Defining the osteoarthritis patient: back to the future.

The history of osteoarthritis (OA) is important because it can help broaden our perspective on past and present controversies. The naming of OA, beginning with Heberden's nodes, is itself a fascinating story. According to Albert Hoffa, R. Llewellyn Jones and Archibald Edward Garrod, the name OA was introduced in the mid-nineteenth century by surgeon Richard von Volkmann who distinguished it from rheumatoid arthritis and gout. Others preferred the terms 'chronical rheumatism', 'senile arthritis', 'hypertrophic arthritis' or 'arthritis deformans'. A similar narrative applies to the concept of OA affecting the whole joint vs the 'wear-and-tear' hypothesis, inflammation and the role of the central nervous system (CNS). In the late nineteenth and early twentieth centuries, the Garrods (father and son) and Hermann Senator argued that OA was a whole joint disease, and that inflammation played a major role in its progression. Garrod Jnr and John Spender also linked OA to a neurogenic lesion 'outside the joint'. The remaining twentieth century was no less dynamic, with major advances in basic science, diagnostics, treatments, surgical interventions and technologies. Today, OA is characterized as a multi-disease with inflammation, immune and CNS dysfunction playing central roles in whole joint damage, injury progression, pain and disability. In the current 'omics' era (genomics, proteomics and metabolomics), we owe a great debt to past physicians and surgeons who dared to think 'outside-the-box' to explain and treat OA. Over 130 years later, despite these developments, we still don't fully understand the underlying complexities of OA, and we still don't have a cure.

Differential expression of calcium channels in sympathetic and parasympathetic preganglionic inputs to neurons in paracervical ganglia of guinea-pigs.

Neurons in pelvic ganglia receive nicotinic excitatory post-synaptic potentials (EPSPs) from sacral preganglionic neurons via the pelvic nerve, lumbar preganglionic neurons via the hypogastric nerve or both. We tested the effect of a range of calcium channel antagonists on EPSPs evoked in paracervical ganglia of female guinea-pigs after pelvic or hypogastric nerve stimulation. omega-Conotoxin GVIA (CTX GVIA, 100 nM) or the novel N-type calcium channel antagonist, CTX CVID (100 nM) reduced the amplitude of EPSPs evoked after pelvic nerve stimulation by 50-75% but had no effect on EPSPs evoked by hypogastric nerve stimulation. Combined addition of CTX GVIA and CTX CVID was no more effective than either antagonist alone. EPSPs evoked by stimulating either nerve trunk were not inhibited by the P/Q calcium channel antagonist, omega-agatoxin IVA (100 nM), nor the L-type calcium channel antagonist, nifedipine (30 microM). SNX 482 (300 nM), an antagonist at some R-type calcium channels, inhibited EPSPs after hypogastric nerve stimulation by 20% but had little effect on EPSPs after pelvic nerve stimulation. Amiloride (100 microM) inhibited EPSPs after stimulation of either trunk by 40%, while nickel (100 microM) was ineffective. CTX GVIA or CTX CVID (100 nM) also slowed the rate of action potential repolarization and reduced afterhyperpolarization amplitude in paracervical neurons. Thus, release of transmitter from the terminals of sacral preganglionic neurons is largely dependent on calcium influx through N-type calcium channels, although an unknown calcium channel which is resistant to selective antagonists also contributes to release. Release of transmitter from lumbar preganglionic neurons does not require calcium entry through either conventional N-type calcium channels or the variant CTX CVID-sensitive N-type calcium channel and seems to be mediated largely by a novel calcium channel.

CD4(+) and CD8(+) cells are key participants in the development of recurrent herpetic stromal keratitis in mice.

