Different changes in the biomarker C-terminal telopeptides of type II collagen (CTX-II) following intra-articular injection of high molecular weight hyaluronic acid and oral non-steroidal anti-inflammatory drugs in patients with knee osteoarthritis: a multi-center randomized controlled study.

OBJECTIVES: We previously reported, based on a multicenter randomized-control study, that the efficacy of intra-articular injections of hyaluronic acid (IA-HA) was not inferior to that of oral non-steroidal anti-inflammatory drugs (NSAIDs) in patients with knee osteoarthritis (OA). However, the molecular effects on the pathophysiology of knee OA remain unclear. C-terminal telopeptides of type II collagen (CTX-II) is reported to primarily originate from the interface between articular cartilage and subchondral bone, which is a site of potential remodeling in OA. We performed a predefined sub-analysis of the previous study to compare the changes of urinary CTX-II (uCTX-II) in response to IA-HA to those in response to NSAID for knee OA. DESIGN: A total of 200 knee OA patients were registered from 20 hospitals and randomized to receive IA-HA (2,700 kDa HA, 5 times at 1-week intervals) or NSAID (loxoprofen sodium, 180 mg/day) for 5 weeks. The uCTX-II levels were measured before and after treatment. RESULTS: The uCTX-II levels were significantly increased by IA-HA treatment (337.7 ± 193.8 to 370.7 ± 234.8 ng/µmol Cr) and were significantly reduced by NSAID treatment (423.2 ± 257.6 to 370.3 ± 250.9 ng/µmol Cr). The %changes of uCTX-II induced by IA-HA (11.6 ± 29.5%) and NSAID (-9.0 ± 26.7%) was significantly different (between-group difference: 20.6, 95% confidence intervals: 10.6 to 30.6). CONCLUSIONS: While both IA-HA and NSAID improved symptoms of knee OA, uCTX-II levels were increased by IA-HA and reduced by NSAIDs treatment, suggesting these treatments may improve symptoms of knee OA through different modes of action.

Are structural abnormalities on knee MRI associated with osteophyte development? Data from the Osteoarthritis Initiative.

OBJECTIVE: To assess which structural abnormalities on knee MRI are associated with development of osteophytes in middle-aged subjects without radiographic knee osteoarthritis. DESIGN: We included subjects from the Osteoarthritis Initiative, aged 40-55 years, Kellgren & Lawrence grade 0 in both knees, and knee MRIs from both knees available at baseline, 24, 48 and 72 months. Structural exposures on MRI assessed using MOAKS included cartilage damage, bone marrow lesions, meniscal tear, meniscal extrusion, and Hoffa/effusion synovitis. We assessed whether each structural exposure was associated with the development of osteophytes on MRI in the medial and lateral tibiofemoral, and patellofemoral compartment. We estimated hazard ratios (HR) including 95% confidence intervals (CI) for osteophyte development using a mixed complementary log-log regression model adjusted for age, sex, and body mass index. RESULTS: We included 680 knees from 340 subjects with a mean (SD) age of 50 years (3.0), and 51% men. In the medial tibiofemoral compartment, the absolute risk of osteophyte development in the first 24-month period was 4% in knees without, and 15% in knees with medial meniscal tear. Corresponding adjusted HR was 6.6 (95%CI = 3.4-12.9). In the lateral tibiofemoral compartment, the adjusted HR for developing osteophytes having a lateral meniscal tear was 3.3 (95%CI = 1.3-8.4). In the patellofemoral compartment, patellofemoral cartilage damage was most clearly associated with developing osteophytes (HR = 2.6, 95%CI = 1.8-3.7). CONCLUSIONS: Meniscal tear seem to be the strongest structural risk factor for the development of tibiofemoral osteophytes, and patellofemoral cartilage damage for the development of patellofemoral osteophytes, respectively. Local biomechanical factors are important in early osteophyte development.

Bone marrow lesions, subchondral bone cysts and subchondral bone attrition are associated with histological synovitis in patients with end-stage knee osteoarthritis: a cross-sectional study.

