AB0964 THE ASSOCIATION BETWEEN RESIDUAL SYMPTOMS AND CERVICAL SPINE LESIONS IN RHEUMATOID ARTHRITIS

Background:

Treatment outcomes in rheumatoid arthritis (RA) have been improved with advances in drug therapy. In daily clinical practice, the outcomes are assessed based on the presence of swollen or tender joints, global assessment using a visual analog scale by a patient (GVAS) and a physician (DrVAS), etc., in addition to inflammatory findings. Although inflammation and joint symptoms are suppressed, many patients show no improvement in GVAS scores. The reported residual RA symptoms include morning stiffness (MS), pain (P), and dullness (D), but their causes are not completely known. Latent cervical spine lesions sometimes exist in RA, but their association with residual RA symptoms is unknown.

Objectives:

We examined cervical spine lesions and residual symptoms in patients with RA who achieved the therapeutic goal.

Methods:

Of 124 patients with RA, 82 (25 men and 57 women) who achieved a low disease activity (LDA) state on the Disease Activity Score for 28 joints with erythrocyte sedimentation rate (DAS28-ESR) were included. The mean age was 65.7 (28- 83) years, and the disease stage was Stage I in 28 patients, Stage II in 14, Stage III in 13, and Stage IV in 27. Dysfunction was graded as Class 1 in 63 patients, Class 2 in 18, and Class 3 in one (Steinbrocker classification). Biopharmaceuticals had been administered in 27 patients. As for disease activity, the DAS28-ESR scores indicated complete remission in 54 patients and LDA in 28. The survey form was used to investigate the presence or absence/duration of MS, the presence or absence/severity of P (Pain VAS), and the presence or absence/severity of D (Dullness VAS). On lateral functional radiographs of the cervical spine, patients with spinal lesions were selected and divided into the asymptotic stability (ASS; atlantoaxial dislocation ≥3 mm) + vertical setting (VS; Ranawat value <13 mm) group, the cervical spondylolisthesis group (≥3 mm of slippage on dynamic radiographs), and the spondylolisthesis group (≥3 mm of slippage on dynamic radiographs). They were examined for association with residual symptoms.

Results:

According to cervical spine lesions, the patients who achieved the therapeutic goal were divided into the ASS+VS group comprising 15 patients (18.3%), the spondylolisthesis group comprising 11 (13.4%), and the stenosis group comprising 18 (22.0%). Among them, only the spondylolisthesis group showed significant differences in residual RA symptoms. In the spondylolisthesis group, the disease duration was longer, but there was no difference in age. MS, P, and D were significantly severer. The duration of MS was longer, and both Pain and Dullness VAS scores were higher. The score on each component of the DAS28 showed no difference in inflammatory findings. GVAS and DrVAS scores were higher. No common perceptions of spinal symptoms were shared between any patients with cervical spine lesions and physicians.

Conclusion:

Improved patient-reported outcomes (PROs) are considered to be important to achieve more complete remission. There are various reports on the causes of residual RA symptoms, but many aspects remain unknown. Based on the results of this study, because asymptomatic subaxial subluxation is one of concerns in patients with spondylolisthesis with dynamic instability of the cervical spine, cervical spine diseases should also be considered in patients with severe residual symptoms. Not only radiography but also magnetic resonance imaging needs to be performed.

Acknowledgments:

The authors wish to acknowledge Miss Sasaki

Disclosure of Interests:

None declared

AB0899 TREATMENT STATUS OF PATIENTS WITH GLUCOCORTICOID-INDUCED OSTEOPOROSIS IN THE AKITA ORTHOPEDIC GROUP ON RHEUMATOID ARTHRITIS REGISTRY

Background:

Glucocorticoids (GC) have potent anti-inflammatory and immunosuppressive effects and are used to treat a variety of diseases. However, GC are associated with several adverse effects. Glucocorticoid-induced osteoporosis (GIO), a bone metabolism disorder, accounts for 25% of the side effects associated with GC, and long-term use of these agents leads to fragility fractures in 30 to 50% of patients [1]. GC are frequently used to treat rheumatoid arthritis (RA). No report on the current treatment status for glucocorticoid-induced osteoporosis (GIO) has been published following the publication of the new guidelines for the management and treatment of GIO issued by the Japanese Society for Bone Mineral Research provided in 2014 (Figure 1) [2].

Objectives:

The present study aimed to investigate the current treatment status of GIO patients in the Akita Orthopedic Group on Rheumatoid Arthritis (AORA) registry.

Methods:

This retrospective, multicenter study included 683 patients (138 men, 545 women) with fracture risk factor scores ≥3 based on the new guidelines who were in the AORA registry. We examined patient characteristics, differences in patient backgrounds between treated and non-treated groups.

Results:

There were no significant differences in mean GC dose between men and women (4.0 ± 2.3 mg/day vs 3.6 ± 1.8 mg/day, p = 0.08). The mean disease duration of RA in women was significantly longer than in men (180.2 ± 140.2 months vs 143.8 ± 129.6 months, Untreated GIO patients were significantly more likely to be men and younger. The univariate analysis showed that clinic visits, male sex, younger age, and longer disease duration were significant risk factors for lack of therapeutic intervention for GIO. Multivariate analysis showed that being treated in a clinic, male sex, and younger age were significant risk factors for lack of therapeutic intervention for GIO.

Conclusion:

Our results emphasize the importance of considering the prevention and treatment of GIO in all patients with RA, including younger and male patients, who have lower intervention rates.

References:

[1]Weinstein RS. Clinical practice. Glucocorticoid-induced bone disease. New Engl J Med. 2011; 365(1): 62-70.

[2]Suzuki Y, Nawata H, Soen S, Fujiwara S, Nakayama H, Tanaka I, et al. Guidelines on the management and treatment of glucocorticoid-induced osteoporosis of the Japanese Society for Bone and Mineral Research: 2014 update. J Bone Miner Metab. 2014; 32(4): 337-350.

Disclosure of Interests:

None declared

The effects of teriparatide on acceleration of bone healing following atypical femoral fracture: comparison between daily and weekly administration

We compared the effectiveness of promoting bone healing between two teriparatide preparations for atypical femoral fracture (AFF). A total of 45 AFFs were included in this study, and we compared the duration of bone union. Teriparatide administered by daily injection enhanced bone union more than weekly administration in complete AFFs.

INTRODUCTION

The efficacy of teriparatide for atypical femoral fracture (AFF) has been recently reported. Although two different teriparatide preparations can be used to treat osteoporosis in Japan, daily or weekly injection, all previous reports on the effectiveness of teriparatide for AFF only examined daily injection formulations. Therefore, we compared the promotion of bone healing between the two teriparatide preparations for AFF.

METHODS

A total of 45 consecutive AFFs in 43 Japanese patients were included in this study. They received either a daily 20-μg teriparatide injection (daily group; n = 32) or a once-a-week 56.5-μg teriparatide injection (weekly group; n = 13). We compared the clinical background and duration of bone union between these two groups.

RESULTS

When all patents were included, the fracture healing time was not significantly different between the two groups. Only patients with complete AFFs had significantly fewer daily bisphosphonate or denosumab injections than the weekly group (P < 0.05). The fracture healing time in the daily group (6.1 ± 4.1 months) was significantly shorter than that in the weekly group (10.1 ± 4.2 months) (P < 0.05). Even if the influence of bisphosphonate or denosumab usage was excluded, a similar significant difference was observed in the fracture healing time (P < 0.05). There was no significant difference between the two groups among patients with incomplete AFFs.

CONCLUSIONS

Daily teriparatide injections enhance bone union more than weekly injections in complete AFF patients.

Comparison of spinal alignment, muscular strength, and quality of life between women with postmenopausal osteoporosis and healthy volunteers

This study compared spinal alignment, muscular strength, and quality of life (QOL) between women with postmenopausal osteoporosis and healthy volunteers. The results indicated that lower QOL in osteoporosis patients may be associated with increased thoracic kyphosis, reduced lean muscle mass, and generalized muscle weakness.

