Rosa Maria Rodrigues Pereira

Cortisol inhibits the differentiation and apoptosis of osteoblasts in culture

Glucocorticoids decrease the replication of cells of the osteoblastic lineage and the function of the osteoblast. However, under certain conditions, they enhance the differentiation of osteoblastic cells, an effect that appears contradictory to their inhibitory actions on cell function. In this study we examine the effects of cortisol on the proliferation, differentiation, and fate of osteoblastic enriched cells from 22-day-old fetal rat calvariae (osteoblastic cells) in the absence and presence of beta-glycerophosphate. In the absence of beta-glycerophosphate, there was a progressive accumulation of DNA and cells, which was impaired by cortisol. In the presence of beta-glycerophosphate, there was an initial accumulation of DNA and cells followed by a marked decline that was prevented by cortisol. Despite the sustained number of cells, cortisol did not affect their mineralization, and inhibited Core binding factor a1 (Cbfa1), but not alkaline phosphatase, osteocalcin, or type I collagen transcripts. The decrease in cell number by cortisol observed in the absence of beta-glycerophosphate was due to a decrease in DNA synthesis, whereas the increase in cell number observed in the presence of beta-glycerophosphate was due to a relative increase in DNA synthesis and a decrease in apoptosis as determined by DNA fragmentation and acridine orange staining of the cells. This was correlated by a decrease in transcripts of proapoptotic genes and caspase 3 activity, and an increase of antiapoptotic genes. In conclusion, cortisol decreases the replication of cells of the osteoblastic lineage, but under conditions of differentiation/mineralization, cortisol prevents terminal differentiation of the cells and maintains an immature cell population.

Effect of impact load and active load on bone metabolism and body composition of adolescent athletes.

PURPOSE It is unclear whether adolescents involved in nonweight-bearing activities experience a delay in bone growth acquisition and sexual maturation. The purpose of this study was to compare bone mineral density (BMD), body composition, hormonal profile, and bone biochemical markers of adolescent athletes active in sports involved in impact load sports with those participating in active load sports. METHODS Forty-five male Caucasian athletes aged 12--18 yr were divided into two groups according to type of skeleton loading, impact (N = 18), or active (N = 27). Twenty-four male Caucasian adolescents (12--18 yr) served as controls and only performed the activities included in their physical education classes. All subjects were assessed for bone mass, body composition, and bone age by dual x-ray absorptiometry (DXA). Serum calcium (Ca), phosphorus (P), bone-specific alkaline phosphatase (BAP), total testosterone, FSH, LH, urinary calcium to creatinine ratio (Ca/Cr), and urinary deoxypyridinoline crosslinks to creatinine ratio (DPD/Cr) were measured. RESULTS The impact load group presented the highest BMD among the three groups for all studied sites. Lean mass and absolute weight were correlated with all of the bone mass measurements. BAP levels were significantly higher and testosterone levels significantly lower in the active load group compared with the impact group. CONCLUSION High-impact load exercises have a beneficial effect on bone mass in male adolescents. There is also a positive correlation of weight and body composition with BMD. However, further longitudinal studies are necessary to determine whether there is a delay in bone growth acquisition among adolescents involved in a nonweight-bearing exercise regimen and its association with sex hormones.

Glucocorticoid-induced myopathy

Glucocorticoid-induced myopathy, characterized by muscle weakness without pain, fatigue and atrophy, is an adverse effect of glucocorticoid use and is the most common type of drug-induced myopathy. This muscle disturbance has a frequency of 60%, and it has been most often associated with fluorinated glucocorticoid preparations. Glucocorticoids have a direct catabolic effect on muscle, decreasing protein synthesis and increasing the rate of protein catabolism leading to muscle atrophy. In clinical practice, it is important to differentiate myopathy due to glucocorticoid from muscle inflammatory diseases. The treatment is based on reduction or, if possible, on discontinuation of the steroid. Fluorinated glucocorticoids such as dexamethasone should be replaced with nonfluorinated glucocorticoids such as prednisone. Other experimental treatments may be tried such as IGF-I, branched-chain amino acids, creatine, androgens such as testosterone, nandrolone and dehydroepiandrosterone (DHEA), and glutamine.

Metabolic syndrome in rheumatological diseases.

Metabolic syndrome is characterized by a combination of various cardiovascular risk factors (age, gender, smoking, hypertension and dyslipidemia) that imply additional cardiovascular morbidity that is greater than the sum of the risks associated with each individual component. Herein, the authors review the rheumatological diseases in which metabolic syndrome has been studied: gout, osteoarthritis, systemic lupus erythematosus, rheumatoid arthritis, Sjögrens syndrome and ankylosing spondylitis. The prevalence of metabolic syndrome in these disorders varies from 14% to 62.8%. The great majority of these studies demonstrated that this frequency was higher in rheumatological diseases than in the control populations, suggesting that either the presence or the treatment of those diseases seems to influence the risk of developing metabolic syndrome.

