular weight polyethylene joint components that had been irradiated and stored on a shelf. Standardized cylindrical samples, taken from a single batch of extruded polyethylene, were cleaned, packaged, and sterilized according to protocols used for commercial joint-replacement components. After sterilization, the samples were stored in the packages for time-periods of one day to more than one year. At each interval studied, thin sections were cut as a function of depth into the bulk of the sample and were used to determine the density and the infrared spectra. Marked alterations in the density and the infrared spectra consistent with continuing oxidative degradation occurred throughout the year of storage on the shelf. The alterations were most severe near the surface of the samples.

Mineral parameters in early fracture repair.

In an effort to define and characterize the initial mineralization product of fracture-healing, we studied the mineral components within a model of endochondral osseous repair. Fracture calluses from the tibiae of rats and rabbits undergoing endochondral fracture-healing were analyzed, in toto and following density fractionation, by physicochemical and crystallographic techniques. Significant changes in mineral composition, crystal size, and density occurred in the early phases of fracture repair. In the rat, two weeks after fracture, the calcium-to-phosphorus ratio was higher than that of the mineral component, possibly due to calcium-binding to some of the macromolecules known to be present. The earliest mineral was poorly crystallized hydroxyapatite with a high carbonate content. Crystal perfection improved rapidly and approached that of normal diaphyseal bone within eight weeks after endochondral fracture in both the rabbit and the rat.

Metal debris from titanium spinal implants.

STUDY DESIGN: A prospective study of tissue surrounding spinal instrumentation was performed using histologic and chemical analysis. OBJECTIVES: To identify and quantify the amount of metal debris generated by titanium pedicle screw instrumentation and to evaluate the histologic response in the spinal tissues. SUMMARY OF BACKGROUND DATA: Microscopic metal particles from the soft tissue surrounding joint arthroplasties have been shown to activate a macrophage response that leads to bone resorption and increased inflammation. The use of titanium spinal implants for spine surgery projects the possibility of generating wear debris in the spine. METHODS: Nine patients with titanium instrumentation from a prior lumbar decompression and fusion procedure who were undergoing reoperation were entered into this study. Tissue samples were collected from areas near the pedicle screw-rod junction, the scar tissue overlying the dura, and the pedicle screw holes. Metal levels for titanium were determined by electrothermal atomic absorption spectroscopy, and histologic analysis was performed by light and electron microscopy. RESULTS: Tissue concentrations of titanium were highest in patients with a pseudarthrosis (30.36 micrograms/g of dry tissue). Patients with a solid fusion had low concentrations of titanium (0.586 microgram/g of dry tissue). Standard light microscopy identified metal particles in the soft tissues. Transmission electron microscopy demonstrated macrophages with numerous secondary lysosomes containing electron-dense bodies and collagenous stroma with electron-dense rod-like profiles consistent with metal debris. CONCLUSIONS: Wear debris is generated by the use of titanium spinal instrumentation in patients with a pseudarthrosis. These particles activate a macrophage cellular response in the spinal tissues similar to that seen in surrounding joint prostheses. Patients with a solid spinal fusion have negligible levels of particulate matter.

Polyethylene and metal debris generated by non-articulating surfaces of modular acetabular components.

We report a prospective study of the liner-metal interfaces of modular uncemented acetabular components as sources of debris. We collected the pseudomembrane from the screw-cup junction and the empty screw holes of the metal backing of 19 acetabula after an average implantation of 22 months. Associated osteolytic lesions were separately collected in two cases. The back surfaces of the liners and the screws were examined for damage, and some liners were scanned by electron microscopy. The tissues were studied histologically and by atomic absorption spectrophotometry to measure titanium content. The pseudomembrane from the screw-cup junction contained polyethylene debris in seven specimens and metal debris in ten. The material from empty screw holes was necrotic tissue or dense fibroconnective tissue with a proliferative histiocytic infiltrate and foreign-body giant-cell reaction. It contained polyethylene debris in 14 cases and metal in five. The two acetabular osteolytic lesions also showed a foreign-body giant-cell reaction to particulate debris. The average titanium levels in pseudomembranes from the screw-cup junction and the empty screw holes were 959 micrograms/g (48 to 11,900) and 74 micrograms/g (0.72 to 331) respectively. The tissue from the two lytic lesions showed average titanium levels of 139 and 147 micrograms/g respectively. The back surfaces of the PE liners showed surface deformation, burnishing, and embedded metal debris. All 30 retrieved screws demonstrated fretting at the base of the head and on the proximal shaft. Non-articular modular junctions create new interfaces for the generation of particulate debris, which may cause granulomatous reaction.

Size of metallic and polyethylene debris particles in failed cemented total hip replacements.