INTRODUCTION

Increased spinal kyphosis is common in patients with osteoporosis and negatively impacts quality of life (QOL). Muscular strength is also important for QOL in patients with osteoporosis. However, spinal kyphosis and muscle weakness also occur in healthy individuals with advancing age. The purposes of this study were thus to compare spinal alignment, muscular strength, and QOL between women with postmenopausal osteoporosis and healthy volunteers.

METHODS

Participants comprised 236 female patients with postmenopausal osteoporosis (mean age, 68.7 years) and 93 healthy volunteer women (mean age, 71.0 years). Body mass index (BMI), angles of spinal kyphosis, back extensor strength, grip strength, and QOL were compared between groups.

RESULTS

BMI, back extensor strength, and grip strength were significantly higher in the volunteer group than in the osteoporosis group (p < 0.01). Both thoracic kyphosis and lumbar lordosis were significantly greater in the osteoporosis group than in the volunteer group (p < 0.01). With regard to QOL, the 36-Item Short-Form Health Survey (SF-36) subscale scores of role physical, bodily pain, general health, and role emotional were all significantly lower in the osteoporosis group than in the volunteer group (p < 0.05 each). SF-36 physical component summary (PCS) score was significantly lower in the osteoporosis group than in the volunteer group (p < 0.001). SF-36 PCS score correlated positively with thoracic kyphosis and negatively with BMI only in the osteoporosis group (p < 0.05 each).

CONCLUSIONS

These results indicated that lower QOL in osteoporosis patients may be associated with increased thoracic kyphosis, reduced lean muscle mass, and generalized muscle weakness.

Improvement of spinal alignment and quality of life after corrective surgery for spinal kyphosis in patients with osteoporosis: a comparative study with non-operated patients

This study evaluated changes in spinal alignment and quality of life (QOL) after corrective spinal surgery for patients with postmenopausal osteoporosis and spinal kyphosis. Spinal global alignment and QOL were significantly improved after corrective spinal surgery but did not reach the level of non-operated controls.

INTRODUCTION

With the increased aging of society, the demand for corrective spinal instrumentation for spinal kyphosis in osteoporotic patients is increasing. However, previous studies have not focused on the improvement of quality of life (QOL) after corrective spinal surgery in patients with osteoporosis, compared to non-operated control patients. The purposes of this study were thus to evaluate changes in spinal alignment and QOL after corrective spinal instrumentation for patients with osteoporosis and spinal kyphosis and to compare these results with non-operated patients.

METHODS

Participants comprised 39 patients with postmenopausal osteoporosis ≥50 years old who underwent corrective spinal surgery using multilevel posterior lumbar interbody fusion (PLIF) for symptomatic thoracolumbar or lumbar kyphosis, and 82 age-matched patients with postmenopausal osteoporosis without prevalent vertebral fractures. Spinopelvic parameters were evaluated with standing lateral spine radiography, and QOL was evaluated with the Japanese Osteoporosis QOL Questionnaire (JOQOL), SF-36, and Roland-Morris Disability Questionnaire (RDQ).

RESULTS

Lumbar kyphosis angle, sagittal vertical axis, and pelvic tilt were significantly improved postoperatively. QOL evaluated with all three questionnaires also significantly improved after 6 months postoperatively, particularly in domain and subscale scores for pain and general/mental health. However, these radiographic parameters, total JOQOL score, SF-36 physical component summary score, and RDQ score were significantly inferior compared with non-operated controls.

CONCLUSIONS

The results indicate that spinal global alignment and QOL were significantly improved after corrective spinal surgery using multilevel PLIF for patients with osteoporosis and spinal kyphosis but did not reach the level of non-operated controls.

Association of spinal curve deformity and back extensor strength in elderly women with osteoporosis in Japan and the United States

The difference in the shape of sagittal spinal curvature and distribution of vertebral fractures in women of comparable age with osteoporosis from Japan and the United States with different cultures and lifestyles was identified. Back extensor strength was significantly associated with lumbar lordosis in Akita group, indicating the potential importance of strengthening the back extensor.

INTRODUCTION

The purpose of the study was to assess the association of osteoporotic spinal deformities with back strength in elderly women in Japan and the United States.

METHODS

Subjects diagnosed with osteoporosis were selected to participate prospectively. In both groups, we measured the angles of thoracic kyphosis and lumbar lordosis with plain lateral radiographs and back extensor strength. The number of vertebral fractures and the ratio of lumbar fractures to thoracic fractures are also evaluated. The level of participants' daily activities was assessed with use of comparable tests in Akita (quality-of-life score) and Minnesota (physical activity score).

RESULTS

A total of 102 Japanese women residing in Akita, Japan (Akita group), and 104 white women evaluated in Rochester, MN, USA (Minnesota group), participated in this study. The angle of thoracic kyphosis and lumbar lordosis was higher in the Minnesota group than in the Akita group. The ratio of lumbar fractures to thoracic fractures was higher in the Akita group than in the Minnesota group. In the Akita group, multiple regression analysis revealed that the angle of lumbar lordosis correlated significantly with back extensor strength.

CONCLUSIONS

We identified the difference in the shape of sagittal spinal curvature and distribution of vertebral fractures in women of comparable age with osteoporosis from two geographic areas of the world with different cultures and lifestyles. Back extensor strength was significantly associated with lumbar lordosis in Akita group, indicating the potential importance of strengthening the back extensor for improving or maintaining lumbar lordosis.

Combined Treatment of Alendronate and Low-Intensity Pulsed Ultrasound (LIPUS) Increases Bone Mineral Density at the Cancellous Bone Osteotomy Site in Aged Rats: A Preliminary Study

Introduction: During fracture healing, alendronate encourages callus volume by inhibiting bone resorption, whereas low-intensity pulsed ultrasound (LIPUS) enhances bone regeneration by promoting an anabolic response. Methods: In the present study, 9-month-old Sprague-Dawley rats, with a unilateral proximal tibial osteotomy, were treated with alendronate (daily, 1 g/kg) plus sham-LIPUS (n = 14), saline plus LIPUS (20 min/day) (n = 18), alendronate plus LIPUS (n = 16), or saline plus sham- LIPUS as a control (n = 13) for 4 weeks. The rats were then examined for changes in bone mineral density (BMD) during metaphyseal bone repair. Results: The combined therapy signi cantly increased BMD at the osteotomy site at 4 weeks (p < 0.001) compared with the control, without affecting the contralateral, non-osteotomized tibia. Both alendronate and LIPUS alone also exerted a positive, albeit less, effect on BMD in the affected limb (p < 0.001 and p = 0.006, respectively). Conclusions: Alendronate and LIPUS cooperate to enhance BMD during metaphyseal bone healing. Keywords: LIPUS, bisphosphonate, bone mineral density.

Combined treatment of alendronate and low-intensity pulsed ultrasound (LIPUS) increases bone mineral density at the cancellous bone osteotomy site in aged rats: a preliminary study

INTRODUCTION

During fracture healing, alendronate encourages callus volume by inhibiting bone resorption, whereas low-intensity pulsed ultrasound (LIPUS) enhances bone regeneration by promoting an anabolic response.

METHODS

In the present study, 9-month-old Sprague-Dawley rats, with a unilateral proximal tibial osteotomy, were treated with alendronate (daily, 1 µg/kg) plus sham-LIPUS (n = 14), saline plus LIPUS (20 min/day) (n = 18), alendronate plus LIPUS (n = 16), or saline plus sham-LIPUS as a control (n = 13) for 4 weeks. The rats were then examined for changes in bone mineral density (BMD) during metaphyseal bone repair.

