University Times

Research on cyclists, golfers presented

Studies that could help cyclists minimize injury risk and help golfers maximize performance were presented recently by researchers from the University’s Neuromuscular Research Laboratory at the annual meeting of the American College of Sports Medicine.

In one study, the University researchers proved the importance of core stability endurance by showing exactly how cyclists’ core fatigue could increase the risk of knee injury.

Another study proved that a specific eight-week exercise program developed in the Neuromuscular Research Laboratory could help improve golfers’ performance.

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Cyclists’ core fatigue may lead to knee injury

It has been well-reported that core stability can influence lower extremity alignment during functional activities, such as cycling. As a result of the fixed pelvis and feet in relation to the bicycle, lower extremity alignment during cycling is critical.

However, limited research has described the influence of core fatigue on cycling mechanics and pedaling forces.

The Pitt team of researchers, led by John Abt of the Department of Sports Medicine and Nutrition, demonstrated how core fatigue could result in altered cycling mechanics and misalignment of the lower extremities in 15 competitive cyclists who participated in the study. The cyclists underwent a previously validated core fatigue workout to diminish core stability just prior to undergoing the cycling mechanics test in the Neuromuscular Research Laboratory.

Researchers used a three-dimensional motion analysis system to collect kinematic data while the fatigued study subjects performed an incremental ramp cycling task on a high-speed treadmill until exhaustion.

Pedal forces were collected with custom-designed testing pedals. While researchers saw effects of core fatigue on knee positioning, no significant differences were demonstrated in the pedal force data, indicating the subjects were able to maintain the same performance while sacrificing their mechanics, Abt reported.

“Improved core stability endurance may promote greater alignment of the lower extremities when riding for extended time periods as the core is more resistant to fatigue,” he said.

The Pitt research team also presented its study that validated the exercise protocol to fatigue the core stabilizer muscles, which was led by James Smoliga, a doctoral student in the Department of Sports Medicine and Nutrition.

Other Pitt investigators included Matthew Brick, a former fellow in orthopaedic surgery; John Jolly, a research associate in sports medicine and nutrition; Scott Lephart, chair of the Department of Sports Medicine and Nutrition, and Freddie Fu, chair of the Department of Orthopaedic Surgery.

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Specific exercise program may help golfers improve performance

Most golfers who want to improve their performance use the expertise of teaching professionals to modify swing mechanics. Yet sports medicine professionals also may have the ability to help maximize performance through a golf-specific exercise program, as proven by a University Neuromuscular Research Laboratory study.

In the study, 15 average recreational golfers completed the eight-week golf conditioning and training program, designed and validated scientifically by a Pitt team of researchers to improve physical characteristics.

Pre- and post-training testing of participants included assessments of hip, torso and shoulder strength, flexibility and balance, swing mechanics and golf performance. Strength was measured with an isokinetic dynamometer. A clinician used a standard goniometer to look at flexibility. Single-leg standing balance was assessed using a force plate. Swing mechanics were studied with a three-dimensional motion analysis system, and golf performance was evaluated with a launch monitor system.

After eight weeks, shoulder, hip and trunk flexibility improved significantly in 22 of the 26 flexibility measurements taken. Hip and torso rotational strength also were improved.

Golf performance improved, including an average carry distance increase of about 18.5 yards, and an average total driving distance increase of about 17.5 yards. Average ball speed increased about 6.5 miles per hour with average club head speed improving about 4.5 miles per hour.

Upper rotational velocity at the acceleration point of a golf swing increased by about 31.7 degrees per second.

“A clinician-prescribed, golf-specific exercise program like the one we’ve validated in our current study would complement the instruction provided by a teaching professional in order to more effectively improve performance in golfers,” said Yung-Shen Tsai, a research associate in the Department of Sports Medicine and Nutrition, who led the study.

Other investigators include James Smoliga, a doctoral student in the Department of Sports Medicine and Nutrition; Timothy Sell, post-doctoral fellow in the Department of Sports Medicine and Nutrition; Joseph Myers, assistant professor in Department of Sports Medicine and Nutrition, and Scott Lephart, chair of the Department of Sports Medicine and Nutrition.

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New treatment targets “complicated” form of grief

Each year in the United States, approximately 2.5 million people die, each leaving behind, on average, five grieving survivors.

Many of these survivors — more than a million people each year — develop a chronic, debilitating condition known as complicated grief that is more intense than normal grief, yet differs from clinical depression. Despite complicated grief being so prevalent, it has been under recognized and under treated.