Reports of differing failure rates of total hip prostheses made of various metals prompted us to measure the size of metallic and polyethylene particulate debris around failed cemented arthroplasties. We used an isolation method, in which metallic debris was extracted from the tissues, and a non-isolation method of routine preparation for light and electron microscopy. Specimens were taken from 30 cases in which the femoral component was of titanium alloy (10), cobalt-chrome alloy (10), or stainless steel (10). The mean size of metallic particles with the isolation method was 0.8 to 1.0 microns by 1.5 to 1.8 microns. The non-isolation method gave a significantly smaller mean size of 0.3 to 0.4 microns by 0.6 to 0.7 microns. For each technique the particle sizes of the three metals were similar. The mean size of polyethylene particles was 2 to 4 microns by 8 to 13 microns. They were larger in tissue retrieved from failed titanium-alloy implants than from cobalt-chrome and stainless-steel implants. Our results suggest that factors other than the size of the metal particles, such as the constituents of the alloy, and the amount and speed of generation of debris, may be more important in the failure of hip replacements.

Metallic wear debris in acetabular osteolysis in a mechanically stable cementless total hip replacement: report of a case.

Wear debris has evolved as the primary etiology of mechanical loosening of cemented as well as uncemented total hip arthroplasty. Osteolysis results from particle formation, and this has been most commonly reported to be secondary to polyethylene wear debris. This article demonstrates that metallic particle debris will also result in significant osteolysis. The two sources in this case are cobalt-chromium (Co-Cr) particles from the acetabular component and titanium-alloy (Ti) particles from the Morse taper junction and the Ti-alloy femoral head. However, it is likely that polyethylene debris also contributed to the osteolysis, because a titanium head was used and we know this results in increased poly wear.

Particulate metallic debris in cemented total hip arthroplasty.

Several studies conducted by the authors in the last six years demonstrate that the generation of metallic debris is more severe with titanium alloy than with cobalt-chrome alloy femoral components in cemented total hip arthroplasty (THA). The debris is generated from the articulating surface, particularly if entrapped acrylic debris produces three-body wear, and from the stem surface when the component loosens and abrades against fragmented cement. In selected cases in which the titanium metallic debris is copious, premature failure and severe progressive bone loss occurs. Electron microscopy demonstrates that the particles of metallic debris can be extremely small (a few hundredths of 1 micron). They are phagocytized by the macrophages and transported to the phagolysosomes. In this highly corrosive environment, the very high surface area of the particles may release toxic concentrations of the constituents of the alloy intracellularly, probably leading to progressive cell degeneration and death, with subsequent release of intracellular enzymes and ingested metallic debris. This cycle most likely repeats itself, leading to tissue necrosis. The results presented do not support the use of titanium alloy femoral components for cemented THA, particularly for the articulating surface.

Formation and structure of Ca-deficient hydroxyapatite.

When amorphous calcium phosphate (ACP) was transformed to crystalline hydroxyapatite (HA) in a series of aqueous slurry concentrations ranging from low to high, the higher slurry concentrations produced more Ca-deficient HA as measured by Ca/P ratio and heat-produced pyrophosphate. We feel that the excess solution phosphate produced in the higher slurry transformations results in lower Ca/P ratio HA. It has been suggested that an ACP is the precursor to bone apatite. Regulation of the in vivo ACP slurry concentration could then control the stoichiometry and, therefore, the metabolic activity of bone apatite. X-ray radial distribution function (RDF) analyses showed that CO3(2-) substitution in HA creates far greater structural distortions than do Ca deficiencies. The latter, however, do produce small, but observable, structural distortions when compared to stoichiometric HA. It now seems clear that the RDF of bone apatite can be modeled by a synthetic, Ca-deficient, CO3(2-)-containing HA.

Effect of carbonate and biological macromolecules on formation and properties of hydroxyapatite.

Amorphous calcium phosphate (ACP) was transformed at 25 degrees to hydroxyapatite (HA) in horse and bovine serum; solutions of serum-protein fractions in tris-HC1 buffer (pH 7.4), and pH 7.4 buffers containing from 0.1 to 10 times physiological CO3(2-) concentration. The ACP-to-HA transformation was slower in whole serum and serum fractions than in control buffer solution. The observed adsorption of serum proteins on ACP and HA probably inhibits both the dissolution of the ACP particles and the growth of HA crystals. After 72 h all transformations were complete as determined by X-ray diffraction. The HA crystal dimensions decreased with increasing C03(2-) but the shape, as shown by X-ray linewidths, was relatively constant up to about 4% CO3(2-). At 15% CO3(2-) the crystals were more equiaxial and less needle-like in habit. The radial distribution function (RDF) of HA with 3.7% CO3(2-) is less well resolved than the RDF of HA with ambient CO3(2-) (1.1%). The peaks are less sharp and their amplitude falls more rapidly with increasing atomic separation than for low CO3(2-)-HA. These effects show that CO3(2-) decreases the regularity of the atomic arrangement when incorporated in HA. The rapid decrease, with increasing CO3(2-) content, of the IR splitting of the P-O bending mode of CO3(2-)-HA is attributed to reduced crystal size and possibly to a perturbation of the crystal field due to CO3(2-)-induced lattice distortion. Finally, for bone mineral, it is probable that the poor resolution of the X-ray and IR patterns is due, in large part, to small crystal size and internal disorder caused by CO3(2-).

