A.E. Nelson

INCREASED LEVELS OF GLYCOSAMINOGLYCANS DURING SEPTIC SHOCK: RELATION TO MORTALITY AND THE ANTIBACTERIAL ACTIONS OF PLASMA.

Glycosaminoglycans (GAGs) are structurally heterogeneous negatively charged polysaccharides. Endothelial GAGs, also known as glycocalyx, are involved in capillary permeability. In rat venules stimulated with proinflammatory substances ex vivo, the GAG-containing proteoglycan, syndecan-1, is shed from the endothelium. We wanted to investigate if we could trace the same response during septic shock as reflected in the circulating GAG levels. Arterial plasma samples were collected from 18 consecutive septic shock patients admitted to our intensive care unit. Plasma GAGs were measured with an Alcian blue slot binding assay, and syndecan-1 levels were measured with enzyme-linked immunosorbent assay. Effects of GAGs on the antibacterial activity of plasma were assessed by a radial diffusion assay. The median plasma GAG level was significantly higher in the septic shock patients than in matched controls (median [interquartile range], 2.7 &mgr;g/mL [1.9 - 4.8 &mgr;g/mL] vs. 1.8 &mgr;g/mL [1.7 - 2.0 &mgr;g/mL]). Furthermore, the GAG levels were significantly higher in nonsurvivors (4.6 &mgr;g/mL [3.1 - 8.8 &mgr;g/mL], n = 8) than survivors (1.8 &mgr;g/mL [1.6 - 2.6 &mgr;g/mL], n = 10). The syndecan-1 levels were also increased in the patients compared with controls (246 ng/mL [180 - 496 ng/mL] vs. 26 ng/mL [23 - 31 ng/mL]) and correlated to the cardiovascular Sequential Organ Failure Assessment (SOFA) score. The GAGs inhibited the endogenous antibacterial activity of plasma as well as isolated antimicrobial peptides. The concentrations required were in the same range as the GAG levels measured in the patients. These results show that the GAG levels are increased in septic shock patients, possibly reflecting peripheral endothelial cell damage. We also found that GAGs in relevant concentrations neutralize antimicrobial peptides in plasma.ABBREVIATIONS-GAG-glycosaminoglycan; PG-proteoglycan; CS-chondroitin sulfate; AMP-antimicrobial peptides; RDA-radial diffusion assay; TSB-tryptic soy broth; BPI-bactericidal/permeability-increasing protein; DEAE-diethylaminoethyl

Elevated Plasma Levels of Antimicrobial Polypeptides in Patients with Severe Sepsis.

We wanted to investigate if plasma levels of antimicrobial polypeptides (AMPs) are increased in severe sepsis and if they correlate with severity and mortality. Samples were collected from 31 sepsis patients at the intensive care unit. The Sequential Organ Failure Assessment (SOFA) score and 90-day mortality were registered, and inflammatory markers and AMP levels were measured by ELISA. A median SOFA score (13) and cardiovascular SOFA score (3) indicated multiorgan failure with severe circulatory derangement, and elevated cytokine levels indicated inflammatory activation. Levels of bactericidal/permeability-increasing protein, heparin-binding protein, α-defensins and lactoferrin but not LL-37 were elevated in sepsis patients compared with controls. Bactericidal/permeability-increasing protein levels correlated with mortality, with lower levels in survivors. Levels of all AMPs, except LL-37, positively correlated with the cardiovascular SOFA score. In conclusion, levels of several AMPs are increased in sepsis and correlate with circulatory derangement. This probably reflects neutrophil activation as part of an innate immune response.

OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hand osteoarthritis☆

The ability to assess the efficacy and effectiveness of an intervention for the treatment of hip osteoarthritis (OA) requires strong clinical trial methodology. This consensus paper provides recommendations based on a narrative literature review and best judgment of the members of the committee for clinical trials of hip OA. We provide recommendations on clinical trial design, outcome measures, including structural (radiography), and patient and physician global assessments, performance based measures, molecular markers and experimental endpoints including MRI imaging. This information can be utilized by sponsors of trials for new therapeutic agents for hip OA.

Effect of charge on microvascular permeability in early experimental sepsis in the rat.

A key feature of sepsis is hypovolemia due to increased microvascular permeability. It has been suggested that the negative charge of albumin and of the endothelial glycocalyx is important for maintenance of the normally low permeability for albumin. Here we tested the hypothesis that charge effects contribute to the increased permeability in sepsis. Transcapillary escape rate (TER) and initial distribution volume for (125)I-labeled bovine serum albumin (BSA, isoelectric point pH 4.6) and for (131)I-labeled charge modified BSA (cBSA, average isoelectric point, pH 7.1) was measured 3h after sepsis was induced by cecal ligation and incision (CLI) (n=11) and in control animals (n=12). The importance of charge for permeability in sepsis was estimated by comparing the ratio between TER for cBSA and TER for BSA during control conditions to that after CLI. Plasma concentration of the glycocalyx component glycosaminoglycans (GAGs) was measured in separate control and CLI animals. The initial distribution volume for BSA and cBSA in control animals was 38 ± 3 ml/kg and 47 ± 4 mL/kg and decreased by 17% and 19%, respectively, following CLI. TER for BSA increased from 16.7 ± 4.1% in the controls to 20.1 ± 1.9% following CLI. Corresponding values for cBSA were 26.7 ± 5.6% and 29.8 ± 3.5%, respectively. The ratio between TER for cBSA and TER for BSA was 1.62 ± 0.1 in the control group and 1.49 ± 0.1 following CLI (p<0.05). Plasma GAG concentrations were higher in CLI animals than in the control group. We conclude that CLI induce hypovolemia secondary to increased microvascular permeability. Negative charge contributes to the normally low permeability of albumin and the importance of charge is decreased in early experimental sepsis. The observed charge effects are associated with CLI-induced breakdown of the glycocalyx.