Ocular herpes simplex virus (HSV) infection results in an immune-mediated inflammation of the corneal stroma known as herpetic stromal keratitis (HSK). Recurrent HSK is a common cause of virus-induced corneal blindness in humans. The role of CD4(+) and CD8(+) T cell subsets in the disease pathogenesis is ill defined and varies with the virus strain and host genetic background. To examine the contribution of T cell subsets to corneal disease, we studied the development of recurrent HSK in CD4 or CD8 gene knockout (KO) mice ocularly infected with HSV-1 McKrae strain. Following UV-B induced viral reactivation, corneal opacity in latently infected BALB/c (HSV sensitive) CD4 and CD8 KO mice was reduced compared to infected BALB/c mice with normal genotype. In contrast, opacity in C57BL/6 (HSV resistant) CD4 and CD8 KO latent mice did not differ from genetically normal latent mice. Virus-induced corneal opacity was not demonstrable in C57BL/6 CD4/CD8 double KO mice. Increased viral shedding, measured by reactivation rate, days shedding or viral titers, occurred in CD4 KO mice of both strains. Our findings indicate that both CD4(+) and CD8(+) cells play a role in the immunopathogenesis of recurrent HSK, and their role is dependent upon the host genetic profile.

Expression of immunoreactivity to neurokinin-1 receptor by subsets of cranial parasympathetic neurons: correlation with neuropeptides, nitric oxide synthase, and pathways.

We examined the patterns of coexistence of immunoreactivity to the neurokinin-1 (NK(1)) tachykinin receptor, nitric oxide synthase, and neuropeptides in the sphenopalatine and otic ganglia of guinea pigs using a combination of multiple-labeling immunohistochemistry and pathway tracing in vitro. Most neurons had immunoreactivity to vasoactive intestinal peptide (85-96%) and neuropeptide Y (60%). Subpopulations of vasoactive intestinal peptide-immunoreactive neurons also had immunoreactivity to nitric oxide synthase (37-48%) or enkephalin (25-35%), but these formed mutually exclusive populations. Almost all neurons expressing NK(1) receptor immunoreactivity contained immunoreactivity to enkephalin, vasoactive intestinal peptide, and neuropeptide Y, but not nitric oxide synthase. Using a combination of retrograde axonal tracing and axonal crushing, we found that most neurons with immunoreactivity to nitric oxide synthase projected along the nasopalatine and ethmoidal nerves to the nasal mucosa. In contrast, most neurons with immunoreactivity to enkephalin followed the zygomatic nerve to the facial skin and lacrimal gland. Based on their peptide content, we conclude that the neurons with immunoreactivity to enkephalin and NK(1) receptor projected selectively to the skin. In both the sphenopalatine and the otic ganglia, about half of the neurons with NK(1) receptor immunoreactivity were surrounded by varicose nerve fibers with substance P immunoreactivity. Many of these fibers are likely to have originated in the trigeminal ganglion. Taken together, these observations establish a strong anatomical basis for a range of interactions between trigeminal and cranial parasympathetic pathways that may underlie pathophysiological conditions such as trigeminal neuralgia.

Differential inhibition by botulinum neurotoxin A of cotransmitters released from autonomic vasodilator neurons.

The role of the soluble NSF attachment protein receptor (SNARE) protein complex in release of multiple cotransmitters from autonomic vasodilator neurons was examined in isolated segments of guinea pig uterine arteries treated with botulinum neurotoxin A (BoNTA; 50 nM). Western blotting of protein extracts from uterine arteries demonstrated partial cleavage of synaptosomal-associated protein of 25 kDa (SNAP-25) to a NH2-terminal fragment of approximately 24 kDa by BoNTA. BoNTA reduced the amplitude (by 70-80%) of isometric contractions of arteries in response to repeated electrical stimulation of sympathetic axons at 1 or 10 Hz. The amplitude of neurogenic relaxations mediated by neuronal nitric oxide (NO) was not affected by BoNTA, whereas the duration of peptide-mediated neurogenic relaxations to stimulation at 10 Hz was reduced (67% reduction in integrated responses). In contrast, presynaptic cholinergic inhibition of neurogenic relaxations was abolished by BoNTA. These results demonstrate that the SNARE complex has differential involvement in release of cotransmitters from the same autonomic neurons: NO release is not dependent on synaptic vesicle exocytosis, acetylcholine release from small vesicles is highly dependent on the SNARE complex, and neuropeptide release from large vesicles involves SNARE proteins that may interact differently with regulatory factors such as calcium.

Neuropeptide Y immunoreactivity in cutaneous sympathetic and sensory neurons during development of the guinea pig.