The effect of gallium nitrate on healing of vitamin D- and phosphate-deficient rickets in the immature rat.

The effect of gallium on rapid in vivo mineralization was studied in a rachitic rat model in which rickets were induced in immature rats then reversed ("healed") with repletion of vitamin D and phosphate. Gallium was administered to selected groups of animals before and during the healing phase. In nonrachitic animals and rachitic animals before healing, the mineral content of diaphyseal and metaphyseal bone was increased, and the crystal size was decreased in those animals that received gallium compared with those that did not. Mineralization of the undermineralized osteoid appeared histologically normal by 72 hours in all animals. However, animals that received gallium both before and during the healing phase had less well-mineralized bones at 18 hours, and by 72 hours, they had lesser increases in osteocalcin and mineral content, which was associated with smaller crystal sizes, than did any animal that did not receive gallium at any time. Prior to the healing phase, the ratio of gallium to hydroxyproline in the metaphyses of rachitic animals was similar to that in nonrachitic animals. Likewise, this ratio did not change in the animals receiving gallium both before and during the healing phase. The ratio of gallium to calcium was higher in rachitic animals compared with controls, and this ratio lowered significantly by the end of the healing phase. Results may be explained in part by direct effect of gallium on the physical process of mineral formation during the rapid healing phase as well as by effects of gallium on osteoblasts and osteoclasts during the induction of rickets.

Fourier transform infrared spectroscopy of the solution-mediated conversion of amorphous calcium phosphate to hydroxyapatite: new correlations between X-ray diffraction and infrared data.

Fourier Transform infrared spectroscopic analysis of maturing, poorly crystalline hydroxyapatite (HA) formed from the conversion of amorphous calcium phosphate (ACP) at constant pH or variable pH show only subtle changes in the v1, v3 phosphate absorption region (900 cm-1-1200 cm-1). This region is of interest because it can be detected by analysis of mineralized tissue sections using FT-IR microscopy. To evaluate the subtle spectral changes occurring during the maturation, second derivatives of the spectra were calculated. HA formed at constant pH showed little or no variation in the second derivative peak positions with bands occurring at 960 cm-1, 985 cm-1, 1030 cm-1, 1055 cm-1, 1075 cm-1, 1096 cm-1, 1116 cm-1, and 1145 cm-1. These bands can be assigned to molecular vibrations of the phosphate (PO4(3-)) moiety in an apatitic/stoichiometric environment of HA. In contrast, during the early stages of maturation of the HA formed at variable pH, second derivative peak positions occurring at 958 cm-1, 985 cm-1, 1020 cm-1, 1038 cm-1, 1112 cm-1, and 1127 cm-1 shifted in position with maturation, indicating that the environment of the phosphate species is changing as the crystals mature. Peaks at 1020 cm-1, 1038 cm-1, 1112 cm-1, and 1127 cm-1 were attributable to nonstoichiometry and/or the presence of acid phosphate-containing species. This concept was supported by the lower Ca:P molar ratios measured by chemical analysis of the synthetic material made at variable pH. Using the second derivative peak positions as initial input parameters, the v1, v3 phosphate region of the synthetic HAs prepared at constant pH were curve fit. X-ray diffraction patterns of these same materials were also curve fit to calculate the changes in crystallinty (size/perfection) in the c-axis 002 reflection as well as the 102, 210, 211, 112, 300, 202, and 301 planes. Linear regression analysis showed that the changes in the percent area of the underlying bands at 982 cm-1, 999 cm-1, 1030 cm-1, 1075 cm-1, 1096 cm-1, 1116 cm-1, and 1145 cm-1 were correlated with changes in crystallinity in one or more of the reflection planes. It is suggested that a combination of second-derivative and curve-fitting analysis of the v1, v3 phosphate contour allows the most reproducible evaluation of these spectra.

FTIR microspectroscopic analysis of human osteonal bone.

