Osteoarthritis-associated basic calcium phosphate crystals alter immune cell metabolism and promote M1 macrophage polarization.

OBJECTIVE: A number of studies have demonstrated that molecules called 'alarmins' or danger-associated molecular patterns (DAMPs), contribute to inflammatory processes in the OA joint. Metabolic reprogramming of immune cells, including macrophages, is emerging as a prominent player in determining immune cell phenotype and function. The aim of this study was to investigate if basic calcium phosphate (BCP) crystals which are OA-associated DAMPs, impact on macrophage phenotype and metabolism. METHODS: Human monocyte derived macrophages were treated with BCP crystals and expression of M1 (CXCL9, CXCL10) and M2 (MRC1, CCL13)-associated markers was assessed by real-time PCR while surface maturation marker (CD40, CD80 & CD86) expression was assessed by flow cytometry. BCP induced metabolic changes were assessed by Seahorse analysis and glycolytic marker expression (hexokinase 2(HK2), Glut1 and HIF1α) was examined using real-time PCR and immunoblotting. RESULTS: Treatment with BCP crystals upregulated mRNA levels of CXCL9 and CXCL10 while concomitantly downregulating expression of CCL13 and MRC1. Furthermore, BCP-treated macrophages enhanced surface expression of the maturation makers, CD40, CD80 and CD86. BCP-treated cells also exhibited a shift towards glycolysis as evidenced by an increased ECAR/OCR ratio and enhanced expression of the glycolytic markers, HK2, Glut1 and HIF1α. Finally, BCP-induced macrophage activation and alarmin expression was reduced in the presence of the glycolytic inhibitor, 2-DG. CONCLUSIONS: This study not only provides further insight into how OA-associated DAMPs impact on immune cell function, but also highlights metabolic reprogramming as a potential therapeutic target for calcium crystal-related arthropathies.

EULAR revised recommendations for the management of fibromyalgia.

OBJECTIVE: The original European League Against Rheumatism recommendations for managing fibromyalgia assessed evidence up to 2005. The paucity of studies meant that most recommendations were 'expert opinion'. METHODS: A multidisciplinary group from 12 countries assessed evidence with a focus on systematic reviews and meta-analyses concerned with pharmacological/non-pharmacological management for fibromyalgia. A review, in May 2015, identified eligible publications and key outcomes assessed were pain, fatigue, sleep and daily functioning. The Grading of Recommendations Assessment, Development and Evaluation system was used for making recommendations. RESULTS: 2979 titles were identified: from these 275 full papers were selected for review and 107 reviews (and/or meta-analyses) evaluated as eligible. Based on meta-analyses, the only 'strong for' therapy-based recommendation in the guidelines was exercise. Based on expert opinion, a graduated approach, the following four main stages are suggested underpinned by shared decision-making with patients. Initial management should involve patient education and focus on non-pharmacological therapies. In case of non-response, further therapies (all of which were evaluated as 'weak for' based on meta-analyses) should be tailored to the specific needs of the individual and may involve psychological therapies (for mood disorders and unhelpful coping strategies), pharmacotherapy (for severe pain or sleep disturbance) and/or a multimodal rehabilitation programme (for severe disability). CONCLUSIONS: These recommendations are underpinned by high-quality reviews and meta-analyses. The size of effect for most treatments is relatively modest. We propose research priorities clarifying who will benefit from specific interventions, their effect in combination and organisation of healthcare systems to optimise outcome.

Intra-articular basic calcium phosphate and monosodium urate crystals inhibit anti-osteoclastogenic cytokine signalling.