But according to a Pitt study reported recently in the Journal of the American Medical Association, a new treatment approach could help millions of adults.

Complicated grief treatment (CGT), which was developed by the study authors specifically to address complicated grief symptoms, was found to be significantly more effective than the comparison psychotherapy, interpersonal psychotherapy (IPT), in the treatment of complicated grief. Over the course of the three-year study, 51 percent of participants treated with CGT significantly improved, compared with 28 percent who improved following IPT. Patients being treated with CGT also responded to the therapy significantly faster.

While IPT is a treatment that has proven to be effective for depression and can be specifically focused for bereavement-related depression in clinical practice, it appeared to be less effective in treating complicated grief. So, the authors enhanced IPT to create complicated grief treatment — unique in its two-pronged approach in which therapists simultaneously guide patients to focus both on the loss and on rebuilding their own lives.

“The bereavement process can go awry, and in 15 to 20 percent of all people who are surviving a loss, it does,” said Katherine Shear, principal investigator of the study and professor of psychiatry at the School of Medicine.

“Grief is natural after the death of someone close and, over time, the yearning for the deceased and the emotional pain diminish in intensity. However, when this natural process is arrested, this may very well be complicated grief, which we now know is treatable,” she said.

While complicated grief is not yet included in the American Psychiatric Association’s Diagnostic and Statistical Manual because it is a newly characterized condition, its symptoms are identifiable and most often occur following the death of one member of a very close and loving relationship.

Key features include a sense of disbelief regarding the death, anger and bitterness over the death, recurrent pangs of painful emotions with intense yearning and longing for the deceased, avoidance of situations and activities that are reminders of the painful loss, and a preoccupation with thoughts of the loved one, often including distressing, intrusive thoughts related to the death.

Left untreated, complicated grief is associated with negative health outcomes, which may include clinical depression, suicidal thoughts or actions, substance abuse, cancer and cardiovascular illness.

“Although it affects millions of Americans at any given time, complicated grief is under recognized by the medical community and physicians are often at a loss to know what is best for their patients,” Shear explained.

“The medical profession has very much oriented itself toward caring and healing, yet eventually, everyone dies. We physicians have been less attentive to bereavement issues in our patients who have lost loved ones. However, we can offer help to the millions of grieving people by understanding more about the psychological response that our patients can have to a loss, by making sure that they know what to anticipate from their grief, by recognizing in our patients when their grief has developed into this more complicated form of grief, and by referring these patients for a treatment that is very likely to help,” said Shear.

“Standard bereavement counseling encourages patients to move forward with their lives after they start to feel better. The treatment we developed encourages people to move forward with their lives at the same time as they are dealing with the loss. This is part of how they can feel better,” she said.

The randomized, controlled trial involved 83 women and 12 men who met the diagnostic criteria for complicated grief and who had lost parents, spouses, children, other relatives or close friends through violent or natural deaths. Participants were assigned randomly to receive either IPT — which focuses on behaviors and relationships, or CGT — which focuses on the dual problem areas of distress caused by the loss as well as the survivor’s personal goals and restoration of a satisfying life. Both treatments were conducted in 16 sessions over a 19-week period.

In CGT, therapists use the IPT structure and attention to interpersonal functioning but add techniques to guide patients as they tell the story of the death, a process called “revisiting,” and produce audio recordings of the exercises that enable patients to listen to the story repeatedly and put aside the thoughts about the death, thereby lessening the effect of the pain. The patient is encouraged to make specific plans for pleasurable activities and to begin to engage in situations that he or she avoided following the death. The therapist also guides the patient through an imagined conversation and reminiscence regarding the person whom he or she has lost, which offers the opportunity to speak openly about the intense feelings that the two shared.

At the same time, patients work on re-engaging in activities and relationships that promise satisfaction and work to define and achieve personal goals. Both patients and therapists evaluate their symptoms throughout the course of the therapy.

“The key findings from this study are that response rate and time to response were significantly better for CGT than IPT. However, also of note, a higher proportion of patients who received IPT responded in this study than we had seen in previous work,” said Shear. “Also, those participants who were already taking an antidepressant drug at the time of their enrollment showed twice the response rate to IPT and slightly better results with CGT than those not on medication,” she added.

Co-authors of the study included Ellen Frank, Patricia Houck and Charles F. Reynolds III, all of the Department of Psychiatry in the School of Medicine.

The study was supported by grants by the National Institute of Mental Health.

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CDC renews funding for Pitt’s Center for Healthy Aging

The Centers for Disease Control (CDC) recently renewed funding for the Center for Healthy Aging in the Graduate School of Public Health (GSPH) for an additional five years until September 2009.

