Calcium intake, bone mineral density, and fragility fractures: evidence from an Italian outpatient population.

This study was performed in 1000 adult Italian subjects to focus on the effects of dietary calcium intake on bone health. A higher fracture risk appears to be associated with a reduced calcium intake. An adequate daily calcium intake is recommended to counteract osteoporotic fractures. PURPOSE: The principal aim of the present study was to focus on the effects of dietary calcium intake on bone mineral density (BMD) and fragility fractures in a representative sample of an adult Italian outpatient population. METHODS: The study group consisted of 1000 consecutive adult Italian subjects [838 women (F) and 162 men (M)] referred to the Bone Metabolic Diseases Unit for the evaluation of their bone metabolism. Daily dietary calcium intake was assessed using a specific food frequency questionnaire (FFQ). Other evaluations included fracture risk, lumbar and femoral BMD, heel ultrasound, fragility fractures, plasma concentration of parathyroid hormone ([PTH]) and 25-hydroxy-vitamin D ([25(OH)D]), and urinary calcium. RESULTS: Only 10.4% of the subjects (n = 104; 71 F and 33 M) had a daily calcium intake adequate for adults (≥1000 mg/day). No correlation was found between calcium intake and BMD. The transition from a daily dietary calcium intake <400 mg/day to a daily dietary calcium intake ≥400 mg/day was associated with a reduced fracture probability ratio at any site [from 42 to 21% (p < 0.05)]. Subjects with one or more vertebral fractures had a significantly lower dietary calcium intake (<400 mg/day) than did subjects without vertebral fractures, and they practiced physical activity only occasionally (p = 0.030). CONCLUSIONS: Daily dietary calcium intake is lower than the recommended daily intake in an Italian ambulatory population, and a higher fracture risk appears to be associated with a reduced calcium intake. An age-adequate daily calcium intake, combined with regular physical activity, is strongly recommended in order to counteract fragility fractures.

Hypersensitivity reactions to metal implants: laboratory options.

BACKGROUND: All implant compounds undergo an electrochemical process when in contact with biological fluids, as well as mechanical corrosion due to abrasive wear, with production of metal debris that may inhibit repair processes. None of the commonly-used methods can diagnose implant allergies when used singly, therefore a panel of tests should be performed on allergic patients as pre-operative screening, or when a postoperative metal sensitisation is suspected. METHODS: We analysed patients with painful prostheses and subjects prone to allergies using the Patch Test in comparison with the Lymphocyte Transformation Test. Cytokine production was evaluated to identify prognostic markers for early diagnosis of aseptic loosening. Metal debris endocytosis and cytoskeletal rearrangement was visualised by confocal microscopy. RESULTS: Our results demonstrate that the Lymphocyte Transformation Test can identify patients who have a predisposition to develop allergic reactions and can confirm the diagnosis of hypersensitivity in patients with painful prostheses. The prevalence of a Th2-cytokine pattern may be used to identify predisposition to the development of allergic diseases, while the selective presence of osteoclastogenic cytokines may be used as predictor of a negative outcome in patients with painful prosthesis. The hypothesis of the prognostic value of these cytokines as early markers of aseptic loosening is attractive, but its confirmation would require extensive testing. CONCLUSIONS: The Lymphocyte Transformation Test is the most suitable method for testing systemic allergies. We suggest that the combined use of the Patch Test and the Lymphocyte Transformation Test, associated with cytokine detection in selected patients, could provide a useful tool for preventive evaluation of immune reactivity in patients undergoing primary joint replacement surgery, and for clinical monitoring of the possible onset of a metal sensitization in patients with implanted devices.

Total knee arthroplasty in patients with hypersensitivity to metals.

PURPOSE: We evaluated the risk of hypersensitivity to metals in a population of consecutive subjects undergoing a total knee arthroplasty (TKA). We also proposed a diagnostic pathway to address any sensitivity to metals. We finally presented the mid-term outcomes of a full non allergenic knee implant. METHODS: We developed a protocol based on the medical history, patch testing, and on specific laboratory assays, in order to assess a sensitization to metals. Twenty-four patients (25 knees) with referred or suspected allergy to metals were found in more than 1,000 treated patients, with a mean age of 72.9 years. We proceeded to a radiologic study, a clinical evaluation by the visual analogic scale (VAS), and Knee Society rating system (KSS). In all cases a full anallergic cemented implant with an oxidized zirconium femoral component and an all-polyethylene tibial baseplate was chosen. RESULTS: Four (16.6%) of the 24 patients were considered to be hypersensitive to metals. The mean follow-up was 79.2 months. No patient reported any reaction related to hypersensitivity or complications after TKA. The VAS improved from a mean preoperative value of 7.2 to 1.8 postoperatively; the KSS and the functional score increased from 38 to 91 points and from 39 to 88 points, respectively. CONCLUSIONS: We consider careful research of medical history for metals hypersensitivity crucial, and we perform patch testing and lab assays in case of doubtful sensitization. The choice of a modern hypoallergenic implant may prevent any kind of potential reactions.