OBJECTIVE: Basic calcium phosphate (BCP) and monosodium urate (MSU) crystals are particulates with potent pro-inflammatory effects, associated with osteoarthritis (OA) and gout, respectively. Bone erosion, due to increased osteoclastogenesis, is a hallmark of both arthropathies and results in severe joint destruction. The aim of this study was to investigate the effect of these endogenous particulates on anti-osteoclastogenic cytokine signalling. METHODS: Human osteoclast precursors (OcP) were treated with BCP and MSU crystals prior to stimulation with Interleukin (IL-6) or Interferon (IFN-γ) and the effect on Signal Transducer and Activator of Transcription (STAT)-3 and STAT-1 activation in addition to Mitogen Activated Protein Kinase (MAPK) activation was examined by immunoblotting. Crystal-induced suppressor of cytokine signalling (SOCS) protein and SH-2 containing tyrosine phosphatase (SHP) expression was assessed by real-time polymerase chain reaction (PCR) in the presence and absence of MAPK inhibitors. RESULTS: Pre-treatment with BCP or MSU crystals for 1 h inhibited IL-6-induced STAT-3 activation in human OcP, while pre-treatment for 3 h inhibited IFN-γ-induced STAT-1 activation. Both crystals activated p38 and extracellular signal-regulated (ERK) MAPKs with BCP crystals also activating c-Jun N-terminal kinase (JNK). Inhibition of p38 counteracted the inhibitory effect of BCP and MSU crystals and restored STAT-3 phosphorylation. In contrast, STAT-1 phosphorylation was not restored by MAPK inhibition. Finally, both crystals potently induced the expression of SOCS-3 in a MAPK dependent manner, while BCP crystals also induced expression of SHP-1 and SHP-2. CONCLUSION: This study provides further insight into the pathogenic effects of endogenous particulates in joint arthropathies and demonstrates how they may contribute to bone erosion via the inhibition of anti-osteoclastogenic cytokine signalling. Potential targets to overcome these effects include p38 MAPK, SOCS-3 and SHP phosphatases.

EULAR evidence-based recommendations for the management of fibromyalgia syndrome.

OBJECTIVE: To develop evidence-based recommendations for the management of fibromyalgia syndrome. METHODS: A multidisciplinary task force was formed representing 11 European countries. The design of the study, including search strategy, participants, interventions, outcome measures, data collection and analytical method, was defined at the outset. A systematic review was undertaken with the keywords "fibromyalgia", "treatment or management" and "trial". Studies were excluded if they did not utilise the American College of Rheumatology classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation. RESULTS: 146 studies were eligible for the review. 39 pharmacological intervention studies and 59 non-pharmacological were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and "other pharmacological" and exercise, cognitive behavioural therapy, education, dietary interventions and "other non-pharmacological". In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made. CONCLUSIONS: Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus.

Calcium crystal deposition diseases: update on pathogenesis and manifestations.

Basic calcium phosphate (BCP) and calcium pyrophosphate dihydrate crystals are the most common types of pathologic calcium-containing crystals. Although these crystals long have been associated with a variety of rheumatic syndromes, recent evidence implicates BCP crystals in the pathogenesis of breast cancer and atherosclerosis. Although understanding of molecular mechanisms involved in generating these pathologic effects has been advanced significantly in recent years, they still are understood incompletely. Such advances are essential to the ongoing search for effective therapies for crystal-associated diseases.

An unusual case of Behçet's syndrome: triggered by typhoid vaccination?

A case of Behçet's syndrome in a 32-year-old woman occurring shortly after her third vaccination against typhoid fever is described. Scleritis and pyoderma gangrenosum were unusual manifestations of BS that occurred in this case. Treatment benefit was provided by mycophenolate mofetil and etanercept. As bacterial antigens have been proposed as potential triggers for the onset of BS, it is possible that the syndrome was precipitated by typhoid vaccination in this patient.

Calcium hydroxyapatite promotes mitogenesis and matrix metalloproteinase expression in human breast cancer cell lines.