OBJECTIVE: The aim of this study was to examine the osteoarthritis (OA)-related structural changes associated with histological synovitis in end-stage knee OA patients. METHODS: Forty end-stage knee OA patients (female: 88%, mean age: 71.8 y) were enrolled. All participants underwent 3.0-T MRI. The structural changes, such as cartilage morphology, subchondral bone marrow lesion (BML), subchondral bone cyst (SBC), subchondral bone attrition (SBA), osteophytes, meniscal lesion and synovitis, were scored using the whole-organ MRI scoring (WORMS) method. Synovial samples were obtained from five regions of interest (ROIs) of the knee joint during total joint replacement surgery. The associations between the histological synovitis score (HSS) and WORMS or the synovial expression levels of cyclooxygenase (COX)-2, interleukin (IL)-1ß, IL-6 and transforming growth factor (TGF)-ß were examined using Spearman's correlation coefficient. RESULTS: Among the seven OA-related structural changes, the BML, SBC, SBA and synovitis were significantly associated with the HSS (r = 0.33, 0.35, 0.48 and 0.36, respectively), while other morphological changes were not. Although synovial COX-2, IL-1ß or IL-6 expression levels were not associated with the HSS, the synovial TGF-ß expression levels were associated with the HSS. CONCLUSION: The presence of BML, SBC and SBA was associated with histological synovitis in end-stage knee OA patients.

The degeneration and destruction of femoral articular cartilage shows a greater degree of deterioration than that of the tibial and patellar articular cartilage in early stage knee osteoarthritis: a cross-sectional study.

OBJECTIVE: The aim of the present study was to examine whether the degenerative and morphological changes of articular cartilage in early stage knee osteoarthritis (OA) occurred equally for both femoral- and tibial- or patellar- articular cartilage using magnetic resonance imaging (MRI)-based analyses. DESIGN: This cross-sectional study was approved by the ethics committee of our university. Fifty patients with early stage painful knee OA were enrolled. The patients underwent 3.0 T MRI on the affected knee joint. Healthy volunteers who did not show MRI-based OA changes were also recruited as controls (n = 19). The degenerative changes of the articular cartilage were quantified by a T2 mapping analysis, and any structural changes were conducted using Whole Organ Magnetic Resonance Imaging Score (WORMS) technique. RESULTS: All patients showed MRI-detected OA morphological changes. The T2 values of femoral condyle (FC) (P < 0.0001) and groove (P = 0.0001) in patients with early stage knee OA were significantly increased in comparison to those in the control, while no significant differences in the T2 values of patellar and tibial plateau (TP) were observed between the patients and the control. The WORMS cartilage and osteophyte scores of the femoral articular cartilage were significantly higher than those in the patellar- (P = 0.001 and P = 0.007, respectively) and tibial- (P = 0.0001 and P < 0.0001, respectively) articular cartilage in the patients with early stage knee OA. CONCLUSIONS: The degradation and destruction of the femoral articular cartilage demonstrated a greater degree of deterioration than those of the tibial- and patellar- articular cartilage in patients with early stage knee OA.

The factors associated with pain severity in patients with knee osteoarthritis vary according to the radiographic disease severity: a cross-sectional study.

OBJECTIVES: Knee osteoarthritis (OA) pain is suggested to be associated with inflammation and detrimental mechanical loading across the joint. In this cross-sectional study, we simultaneously examined the inflammation and alignment of the lower limb and examined how the pain components varied depending on the disease progression. DESIGN: One-hundred sixty female medial type of early- [n = 74 in Kellgren-Lawrence (K/L) 2] to advanced-stage (n = 96 in K/L >2) knee OA subjects (70.5 years on average) were enrolled. Knee pain was evaluated using a pain visual analog scale (VAS) and the pain-related subcategory of the Japanese Knee Osteoarthritis Measure (JKOM-pain). The serum interleukin (sIL)-6 level reflecting synovitis, and the high sensitivity C-reactive protein (hs-CRP) level were measured to evaluate the severity of inflammation. The anatomical axis angle (AAA) was measured as an alignment index. The ß-coefficient was estimated after adjusting for age and the body mass index (BMI) using a multiple linear regression analysis. RESULTS: Multiple linear regression analyses showed that the sIL-6 levels, but not AAA, associated with the pain VAS [ß = 10.77 (95% confidence interval (CI): 4.14-17.40), P < 0.01] and JKOM-pain scores [ß = 3.19 (95% CI: 1.93-4.44), P < 0.001] in the early stage. Conversely, AAA, but not the sIL-6 levels, was found to be associated with the pain VAS [ß = -1.29 (95% CI: -2.51 to -0.08), P < 0.05] and JKOM-pain scores [ß = -0.49 (95% CI: -0.82 to -0.16), P < 0.01] in the advanced stage. CONCLUSIONS: The presence of a higher level of sIL-6 and the varus alignment of the joint is associated with pain in early- and advanced-stage knee OA patients, respectively.