Fourier Transform Infrared Microspectroscopy (FTIRM) has been used to study the changes in mineral and matrix content and composition in replicate biopsies of nonosteoporotic human osteonal bone. Spectral maps in four orthogonal directions (in 10 microm steps) from the centers towards the peripheries of individual osteons were obtained from iliac crest biopsies of two necropsy cases. Mineral to matrix ratios, calculated from the ratio of integrated areas of the phosphate nu1,nu3 band at 900-1200 cm-1 to the amide I band at 1585-1725 cm-1, increased from the center to the periphery of the osteon. The total carbonate (based on the nu2 band at approximately 850-900 cm-1) to phosphate nu1,nu3 ratio decreased as the mineral to matrix ratio increased. Analysis of the nu2 CO32- band with a combination of second-derivative spectroscopy and curve fitting revealed a decrease in "labile" carbonate, a slight decrease in Type A and a slight increase in Type B carbonate from the center to the periphery of the osteon. Similar analysis of the components of the nu1,nu3 phosphate band with a combination of second-derivative spectroscopy and curve fitting revealed the presence of 11 major underlying moieties. These components were assigned by comparison with published frequencies for apatite and acid-phosphate containing calcium phosphates. The most consistent variations were alterations in the relative percent areas of bands at approximately 1020 and approximately 1030 cm-1, which had previously been assigned to nonstoichiometric and stoichiometric apatites, respectively. This ratio was used as an index of variation in crystal perfection throughout the osteon. This ratio decreased as the mineral to matrix ratio increased. The reproducibility of these parameters at multiple sites in multiple biopsies suggests their applicability for the analysis of mineral changes in disease.

Physicochemical study of plasma-sprayed hydroxyapatite-coated implants in humans.

This study represents the first report of the physical and chemical changes occurring in coatings of failed hydroxyapatite (HA)-coated titanium implants obtained from a comprehensive, multicenter human dental implant study. A total of 53 retrieved samples were obtained and compared with unimplanted controls with the same manufacturer and similar manufacture dates. Forty-five retrieved implants were examined for surface characteristics and bulk composition. Implants were staged based on implantation history: stage 1 (implants retrieved between surgical placement and surgical uncovering), stage 2 (implants retrieved at surgical uncovering and evaluation), stage 3 (implants retrieved between surgical uncovering evaluation and occlusal loading), and stage 4 (implants retrieved after occlusal loading). Scanning electron microscopy showed progressive coating thinning with implantation time. At later stages, bare Ti metal was detected by energy-dispersive X-ray analysis and electron spectroscopy for chemical analysis. Increases in Ti and Al (2-7.5 atm % each) were detected at the apical ends of all stage 4 samples. In unimplanted coatings, X-ray diffraction analysis demonstrated the presence of amorphous calcium phosphate, beta-tricalcium phosphate, tetracalcium phosphate, and calcium oxide in addition to large hydroxyapatite crystals (c axis size, D002 = 429 +/- 13 A; a axis size, D300 = 402 +/- 11 A, a/c aspect ratio 0.92). The nonapatitic phases disappeared with increased implantation time, although there was a persistence of amorphous calcium phosphate. Bulk coating chemical analysis showed that Ca/P ratios for implant controls (1.81 +/- 0.01) were greater than stoichiometric HA (1.67) and decreased for implant stages 3 and 4 (1.69 +/- 0.09 and 1.67 +/- 0.09, respectively), explained by the dissolution of the non apatitic phases. Crystal sizes also changed with implantation times, being smaller than the control at all but stage 4. Fourier transform infrared analyses agreed with these results, and also indicated the accumulation of bone (protein and carbonate-apatite) in the retrieved coatings. The accumulation of bone was not stage dependent. These findings indicate that there was some biointegration with the surrounding bone, but the greatest changes occurred with the HA coating materials, their loss, and chemical change.

Atomic structure of intracellular amorphous calcium phosphate deposits.

The radial distribution function calculated from x-ray diffraction of mineralized cytoplasmic structures isolated from the hepatopancreas of the blue crab (Callinectes sapidus) is very similar to that previously found for synthetic amorphous calcium phosphate. Both types of mineral apparently have only short-range atomic order, represented as a neutral ion cluster of about 10 A in longest dimension, whose probable composition is expressed by the formula Ca9(PO4)6. The minor differences observed are attributed to the presence in the biological mineral of significant amounts of Mg-2+ and ATP. Synthetic amorphous calcium phosphate in contact with a solution containing an amount of ATP equivalent to that of the biological mineral failed to undergo conversion to the thermodynamically more stable hydroxyapatite. The amorphous calcium phosphate of the cytoplasmic mineral granules is similarly stable, and does not undergo conversion to hydroxyapatite, presumably owing to the presence of ATP and Mg-2+, known in inhibitors of the conversion process. The physiological implications of mineral deposits consisting of stabilized calcium phosphate ion clusters are discussed.