Radiographic mammary microcalcifications are one of the most pertinent diagnostic markers of breast cancer. Breast tissue calcification in the form of calcium hydroxyapatite (HA) is strongly associated with malignant disease. We tested the hypothesis that calcium HA may exert biological effects on surrounding cells, thereby facilitating breast cancer progression. Our findings showed that HA crystals enhanced mitogenesis in breast cancer cell lines MCF-7 and Hs578T and also in normal human mammary epithelial cells. HA crystals were also found to upregulate the production of a variety of matrix metalloproteinases (MMPs), including MMP-2, -9, and -13 in MCF-7 and MMP-9 in human mammary epithelial cell lines. HA crystals were found to greatly augment prostaglandin E(2) levels in Hs578T cells, and treatment with a cyclooxygenase inhibitor, aspirin, abrogated the HA-induced mitogenesis. These results suggest that calcium HA crystals may play an active role in amplifying the pathological process involved in breast cancer.

Basic calcium phosphate crystals activate human osteoarthritic synovial fibroblasts and induce matrix metalloproteinase-13 (collagenase-3) in adult porcine articular chondrocytes.

OBJECTIVE: To determine the ability of basic calcium phosphate (BCP) crystals to induce (a) mitogenesis, matrix metalloproteinase (MMP)-1, and MMP-13 in human osteoarthritic synovial fibroblasts (HOAS) and (b) MMP-13 in cultured porcine articular chondrocytes. METHODS: Mitogenesis of HOAS was measured by [3H]thymidine incorporation assay and counts of cells in monolayer culture. MMP messenger RNA (mRNA) accumulation was determined either by northern blot analysis or reverse transcriptase-polymerase chain reaction (RT-PCR) of RNA from chondrocytes or HOAS treated with BCP crystals. MMP-13 secretion was identified by immunoprecipitation and MMP-1 secretion by western blot of conditioned media. RESULTS: BCP crystals caused a 4.5-fold increase in [3H]thymidine incorporation by HOAS within 20 hours compared with untreated control cultures (p< or =0.05). BCP crystals induced MMP-13 mRNA accumulation and MMP-13 protein secretion by articular chondrocytes. In contrast, in HOAS, MMP-13 mRNA induced by BCP crystals was detectable only by RT-PCR, and MMP-13 protein was undetectable. BCP crystals induced MMP-1 mRNA accumulation and MMP-1 protein secretion by HOAS. MMP-1 expression was further augmented when HOAS were co-incubated with either BCP and tumour necrosis factor alpha (TNFalpha; threefold) or BCP and interleukin 1alpha (IL1alpha; twofold). CONCLUSION: These data confirm the ability of BCP crystals to activate HOAS, leading to the induction of mitogenesis and MMP-1 production. MMP-13 production in response to BCP crystals is substantially more detectable in porcine articular chondrocytes than in HOAS. These data support the active role of BCP crystals in osteoarthritis and suggest that BCP crystals act synergistically with IL1alpha and TNFalpha to promote MMP production and subsequent joint degeneration.

Primary pulmonary artery leiomyosarcoma in an adult dog.

A 7-year-old neutered female English Setter presented with syncope, anemia, and weight loss. Clinical examination revealed a systolic murmur and echocardiography demonstrated a mass on the pulmonic valve. Postmortem examination confirmed the presence of a pulmonic valve mass that extended along the pulmonary trunk and into the left pulmonary artery. Multiple pale nodules were observed in the right lung. Microscopic examinations of the pulmonary artery mass and the lung nodules revealed a pleomorphic population of spindle cells often arranged in broad bands containing strap-like nuclei and eosinophilic cytoplasm devoid of cross striations. The neoplastic cells expressed vimentin and alpha-smooth muscle actin but did not express desmin, CD31, factor VIII, or S100. The presentation, histological features, immunocytochemical profiles, and behavior of this tumor were indicative of a primary pulmonary artery leiomyosarcoma with lung metastasis.

Crystal-induced inflammation and cartilage degradation.

