A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years

BACKGROUND: The optimal treatment for cartilage lesions has not yet been established. The objective of this randomized trial was to compare autologous chondrocyte implantation with microfracture. This paper represents an update, with presentation of the clinical results at five years. METHODS: Eighty patients who had a single chronic symptomatic cartilage defect on the femoral condyle in a stable knee without general osteoarthritis were included in the study. Forty patients were treated with autologous chondrocyte implantation, and forty were treated with microfracture. We used the International Cartilage Repair Society, Lysholm, Short Form-36, and Tegner forms to collect clinical data, and radiographs were evaluated with use of the Kellgren and Lawrence grading system. RESULTS: At two and five years, both groups had significant clinical improvement compared with the preoperative status. At the five-year follow-up interval, there were nine failures (23%) in both groups compared with two failures of the autologous chondrocyte implantation and one failure of the microfracture treatment at two years. Younger patients did better in both groups. We did not find a correlation between histological quality and clinical outcome. However, none of the patients with the best-quality cartilage (predominantly hyaline) at the two-year mark had a later failure. One-third of the patients in both groups had radiographic evidence of early osteoarthritis at five years. CONCLUSIONS: Both methods provided satisfactory results in 77% of the patients at five years. There was no significant difference in the clinical and radiographic results between the two treatment groups and no correlation between the histological findings and the clinical outcome. One-third of the patients had early radiographic signs of osteoarthritis five years after the surgery. Further long-term follow-up is needed to determine if one method is better than the other and to study the progression of osteoarthritis.     

Inhibition of Complement and CD14 Attenuates the Escherichia coli-Induced Inflammatory Response in Porcine Whole Blood

The innate immune response is a double-edged sword in systemic inflammation and sepsis. Uncontrolled or inappropriate activation can damage and be lethal to the host. Several studies have investigated inhibition of downstream mediators, including tumor necrosis factor alpha (TNF-α) and interleukin-1β (IL-1β). Emerging evidence indicates that upstream inhibition is a better therapeutic approach for attenuating damaging immune activation. Therefore, we investigated inhibition of two central innate immune pathways, those of complement and CD14/Toll-like receptor 4 (TLR4)/myeloid differentiation protein 2 (MD-2), in a porcine in vitro model of Escherichia coli-induced inflammation. Porcine whole blood anticoagulated with lepuridin, which did not interfere with the complement system, was incubated with E. coli lipopolysaccharide (LPS) or whole bacteria. Inhibitors of complement and CD14 and thus the LPS CD14/TLR4/MD-2 receptor complex were tested to investigate the effect on the inflammatory response. A broad range of inflammatory readouts were used to monitor the effect. Anti-CD14 was found to saturate the CD14 molecule on granulocytes and completely inhibited LPS-induced proinflammatory cytokines in a dose-dependent manner. Anti-CD14 significantly reduced the levels of the E. coli-induced proinflammatory cytokines TNF-α and IL-1β, but not IL-8, in a dose-dependent manner. No effect on bacterial clearance was seen. Vaccinia complement control protein and smallpox inhibitor of complement enzymes, two Orthopoxvirus-encoded complement inhibitors, completely inhibited complement activation. Furthermore, these agents almost completely inhibited the expression of wCD11R3, which is associated with CD18 as a β2 integrin, on porcine granulocytes and decreased IL-8 levels significantly in a dose-dependent manner. As expected, complement inhibition reduced bacterial clearance. We conclude that inhibition of complement and CD14 attenuates E. coli-induced inflammation and might be used as a therapeutic regimen in gram-negative sepsis along with appropriate treatment with antibiotics.     