Antibacterial and Osteoinductive Implant Surface Using Layer-by-Layer Assembly.

Osseointegration of dental, craniofacial, and orthopedic implants is critical for their long-term success. Multifunctional surface treatment of implants was found to significantly improve cell adhesion and induce osteogenic differentiation of dental-derived stem cells in vitro. Moreover, local and sustained release of antibiotics via nanolayers from the surface of implants can present unparalleled therapeutic benefits in implant dentistry. Here, we present a layer-by-layer surface treatment of titanium implants capable of incorporating BMP-2-mimicking short peptides and gentamicin to improve their osseointegration and antibacterial features. Additionally, instead of conventional surface treatments, we employed polydopamine coating before layer-by-layer assembly to initiate the formation of the nanolayers on rough titanium surfaces. Cytocompatibility analysis demonstrated that modifying the titanium implant surface with layer-by-layer assembly did not have adverse effects on cellular viability. The implemented nanoscale coating provided sustained release of osteoinductive peptides with an antibacterial drug. The surface-functionalized implants showed successful osteogenic differentiation of periodontal ligament stem cells and antimicrobial activity in vitro and increased osseointegration in a rodent animal model 4 wk postsurgery as compared with untreated implants. Altogether, our in vitro and in vivo studies suggest that this approach can be extended to other dental and orthopedic implants since this surface functionalization showed improved osseointegration and an enhanced success rate.

Enhancement of osteoclastic bone resorption and suppression of osteoblastic bone formation in response to reduced mechanical stress do not occur in the absence of osteopontin.

Reduced mechanical stress to bone in bedridden patients and astronauts leads to bone loss and increase in fracture risk which is one of the major medical and health issues in modern aging society and space medicine. However, no molecule involved in the mechanisms underlying this phenomenon has been identified to date. Osteopontin (OPN) is one of the major noncollagenous proteins in bone matrix, but its function in mediating physical-force effects on bone in vivo has not been known. To investigate the possible requirement for OPN in the transduction of mechanical signaling in bone metabolism in vivo, we examined the effect of unloading on the bones of OPN(-/-) mice using a tail suspension model. In contrast to the tail suspension-induced bone loss in wild-type mice, OPN(-/-) mice did not lose bone. Elevation of urinary deoxypyridinoline levels due to unloading was observed in wild-type but not in OPN(-/-) mice. Analysis of the mechanisms of OPN deficiency-dependent reduction in bone on the cellular basis resulted in two unexpected findings. First, osteoclasts, which were increased by unloading in wild-type mice, were not increased by tail suspension in OPN(-/-) mice. Second, measures of osteoblastic bone formation, which were decreased in wild-type mice by unloading, were not altered in OPN(-/-) mice. These observations indicate that the presence of OPN is a prerequisite for the activation of osteoclastic bone resorption and for the reduction in osteoblastic bone formation in unloaded mice. Thus, OPN is a molecule required for the bone loss induced by mechanical stress that regulates the functions of osteoblasts and osteoclasts.

Identification of the Novel Tooth-Specific Transcription Factor AmeloD.