The Pitt center is dedicated to investigating ways to prevent disability and disease in seniors by teaching them how to work with their physicians to take charge of their health.

Lewis Kuller, professor of epidemiology at GSPH, said: “With the second largest senior population in the United States, Allegheny County is the best place to determine which prevention strategies lead to successful healthy aging. We are hoping our research and programs will lead to an overall better quality of life for senior citizens.”

The center first received CDC funding in October 2001 and, since then, researchers at the center have developed a list of keys for seniors to follow to aid in healthy aging. The “10 Keys to Healthy Aging” have the potential to impact the quality of life for older adults, to lower health care costs, to affect the direction of research and to influence health care policy and funding. Prevention of disease and health promotion through modification of lifestyle behaviors can help extend disability-free longevity. The prevention approaches are based on solid scientific research but are underutilized in the community. The major focus, therefore, is to increase the use of prevention programs for all older individuals in the community.

“The 10 Keys to Healthy Aging are supported by numerous studies. The center is moving into a new phase of spreading the keys and their message to seniors in Allegheny County,” said Constance M. Bayles, program director for the center. “Our plan is to use the funding from the CDC to continue our research efforts, train center participants to be ambassadors to the surrounding community and to promote prevention education to everyone, including medical professionals. Our ultimate goal is to take the 10 Keys to Healthy Aging and implement them on both a state and national level.”

The 10 Keys, selected on the basis of epidemiological, clinical and laboratory studies, are: maintaining social contacts; combating depression; increasing physical activity; stopping smoking; preventing bone loss; getting regular immunizations; participating in cancer screenings; lowering LDL cholesterol; controlling systolic blood pressure, and regulating blood glucose.

Along with Kuller and Bayles, Bob Goodman and Anne Newman are co-principal investigators of the project.

GSPH Dean Bernard Goldstein, along with Sen. Arlen Specter, worked to secure the funding for the center.

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Urologic research presented

Pitt researchers presented the results of several studies on incontinence and other urologic disorders at the American Urological Association meeting.

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Pure culture of muscle-derived stem cells not necessary in treatment for incontinence

A pure culture of muscle-derived stem cells (MDC) may not be needed to cure incontinence, according to a Pitt study.

“When isolating a specific type of cell for transplantation into the body, the common thought is that the cells must be a pure culture. Getting a pure culture of muscle-derived cells, free of contaminating fibroblasts, is difficult,” said Michael B. Chancellor, professor of urology in the School of Medicine. “But, if the fibroblasts don’t interfere with the muscle-derived cells, using these cells to regenerate muscle just got a great deal easier.”

In animal models of stress urinary incontinence, researchers injected muscle-derived cells, fibroblasts and a mixture of MDC and fibroblasts into the tissue surrounding the urethra. Prior to injection, the models showed a significant decrease in leak point pressure, the point where the bladder leaks passively.

Post-injection, all three groups showed an improved leak point pressure of the surrounding urethral tissue. Four weeks post-injection, MDC, fibroblasts and the combination MDC/fibroblast mixture were still present at their respective injection sites. There were no complications.

Fibroblasts did not interfere with the MDC ability to improve leak point pressure. However, the mechanism by which leak point pressure was improved, whether it be muscle regeneration from the MDC or a bulking effect from the fibroblasts, is still being investigated.

Prior animal model studies by the Pitt group have found that MDC were able to regenerate deficient urethral muscle.

In addition to Chancellor, Irmute Usiene, Ron Jankowski, Ryan Pruchnic, Dongdeuk Kwon, Johnny Huard and Fernando de Miguel, all from the University, contributed to this study.

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Contrary to common belief, bladders do not shrink with age

The idea that your bladder shrinks as you get older may be nothing more than an old wives’ tale, according to a University study. The symptoms caused by what was believed to be a shrinking bladder may, however, signal a treatable underlying condition.

“Many of us, after reaching a certain age, notice that we have to urinate more frequently and with more urgency. The standard assumption, that seems to have become part of our folklore, is that your bladder shrinks as you get older. We found that this may not be the case,” said Neil Resnick, professor and chief, Division of Geriatric Medicine in the School of Medicine.

In the study, the researchers compared data on a number of variables including bladder capacity and stability, urethral closure pressure, voiding flow rate and detrusor contraction strength from 95 females between the ages of 22 and 90. The researchers found that while bladder and urethral function deteriorate throughout adult life, bladder capacity rarely changes.