Painful prosthesis: approaching the patient with persistent pain following total hip and knee arthroplasty.

BACKGROUND: Symptomatic severe osteoarthritis and hip osteoporotic fractures are the main conditions requiring total hip arthroplasty (THA), whereas total knee arthroplasty (TKA) is mainly performed for pain, disability or deformity due to osteoarthritis. After surgery, some patients suffer from "painful prosthesis", which currently represents a clinical problem. METHODS: A systematic review of scientific literature has been performed. A panel of experts has examined the issue of persistent pain following total hip or knee arthroplasty, in order to characterize etiopathological mechanisms and define how to cope with this condition. RESULTS: Four major categories (non infective, septic, other and idiopathic causes) have been identified as possible origin of persistent pain after total joint arthroplasty (TJA). Time to surgery, pain level and function impairment before surgical intervention, mechanical stress following prosthesis implant, osseointegration deficiency, and post-traumatic or allergic inflammatory response are all factors playing an important role in causing persistent pain after joint arthroplasty. Diagnosis of persistent pain should be made in case of post-operative pain (self-reported as VAS ≥3) persisting for at least 4 months after surgery, or new onset of pain (VAS ≥3) after the first 4 months, lasting ≥2 months. Acute pain reported as VAS score ≥7 in patients who underwent TJA should be always immediately investigated. CONCLUSIONS: The cause of pain needs always to be indentified and removed whenever possible. Implant revision is indicated only when septic or aseptic loosening is diagnosed. Current evidence has shown that peri-and/or post-operative administration of bisphosphonates may have a role in pain management and periprosthetic bone loss prevention.

Cystic bone angiomatosis: a case report treated with aminobisphosphonates and review of the literature.

Cystic angiomatosis (CA) is a rare disease characterized by multifocal hemangiomatous and/or lymphangiomatous lesions of the skeleton with possible visceral organ involvement. The exact pathogenetic mechanism of the disease is still unknown. We describe a patient affected by CA of bone treated with surgical procedures and subsequently with intravenous aminobisphosphonates for 7 years. During the follow-up progression of lesions, the painful symptoms, markers of bone turnover, computed tomographic examination, and bone mineral density were evaluated. Aminobisphosphonate therapy showed an immediate effectiveness in reducing bone pain, with a significant decrease in circulating bone alkaline phosphatase and stable radiological findings during clinical follow-up. In addition, at baseline, high levels of bone biomarkers and cytokines (osteoprotegerin, osteopontin, and interleukin-6) capable of controlling bone metabolism and angiomatosis were identified. Aminobisphosphonate treatment produced a decrease of all these increased markers. Local cell therapy with bone marrow osteoblast precursors did not produce any measurable clinical improvement. Aminobisphosphonate therapy represents an elective treatment for bone angiomatosis syndromes, but further studies are necessary to understand the molecular basis of these disorders and of their pharmacological treatment.

Therapeutic effects of the superoxide dismutase mimetic compound MnIIMe2DO2A on experimental articular pain in rats.

Superoxide anion (O(2) (•-)) is overproduced in joint inflammation, rheumatoid arthritis, and osteoarthritis. Increased O(2) (•-) production leads to tissue damage, articular degeneration, and pain. In these conditions, the physiological defense against O(2) (•-), superoxide dismutases (SOD) are decreased. The Mn(II) complex MnL4 is a potent SOD mimetic, and in this study it was tested in inflammatory and osteoarticular rat pain models. In vivo protocols were approved by the animal Ethical Committee of the University of Florence. Pain was measured by paw pressure and hind limb weight bearing alterations tests. MnL4 (15 mg kg(-1)) acutely administered, significantly reduced pain induced by carrageenan, complete Freund's adjuvant (CFA), and sodium monoiodoacetate (MIA). In CFA and MIA protocols, it ameliorated the alteration of postural equilibrium. When administered by osmotic pump in the MIA osteoarthritis, MnL4 reduced pain, articular derangement, plasma TNF alpha levels, and protein carbonylation. The scaffold ring was ineffective. MnL4 (10(-7) M) prevented the lipid peroxidation of isolated human chondrocytes when O(2) (•-) was produced by RAW 264.7. MnL4 behaves as a potent pain reliever in acute inflammatory and chronic articular pain, being its efficacy related to antioxidant property. Therefore MnL4 appears as a novel protective compound potentially suitable for the treatment of joint diseases.