RESULTS

The combined therapy significantly increased BMD at the osteotomy site at 4 weeks (p < 0.001) compared with the control, without affecting the contralateral, non-osteotomized tibia. Both alendronate and LIPUS alone also exerted a positive, albeit less, effect on BMD in the affected limb (p < 0.001 and p = 0.006, respectively).

CONCLUSION

Alendronate and LIPUS cooperate to enhance BMD during metaphyseal bone healing.

Spinal curvature and postural balance in patients with osteoporosis

SUMMARY

Postural deformity might represent another risk factor for postural instability and falls. Relation between spinal curvatures and postural sway were evaluated. Lumbar (not thoracic) kyphosis and spinal inclination have a statistical correlation with postural sway. Postural deformity with lumber kyphosis may represent as a risk factor for falls.

INTRODUCTION

Postural instability has been considered as a risk factor for falls and osteoporotic fractures. Previous studies have demonstrated that several factors display significant relationships with postural instability. Postural deformity might represent another risk factor for postural instability and falls. This study evaluates the influence of spinal curvature on postural instability in patients with osteoporosis.

METHODS

Subjects comprised 93 patients with a mean age of 70 years. Angles of thoracic and lumbar kyphosis and spinal inclination that reflected a forward stooped posture were evaluated using a computer-assisted device. Sway and postural instability were evaluated using a computerized stabilometer showing seven parameters. Relationships among parameters of postural deformity and postural balance were analyzed using Pearson's correlation coefficients.

RESULTS

No significant correlations were observed between any parameters of postural balance and angle of thoracic kyphosis. However, all parameters showed significant positive correlations with angle of lumbar kyphosis (r = 0.251-0.334; p < 0.05-0.001). Moreover, lumbar kyphosis, but not thoracic kyphosis, showed a positive correlation with spinal inclination (r = 0.692, p < 0.001), and all parameters of postural balance showed significant positive correlations with spinal inclination (r = 0.417-0.551, p < 0.001).

CONCLUSION

Lumbar kyphosis, but not thoracic kyphosis, affecting spinal inclination and postural balance may represent a risk factor for falls.

Impact of spinal kyphosis on gastroesophageal reflux disease symptoms in patients with osteoporosis

SUMMARY

Spinal kyphosis has been speculated to participate in the increased frequency of gastroesophageal reflux disease (GERD) in patients with osteoporosis. The present study provides further evidence that increases in lumbar kyphosis and number of vertebral fractures represent very important risk factors for GERD in patients with osteoporosis.

INTRODUCTION

Osteoporosis and spinal kyphosis have been speculated to participate in the increased frequency of gastroesophageal reflux disease (GERD). The present study examined whether GERD in patients with osteoporosis is affected by spinal factors including spinal kyphosis in the presence of oral pharmacotherapies.

METHODS

Subjects comprised 112 patients with osteoporosis (mean age, 78 years) who responded to the Frequency Scale for Symptoms of GERD (FSSG) questionnaire, regardless of complaints. Relationships between total FSSG score and number of vertebral fractures, angles of kyphosis, use of bisphosphonates and nonsteroidal anti-inflammatory drugs (NSAIDs), and total number of oral medicines per day were evaluated. Logistic regression identified factors associated with GERD.

RESULTS

Bisphosphonates and NSAIDs did not affect total FSSG score. Total FSSG score showed significant positive correlations with total number of medicines (r = 0.283, p = 0.0025), angle of lumbar kyphosis (r = 0.576, p = 0.0001), and numbers of thoracic vertebral fractures (r = 0.214, p = 0.0232) and lumbar vertebral fractures (r = 0.471, p < 0.0001). Angle of lumbar kyphosis and number of lumbar vertebral fractures were identified by multivariate analysis as indices affecting the presence of GERD.

CONCLUSION

Increases in angle of lumbar kyphosis and number of lumbar vertebral fractures may represent very important risk factors for GERD in osteoporotic patients.

Back extensor strength and lumbar spinal mobility are predictors of quality of life in patients with postmenopausal osteoporosis

To assess the effect of multiple factors on quality of life (QOL) in osteoporosis, relationships between the QOL and possible spinal factors were analyzed in 174 postmenopausal women with osteoporosis. Back extensor strength and lumbar spinal mobility were the most important factors for QOL in these patients.

INTRODUCTION

Quality of life (QOL) in patients with osteoporosis and vertebral fractures is impaired by the decline of total spinal mobility, although it is not clear to what extent. This study aimed to assess the effect of multiple factors on QOL in patients with osteoporosis.

METHODS

QOL of 174 postmenopausal women with osteoporosis (mean, 68 years old) was evaluated using the Japanese Osteoporosis QOL Questionnaire (JOQOL). Correlations between the JOQOL score, bone mineral density (BMD) of the lumbar spine/proximal femur/whole body, the kyphosis angle and mobility of thoracic and lumbar spine, the number of vertebral fractures, grip strengths of dominant and non-dominant hands, and isometric back extensor strength (BES) were analyzed.

RESULTS

JOQOL showed significant correlation (p < 0.05) with age (r = -0.303), BES (r = 0.455), dominant and non-dominant grip strengths (r = 0.273 and r = 0.255, respectively), number of vertebral fractures (r = -0.282), BMDs of proximal femur and whole body (r = 0.200 and r = 0.157, respectively), lumbar kyphosis angle (r = -0.296), and lumbar spinal mobility (r = 0.345). Multiple regression analysis revealed that the BES and lumbar spinal mobility were the significant contributors to the JOQOL (p < 0.05).

CONCLUSION

BES and lumbar spinal mobility are the important factors for QOL in patients with postmenopausal osteoporosis.

Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis: a randomized controlled trial

Randomized controlled study in 80 postmenopausal women with osteoporosis was conducted to investigate the effect of a home-based, simple, low-intensity exercise. Low-intensity back-strengthening exercise was effective in improving the quality of life and back extensor strength.

INTRODUCTION AND HYPOTHESIS

Back-strengthening exercise is effective in increasing back extensor strength and decreasing risk of vertebral fractures. We hypothesized that a home-based, simple, low-intensity exercise could enhance back extensor strength and improve the quality of life and/or spinal range of motion in postmenopausal women in a short-term follow-up.

METHODS

Eighty postmenopausal women with osteoporosis were randomly assigned to a control group (n = 38) or an exercise group (n = 42). Subjects were instructed to lift their upper trunk from a prone position antigravity and maintain the neutral position. Isometric back extensor strength, spinal range of motion, and scores for quality of life were evaluated at baseline and 4 months.

RESULTS

Back extensor strength significantly increased both in the exercise group (26%) and in the control group (11%). Scores for quality of life increased in the exercise group (7%), whereas it remained unchanged in the control group (0%). There was a significant difference in quality of life score between the groups (p = 0.012).

CONCLUSIONS

Low-intensity back-strengthening exercise was effective in improving the quality of life and back extensor strength in patients with osteoporosis.

Effects of h-PTH on cancellous bone mass, connectivity, and bone strength in ovariectomized rats with and without sciatic-neurectomy

The purpose of this study was to determine whether h-PTH (1-34) treatment would recover cancellous bone connectivity and bone strength in ovariectomized (OVX) or ovariectomized and sciatic-neurectomized (OVX+NX) rats. Seven-month-old female Wistar rats were treated with h-PTH or vehicle (6.0 microg/kg, six times a week, subcutaneously) for four weeks beginning 4, 8, or 12 weeks after OVX or OVX+NX. These were compared to age-matched baseline and sham-operated groups. Right tibiae were used for bone histomorphometry and node-strut analysis, and left tibiae were used for mechanical testing. The bone formation rates in the OVX and OVX+NX rats treated with h-PTH were significantly higher than those in their baseline controls. h-PTH treatment increased the node numbers and failure energies in the OVX rats, compared to their baseline controls, at all time points. However, in the OVX+NX rats, the effects of h-PTH treatment on the node number and failure energy were observed only at four weeks after surgery, but not at eight weeks or 12 weeks after surgery. These results suggest that the lowest limit, at which trabecular connectivity and bone strength are able to be restored by h-PTH, occurred between four and eight weeks in OVX+NX rats, but not in OVX rats. h-PTH cannot recover trabecular connectivity and bone strength in advanced osteopenia.