Clinical algorithms to aid osteoarthritis guideline dissemination

BACKGROUND Numerous scientific organisations have developed evidence-based recommendations aiming to optimise the management of osteoarthritis (OA). Uptake, however, has been suboptimal. The purpose of this exercise was to harmonize the recent recommendations and develop a user-friendly treatment algorithm to facilitate translation of evidence into practice. METHODS We updated a previous systematic review on clinical practice guidelines (CPGs) for OA management. The guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation for quality and the standards for developing trustworthy CPGs as established by the National Academy of Medicine (NAM). Four case scenarios and algorithms were developed by consensus of a multidisciplinary panel. RESULTS Sixteen guidelines were included in the systematic review. Most recommendations were directed toward physicians and allied health professionals, and most had multi-disciplinary input. Analysis for trustworthiness suggests that many guidelines still present a lack of transparency. A treatment algorithm was developed for each case scenario advised by recommendations from guidelines and based on panel consensus. CONCLUSION Strategies to facilitate the implementation of guidelines in clinical practice are necessary. The algorithms proposed are examples of how to apply recommendations in the clinical context, helping the clinician to visualise the patient flow and timing of different treatment modalities.

Endogenous antimicrobial peptide LL-37 induces human vasodilatation.

BACKGROUND Septic shock includes blood vessel dilatation and activation of innate immunity, which in turn causes release of antimicrobial peptides such as LL-37. It has been shown that LL-37 can attract leucocytes via the lipoxin A(4) receptor (ALX, FPRL1). ALX is also present in vascular endothelial cells. To explore possible ways of pharmacological intervention in septic shock, we investigated if LL-37 can affect vascular tone. METHODS Human omental arteries and veins were obtained during abdominal surgery, and circular smooth muscle activity was studied in organ baths. Gene expression was studied using reverse transcriptase-polymerase chain reaction. RESULTS LL-37, at micromolar concentrations, induced a concentration- and endothelium-dependent relaxation in vein but not in artery segments precontracted by endothelin-1. The relaxation was profoundly reduced by potassium chloride (30 mM) to inhibit endothelium-derived hyperpolarizing factor (EDHF), whereas it was less affected by the NOS inhibitor, l-N(G)-nitroarginine methyl ester, and not at all by indomethacin. The ALX agonist, WKYMVm, also induced a relaxation and both the relaxations induced by LL-37 and WKYMVm were inhibited by the ALX antagonist, WRWWWW. ALX was expressed in the vein endothelium. CONCLUSIONS We demonstrate, for the first time, that the human antimicrobial peptide, LL-37, induces endothelium-dependent relaxation in human omental veins mediated via an effect on endothelial ALX. The relaxation involves the release of nitric oxide and EDHF but not prostanoids. LL-37 released from white blood cells could contribute to blood vessel dilatation during sepsis and treatment with ALX antagonists might be successful.

Defining osteoarthritis: a moving target

1063-4584/

335 PSYCHOMETRIC PROPERTIES OF THE FOOT AND ANKLE OUTCOME SCORE (FAOS) IN A COMMUNITY-BASED OSTEOARTHRITIS STUDY

– see front matter 2011 Osteoarthritis doi:10.1016/j.joca.2011.10.008 The challenge of disease definition in osteoarthritis (OA) continues to grow. As described by Pereira et al., in a recent issue of Osteoarthritis and Cartilage (OAC), there are substantial differences in prevalence and incidence estimates when defining OA by radiographic changes alone, as symptomatic OA (requiring a combination of both symptoms and radiographic change) or as selfreported OA, using patient/participant self-report of a previous OA diagnosis1. The authors find, not surprisingly to those in the field, a higher prevalence of radiographic OA in comparison to the symptomatic definitions. What may be more surprising is the close relationship between symptomatic OA, which requires both radiographs and a report of symptoms, and self-reported OA, requiring perhaps only a single question, both having a prevalence w10– 40% lower than that estimated based on radiographic OA. The estimates are most dissimilar for hand OA, which has a remarkably high radiographic prevalence on the order of 50%, but is symptomatic in 15% and reported by only 5% in the pooled estimates. In contrast, the prevalence estimates for hip OA are more comparable, with a radiographic prevalence of 15%, symptomatic prevalence of 6%, and was reported by 7% of subjects (Fig. 1). As discussed by the authors, even these three seemingly straightforward definitions are highly variable across studies. Radiographic OA can be determined based on one of many available scoring systems, including theKellgren–Lawrence scale, assessment of individual radiographic features such as osteophytes or joint space narrowing and their combinations, or quantitative assessment of joint space width. These measures are most commonly applied to the knee, and may be less reliable at other joint sites. Hand OA, in particular, is a challenge to define. Should one distal interphalangeal joint with a Kellgren–Lawrence grade 2 define OA of the hand, or should multiple, bilateral joint involvement be required2? While Pereira et al. have necessarily combined different radiographic definitions to achieve their goal of pooled prevalence estimates, such differences in radiographic definition are likely responsible for the greater variation demonstrated in the forest plots (Pereira et al., Figures 2–5) among radiographic OA prevalence estimates compared to symptomatic or self-report estimates1. The concept of symptomatic OA is attractive to clinicians, as it seems to represent the best of both worlds, by combining information on structural damage with the patient’s symptoms. However,