In vitro differentiation of human mesenchymal stem cells on Ti6Al4V surfaces.

Long-term stability of arthroplasty prosthesis depends on the integration between the bone tissue and the implanted biomaterials, which requires the contribution of osteoblastic precursors and their continuous differentiation into the osteoblastic phenotype. Classically, these interactions are tested in vitro using mesenchymal stem cells (MSCs) isolated and ex vivo expanded from bone marrow aspirates. Human adipose tissue-derived stromal cells (AMSCs) may be a more convenient source of MSCs, according to their abundance and accessibility, but no data are available on their in vitro interactions with hard biomaterials. The aim of this work is to compare the osteogenic potential of human AMSCs and bone marrow-derived MSCs (BMMSCs) and to evaluate their response to Ti6Al4V alloy in terms of adhesion, proliferation and differentiation features, using the human osteosarcoma cell line SaOS-2 for comparison. The overall results showed that AMSCs have the same ability to produce bone matrix as BMMSCs and that Ti6Al4V surfaces exhibit an osteoinductive action on AMSCs, promoting their differentiation into functional osteoblasts and increasing bone formation. In conclusion, adipose tissue is a promising autologous source of osteoblastic cells with important clinical implications for bone tissue engineering.

Methodological models for in vitro amplification and maintenance of human articular chondrocytes from elderly patients.

Articular cartilage defects, an exceedingly common problem closely correlated with advancing age, is characterized by lack of spontaneous resolution because of the limited regenerative capacity of adult articular chondrocytes. Medical and surgical therapies yield unsatisfactory short-lasting results. Recently, cultured autologous chondrocytes have been proposed as a source to promote repair of deep cartilage defects. Despite encouraging preliminary results, this approach is not yet routinely applicable in clinical practice, but for young patients. One critical points is the isolation and ex vivo expansion of large enough number of differentiated articular chondrocytes. In general, human articular chondrocytes grown in monolayer cultures tend to undergo dedifferentiation. This reversible process produces morphological changes by which cells acquire fibroblast-like features, loosing typical functional characteristics, such as the ability to synthesize type II collagen. The aim of this study was to isolate human articular chondrocytes from elderly patients and to carefully characterize their morphological, proliferative, and differentiative features. Cells were morphologically analyzed by optic and transmission electron microscopy (TEM). Production of periodic acid-schiff (PAS)-positive cellular products and of type II collagen mRNA was monitored at different cellular passages. Typical chondrocytic characteristics were also studied in a suspension culture system with cells encapsulated in alginate-polylysine-alginate (APA) membranes. Results showed that human articular chondrocytes can be expanded in monolayers for several passages, and then microencapsulated, retaining their morphological and functional characteristics. The results obtained could contribute to optimize expansion and redifferentiation sequences for applying cartilage tissue engineering in the elderly patients.

Phytoestrogens: food or drug?

Within the past several years, the relation between diet and health has been accepted by the mainstream nutrition community and in this connection interest in the physiological role of bioactive compounds present in plants has dramatically increased over the last decade.The phytoestrogens are bioactive molecules present as nutritional constituents of widely consumed vegetables. Their name derives from the fact that they are able to bind to estrogen receptors and to induce an estrogenic/antiestrogenic response in target tissues. Natural estrogens are involved in a multiplicity of programmed events in target tissues as uterus, breast, pituitary gland and hormone responsive tumors. Phytoestrogens are present in many human foodstuffs including fruits (plum, pear, apple grape berries, …), vegetables (beans, sprouts, cabbage, spinach, soybeans, grains, hops, garlic, onion,…), wine, tea, and they have been identified in a number of botanical dietary supplements. They include a wide variety of structurally different compounds such as isoflavones, mainly found in soy, lignans found in grains, stilbenes found in the skin of grapes. Other less investigated compounds include flavones, flavans, isoflavanes and coumestans. The estrogenic or antiestrogenic activity of any chemicals depends on the ability of the compound to interact with the ERs (ERα , ERß ).This article reported the knowledge about the activity of phytoestrogens from a pharmacological point of view for their estrogenicity or antiestrogenicity.

Clodronate acts on human osteoclastic cell proliferation, differentiation and function in a bioreversible manner.