Different levels of the cutaneous vasculature are innervated selectively by subpopulations of sympathetic neurons distinguished by the presence or absence of immunoreactivity (-IR) for neuropeptide Y (NPY). This study used multiple-labelling immunohistochemistry to examine the appearance of NPY-IR in neurons innervating cutaneous vessels in the ear pinna of embryonic, fetal, and neonatal guinea pigs. NPY-immunoreactive axons were detected in the ear bud at embryonic day 25. However, these axons lacked IR for tyrosine hydroxylase (TH) and often ran in bundles with substance P (SP)-immunoreactive axons close to the epidermis. Many neuronal somata in the cervical dorsal root ganglia (DRG) at late embryonic stages contained NPY-IR with or without SP-IR, but no NPY-IR was detected in DRG or subepidermal axons by late fetal stages. IR for calcitonin gene-related peptide increased in DRG neurons from midfetal to late fetal stages, after the decrease in NPY-IR. Populations of TH-IR neurons with or without NPY-IR were present in the superior cervical ganglion (SCG) from midembryonic stages. TH-immunoreactive axons were not detected in the ear pinna until midfetal stages, when axons with TH-IR and NPY-IR innervated proximal arteries and TH-immunoreactive axons without NPY-IR innervated distal vessels. Vasoactive intestinal peptide-IR was detected transiently in most fetal SCG neurons with TH-IR and NPY-IR but was not detected in cutaneous axons. These results demonstrate that selective expression of NPY by subpopulations of sympathetic neurons occurs prior to innervation of their targets. This suggests that target contact is not required to establish appropriate patterns of expression of peptide neurotransmitters by cutaneous sympathetic neurons.

Transdermal dopaminergic D(2) receptor agonist therapy in Parkinson's disease with N-0923 TDS: a double-blind, placebo-controlled study.

N-0923 is a non-ergot, dopaminergic D(2) agonist designed to be transdermally available. It has anti-parkinsonian effects when infused intravenously. An adhesive matrix patch was developed to deliver N-0923 transdermally (N-0923 TDS). In this phase II trial, we evaluated the effectiveness of various doses of N-0923 TDS at replacing levodopa. Eighty-five Parkinson's disease (PD) patients were randomized to placebo or one of four doses of N-0923 TDS for 21 days. Change in daily levodopa dose was the primary efficacy measure. Significantly greater reductions in levodopa dose were achieved as compared to placebo for the two highest doses of N-0923 TDS. Patients treated with 33.5 mg and 67 mg N-0923 TDS decreased levodopa use by 26% and 28%, vs. 7% for placebo. N-0923 TDS was safe and well tolerated.

Neurochemical differentiation of functionally distinct populations of autonomic neurons.

The coeliac ganglion of guinea pigs displays a unique topographical arrangement of neurochemically and functionally distinct populations of sympathetic neurons. The authors used multiple-labeling immunohistochemistry to investigate the neurochemical differentiation of these neurons during embryonic and fetal development. Sympathoadrenal precursors, located on either side of the abdominal aorta, were intensely immunoreactive for tyrosine hydroxylase (TH-IR), neurofilament, and the human natural killer 1 antibody at midembryonic stages (Carnegie stages 16-19). During late embryonic stages (stages 20-23), a single bilobed ganglion had formed. At this time, neuropeptide Y immunoreactivity (NPY-IR) was widely expressed in sympathetic neurons (with moderate TH-IR) and chromaffin cells (with intense TH-IR). The onset of somatostatin (Som-IR) expression followed that of NPY-IR and was restricted to sympathetic neurons. However, at late embryonic stages, most TH-IR neurons with Som-IR also expressed NPY-IR (a combination of peptides not found in the mature coeliac ganglion). Between late embryonic stages and the end of the early fetal period, there was a significant increase in the proportion of neurons in lateral regions that had both NPY-IR and TH-IR. At the same time, there was an increase in the proportion of neurons in medial regions that had both Som-IR and TH-IR. Neurons expressing both Som-IR and TH-IR were rarely observed in lateral regions of the coeliac ganglion. Thus, a clear topography within the coeliac ganglion is established during late embryonic and early fetal stages of development and reflects that found in the mature animal by the end of the early fetal period.

Different levels of immunoreactivity for synaptosomal-associated protein of 25 kDa in vasoconstrictor and vasodilator axons of guinea-pigs.