Cortisol regulates the expression of Notch in osteoblasts

Glucocorticoids have important effects on osteoblastic replication, differentiation, and function, and the Notch family of receptors is considered to play a role in osteoblastic cell differentiation. We postulated that cortisol could regulate Notch and Notch ligand expression in osteoblastic cells, providing an additional mechanism by which glucocorticoids could regulate osteoblastic differentiation. We examined the expression and regulation of Notch1, 2, 3, and 4 and their ligands Jagged 1 and 2 and Delta 1 and 3 by cortisol in cultures of osteoblastic MC3T3‐E1 cells. Cortisol caused a time‐dependent increase in Notch1 and 2 mRNA levels in MC3T3 cells. Notch3 and 4 were not detected in the presence or absence of cortisol. MC3T3 cells expressed Delta 1 and Jagged 1 but not Jagged 2 or Delta 3 mRNAs, and cortisol did not have a substantial effect on the expression of any of these ligands. Cortisol increased the rate of Notch1 and 2 transcription and, in transcriptionally arrested cells, did not modify the decay of the transcripts, indicating a transcriptional level of control. In conclusion, cortisol stimulates Notch1 and 2 transcription in osteoblasts. Since Notch signaling appears to play a negative role in osteoblastic differentiation, its increased expression could be relevant to the actions of cortisol in bone. J. Cell. Biochem. 85: 252–258, 2002.

RANK, RANKL and osteoprotegerin in arthritic bone loss.

Rheumatoid arthritis is characterized by the presence of inflammatory synovitis and destruction of joint cartilage and bone. Tissue proteinases released by synovia, chondrocytes and pannus can cause cartilage destruction and cytokine-activated osteoclasts have been implicated in bone erosions. Rheumatoid arthritis synovial tissues produce a variety of cytokines and growth factors that induce monocyte differentiation to osteoclasts and their proliferation, activation and longer survival in tissues. More recently, a major role in bone erosion has been attributed to the receptor activator of nuclear factor kappa B ligand (RANKL) released by activated lymphocytes and osteoblasts. In fact, osteoclasts are markedly activated after RANKL binding to the cognate RANK expressed on the surface of these cells. RANKL expression can be upregulated by bone-resorbing factors such as glucocorticoids, vitamin D3, interleukin 1 (IL-1), IL-6, IL-11, IL-17, tumor necrosis factor-alpha, prostaglandin E2, or parathyroid hormone-related peptide. Supporting this idea, inhibition of RANKL by osteoprotegerin, a natural soluble RANKL receptor, prevents bone loss in experimental models. Tumor growth factor-beta released from bone during active bone resorption has been suggested as one feedback mechanism for upregulating osteoprotegerin and estrogen can increase its production on osteoblasts. Modulation of these systems provides the opportunity to inhibit bone loss and deformity in chronic arthritis.

Immunogenicity and safety of the 2009 non-adjuvanted influenza A/H1N1 vaccine in a large cohort of autoimmune rheumatic diseases

Background Despite the WHO recommendation that the 2010–2011 trivalent seasonal flu vaccine must contain A/California/7/2009/H1N1-like virus there is no consistent data regarding its immunogenicity and safety in a large autoimmune rheumatic disease (ARD) population. Methods 1668 ARD patients (systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), ankylosing spondylitis (AS), systemic sclerosis, psoriatic arthritis (PsA), Behçets disease (BD), mixed connective tissue disease, primary antiphospholipid syndrome (PAPS), dermatomyositis (DM), primary Sjögrens syndrome, Takayasus arteritis, polymyositis and Granulomatosis with polyangiitis (Wegeners) (GPA)) and 234 healthy controls were vaccinated with a non-adjuvanted influenza A/California/7/2009(H1N1) virus-like strain flu. Subjects were evaluated before vaccination and 21 days post-vaccination. The percentage of seroprotection, seroconversion and the factor increase in geometric mean titre (GMT) were calculated. Results After immunisation, seroprotection rates (68.5% vs 82.9% p<0.0001), seroconversion rates (63.4% vs 76.9%, p<0.001) and the factor increase in GMT (8.9 vs 13.2 p<0.0001) were significantly lower in ARD than controls. Analysis of specific diseases revealed that seroprotection significantly reduced in SLE (p<0.0001), RA (p<0.0001), PsA (p=0.0006), AS (p=0.04), BD (p=0.04) and DM (p=0.04) patients than controls. The seroconversion rates in SLE (p<0.0001), RA (p<0.0001) and PsA (p=0.0006) patients and the increase in GMTs in SLE (p<0.0001), RA (p<0.0001) and PsA (p<0.0001) patients were also reduced compared with controls. Moderate and severe side effects were not reported. Conclusions The novel recognition of a diverse vaccine immunogenicity profile in distinct ARDs supports the notion that a booster dose may be recommended for diseases with suboptimal immune responses. This large study also settles the issue of vaccine safety. (ClinicalTrials.gov #NCT01151644)

Effectiveness of medial-wedge insole treatment for valgus knee osteoarthritis.