In the past year, there have been advances in our understanding of the induction of cartilage damage by calcium-containing crystals. Mechanisms of deposition and the biologic effects of crystals have been further characterized, as has the interaction between crystals and leukocytes. Studies of the clinical diagnosis of crystal deposition diseases suggest that accuracy with microscopy needs to be enhanced. Normal values for serum NTPPPHase have been established and optimal diagnostic imaging strategies for calcium pyrophosphate deposition disease have been suggested. There are still no available drugs to inhibit deposition or effect reabsorption of calcium-containing crystals.

Molecular mechanism of basic calcium phosphate crystal-induced activation of human fibroblasts. Role of nuclear factor kappab, activator protein 1, and protein kinase c.

Synovial fluid basic calcium phosphate (BCP) crystals are markers of severe joint degeneration in osteoarthritis. BCP crystals cause mitogenesis of articular cells and stimulate matrix metalloprotease production, thus promoting degradation of articular tissues. Previous work suggested that BCP crystal-induced cell activation required intracellular crystal dissolution, induction of proto-oncogene expression, and activation of signal transduction pathways involving protein kinase C and mitogen-activated protein kinases. Here we further elucidate the mechanisms of BCP crystal-induced cell activation as BCP crystals activate transcription factors nuclear factor kappaB and activator protein 1 in human fibroblasts. We confirm the role of protein kinase C in BCP crystal-induced mitogenesis in human fibroblasts. In contrast, we demonstrate that BCP crystals do not activate signal transduction pathways involving protein tyrosine kinases or phosphatidylinositol 3-kinase. These data further define the mechanism of cell activation by BCP crystals and confirm its selectivity, an observation that may have therapeutic implications.

A comparison of infection control practices of different groups of oral specialists and general dental practitioners.

OBJECTIVE: The purpose of this study was to compare the infection control practices of general dentists and dental specialty groups. METHODS: A survey was mailed to 5997 dentists in 1994; the response rate was 70%. The data were analyzed with multiple logistic regression (reference group: general dentists). RESULTS: When sociodemographic influences were taken into consideration, significant predictors of routine infection control practices included all of the following characteristics (odds ratios are in parentheses): 1. Gloves: being younger than 40 years of age (4.5) and being female (5.9). 2. Using gloves and changing gloves after each patient: being younger than 40 years of age (4.0), being female (3.0), being an oral surgeon (3.6), and being an orthodontist (0.2). 3. Using gloves, masks, and protective eyewear: being younger than 40 years of age (2.5), being female (2.3), and being an orthodontist, oral physician, or oral pathologist (0.2). 4. Hepatitis B vaccination for the practitioner: being younger than 40 years of age (5.1). 5. Hepatitis B vaccination for all clinical staff members: being younger than 40 years of age (1.2), being an oral surgeon (1.7), and being an orthodontist (0.6). 6. Heat sterilization of handpieces: being younger than 40 years of age (1.5), being an oral surgeon (5.4), and being an orthodontist (0.2). 7. Taking no additional precautions for patients with HIV: being younger than 40 years of age (1.7), being a periodontist (2.6), being a pedodontist (2.3), and being an oral physician/oral pathologist (4.3). CONCLUSION: Improved compliance with recommended infection control procedures is required for all groups and is particularly necessary for orthodontists.

Risk factors associated with mucositis in cancer patients receiving 5-fluorouracil.

Oral mucositis is a dose-limiting toxicity of 5-fluorouracil (5-FU). This prospective cohort study investigated factors associated with mucositis in patients receiving 5-FU for cancer of the digestive tract. Sixty-three patients (mean age 65 years) completed self-administered questionnaires and had interviews, oral examinations and unstimulated whole salivary flow measurements at baseline and follow-up appointments. The duration of follow-up was 2 months. Predictor variables included sociodemographic data, body surface area, diabetes, smoking, alcohol consumption, salivary flow, oral hygiene, presence of prostheses, performance status, regimen of cytotoxic drugs, hematological data, and herpes simplex virus antibody titer. Forty-six per cent of patients developed at least one episode of oral mucositis during cytotoxic treatment. Pearson's chi-square analysis showed that mucositis was significantly associated with xerostomia at baseline, xerostomia during chemotherapy, and lower baseline neutrophil counts (P < or = 0.05). Multiple logistic regression analysis indicated that xerostomia at baseline (odds ratio, OR = 10.0), or baseline neutrophil level under 4000 cells/mm3 (OR = 3.9) were significant predictors of mucositis. Taking into account the effect of neutrophil level at baseline, xerostomia during chemotherapy (OR = 4.5) was also a significant predictor of mucositis. The results showed that xerostomia and lower baseline neutrophil levels are significantly associated with oral mucositis. These variables should be taken into consideration in the design of intervention studies to reduce the frequency and severity of mucositis. More research is required to investigate the role of saliva and neutrophils in the pathogenesis of chemotherapy-induced mucositis.