Immunoreactivity (IR) for synaptosomal-associated protein of 25 kDa (SNAP-25) was examined in axons of autonomic vasoconstrictor and vasodilator neurons innervating the lingual and uterine arteries of guinea-pigs. Polyacrylamide gel electrophoresis and immunoblotting of protein extracts demonstrated a SNAP-25-IR band at 25 kDa in both arteries. Quantitative confocal microscopy demonstrated significantly higher levels of SNAP-25-IR in varicosities with IR for vasoactive intestinal peptide (VIP) than in adjacent axons with IR for tyrosine hydroxylase (TH). Levels of SNAP-25-IR in TH-IR axons, relative to adjacent VIP-IR axons, were significantly higher in the lingual artery than the uterine artery. These differences in IR for SNAP-25, a protein considered essential for calcium-dependent exocytosis of neurotransmitters, raise the possibility that mechanisms of transmitter release may vary between different classes of autonomic neurons.

Pathway specific expression of neuropeptides and autonomic control of the vasculature.

In this article, we review the immunohistochemical evidence for the pathway-specific expression of co-existing neuropeptides in autonomic vasomotor neurons, and examine the functional significance of these expression patterns for the autonomic regulation of the vasculature. Most final motor neurons in autonomic vasomotor pathways contain neuropeptides in addition to non-peptide co-transmitters such as catecholamines, acetylcholine and nitric oxide. Neuropeptides also occur in preganglionic vasomotor neurons. The precise combinations of neuropeptides expressed by neurons in vasomotor pathways vary with species, vascular bed, and the level within the vascular bed. This applies to both vasoconstrictor and vasodilator pathways. There is a similar degree of variation in the expression of neuropeptide receptors in the vasculature. Consequently, the contributions of different peptides to autonomic vasomotor control are closely matched to the functional requirements of specific vascular beds. This arrangement allows for a high degree of precision in vascular control in normal conditions and has the potential for considerable plasticity under pathophysiological conditions.

Ventricular dilation after anterior ST-elevation myocardial infarction in the thrombolytic era.

BACKGROUND: The aim of this work was to study changes in end-diastolic volume 6 months after Q-wave and non-Q-wave anterior ST-elevation myocardial infarction by echocardiography. Ventricular dilation after anterior Q-wave myocardial infarction is well-recognized. However, there is a dearth of information about the natural history of ventricular volumes after non-Q-wave myocardial infarction. METHODS: One hundred ninety patients receiving thrombolytic therapy after anterior ST-elevation myocardial infarction were studied. All patients had 2D echocardiograms and 12-lead electrocardiograms recorded within 24 hours of symptoms and at 3, 42, and 180 days later. In addition, a further electrocardiogram was recorded on day 7 to assess patients for the presence of Q waves. Peak creatine kinase over the first 3 days of admission was recorded. End-diastolic volume index was the study end point. RESULTS: Peak creatine kinase was strongly associated with ventricular dilation in both groups (P <.001). Mean end-diastolic volume in the Q-wave group increased significantly from day 1 to 6 months (P <.05) but did not alter after non-Q-wave infarction. However, when patients were selected on predefined criteria for significant change in ventricular dilation (>10 mL/m(2)), then 35% of those with and 15% of those without Q waves fell into this category. Within this group, the increase in end-diastolic volume followed a similar pattern, with the maximum percentage increase occurring between day 1 and 6 weeks. CONCLUSIONS: In the postthrombolytic group of anterior ST-elevation myocardial infarction, a minority of patients without Q-wave development also undergo significant ventricular dilation.

Nalmefene to prevent epidural narcotic side effects in pediatric patients: a pharmacokinetic and safety study.