OBJECTIVE To assess the efficacy of medial-wedge insoles in valgus knee osteoarthritis (OA). METHODS Thirty consecutive women with valgus-deformity knee OA > or = 8 degrees were randomized into 2 groups: medial insole (insoles with 8-mm medial elevation at the rearfoot [n = 16]) and neutral insole (similar insole without elevation [n = 14]). Both groups also wore ankle supports. A blinded examiner assessed pain on movement, at rest, and at night with a visual analog scale (VAS), the Lequesne index, and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index. Femorotibial, talocalcaneal, and talar tilt angles were evaluated at baseline and after 8 weeks of insole use. RESULTS Significant reductions in the medial insole group were observed for pain on movement (mean +/- SD VAS pre- and postintervention 8.1 +/- 1.5 versus 4.2 +/- 2.4; P = 0.001), at rest (5.1 +/- 2.3 versus 2.7 +/- 2.4; P = 0.002), and at night (6.1 +/- 2.7 versus 3.1 +/- 2.1; P = 0.001). In addition, a decrease in Lequesne (14.7 +/- 3.4 versus 9.6 +/- 3.8; P = 0.001) and WOMAC scores (74.1 +/- 14.2 versus 56.1 +/- 14.9; P = 0.001) was observed for the medial insole group. In the neutral insole group, a significant reduction was observed only for night pain (mean +/- SD VAS pre- and postintervention 5.8 +/- 2.4 versus 4.6 +/- 2.4; P = 0.019). An increase in femorotibial angle (169.0 +/- 3.4 versus 170.8 +/- 3.7; P = 0.001) occurred only in the medial insole group. Moreover, the difference in measured femorotibial angles pre- and postintervention was 1.84 +/- 1.42 versus -0.18 +/- 0.67 (P < 0.001) for the medial and neutral insole groups. CONCLUSION The use of medial-wedge insoles was highly effective in reducing pain at rest and on movement and promoted a functional improvement of valgus knee OA.

Osteoporosis in childhood and adolescence

OBJECTIVE To review recent data concerning osteoporosis and osteopenia in childhood and adolescence, focusing on diagnosis, prevention and treatment. SOURCES OF DATA Literature review of Medline and Lilacs databases (1992 to 2002). SUMMARY OF THE FINDINGS Childhood osteoporosis is defined and classified. Imaging and laboratory diagnostic techniques are emphasized, as well as prevention and drug treatment. CONCLUSIONS Pediatricians should identify the risk factors for osteoporosis and guide patients in terms of its prevention and treatment.

A 12-month randomized controlled trial of balance training in elderly women with osteoporosis: Improvement of quality of life

OBJECTIVE Physical and psychological incapacity, including fear of falling is related to decreased satisfaction with life in osteoporosis (OP). The impact of a balance exercise program on improving the quality of life is not well established. We have, therefore, investigated the effect of 12-month Balance Training Program in quality of life, functional balance and falls in elderly OP women. METHODS Sixty consecutive women with senile OP were randomized into a Balance Training Group (BT) of 30 patients and no intervention control group (CG) of 30 patients. The BT program included techniques to improve balance over a period of 12 months (1h exercise session/week and home-based exercises). The quality of life was evaluated before and at the end of the trial using the Osteoporosis Assessment Questionnaire (OPAQ), functional balance was evaluated by Berg Balance Scale (BBS). Falls in the preceding year were noted and compared to the period of study. RESULTS The comparison of OPAQ variations (INITIAL-FINAL) revealed a significant improvement in quality of life in all parameters for BT compared to CG: well-being (1.61+/-1.44 vs. -1.46+/-1.32, p<0001), physical function (1.30+/-1.33 vs. -0.36+/-0.82, p<0.001), psychological status (1.58+/-1.36 vs. -1.02+/-0.83, p<0.001), symptoms (2.76+/-1.96 vs. -0.63+/-0.87, p<0.001), social interaction (1.01+/-1.51 vs. 0.35+/-1.08, p<0.001). Of note, this overall benefit was paralleled by an improvement of BBS (-5.5+/-5.67 vs. +0.5+/-4.88 p<0.001) and a reduction of falls in 50% in BT group vs. 26.6% for the CG (RR: 1.88, p<0.025). CONCLUSION The long-term Balance Training Program of OP women provides a striking overall health quality of life improvement in parallel with improving functional balance and reduced falls.