Circulating syndecans during critical illness

Purpose: The Foot and Ankle Outcome Score (FAOS) is a 42-item questionnaire with 5 subscales: pain, other symptoms, activities of daily living (ADL), sport and recreational function (Sport/Rec), and foot and ankle related quality of life (QOL). This measure has been validated among 213 Caucasian patients 20–60 years of age with lateral ankle instability. The purpose of this analysis was to determine the psychometric properties of the FAOS in a large, community-based biracial sample of males and females 45+ years of age. Methods: FAOS data were available for analyses from 1670 participants enrolled in the Johnston County Osteoarthritis Project during 2006– 2010 (mean age 69 years, 68% female, 31% African American, mean body mass index [BMI] 31.5 kg/m2, 24% with foot symptoms, 15% with ankle symptoms). The FAOS was administered by trained interviewers. Each item was scored 0–4 (none, mild, moderate, severe, and extreme problems), and a normalized score was calculated for each subscale (100 = no problems and 0 = extreme problems). Internal consistency, construct validity, and factor structure of the FAOS subscales were examined for the total sample and for subgroups according to race (African American and Caucasian), gender, age (45–55, 55–65, 65+ years), BMI (<25, 25–30, 30+ kg/m), presence of knee or hip osteoarthritis, and presence of chronic knee, hip or low back symptoms (pain, aching, or stiffness on most days). Results: For the total study sample and all subgroups, the internal consistency was high for the pain (0.95–0.96), ADL (0.97–0.99), Sport/Rec (0.94–0.96), and QOL (0.87–0.92) subscales. The Cronbach’s alphas were slightly lower for the symptoms subscale (0.72–0.82). Correlations between FAOS subscales were moderate to high among the full study sample and all subgroups (r = 0.47–0.91). Overall, construct validity was supported for the total sample and subgroups, as the pain and symptoms subscales were moderately correlated with participant report of chronic foot and ankle symptoms (r = −0.25 to −0.55), and the ADL and Sport/Rec subscales were moderately correlated with the function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; worst score of both hips and knees; r = −0.30 to −0.60). Separate principal component analysis for each subscale revealed that all items loaded on a single factor for the pain, ADL, Sport/Rec, and QOL subscales (eigenvalues 6.9, 12.5, 4.3, and 3.2, respectively). For the symptoms subscale, all but the two range of motion items (those addressing straightening and bending foot/ankle fully) loaded on a single factor (eigenvalues: Factor 1 = 3.1, Factor 2 = 1.6). For these two items, the level of problem severity expressed in the response options was reversed compared to other FAOS items. Similar results for each subscale were noted across subgroups. Conclusion: The FAOS was found to be a valid measure when applied by trained interviewers in this sample and across subgroups. The internal consistency of the symptoms subscale and the lack of all items loading on a single factor may be explained by confusion in responding to the reversed polarity of the two range of motion symptoms items compared to other FAOS items. Alerting interviewers and participants of these differences may improve the performance of the symptoms subscale.

SAT0614 Joint Hypermobility and Ankle Osteoarthritis in A Community-Based Cohort

Circulating syndecans are proposed to be markers of glycocalyx degradation and previous investigations have found higher plasma levels of syndecan‐1 among patients with different pathological conditions. We wanted to investigate if levels of other syndecans (‐2,‐3 and ‐4) are altered during critical illness and compare the levels to syndecan‐1. In 137 consecutive intensive care unit (ICU) patients with sepsis, cardiac arrest, gastrointestinal bleeding, intoxication or trauma, plasma levels of syndecan‐1, ‐2, ‐3 and ‐4 were measured using ELISA. Syndecan‐1 and syndecan‐3 levels were similar among the different ICU patient groups but higher than controls. No differences in plasma levels of syndecan‐2 or syndecan‐4 were found neither among the different ICU patient groups nor compared to controls. All syndecans showed an association with mortality and the levels of syndecan‐1 and ‐3 and correlated with each other. The results indicate that syndecan release is triggered by the physiological stress of critical illness in general and involves several subtypes such as syndecan‐1 and syndecan‐3.