STUDY OBJECTIVE: To determine the pharmacokinetics and preliminary efficacy of nalmefene in children in preventing epidural-induced narcotic side effects. DESIGN: Double-blind, placebo-controlled study. SETTING: University-affiliated children's hospital. PATIENTS: Thirty-four children (aged 2-12 yrs) undergoing cardiothoracic surgery with epidural anesthesia. INTERVENTIONS: Patients were randomized to receive intravenous bolus nalmefene 1 microg/kg or placebo. MEASUREMENTS AND MAIN RESULTS: Six blood samples (one before nalmefene administration and five from 13 randomly designated time points) from each patient were assayed to determine plasma nalmefene concentrations. Patients were assessed for pain, nausea, vomiting, and urinary retention for 24 hours after administration. Concentration-time data were analyzed by a limited sampling strategy with adult pharmacokinetic parameters used as Bayesian priors. A two-compartment, first-order model was fitted to the data using ADAPT II. Pharmacokinetic parameter estimates in these patients were similar to values reported in adults. The initial disposition half-life (t(1/2alpha)) was 0.36+/-0.11 hour, the terminal elimination half-life (t(1/2beta)) 8.7+/-2.3 hours, clearance 0.729+/-0.172 L/kg/hr, and steady-state volume of distribution 7.21+/-2.49 L/kg. Ability to prevent epidural narcotic-induced side effects could not be documented at the 1-microg/kg dose. No statistically significant differences were noted between study and placebo groups with regard to pain, nausea, vomiting, or urinary retention. CONCLUSION: Nalmefene has similar pharmacokinetics in children as in adults. It was administered safely to these patients and did not produce unmanageable pain.

Neuronal morphology and the synaptic organisation of sympathetic ganglia.

In this article, we provide a short review of the structure and synaptic organisation of the final motor neurons in the sympathetic ganglia of mammals. Combinations of pathway tracing, multiple-labelling immunofluorescence and intracellular dye injection have shown that neurons in different functional pathways differ not only in their patterns of neuropeptide expression, but also in the size of their cell bodies and dendritic fields. Thus, vasoconstrictor neurons consistently are smaller than any other major functional class of neurons. Serial section ultrastructural analysis of dye filled neurons, together with electron microscopic and confocal microscopic analysis of immunolabelled synaptic inputs to sympathetic final motor neurons indicate that synapses are rare and randomly distributed over the surface of the neurons. The total number of synapses is simply proportional to the total surface area of the neurons. Many terminal boutons of peptide-containing preganglionic neurons do not make conventional synapses with target neurons. Furthermore, there is a spatial mismatch in the distribution of peptide-containing terminals and neurons expressing receptors for the corresponding peptides. Together, these results suggest that there are likely to be significant differences in the ways that the final sympathetic motor neurons in distinct functional pathways integrate their synaptic inputs. In at least some pathways, heterosynaptic actions of neuropeptides probably contribute to subtle modulation of ganglionic transmission.

Analgesia for pediatric thoracostomy tube removal.

Eutectic mixture of local anesthetics (EMLA; Astra Pharmaceuticals, Wayne, PA) has been shown to reduce the pain of blood draws in children. We investigated the use of EMLA versus IV morphine for providing analgesia during chest tube removal (CTR) in children. One hundred twenty pediatric cardiothoracic surgery patients were enrolled. Patients were randomly assigned to receive either morphine (0.1 mg/kg up to 10 mg IV 30 min before CTR) or EMLA cream (5 g per chest tube cutaneously 3 h before CTR). A single, trained observer rated the patient's pain before, during, and after CTR using a 10-cm visual analog scale. The sites were evaluated for adverse effect. Methylhemoglobin levels were monitored in infants. Before CTR, the pain scores of the children who received morphine were rated lower than those who received EMLA (P < 0.01). During CTR, there was no difference in the pain score between the morphine or EMLA group. The change from baseline pain score in the morphine group was significantly larger than in the EMLA group (P < 0.01). We conclude that EMLA is safe and useful for blunting the pain of CTR.

Subpopulations of sympathetic neurons project to specific vascular targets in the pinna of the rabbit ear.