Background. Clodronate is used in high bone resorption diseases. Its action was defined as "cytotoxic" based on the induced cellular ATP loss, without any experimental verification of reversibility. In the present report the reversibility of clodronate action was tested on cultured human osteoclastic cell cultures. As "in vitro" bioeffects of clodronate are reversible, this compound should not be defined as "cytotoxic".Introduction. Bisphosphonates are pyrophosphate analogs able to inhibit osteoclast-mediated bone resorption widely used in the treatment of diseases with high bone turnover. Several evidences have shown that bisphosphonates can be divided into two groups with distinct molecular mechanisms of action depending on the nature of the R(2)side chain. The nitrogen-containing bisphosphonates act on osteoclasts by preventing protein prenylation, while non-nitrogen-containing bisphosphonates, like clodronate, are metabolized intracellularly to a ß-γ-methylene analog of ATP that induces inhibition of the ADP/ATP translocase.Materials and Methods. In order to evaluate clodronate effects on osteoclastic cells and the bioreversibility of its action, we have used a human preosteoclastic (FLG 29.1) cell line and primary cultures of human osteoclast-like (HOC) cells. Functional and differentiative modifications were evaluated with immunocytochemical tartrate-resistant acid phosphatase activity (TRAcP) assay and with rapid quantitative detection of the complex "matrix metalloproteinase 9/tissue inhibitor of metalloproteinase" (MMP9/TIMP1) by RT-PCR analysis based on "TaqMan" technology. The apoptosis phenomenon were detected by DNA ladder analysis and quantified by counting apoptotic cells with Transmission Electron Microscopy (TEM) analysis. Adenosine-5'-[ ß - γ -dichloromethylene] triphosphate (AppCCl(2)p) was detected and identified in cell extract by HPLC-ESI-MS-MS Mass Spectrometry. Intracellular ATP modulation in the presence of clodronate was evaluated by luciferin-luciferase assay. The Mann-Whitney "U" test was conducted for statistical analysis.Results. We found that clodronate inhibited both proliferation and differentiative features of cells of the osteoclastic lineage. Furthermore, treatment of both cell types with clodronate caused apoptosis, generation of measurable levels of AppCCl(2)p, and reduction of intracellular ATP levels. Addition of ATP to the culture medium caused an inhibition of the biological actions of clodronate on the human osteoclastic cell lineage.Conclusions. These data indicate that intracellular accumulation of the metabolite AppCCl(2)p is the likely route by which clodronate inhibits osteoclastic function and this effect is reversed by ATP.

Genetics and pharmacogenetics of estrogen response.

Estrogens are a steroid hormone group distributed widely in animals and human beings. Estrogens diffuse across cell phospholipidic membranes and interact with estrogen receptors. Their highest concentration is found in target tissues with reproductive function (breast, ovary, vagina and uterus). High estrogen levels are usually associated with tumor onset and progression, while loss of estrogen or its receptor(s) contributes to development and/or progression of various diseases (osteoporosis, neurodegenerative disease and cardiovascular disease). Despite the numerous efforts to highlight estrogen's mechanism of action, recent discoveries showed an unexpected degree of complexity of estrogenic response.

Melatonin is a safe and effective treatment for chronic pulmonary and extrapulmonary sarcoidosis.

Chronic sarcoidosis (CS) is often unresponsive to usual treatments. Melatonin, an immunoregulatory drug, was employed in CS patients in whom usual treatments were ineffective or induced severe side effects. Melatonin was given for 2 yr (20 mg/day in the first year, 10 mg/day in the second year) to 18 CS patients. Pulmonary function tests, chest X rays, pulmonary computed tomography, Ga(67) scintigraphy and angiotensin-converting enzyme (ACE) were assayed at baseline and in the follow-up. Normalization of ACE, improvement of pulmonary parameters and resolution of skin involvement were found in the patients given melatonin. After 24 months of melatonin therapy, hylar adenopathy completely resolved in eight patients and parenchymal lesions were markedly improved in all patients; in the five patients with reduced diffusion capacity of the lung for carbon monoxide, the values normalized after 6 months of therapy and remained stable until month 24. After 24 months, Ga(67) pulmonary and extra-pulmonary uptake was totally normalized in seven patients and, at month 12 months, ACE was normalized in six patients in which the values were high at the baseline. Skin lesions, present in three patients, completely disappeared at month 24 months. No side effects were experienced and no disease relapse was observed during melatonin treatment. Melatonin may be an effective and safe therapy for CS when other treatments fail or cause side effects.