Basic-helix-loop-helix (bHLH) transcription factors play an important role in various organs' development; however, a tooth-specific bHLH factor has not been reported. In this study, we identified a novel tooth-specific bHLH transcription factor, which we named AmeloD, by screening a tooth germ complementary DNA (cDNA) library using a yeast 2-hybrid system. AmeloD was mapped onto the mouse chromosome 1q32. Phylogenetic analysis showed that AmeloD belongs to the achaete-scute complex-like ( ASCL) gene family and is a homologue of ASCL5. AmeloD was uniquely expressed in the inner enamel epithelium (IEE), but its expression was suppressed after IEE cell differentiation into ameloblasts. Furthermore, AmeloD expression showed an inverse expression pattern with the epithelial cell-specific cell-cell adhesion molecule E-cadherin in the dental epithelium. Overexpression of AmeloD in dental epithelial cell line CLDE cells resulted in E-cadherin suppression. We found that AmeloD bound to E-box cis-regulatory elements in the proximal promoter region of the E-cadherin gene. These results reveal that AmeloD functions as a suppressor of E-cadherin transcription in IEE cells. Our study demonstrated that AmeloD is a novel tooth-specific bHLH transcription factor that may regulate tooth development through the suppression of E-cadherin in IEE cells.

Single motor unit F-waves in the thenar muscles studied by the multichannel surface EMG.

The thenar motor units (MUs) were studied by the multichannel surface electromyography (EMG) technique. The median nerve was stimulated at the wrist by repetitive submaximal stimulation. Three hundred consecutive evoked responses were recorded from the thenar muscles of 5 healthy volunteers with a 32 channel matrix-type multielectrode. Seven channel F-wave waveforms in a selected electrode array were classified using a template-matching method. The F-wave parameters, amplitudes, latencies and muscle fiber conduction velocities (MFCVs), were calculated to evaluate the properties of single MU F-wave. Most of the F-waves (93.3%) were composed of a single motor unit action potential (MUAP). The numbers of MU classified from single MU F-waves in 5 subjects were 11, 8, 13, 13 and 13, respectively. Many of them (84.5%) were originated from the abductor pollicis brevis (APB), and there were a few MUs originated from the flexor pollicis brevis (FPB). Significant correlations were found between F-wave amplitudes and latencies in 3 subjects.

Patients with severe emphysema have a low risk of radiation pneumonitis following stereotactic body radiotherapy.

OBJECTIVE: To evaluate the risk of radiation pneumonitis (RP) after stereotactic radiotherapy (SBRT) for patients presenting with severe pulmonary emphysema. METHODS: This study included 40 patients with Stage I non-small-cell lung cancer who underwent SBRT, 75 Gy given in 30 fractions, at the Tokyo Medical University, Tokyo, Japan, between February 2010 and February 2013. The median age of the patients was 79 years (range, 49-90 years), and the male:female ratio was 24:16. There were 20 T1 and 20 T2 tumours. 17 patients had emphysema, 6 had slight interstitial changes on CT images and the remaining 17 had no underlying lung disease. The level of emphysema was classified into three groups according to the modified Goddard's criteria (severe: three patients, moderate: eight patients and mild: six patients). Changes in the irradiated lung following SBRT were evaluated by CT. RESULTS: On CT images, RP was detected in 34 (85%) patients, and not in 6 (15%) patients, during a median observation period of 313 days. Of the six patients, three had severe emphysema and three had no underlying lung disease. Patients with severe emphysema had lower risk of RP than those with moderate emphysema (p = 0.01), mild emphysema (p = 0.04) and no underlying lung disease (p = 0.01). CONCLUSION: Patients with severe emphysema had a low risk of RP following SBRT. ADVANCES IN KNOWLEDGE: Little is known about the association between RP and pulmonary emphysema. Patients with severe emphysema had lower risk of RP than those with no underlying lung disease.

Relation between coronary stenosis and myocardial lesions determined by a semiquantitative approach to myocardial fibrosis and hypertrophy due to ischemia.