We have characterised sympathetic neurons projecting to a range of cutaneous and striated muscle vascular targets in the pinna of the rabbit ear by examining neurotransmitter-related enzymes and peptides in perivascular axons and in somata identified by retrograde axonal tracing. Fast Blue was injected into one of seven sites in each pinna (n = 21 pinnae). The soma cross-sectional area and immunoreactivity (IR) for tyrosine hydroxylase (TH) and neuropeptide Y (NPY) were determined for each of 2,041 retrogradely labelled neurons in the ipsilateral superior cervical ganglion (SCG) or stellate ganglion (StG). Larger neurons in the SCG with TH-IR but not NPY-IR projected predominantly to veins along the medial edge of the pinna. Larger neurons in the StG with TH-IR but not NPY-IR projected predominantly to arteries and veins in the tip and lateral edge of the pinna. Smaller neurons in the SCG with IR to both TH and NPY projected predominantly to arteries in the striated muscles at the base of the ear. The smallest retrogradely labelled neurons in the SCG or StG lacked TH-IR but contained NPY-IR and projected almost exclusively to arterial vessels in the lateral muscle at the base of the ear. Thus, somata of sympathetic neurons projecting to cutaneous versus striated muscle vessels or to different regions of the cutaneous bed could be distinguished by a combination of location, size, and immunohistochemical profile. Consequently, regulation of blood flow within the rabbit ear is likely to involve coordination between neuronal pathways containing neurochemically and morphologically distinct populations of sympathetic neurons.

Cotransmission from sympathetic vasoconstrictor neurons to small cutaneous arteries in vivo.

This study has characterized constrictions of small cutaneous arteries in the guinea pig ear in response to electrical stimulation of the cervical sympathetic nerve (SNS) in vivo. Video microscopy and on-line image analysis were used to examine diameter changes of ear arteries (80-140 micrometers resting diameter) in anesthetized guinea pigs. Trains of 50-300 impulses, but not single pulses or short trains, produced frequency-dependent (2-20 Hz) constrictions. The purinoceptor antagonist suramin (30 microM) greatly reduced constrictions produced by exogenous ATP but did not affect constrictions produced by SNS at 10 Hz or exogenous norepinephrine. The alpha(2)-adrenoceptor antagonist yohimbine (1 microM) enhanced the peak amplitude of sympathetic constrictions at lower stimulation frequencies (1-5 Hz). The amplitude of constrictions to SNS at 10 Hz was reduced, and the latency of constrictions was increased by the alpha(1)-adrenoceptor antagonist prazosin (1 microM). Constrictions to SNS at 10 Hz remaining after prazosin treatment were reduced in amplitude by dihydroergotamine (2 microM) and were attenuated further by the neuropeptide Y Y(1)-receptor antagonist 1229U91 (0.3 microM). Thus norepinephrine and neuropeptide Y act as cotransmitters to mediate sympathetic constriction of small ear arteries at higher stimulation frequencies (10 Hz), but ATP does not seem to contribute directly to these constrictions.

Octreotide is not useful for clomiphene citrate resistance in patients with polycystic ovary syndrome but may reduce the likelihood of ovarian hyperstimulation syndrome.

OBJECTIVE: To determine whether octreotide is effective for ovulation induction in patients with polycystic ovary syndrome (PCOS) and clomiphene citrate resistance or for reduction of the risk of ovarian hyperstimulation syndrome (OHSS) with gonadotropin therapy. DESIGN: Prospective, double-blind, placebo-controlled, crossover trial. SETTING: Private infertility practice. PATIENT(S): Twelve patients with PCOS undergoing therapy for infertility. INTERVENTION(S): The patients were assigned randomly to receive either octreotide or placebo. Those with clomiphene citrate-resistant PCOS received clomiphene citrate, 150 mg. Patients at risk for the development of OHSS received urinary FSH for ovulation induction. MAIN OUTCOME MEASURE(S): Ovulation, pregnancy, the development of OHSS, and levels of fasting insulin, insulin-like growth factor 1, insulin-like growth factor binding proteins 1 and 3, testosterone, androstenedione, DHEAS, E2, LH, and FSH. RESULT(S): Octreotide significantly reduced levels of fasting insulin, insulin-like growth factor 1, and LH in both clomiphene citrate- and urinary FSH-stimulated cycles. Levels of insulin-like growth factor binding protein 3 were increased. Two of six clomiphene citrate-stimulated cycles reached ovulation with the use of either octreotide or placebo. In urinary FSH-stimulated cycles, patients who received octreotide had significantly lower E2 levels at the time of hCG administration and fewer mature follicles. No cases of OHSS occurred in either group. One pregnancy occurred in each group. CONCLUSION(S): Octreotide was no more effective than placebo for clomiphene citrate resistance in patients with PCOS, but it did reduce E2 levels and follicle numbers when combined with urinary FSH. Thus, octreotide may reduce the incidence of OHSS in patients with PCOS.