Progress in HIV and AIDS care.

These recent meetings emphasized the considerable progress that has been made in HIV/AIDS. The prospect for non-progression of the disease, improved management of complications arising from the condition, and the potential for additional progress were the hallmarks of these meetings. The considerable developments that have occurred make it necessary for the dental profession to continue to play a role in the recognition, diagnosis, and management of oral conditions, and to keep abreast of the considerable developments in this field-and the implications that these developments have for patients presenting with complications related to other conditions, which may include bacterial, fungal or viral infections and malignant disease.

Changes in dentists' infection control practices, knowledge, and attitudes about HIV over a 2-year period.

OBJECTIVE: To investigate changes in the infection control practices, attitudes, and knowledge of dentists as they relate to HIV/AIDS: STUDY DESIGN: A comparison of responses to surveys conducted in 1992 (n = 258) and 1994 (n = 262) with the use of univariate/multivariate analyses and McNemar's test for paired data. RESULTS: The response rate were > 70%. There were significant increases in reports of continuing education related to HIV/AIDS, heat sterilization of handpieces, use of masks, and knowledge of risk of HIV infection after a needlestick injury. Significantly fewer respondents reported concerns about staff fears about HIV/AIDS: Reports of willingness to treat patients with HIV increased from 68% to 77%. The best predictors of willingness to treat changed from primarily infection control variables to lack of concern with respect to risk or loss of patients when treating persons with HIV. CONCLUSIONS: Increased use of infection control procedures and knowledge may be partly attributable to the introduction of mandatory continuing education in 1993.

HIV-infected patients and dental care: nondisclosure of HIV status and rejection for treatment.

OBJECTIVE: To investigate reports of nondisclosure of HIV-seropositivity to dentists by HIV-infected patients and their rejection for dental treatment. STUDY DESIGN: An anonymous self-administered questionnaire was completed by 101 consecutive consenting HIV-infected patients. RESULTS: Eighty percent of respondents (mean age, 36 years) had visited a dentist since their HIV diagnosis; 15% of these reported that they had been refused treatment because the dentist did not want to treat HIV-infected patients. Rejection was reported by 25% of respondents with heterosexual and 14% with homosexual risk factors, 11% of recipients of blood or blood products, and 8% with unknown or multiple risk factors. Refusal was not associated with economic factors. Nondisclosure of HIV-seropositivity to their current dentist was reported by 13% of respondents. No respondents attending hospitals or health units reported nondisclosure, compared with 18% of respondents attending private dental offices (p < 0.05). CONCLUSION: More research is required with a larger sample to improve generalizability and to permit subgroup analysis.

The role of cyclic-3',5'-adenosine monophosphate in prostaglandin-mediated inhibition of basic calcium phosphate crystal-induced mitogenesis and collagenase induction in cultured human fibroblasts.