To clarify the cause of myocardial hypertrophy in ischemic heart disease, the relation between the extent of fibrosis and myocyte diameter was examined in patients with cardiac hypertrophy of unknown etiology except for coronary sclerosis. In 79 unselected cases, the heart weight tended to be higher in patients with severe coronary stenosis and fibrosis. In a morphometric study of 33 additional hearts of patients without a clinical history of hypertension, valvular disease or diabetes mellitus, 15 of which had anterior infarction, a positive correlation (r = 0.63) was observed between myocyte diameter and the percent area of fibrosis in the anterior wall of the left ventricle. In the heart of patients with severe coronary stenosis (more than 75% luminal narrowing), the regression coefficient was 0.83. The hearts of 8 patients with nontransmural infarction showed a strong correlation between myocyte diameter and fibrosis, compared with the hearts of 7 patients with transmural infarction. In most cases, the main mechanism of hypertrophy in ischemic heart disease was considered to be compensatory hypertrophy for existence of myocardial fibrosis.

Serum levels of five tumor markers for lung cancer in patients with chronic renal failure.

The soluble cytokeratin 19 fragment (CYFRA) and pro-gastrin-releasing peptide (ProGRP) are recently described promising tumor markers for lung cancers. To assess their alterations in renal dysfunction, serum levels of CYFRA and ProGRP were determined together with conventional markers including carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC), neuron specific enolase (NSE) in patients with renal failure of varying degrees. The mean concentration of all these markers but NSE significantly increased with the severity of renal failure. After hemodialysis (HD), the mean concentration of ProGRP, the molecular weight of which is comparable to that of 2-microglobulin, was significantly decreased. High false positive rates for tumor markers of lung cancer in patients with renal failure should be considered to avoid unnecessary diagnostic procedures.

Monitoring of electrocardiograms in bed without utilizing body surface electrodes.

We investigated a system by which an electrocardiogram can be obtained without the individual's awareness. The practice of this concept involves placing the electrodes in a bed set composed of electrically conductive textiles. Electrocardiograms were successfully obtained during sleep. However, during the periods of subject's movement in bed, the waveform became unrecognizable.

Chronodiagnostic acquisition of recovery speed of heart rate under bathing stress.

Cycling on an ergometer is one effective means of measuring cardiovascular function while applying stress on the heart. Bathing in a hot water bath applies a low stress to the heart. The electrocardiograms of a healthy adult male (aged 35 at the start of study) were recorded while taking a hot water bath with no electrode attached to the body over a period of 2 years (376 days over a 762 day period). The recovery speed following the initial overshoot of the heart rate (HR) was observed. The bathtub was designed for the automatic acquisition of ECG data. Immediately after immersion in the tub, the HR reached a peak within 20 s and then exponentially decreased toward the lowest rate in the 120 s of bathing. The initial recovery speed of the HR from the stress of bathing had a specific rhythm in the subject. Spectrum analysis of the speed series indicated that slow recovery speed appeared in cyclic periods of approximately 1 year, 42 days and 17 days. The methodology may provide a chronodiagnostic index of an exercise test for cardiovascular function.

Cardiopulmonary monitoring by textile electrodes without subject-awareness of being monitored.

An automated system is developed to monitor cardiopulmonary functions during sleep using electrically conductive textiles. The system obviates the need to attach transducers or electrodes to the body surface, and the subject can follow his or her normal daily routine, wearing regular pajamas to bed. Part of the bed sheet consists of electrically conductive textiles under the positions of the head, torso and legs. Respiratory activity and electrocardiograms of diagnostic quality are observed by means of the electrodes while the subject is sleeping. Respiration is sensed by means of electrical capacitance in/around the thorax. Data acquisition and storage are fully automated; thus, the subject's awareness of being monitored is greatly reduced. This system could detect disorders of cardiopulmonary functions at an early stage, if used daily in the home with the concept of chronodiagnosis.

Medical informatics education by medical professors within their discipline.

A system for medical informatics education for medical students has been developed in the medical school. This paper describes the concept underlying the development of this system and its progressive outcomes over 8 years. In order to stimulate students to acquire computer-related knowledge and skills, this subject has been integrated into the course works of various medical subjects such as physiology. In addition, acquired knowledge and skills are evaluated within each subject by the production of reports for example, using computers. This provides a concrete example for students of the relevance of the information sciences to the solving of medical problems. A well equipped computer facility for the study of medicine also plays a significant role in inspiring student incentive. A computer room equipped with Macintosh computers was opened adjacent to the main medical library and is used in the same manner as the library, with books replaced by computers. In addition, all new students acquire their own Macintosh PowerBook. These various initiations have facilitated concept that the computer may be applied to medical problem solving at any time or place and may become as commonplace as a pen in daily medical practice.