Impact of postural deformities and spinal mobility on quality of life in postmenopausal osteoporosis

The objective of the study was to evaluate the impact of postural deformities and spinal mobility on quality of life (QOL) in patients with spinal osteoporosis. A total of 157 postmenopausal women aged over 60 years with osteoporosis were divided into five groups according to their postural deformities: round back (RB, n=41), hollow round back (HRB, n=33), whole kyphosis (WK, n=40), lower acute kyphosis (LAK, n=18), and normal posture (NP, n=25). QOL was evaluated using the Japanese Osteoporosis QOL Questionnaire (JOQOL) proposed by the Japanese Society for Bone and Mineral Research. This questionnaire contains six domains, with higher scores indicating higher levels of QOL. The number of vertebral fractures, thoracic kyphosis and lumbar lordosis angles, and spinal range of motion (ROM) during maximum flexion and extension were also measured with radiographs. Total QOL scores in RB, HRB, WK, and LAK groups were significantly lower than those in the NP group, and those in WK group were even lower compared with the other groups ( P<0.05). All the groups with postural deformities, but not the NP group, showed significant positive correlations between total QOL score and spinal ROM (0.521</= r</=0.747, P<0.05). Total QOL score showed a significant correlation with age, number of vertebral fractures, lumbar lordosis angle, and spinal ROM in a total of 157 patients. However, multiple regression analysis revealed that spinal ROM best correlated with total QOL score. We concluded that QOL in patients with osteoporosis was impaired by postural deformities, especially by whole kyphosis, and that spinal mobility has a strong effect on QOL in these patients.

Effects of combined treatment of insulin and human parathyroid hormone(1-34) on cancellous bone mass and structure in streptozotocin-induced diabetic rats

The purpose of this study was to test the hypothesis that combined treatment with insulin and human parathyroid hormone (hPTH) is more effective than treatment with insulin or hPTH alone in improving cancellous bone mass, connectivity, and strength in insulin-dependent diabetic rats. Diabetes was induced by intraperitoneal injection of streptozotocin (STZ) in 7-month-old female Wistar rats. The diabetic rats received insulin, hPTH, insulin and hPTH, or hPTH vehicle for 4 weeks, starting 8 weeks after STZ injection. They were compared with baseline controls and normal controls that received STZ alone and STZ vehicle alone, respectively. The rats' proximal right tibias were processed to serve as undecalcified Villanueva-stained bone sections for histomorphometry. Changes in trabecular connectivity were determined through node-strut analysis. The decreased cancellous bone volume (BV/TV) and bone formation in diabetic rats improved in all the drug-treated groups compared with baseline controls. Furthermore, recovery of BV/TV was greater in rats that received the combination of insulin and hPTH than in those that received insulin or hPTH alone. In node-strut analysis, the node-related parameter (N.Nd/TV) significantly increased in rats that received the combination of insulin and hPTH, but did not increase in those that received insulin or hPTH alone. In addition to these results, the combination treatment significantly increased bone mineral density of the femur and bone strength in the femoral metaphysis compared with treatment with insulin or hPTH alone. These results indicate that the doses of insulin and hPTH employed in the combination treatment were more effective in improving not only bone mass but also trabecular connectivity and bone strength than treatment with insulin or hPTH alone in insulin-dependent diabetic rats.

Ex vivo gene therapy with stromal cells transduced with a retroviral vector containing the BMP4 gene completely heals critical size calvarial defect in rats

In order to develop a successful gene therapy system for the healing of bone defects, we developed a murine leukemia virus (MLV)-based retroviral system expressing the human bone morphogenetic protein (BMP) 4 transgene with high transduction efficiency. The bone formation potential of BMP4 transduced cells was tested by embedding 2.5 x 10(6) transduced stromal cells in a gelatin matrix that was then placed in a critical size defect in calvariae of syngenic rats. Gelatin matrix without cells or with untransduced stromal cells were the two control groups. The defect area was completely filled with new bone in experimental rats after 4 weeks, while limited bone formation occurred in either control group. Bone mineral density (BMD) of the defect in the gene therapy group was 67.8 +/- 5.7 mg/cm(2) (mean +/- s.d., n = 4), which was 119 +/- 10% of the control BMD of bone surrounding the defect (57.2 +/- 1.5 mg/cm(2)). In contrast, BMD of rats implanted with untransduced stromal cells was five-fold lower (13.8 +/- 7.4 mg/cm(2), P < 0.001). Time course studies revealed that there was a linear increase in BMD between 2-4 weeks after inoculation of the critical size defect with 2.5 x 10(6) implanted BMP4 cells. In conclusion, the retroviral-based BMP4 gene therapy system that we have developed has the potential for regeneration of large skeletal defects.

Evidence that anabolic effects of PTH on bone require IGF-I in growing mice

Although it has been established that PTH exerts potent anabolic effects on bone in animals and humans, the mechanism of PTH action on bone remains controversial. Based on the previous findings that PTH treatment increased production of IGF-I in bone cells and that PTH effects on bone cells in vitro were blocked by IGF-I-blocking antibodies, we proposed that IGF-I action is required for the stimulatory effects of PTH on bone formation. To test this hypothesis, we evaluated the effects of PTH on bone formation parameters in growing mice lacking functional IGF-I genes. Five-week-old IGF-I(-/-) mice and wild-type littermates were given daily sc injections of 160 microg/kg body weight of PTH (1-34) or vehicle for 10 d. In wild-type animals, PTH caused a significant increase in serum osteocalcin levels (113%), serum alkaline phosphatase activity (48%), and alkaline phosphatase activity in femoral bone extracts (>80%), compared with the vehicle-treated control group. In contrast, in IGF-I(-/-) mice, there was no significant effect of PTH on any bone formation parameters. PTH treatment increased total bone mineral density, as evaluated by peripheral quantitative computer tomography, at the distal metaphysis of the femur by 40% in wild-type mice, but it had no effect on bone mineral density in mice lacking functional IGF-I genes. In vitro studies using osteoblasts derived from control and IGF-I(-/-) mice revealed that PTH treatment increased cell number in osteoblasts derived from IGF-I knockout mice in the presence of exogenously added IGF-I but not without IGF-I. These data to our knowledge provide the first direct evidence that the anabolic effects of PTH on bone formation in vivo require IGF-I action in growing mice.

Evaluation of long-term sequential changes in bone mass and strength following withdrawal of incadronate disodium (YM175) in ovariectomized rats

We evaluated the long-term effects of withdrawal of a newer third-generation bisphosphonate, incadronate disodium (YM175), on both cancellous and cortical bone mass and strength in ovariectomized (OVX) rats. One hundred and sixty female SD rats at 13 weeks of age were randomized into four groups: sham-operated, OVX, and low- and high- YM (0.01 or 0.1 mg/kg s.c., three times a week after OVX). After 4 weeks of treatment with vehicle or incadronate disodium, rats from each group (n = 8) were killed at 0 (baseline), 3, 6, 9, and 12 months after the withdrawal of YM175. Histomorphometric studies of the proximal tibia revealed a dose-dependent decrease in OVX-induced bone turnover; cancellous bone volume was significantly higher in the YM groups compared with the OVX control group up to 6 months after withdrawal at low dose and up to 12 months after withdrawal at high dose. The low-dose group showed little effect on tibial diaphyseal cortical bone volume and width, while the high-dose group preserved both cortical parameters 12 months after withdrawal. Mechanical testing of femurs revealed that both metaphyseal and diaphyseal strengths were significantly higher at high dose compared with the OVX group until 12 months after withdrawal. These observations demonstrated that high-dose incadronate disodium preserved both cancellous and cortical bone mass and strength in OVX rats for 12 months after withdrawal of the agent.