Synovial fluid basic calcium phosphate (BCP) crystals are associated with severe destructive arthropathies characterised by synovial proliferation and non-inflammatory degradation of intra-articular collagenous structures. BCP crystals stimulate fibroblast and chondrocyte mitogenesis, metalloprotease secretion and prostaglandin production. As a tissue protective effect of prostaglandins has been suggested, we recently studied the effect of PGE1 on BCP crystal-induced mitogenesis and collagenase mRNA accumulation in human fibroblasts (HF). We demonstrated a dose-dependent inhibition of BCP crystal-induced mitogenesis and collagenase mRNA accumulation. The mechanism of PGE1 inhibition of BCP crystal-induced mitogenesis and collagenase mRNA accumulation was therefore explored. PGE1 (100 ng/ml) increased HF intracellular cAMP 40-fold over control. BCP alone caused no such change but inhibited the PGE1-induced increase in intracellular cAMP by at least 60%. The PGE1-induced increase in intracellular cAMP was also blocked by the adenyl cyclase inhibitor, 2',5'-dideoxyadenosine (ddA) (10 microM) and ddA reversed the PGE1-mediated inhibition of BCP crystal-induced mitogenesis. Dibutyryl cAMP also inhibited BCP crystal-induced mitogenesis in a concentration-dependent manner. Agents which increase intracellular cAMP levels such as the adenyl cyclase activator forskolin and the phosphodiesterase, inhibitor 3-isobutyl-1-methylxanthine (IBMX) mimicked the effect of PGE1 on HF collagenase mRNA levels. PGE1 inhibits the biologic effects of BCP crystals through the cAMP signal transduction pathway and such inhibition may have significant therapeutic implications.

Acute calcific periarthritis of the finger joints: a syndrome of women.

We describe a 33-year-old woman with acute calcific periarthritis (ACP) of the interphalangeal joint of the thumb and review 42 reported cases of ACP involving the finger joints. A computer assisted literature search for reported cases of ACP involving the finger joints was performed. Clinical features of our case and those fulfilling the criteria for entry into this study were analyzed.

Jaw and other orofacial pain in patients receiving vincristine for the treatment of cancer.

This prospective cohort study investigated orofacial pain occurring as a manifestation of vincristine neurotoxicity. Forty cancer patients (28 to 63 years of age) receiving vincristine were given baseline interviews and orofacial examinations, which were repeated weekly for 7 weeks of treatment. Twenty-two patients (55%) had neurotoxicity manifesting as orofacial pain. Onset was usually 3 days after vincristine administration; mean duration was 2 days. Twenty patients (50%) were affected in the first week: nine (22%) with severe and five (12%) with moderate pain. Symptoms were mild and infrequent in subsequent weeks. Eighteen control patients receiving chemotherapy without vincristine had no comparable orofacial symptoms. Multiple sites in the distribution of the trigeminal and glossopharyngeal nerves were affected: primarily the temporomandibular joint, mandible, throat, ears, and mandibular teeth. The frequency of orofacial pain increased with younger age. Pain was significantly associated with smaller body surface area (p less than 0.05), indicating a dose-related toxicity, and with sociodemographic variables including smoking (p less than 0.05).

Orofacial complications of chemotherapy for breast cancer.

The National Institutes of Health recently recommended research initiatives to investigate oral complications of cancer chemotherapy. This prospective cohort study investigated orofacial complications of combination chemotherapy (cyclophosphamide, methotrexate, fluorouracil, vincristine, and prednisone) in women with breast cancer. Thirty-four patients were given baseline interviews and examinations. Each patient was given weekly orofacial examinations and biweekly interviews for the first seven cycles of cytotoxic treatment. The orofacial complications included neurotoxicity caused by vincristine, mucositis, and candidiasis. Neurotoxicity affected 22 of 34 (65%) patients, was significantly associated with age less than 50 years (p less than 0.05), and manifested as pain in 19 of 34 (56%) patients. Mucositis affected 7 of 34 (21%) patients and was significantly associated with the occurrence of lesions of the oral mucosa at baseline examination; and smaller body surface area--indicating a dose-related toxicity (p less than 0.05). In four of the patients with mucositis (57%) granulocytopenia developed during the 7 days after the onset of mucositis. Intraoral candidiasis affected 4 of 34 (12%) patients.