Electrode catheterization for recording electrical activity of fasciculus atrioventricularis (bundle of His).

A method for locating an electrode catheter for observing electrical activities of the fasciculus atrioventricularis (bundle of His) without fluoroscopic guidance is described. A catheter which contains 4 electrodes and 2 internal capillary tubes was developed; the catheter has 2 distal orifices 18 mm apart. The position of the catheter tip is determined by observing blood pressure recordings from the two internal capillary tubes; when the tip is positioned properly, the proximal orifice will monitor atrial pressure and the distal orifice will detect ventricular pressure. This catheter was utilized on 14 mongrel dogs (19 to 27 kg). Recordings of atrioventricular bundle activities were successfully obtained from 12 of 14 dogs without any fluoroscopic guidances.

[Determination of PIVKA-II levels in patients with small hepatocellular carcinoma--comparison of new sensitive methods].

Current EIA for PIVKA-II is not sensitive enough to detect small Hepatocellular Carcinoma (HCC). In an attempt to increase the diagnostic threshold, the current EIA was modified in two different ways: 1) immunoreaction of PIVKA-II in the sample with its monoclonal antibody was carried out overnight at 5 degrees C instead of for two hours at room temperature (the overnight method), 2) Avidin-Biotin technique was used for the second reaction(the ABC method);and their diagnostic values were determined as compared with the current EIA(2hr method) in a total of 138 patients including 36 patients with HCC. In 27 patients with HCC(< 3 cm in diameter), the rates of abnormal values obtained by the 2hr-, the overnight- and the ABC method were 14.8, 25.9 and 29.6% respectively. False positive rates of these three methods in 69 patients with liver cirrhosis were 1.4, 8.6 and 22.9% respectively. Thus, these two modifications improved the sensitivity of the current EIA and the overnight method appears to be superior to the ABC method in terms of specificity and simplicity. This conclusion was confirmed by ROC analysis.

[A preliminary study on transurethral electrovaporization of the prostate (TVP) using VaporTrode].

BACKGROUND: Surgical therapy for Benign Prostatic Hypertrophy (B.P.H.) has mainly depended upon Transurethral Resection of the Prostate (TUR-P) using a cutting loop electrode. Recently, a new technique TVP was reported using the VaporTrode apparatus. We assessed the safety and efficacy of the VaporTrode in a preliminary study. METHODS: Histological changes of the muscle and liver of pigs were examined after vaporization using the VaporTrode and a cutting loop electrode. First, histological changes were investigated following vaporization after one stroke at a slow hand speed. Next, histological changes were assessed following vaporization at fixed stroke speed in an experimental model. RESULTS: At an electrical output of less than 275 W, the depth of the vaporized layer increased as the stroke speed became slower (4.0 cm/s-2.5 cm/s). When the electrical output was 300 W, the depth of vaporized layer increased even at a faster stroke speed (2.5 cm/s-3.0 cm/s.) The depth of the desiccated layer increased as the stroke speed became slower at any electrical output. However, when the stroke speed was 4.0 cm/s, the depth of this layer was less than 2.0 mm. With the cutting loop electrode, the depth of the desiccated layer increased at a higher electrical power, but the change was very small. CONCLUSION: To achieve deep enough vaporized and desiccated layers safely, the VaporTrode should be used at a stroke speed slower than 3.0 cm/s and a high electrical power of about 275 W.

[Bone metabolism and angiogenesis].

Bone metabolism is regulated not only by the nutrition supplied by vessel but also by the signals from the cells in vascular tissues. Identification of such signaling molecules has been the major issue in the field of research on the relationship between bone and vasculatures. This review touches on the recent findings on the expression and functions of such signaling molecules including VEGF, MMP and non-collagenous bone matrix proteins.