First total synthesis of (-)-ichthyothereol and its acetate

The first and stereoselective total syntheses of (-)-ichthyothereol (1) and its acetate ((+)-2) were achieved by incorporation of the two chiral centers of diethyl L-tartrate. The starting diethyl L-tartrate was converted into trans-2-ethynyl-3-hydroxytetrahydropyran 14 in a stereoselective manner via the endo mode cyclization of the epoxy-alkyne derivative 12. The alcohol 12 was then transformed into (E)-iodoolefin derivative 15, which was exposed to a coupling reaction with 1-tributylstannyl-1,3,5-heptyne (19), derived from the corresponding 1-trimethylsilyl-1,3,5-heptyne (18), under Stille conditions to produce the all-carbon framework of the target natural products. Chemical modification of the coupled product 20 under conventional conditions completed the first total synthesis of (-)-ichthyothereol (1) and its acetate ((+)-2).

Restoring effect of human parathyroid hormone (1-34) on trabecular connectivity in ovariectomized rats

The purpose of this study was to determine if the loss of the trabecular connectivities can be recovered by human parathyroid hormone-(1-34) therapy in ovariectomized (OVX) rats. Seven-month old female Wistar rats underwent ovariectomy or sham-operation at the beginning of the experiment. All sham operated groups (sham groups) were sacrificed after 0 (initial-BL group), 4, 8, 12, and 16 weeks, and one-third of the OVX rats were sacrificed as the baseline controls (OVX-BL groups) at 4, 8, and 12 weeks after OVX. Four weeks PTH or its vehicle treatment for residual OVX rats was started at 4, 8, or 12 weeks after OVX (OVX+PTH groups, OVX+vehicle groups). h-PTH (6.0 microg/kg) was injected subcutaneously six times a week for 4 weeks for each group. Their proximal right tibiae were processed for undecalcified Villanueva bone staining sections for bone histomorphometry. Furthermore, changes in trabecular connectivities were determined by node-strut analysis. h-PTH completely restored OVX-induced cancellous bone loss by stimulating bone formation. In node-strut analysis, node number in the OVX-BL-4, -8, and -12 groups was decreased to 53%, 49% and 44% of the initial-BL value respectively, and that in the OVX-4, -8, -12 + PTH groups recovered to 80%, 66%, 56% of the initial-BL value respectively. However, they were lower than those in their corresponding sham groups. The findings of this study suggested that decreased trabecular connectivity by OVX was recovered by intermittent h-PTH administration. However, delayed treatment blunted the restoration of trabecular connectivity.

Systemic administration of insulin-like growth factor (IGF)-binding protein-4 (IGFBP-4) increases bone formation parameters in mice by increasing IGF bioavailability via an IGFBP-4 protease-dependent mechanism

Insulin-like growth factor (IGF)-binding protein-4 (IGFBP-4) is a potent inhibitor of IGF actions in vitro. However, we found that systemic administration of IGFBP-4 at pharmacological doses caused a significant increase in bone formation parameters in mice by a mechanism that may involve increased IGF bioavailability via proteolysis of IGFBP-4. To evaluate the hypothesis that proteolysis of IGFBP-4 is essential for the stimulatory effects of systemically administered IGFBP-4, we produced wild-type, protease-resistant, and IGFBP-4 proteolytic fragments and evaluated their effects using biochemical markers. Protease-resistant IGFBP-4 was more potent than wild-type IGFBP-4 in inhibiting IGF-I-induced mouse osteoblast cell proliferation in vitro and in inhibiting IGF-I-induced increase in alkaline phosphatase (ALP) activity in bone extract after local administration in vivo. Systemic administration of wild-type IGFBP-4, but not protease-resistant IGFBP-4, increased serum osteocalcin, serum ALP, and ALP in skeletal extracts in a dose-dependent manner, with a maximal effect of 40% (P < 0.05) at 1.25 nmol/mouse. Systemic administration of wild-type, but not protease-resistant, IGFBP-4 increased free IGF-I levels in serum in normal mice. IGF-I, but not wild-type IGFBP-4, increased bone formation parameters in IGF-I-deficient mice. This study demonstrates that systemic administration of IGFBP-4 increases bone formation parameters in mice by increasing IGF bioavailability in the circulation via an IGFBP-4 protease-dependent mechanism.

Long-term effects of withdrawal of bisphosphonate incadronate disodium (YM175) on bone mineral density, mass, structure, and turnover in the lumbar vertebrae of ovariectomized rats

This study was designed to evaluate the long-term effects of incadronate disodium (YM175) after its withdrawal on cancellous bone mass in ovariectomized (OVX) rats. Thirteen-week-old female SD rats were randomized into four groups: sham-operated, OVX, low-YM, and high-YM (0.01 mg/kg or 0.1 mg/kg subcutaneously [sc], three times a week after OVX) groups. After 4 weeks of treatment with vehicle or YM175, rats from each group were killed at time points of 0 (baseline), 3, 6, 9, and 12 months after withdrawal of the agent. Bone mineral density (BMD) of the lumbar vertebrae was measured by dual-energy X-ray absorptiometry (DXA). Bone volume (BV/TV), trabecular number and trabecular separation (Tb.N and Tb.Sp), eroded surface (ES/BS), osteoclast number and osteoclast surface (N.Oc/BS and Oc.S/BS), osteoid surface (OS/BS), and bone formation rate (BFR/BS) were measured as histomorphometric parameters of the fifth lumbar vertebra. BMD, BV/TV, Tb.N, and Tb.Sp in YM175-treated groups were maintained at the same level as in the sham group until 12 months after withdrawal in the high-YM group and until 3 months after withdrawal in the low-YM group. YM175 decreased both bone formative and resorptive parameters in histomorphometry. Serum bone-specific alkaline phosphatase (ALP) and urinary deoxypyridinoline at both doses of YM175 also showed a suppressive effect of this agent on bone turnover. These results indicate that YM175, after withdrawal, still maintains bone volume dose dependently by depressing bone resorption and formation in OVX rats. Intermittent YM175 treatment with a long interval may be sufficient to maintain the bone volume and structure in OVX rats.

Postnatal and pubertal skeletal changes contribute predominantly to the differences in peak bone density between C3H/HeJ and C57BL/6J mice

Previous studies have shown that 60-70% of variance in peak bone density is determined genetically. The higher the peak bone density, the less likely an individual is to eventually develop osteoporosis. Therefore, the amount of bone accrued during postnatal and pubertal growth is an important determining factor in the development of osteoporosis. We evaluated the contribution of skeletal changes before, during, and after puberty to the development of peak bone density in C3H/HeJ (C3H) and C57BL/6J (B6) mice. Volumetric bone density and geometric parameters at the middiaphysis of femora were measured by peripheral quantitative computed tomography (pQCT) from days 7 to 56. Additionally, biochemical markers of bone remodeling in serum and bone extracts were quantified. Both B6 and C3H mice showed similar body and femoral weights. B6 mice had greater middiaphyseal total bone area and thinner cortices than did C3H mice. Within strains, males had thicker cortices than did females. C3H mice accumulated more minerals throughout the study, with the most rapid accumulation occurring postnatally (days 7-23) and during pubertal maturation (days 23-31). C3H mice had higher volumetric bone density as early as day 7, compared with B6 mice. Higher serum insulin-like growth factor I (IGF-I) was present in C3H mice postnatally at day 7 and day 14. Until day 31, B6 male and female mice had significantly higher serum osteocalcin than C3H male and female mice, respectively. Alkaline phosphatase (ALP) was found to be significantly higher in the bone extract of C3H mice compared with B6 mice at day 14. These data are consistent with and support the hypothesis that the greater amount of bone accrued during postnatal and pubertal growth in C3H mice compared with B6 mice may be caused by increased cortical thickness, increased endosteal bone formation, and decreased endosteal bone resorption.