Radiotherapy adapted to spatial and temporal variability in tumor hypoxia

PURPOSE: To explore the feasibility and clinical potential of adapting radiotherapy to temporal and spatial variations in tumor oxygenation. METHODS AND MATERIALS: Repeated dynamic contrast enhanced magnetic resonance (DCEMR) images were taken of a canine sarcoma during the course of fractionated radiation therapy. The tumor contrast enhancement was assumed to represent the oxygen distribution. The IMRT plans were retrospectively adapted to the DCEMR images by employing tumor dose redistribution. Optimized nonuniform tumor dose distributions were calculated and compared with a uniform dose distribution delivering the same integral dose to the tumor. Clinical outcome was estimated from tumor control probability (TCP) and normal tissue complication probability (NTCP) modeling. RESULTS: The biologically adapted treatment was found to give a substantial increase in TCP compared with conventional radiotherapy, even when only pretreatment images were used as basis for the treatment planning. The TCP was further increased by repeated replanning during the course of treatment, and replanning twice a week was found to give near optimal TCP. Random errors in patient positioning were found to give a small decrease in TCP, whereas systematic errors were found to reduce TCP substantially. NTCP for the adapted treatment was similar to or lower than for the conventional treatment, both for parallel and serial normal tissue structures. CONCLUSION: Biologically adapted radiotherapy is estimated to improve treatment outcome of tumors having spatial and temporal variations in radiosensitivity.     

High mobility group box-1 protein--one step closer to the clinic?

High mobility group box (HMGB)1, originally described as a nuclear protein that binds to and modifies DNA, is now regarded as a central mediator of inflammation by acting as a cytokine. HMGB1 is postulated to be particularly important as a late acting mediator of lethal septicaemia in mice. Furthermore, it has been suggested that HMGB1 plays a role in clinical conditions such as autoimmunity, acute ischaemia-reperfusion injury, cardiovascular disease and cancer. HMGB1 has emerged as a candidate for therapeutic intervention in various disease conditions. However, further basic and clinical studies are warranted to confirm the roles played by HMGB1 in clinical medicine.     

Evaluation of a mucosal-plaque index (MPS) designed to assess oral care in groups of elderly

An index, called the mucosal-plaque score (MPS), was tested for intra- and inter-examiner agreement at an institution for elderly individuals with mental disabilities. This index was designed to evaluate oral health and oral hygiene in groups of individuals, particularly in hospitals or at other institutions. MPS consists of the sum of a four-point mucosal score (MS) and a four-point plaque score (PS). Intra-examiner agreement was assessed for one dentist (BMH), who examined 24 individuals twice with a one-week interval. Weighted kappa values were 0.60 for MS, 0.62 for PS, and 0.62 for MPS. Inter-examiner agreement between two dentists was conducted by duplicate examinations on 20 persons. Weighted kappa values were 0.47 for MS, 0.71 for PS, and 0.70 for MPS. In a second assessment of Inter-examiner-agreement, eight individuals were each examined by a dentist, two dental hygienists, and one medical nurse. Weighted kappa values were 0.79 for MS, 0.80 for PS, and 0.77 for MPS. These results support the conclusion that the MPS can serve as a reliable measure for the assessment of oral health care in groups of older Individuals .     

Distinct roles of integrins alpha6 and alpha4 in homing of fetal liver hematopoietic stem and progenitor cells

Homing of hematopoietic stem cells (HSCs) into the bone marrow (BM) is a prerequisite for establishment of hematopoiesis during development and following transplantation. However, the molecular interactions that control homing of HSCs, in particular, of fetal HSCs, are not well understood. Herein, we studied the role of the alpha6 and alpha4 integrin receptors for homing and engraftment of fetal liver (FL) HSCs and hematopoietic progenitor cells (HPCs) to adult BM by using integrin alpha6 gene-deleted mice and function-blocking antibodies. Both integrins were ubiquitously expressed in FL Lin(-)Sca-1(+)Kit(+) (LSK) cells. Deletion of integrin alpha6 receptor or inhibition by a function-blocking antibody inhibited FL LSK cell adhesion to its extracellular ligands, laminins-411 and -511 in vitro, and significantly reduced homing of HPCs to BM. In contrast, the anti-integrin alpha6 antibody did not inhibit BM homing of HSCs. In agreement with this, integrin alpha6 gene-deleted FL HSCs did not display any homing or engraftment defect compared with wild-type littermates. In contrast, inhibition of integrin alpha4 receptor by a function-blocking antibody virtually abrogated homing of both FL HSCs and HPCs to BM, indicating distinct functions for integrin alpha6 and alpha4 receptors during homing of fetal HSCs and HPCs.