Evidence that IGF-binding protein-5 functions as a growth factor

Recent studies support the concept that IGF-binding protein-5 (IGFBP-5) stimulates bone formation, at least in part, via IGF-independent mechanisms. To evaluate this hypothesis further, we evaluated in vitro and in vivo effects of IGFBP-5 on bone formation parameters using the IGF-I knockout (KO) mouse. Treatment of serum-free cultures of osteoblast clones derived from IGF-I KO mice with recombinant human IGFBP-5 increased both proliferation and alkaline phosphatase (ALP) activity in a dose-dependent manner, an effect comparable to that seen with IGF-I. IGF-II levels from media conditioned by osteoblasts derived from IGF-I KO mouse were below those detectable by RIA. To eliminate possible actions of IGF-II, if any was produced by osteoblasts derived from IGF-I knockout mice, the IGFBP-5 effect was studied in the presence of exogenously added IGFBP-4, a potent inhibitor of IGF-II actions in bone cells. Addition of IGFBP-4 blocked IGF-I- but not IGFBP-5-induced cell proliferation in osteoblasts derived from IGF-I knockout mice. Consistent with in vitro results, a single local injection of IGFBP-5 to the outer periosteum of the parietal bone of IGF-I KO mice increased ALP activity and osteocalcin levels of calvarial bone extracts. The magnitudes of IGFBP-5-induced increases in ALP and osteocalcin in parietal bone extracts of IGF-I KO mice were comparable to those seen in C3H mice. In contrast to IGFBP-5, local administration of IGFBP-4 had no significant effect on bone formation in C3H and IGF-I KO mice. These results provide the first direct evidence to our knowledge that IGFBP-5 functions as a growth factor that stimulates its actions in part via an IGF-independent mechanism.

Differential protein profile in the ear-punched tissue of regeneration and non-regeneration strains of mice: a novel approach to explore the candidate genes for soft-tissue regeneration

Wound repair/regeneration is a genetically controlled, complex process. In order to identify candidate genes regulating fast wound repair/regeneration in soft-tissue, the temporal protein profile of the soft-tissue healing process was analyzed in the ear-punched tissue of regeneration strain MRL/MpJ-Fas(lpr) (MRL) mice and non-regeneration strain C57BL/6J(B6) mice using surface-enhanced laser desorption and ionization (SELDI) ProteinChip technology. Five candidate proteins were identified in which responses of MRL to the ear punch were 2-4-fold different compared to that of B6. Their corresponding genes were predicted using an antigen-antibody assay validated mass-based approach. Most of the predicted genes are known to play a role or are likely to play a role in the wound repair/regeneration. Of the five candidate proteins, the amount of the 23560 Da protein in the ear-punched tissue was significantly correlated with the rate of ear healing in six representative strains of mice, making it a good candidate for fast wound repair/regeneration. We speculate that the increased concentration of the 23560 Da protein in the wound tissue could stimulate the expression of various growth-promoting proteins and consequently speed up the wound repair/regeneration processes. Here, we have shown that examination of protein expression profile using SELDI technology, coupled with database search, is an alternative approach to search for candidate genes for wound repair/regeneration. This novel approach can be implemented in a variety of biological applications.

Development and evaluation of C-telopeptide enzyme-linked immunoassay for measurement of bone resorption in mouse serum

The mouse is increasingly being used as an animal model for the study of skeletal phenotypes in humans, mainly because of the ease of genetic manipulation. Biochemical markers of bone metabolism provide a valuable parameter for the assessment of skeletal metabolism. In the mouse model, assays for bone formation have been available for a long time; however, little is known about bone resorption markers. The present study describes the development of a serum C-telopeptide enzyme-linked immunoassay (ELISA), which measures degradation products of type I collagen that are generated by osteoclastic bone resorption. The C-telopeptide ELISA uses affinity-purified antibodies generated against human sequence DFSFLPQPPQEKAHDGGR. The epitope involves an amino acid sequence, which is identical in the mouse and human C-terminal peptide of type I collagen (alpha1 chain). Sensitivity of the ELISA used was <0.1 ng/mL. The average intra- (n = 10) and interassay (n = 8) coefficient of variation for two controls was <12%. The average dilution and spike recovery rates were 98% and 97%, respectively. Application of the ELISA to measure C-telopeptide in 3-4-week postovariectomized (ovx) C57BL/6J (B6) mice (n = 9 or 10) showed a 45% higher C-telopeptide concentration than the sham-operated mice. Treatment of ovx mice with estradiol (400 microg/kg body weight) or alendronate (1.0 mg/kg body weight) resulted in a 20%-50% decrease in C-telopeptide levels compared to the vehicle-treated ovx group. In addition, B6 mice fed a calcium-deficient diet (0.01% calcium) showed a 50% higher C-telopeptide concentration compared to the B6 mice receiving a normal diet (0.6% calcium). In conclusion, the C-telopeptide ELISA exhibited acceptable analytical performance and sufficient discriminatory power to show expected directional changes in the rate of bone resorption following ovariectomy, ovx plus estradiol or alendronate treatment, and administration of a calcium-deficient diet. Therefore, the ELISA developed in this study could be used for measuring bone resorption in the mouse model.

Effects of dietary calcium depletion and repletion on dynamic determinants of tibial bone volume in two inbred strains of mice

As an adjunct to our efforts to identify the genes that determine peak bone density, we examined phenotypic differences between two inbred strains of mice, C3H/HeJ (C3H) and C57BL/6J (B6), which are of similar size but differ with respect to peak bone density (e.g., C3H mice have 53% higher femoral bone density than B6 mice). The current studies were intended to compare the skeletal responses of C3H and B6 mice to 2 weeks of dietary calcium (Ca) depletion, followed by 2 weeks of Ca repletion. Initial studies showed that: (a) femur dry weight decreased during Ca depletion in both C3H and B6 mice (by 25% and 19%, respectively, p < 0.001) and most of this loss was recovered during Ca repletion; and (b) serum alkaline phosphatase (ALP) activity increased during Ca depletion, in both strains of mice (p < 0.001), and returned to normal after Ca repletion. Histological analyses of ground cross sections prepared at the tibiofibular junction showed that Ca-depletion increased medullary area in both C3H and B6 mice (indicating endosteal bone loss, p < 0.01), with reversal during Ca repletion. There were no effects of Ca depletion or repletion on periosteal bone growth. Endosteal bone forming surface and endosteal mineral apposition decreased during Ca depletion and increased during repletion in both C3H and B6 mice (p < 0.05). Net bone formation decreased during Ca depletion in C3H mice, but not B6 mice (p < 0.01), and was normal during Ca repletion in both strains. Endosteal bone resorbing surface and net bone resorption increased during Ca depletion and decreased during repletion in both strains (p < 0.01). A supplemental study (of Ca depletion without repletion) confirmed the effects of Ca depletion on femoral dry weight and serum ALP activity (p < 0.001 for each). This supplemental study also showed that Ca deficiency increased serum parathyroid hormone (PTH) (p < 0.05) and decreased (tibial) cortical bone area and cortical mineral content (p < 0.05 to p < 0.001) in both strains of mice. Together, these data demonstrate that the skeletal responses to Ca depletion and repletion are, qualitatively, similar in C3H and B6 mice.

Outcome of one-level posterior lumbar interbody fusion for spondylolisthesis and postoperative intervertebral disc degeneration adjacent to the fusion

STUDY DESIGN

Review of the clinical and radiologic records of patients who underwent one-level posterior lumbar interbody fusion (PLIF) at L4-L5.

OBJECTIVE

To determine whether adjacent intervertebral disc degeneration after PLIF affects the clinical results, and whether preoperative caudal disc (L5-S1) degeneration affects postoperative clinical results.

SUMMARY OF BACKGROUND DATA

There is little reliable information in the literature regarding clinical results and adjacent disc degeneration after PLIF.

METHODS

Forty-five patients who underwent L4-L5 PLIF for spondylolisthesis with more than 5 years of postoperative observation were included in this study. PLIF was performed in conjunction with posterior instrumentation. The posterior lumbar intervertebral grafting was performed using both autograft and a ceramic spacer. Intervertebral disc heights at L2-L3, L3-L4, and L5-S1 were measured before and after surgery. The patients were divided into two groups based on the presence or absence of the preoperative L5-S1 narrowing. Correlation between clinical status evaluated by the recovery rate of the Japanese Orthopedic Association (JOA) score and disc heights were determined.

RESULTS

All intervertebral disc heights adjacent to the fusion decreased after surgery (P < 0.05). However, no significant correlation was seen between clinical results estimated by the recovery rate and postoperative disc narrowing. There was also no significant difference in clinical results between patients with or without preoperative L5-S1 narrowing.

CONCLUSIONS

There is no evidence from the results that postoperative narrowing of the adjacent disc and preoperative narrowing of the L5-S1 disc affects the clinical outcome of L4-L5 PLIF.

Histomorphometric evaluation of the recovering effect of human parathyroid hormone (1-34) on bone structure and turnover in streptozotocin-induced diabetic rats

The purpose of this study was to determine whether human parathyroid hormone (h-PTH) enhances trabecular bone mass and connectivities that were reduced by streptozotocin (STZ)-induced diabetes in rats. Seven-month-old female Wistar rats were injected with STZ or its vehicle intraperitoneally. All vehicle-injected normal controls were sacrificed 0, 4, 6, 8, 12, 14, and 16 weeks after injection, and one-third of the STZ-injected rats were sacrificed as the baseline controls 4, 6, and 8 weeks after the injection. Eight-week h-PTH (6. 0 microg/kg, 6 times a week) or its vehicle treatment by subcutaneous injection for residual diabetic rats was started 4, 6, or 8 weeks after the STZ injection. The rats' proximal right tibiae were processed for undecalcified Villanueva bone staining sections for bone histomorphometry. Furthermore, changes in trabecular connectivities were determined by node-strut analysis. The decreased cancellous bone volume (BV/TV) and turnover in diabetic rats were recovered in all PTH-treated groups. In node-strut analysis, the node-related parameters (N.Nd/TV, NdNd/TV) were significantly increased by PTH when it was administered 4 weeks after STZ injection but were not increased when administration was started after 6 weeks. The results indicated that PTH enhanced bone turnover and bone mass but not trabecular connectivity in the late stage of diabetes in rats. Early treatment of osteoporosis is important in preventing fractures caused by decreased bone strength resulting from decreased trabecular connectivity.

Insufficiency fractures of the distal tibiae

We describe two patients with uncommon types of insufficiency fractures that occurred at the distal tibiae. In case 1, a 71-year-old man with secondary osteoporosis due to hypogonadism fracture of his left distal tibia was overlooked because initial radiographs had seemed normal. However, bone scintigram obtained 2 months prior to the onset of fracture had already demonstrated abnormally high uptake at the site. In case 2, a 62-year-old woman with postmenopausal osteoporosis sustained an insufficiency fracture of the left distal tibia. Good clinical results were obtained with nonsurgical treatment. Based on the clinical course of case 1, we believe that bone scintigrams may be useful not only for the early diagnosis of insufficiency fracture but also for predicting such fractures.

Effects of recombinant insulin-like growth factor-binding protein-4 on bone formation parameters in mice

Insulin-like growth factor (IGF)-binding protein-4 (IGFBP-4), one of the most abundant IGFBPs produced by bone cells, is a potent inhibitor of IGF actions in vitro. To evaluate the modulation of IGF actions on bone formation in vivo by IGFBP-4, we produced intact and fragment (50- to 100-fold reduced IGF affinity) forms of BP-4 and examined their local and systemic effects using biochemical markers. Local administration of IGF-I over the right parietal bone significantly increased bone extract alkaline phosphatase activity; this was completely blocked by an equimolar dose of intact IGFBP-4, but not IGFBP-4 fragment. A single sc administration of IGF-I (2 microg/g BW) significantly increased bone formation markers in both serum and skeletal extracts; surprisingly, so did intact IGFBP-4, but not fragment IGFBP-4. Subcutaneous administration of an equimolar dose of IGFBP-4 along with IGF-I did not significantly block the IGF-I effect. Administration of intact IGFBP-4 significantly increased the serum 50-kDa IGF pool and decreased the 150-kDa IGF pool without significantly changing total IGF-I. We postulate that the increase in the 50-kDa IGF pool might enhance IGFs bioavailability via a mechanism involving IGFBP-4-specific protease. This study demonstrates for the first time that a single local administration of IGFBP-4 inhibits IGF-I-induced increases in bone formation, whereas systemic administration of IGFBP-4 alone increases serum levels of bone formation markers.

Trabecular remodeling processes in the ovariectomized rat: modified node-strut analysis

The purpose of this study was to evaluate the trabecular bone remodeling processes in ovariectomized rats, focusing on diminishing trabecular connectivity. We used modified node-strut analysis defining three areas in the trabecular surfaces for the three-dimensional understanding of trabecular resorption derived from two-dimensional conventional sections, in addition to conventional bone histomorphometry and node-strut analysis. Seven-month-old female Wistar rats were used and treated with bilateral ovariectomy (ovx) and sham operation. Six rats in each group were examined at 4 and 8 weeks. We prepared undecalcified sections from the left tibiae with Villanueva bone and Goldner stains. We divided the trabecular bone surfaces (BS) into three areas: node (Nd), terminus (Tm), and strut (St), and measured the bone resorption and formation parameters, including eroded surface (ES), osteoclast surface (Oc.S), osteoid surface (OS), and double-labeled surface (dLS) in each defined area. In conventional bone histomorphometry, the ovx group showed high turnover osteopenia compared with the sham operation group. In node-strut analysis, the ovx group showed significantly lower values for node-related parameters than did the sham operation group. In the modified node-strut analysis, bone resorption parameters in the ovx group showed significantly higher values, particularly for strut and terminus-eroded surfaces (StES/BS, TmES/BS), and for each area of osteoclast surface (NdOc.S/BS, TmOc.S/BS, and StOc.S/BS) compared with the sham operation group. Bone formation parameters in the ovx group also showed significantly higher values, particularly for strut and terminus osteoid surfaces (TmOS/BS, StOS/BS), and for each area of double-labeled surface (NddLS/BS, TmdLS/BS, and StdLS/BS) compared with the sham operation group at 4 weeks. At 8 weeks, each area of bone formation parameter in the ovx group showed significantly higher values than that in the sham operation group. These results suggest that in the ovx group, the trabecular plates became perforated and the perforative cavities progressively enlarged, and/or the edges of plates were eroded regardless of elevated bone formation, resulting in diminished trabecular connectivity, and the node area might not be influenced relatively by bone remodeling in the early resorption.

Histomorphometric evaluation of the effects of ovariectomy on bone turnover in rat caudal vertebrae

The purpose of this study was to learn whether caudal vertebrae can be used to evaluate the effects of ovariectomy (OVX) in rats. Seven-month-old female Wistar rats were divided into two groups: the OVX group and the untreated control group. All rats were killed at 8 weeks and their 4th lumbar (L4), 1st caudal (C1), 3rd caudal (C3), and 5th caudal (C5) vertebrae were processed undecalcified and sectioned with Villanueva bone stain for quantitative bone histomorphometry. Both length of vertebral bodies and the cancellous tissue area in C1 were similar in size to L4 but significantly bigger than C3 and C5. Within the groups, cancellous bone volume (BV/TV) and trabecular thickness in both groups gradually increased in caudal vertebrae in relation to the distal direction. Between the groups, OVX rats exhibited a significantly lower BV/TV relative to control rats at L4 and C1, however, no significant difference were seen at C3 and C5. Bone formation-related parameters such as osteoid and mineralizing surface, and eroded surface were higher in the OVX group than in the control group in caudal as well as in lumbar vertebrae. By quantitative analysis of bone marrow composition, yellow marrow volume in C3 and C5 was significantly higher than that in L4 and C1, in both groups. Our results suggest that C1 is similar to L4 in size, bone turnover, and bone marrow composition. However, further experiments are needed to evaluate the possibility that C1 vertebra could be used as an alternative site for histomorphometric evaluation of bone changes in OVX rats.

Anterior decompression with single segmental spinal interbody fusion for lumbar burst fracture

STUDY DESIGN

The clinical and radiologic records for seven patients with lumbar burst fracture who underwent anterior decompression with single segmental interbody fusion were reviewed.

OBJECTIVE

To determine the clinical results obtained with this method and its influence on the intervertebral disc degeneration inferior to the fusion.

SUMMARY OF BACKGROUND DATA

Some patients with Denis' type B fracture can tolerate one-segment anterior fusion. However, there is no reliable information in the literature regarding the juxtafusional disc degeneration after one-segment fusion.

METHODS

Seven patients with type B lumbar burst fractures, including four with cleavage fracture of the lower endplate, underwent anterior single segmental fusion; three patients underwent surgery with no instrumentation, and four underwent surgery with Kaneda instrumentation. The mean follow-up period lasted 85 months. The kyphosis angle and inferior intervertebral disc height adjacent to the fusion were measured before and after surgery. Pain and working status were evaluated using the scales proposed by Denis et al.

RESULTS

Significant correction loss was obtained 1 year after surgery in the patients in whom no instrumentation was used (7.3 +/- 0.6 degrees), compared with the correction loss in patients whose surgery included the use of instrumentation (0.3 +/- 0.5 degree; P = 0.00001). No further correction losses were seen in either group at the final follow-up examination. No marked reduction in disc height was observed in any patient, including the four patients with cleavage fracture of the lower endplate. All patients returned to their previous occupation; five patients were rated as P1 (no pain) and W1 (returned to heavy labor), and two patients were rated as P2 (minimal pain) and W2 (return to heavy labor with lifting restrictions) at the final follow-up examination.

CONCLUSIONS

There was slight correction loss within 1 year when no instrumentation was used, but this deformity did not affect the clinical results. The results provided no evidence that cleavage fracture of the lower endplate accelerates degeneration of the adjacent intervertebral disc.

Skin temperature of the shoulder: circadian rhythms in normal and pathologic shoulders

Circadian rhythm of the shoulder skin temperature was studied in 21 shoulders of 20 patients with rotator cuff tears (average age, 58 years) and 4 shoulders of 4 patients with rotator cuff tendinitis (average age, 34 years). Fourteen of the 23 uninvolved shoulders with no abnormalities on magnetic resonance imaging were also studied as normal shoulders. With a portable thermometer with the probes attached to the anterior surface of both shoulders, the skin temperature was recorded every 5 minutes from 1:00 PM to 9:00 AM (20 hours). Both the normal and cuff tear shoulders showed a similar circadian rhythm with the temperature at night significantly lower than the temperature during the daytime (P < .0001). On the other hand, the tendinitis shoulders did not show this circadian rhythm; the temperature did not change significantly through the range of measurement. We conclude that the skin temperature shows a circadian rhythm in normal shoulders, and this rhythm may be affected by certain pathologic conditions of the shoulder.

Spinal subdural hematoma

We report the case of a 68-year-old patient with a traumatic spinal subdural hematoma. MRI demonstrated an area of abnormal intensity and a black line in the inner part of the intradural space. We anticipate that MRI will help to make one more confident in the preoperative diagnosis of spinal subdural hematoma. The symptoms completely disappeared immediately after the operation. Spinal subdural hematoma requires immediate surgical evacuation. The prognosis for functional recovery is good if the condition is appropriately diagnosed and treated before development of irreversible paralysis. We recommend MRI to make an early diagnosis and early evacuation of spinal subdural hematoma.

Case report 858: Postradiation osteosarcoma of the patella

A case of postradiation osteosarcoma of the patella in a 54-year-old man was presented. The lesion in the patella was diffuse and highly sclerotic, and was partially radiolucent in radiographs. The whole patella was removed by Miyakawa's method. Diagnostic criteria, clinical features, and radiographic findings of postradiation sarcoma were described. The rarity of osteosarcoma of the patella was emphasized.

Long term oral administration study of pravastatin sodium to beagles for 104 weeks

Pravastatin sodium was successively given for 104 weeks to beagles orally at doses of 5 and 25 mg/kg/day. A decrease in serum cholesterol levels was observed at week 4 and thereafter. No other abnormal findings were obtained in any animals in general conditions, hematological and biochemical examination, various function tests, and pathological examinations. The no-effect dose level in beagles receiving pravastatin sodium orally for 104 weeks is toxicologically estimated to be more than 25 mg/kg/day.

Preliminary dose finding study for subacute toxicological study of pravastatin sodium in monkeys

Pravastatin sodium was orally administered to cynomolgus monkeys at dosage levels of 50, 200 and 800 mg/kg/day for 7 successive days. Excretion of diarrhea and/or loose stool were observed in the more than 50 mg/kg dose group, but the changes are quite mild. Animals of the 800 mg/kg dose group showed vomiting, diarrhea and/or excretion of soft stool and reduction of cholesterol content in serum. In conclusion, it is estimated that the no effective level is less than 200 mg/kg because no abnormalities were observed except for only very slight excretions of diarrhea and/or loose stool, and that the effective dose is 800 mg/kg in which vomiting was observed.

Subacute toxicological study in monkeys treated orally with pravastatin sodium for 5 weeks

Pravastatin sodium was administered orally to cynomolgus monkeys at dosage levels of 50, 100, 200 and 400 mg/kg/day for 5 successive weeks. Five animals of 200 mg/kg and 400 mg/kg dose groups were sacrificed during the study period, because these animals deteriorated in general condition and/or showed remarkable changes in serum biochemical examination. Pathological examination revealed hepatic and/or renal disturbance in these animals. These changes are thought to be the cause of deterioration of general condition or changes in serum biochemical examination. All other animals were terminated at the end of the study period. In the animals of the 100 mg/kg dose group, only one animal showed hepatic and renal disorder similar in nature to the changes in the animals sacrificed during the study period. No animals in the 50 mg/kg dose group showed toxic findings in any examination.

Autoradiographic studies on distribution of L-3,4-dihydroxyphenylalanine (L-DOPA)-14C and L-5-hydroxytryptophan (L-5-HTP)-14C in the cat brain

The distribution and metabolism of L-DOPA-14C and L-5-HTP-14C in the cat brain were examined by means of autoradiography and chromatography. The results revealed that an appreciable amount of radioactivity in the gray matter, but not the white, and that the localization of radioactivity of L-DOPA and L-5-HTP significantly differed. After L-DOPA-14C administration, a high accumulation was found in the caudate nucleus, putamen and pallidum. With L-5-HTP-14C administration, high radioactivity was observed in the hypothalamus, raphe nucleus, substantia nigra, inferior olivalis and caudate nucleus. An analysis of the main metabolites of both amino acids in various regions of the brain was also made. When L-DOPA was given, a high concentration of dopamine was detected in the caudate nucleus, followed by the hypothalamus. In the case of L-5-HTP, a high concentration of serotonin was detected in the hypothalamus and the medulla oblongata. These results suggest that amines derived from exogenously administered L-DOPA and L-5-HTP accumulate in the brain regions known as the corresponding amine rich regions, under physiological conditions.