Women with normally aging bladders had weaker bladder sensation, while women who experienced increased bladder sensation actually had an underlying condition called detrusor overactivity (DO). DO is a common condition, often referred to as overactive bladder, where the detrusor muscle that controls the emptying of the bladder contracts involuntarily, creating a strong, sometimes uncontrollable urge to empty the bladder.

“Now, when a woman comes to her doctor and says that she thinks her bladder is shrinking, we realize that it is more likely she suffers from DO than from a smaller bladder,” Resnick said. “The good news is that DO is treatable, so that any woman experiencing urgency or incontinence should see her doctor.”

Over 17 million Americans suffer from overactive bladder. An estimated 80 percent of these patients do not seek help or treatment for this condition. Overactive bladder is characterized by the following conditions: frequency — urinating more than eight times in a 24-hour period; urgency — the immediate and strong urge to urinate, and, for some, urge incontinence — the inability to suppress urgency resulting in the leaking or loss of urine.

In addition to Resnick, Werner Schaefer and Derek Griffiths both from Pitt, and Mathias Pfisterer from the University of Heidelberg, Germany, contributed to this research.

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Common incontinence drug may have a topical effect on bladder itself

A commonly prescribed incontinence drug may help patients in more than one way, according to research completed at Pitt.

When taken orally, trospium chloride not only helps control symptoms of overactive bladder systemically but, according to this study, it also may help control symptoms in the bladder itself when it comes into contact with the bladder walls.

“When taken orally, certain classes of drugs can control the muscle contractions that cause conditions like overactive bladder. In this study, we have found one drug, trospium, reacts with the bladder muscle as urine is stored in the bladder,” said Michael Chancellor, professor of urology in the School of Medicine.

In the study, urine samples from human subjects taking the anti-muscarinic drugs trospium, tolterodine LA and oxybutynin XL and from control subjects were instilled into the bladders of animal models.

Researchers induced bladder overactivity using carbachol. The trospium bladder did not react to the carbachol, indicating that the trospium had a topical effect on controlling the muscle contractions. In the control tol-terodine- and oxybutynin-treated bladders, the length of time between bladder contractions and the bladder’s capacity were decreased, representing overactive bladder-type conditions and indicating no topical effect.

Anti-muscarinic drugs block receptors in the bladder responsible for smooth muscle contractions. By easing the muscle contractions, the number of incontinence episodes are reduced and bladder capacity is increased. Common urologic conditions like overactive bladder are caused by involuntary contractions of the detrusor muscle, which controls the bladder.

In addition to Chancellor, Yong Tae Kim, Hitoshi Masuda and Fernando de Miguel, all from Pitt’s School of Medicine, contributed to this study.

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Markers for painful pelvic disease, interstitial cystitis, identified

University researchers have isolated two biomarkers for interstitial cystitis (IC), a chronic and painful pelvic disease for which there currently is no test. The discovery of these biomarkers could lead to a definitive test for IC and has the potential to lead to new therapies.

“IC is a frustrating disease for patients because, to this point, there is no accurate way of diagnosing the condition. Patients undergo a variety of tests to rule out other diseases, all while experiencing significant pain and discomfort. Only after these tests come back negative can a doctor make the diagnosis of IC,” said Michael Chancellor, professor of urology in the School of Medicine.

“Finding a marker for IC can not only make developing an early test for IC possible, but it can lead to new targeted molecular therapies for the condition,” said Fernando de Miguel, assistant professor of urology at the School of Medicine.

In the first study, titled “Identification of Nuclear Proteins in the Chronic Cystitic Rat Model,” researchers used a proteomic approach to identify specific markers related to IC. By comparing protein expression in the bladder tissue of two animal models of IC to expression in the tissue of a normal animal, the researchers found three nuclear proteins that were unique to the animals with IC. Using protein mass fingerprinting, the proteins were identified as transgelin (SM-22), ras suppressor protein (RSU-1) and GAPDH.

In the second study, titled “Time-point study of the Regulation of Nuclear Protein SM-22 (Transgelin) in the Rat Cystitis Model,” the researchers expanded their investigation into the expression of SM-22 in both normal and IC-model bladders. The bladders were instilled with hydrochloric acid; tissue was analyzed at one, four, seven, 13 and 28 days after instillation. After days one and four, there was a noticeable down-regulation of SM-22 in the IC-model bladders; by day 28, there was a reduction by 31 percent of the SM-22 in the diseased models.

The early down-regulation of SM-22, evident as early as day one, shows that the absence of SM-22 potentially can be used as an early diagnostic marker for IC. Pitt researchers plan to conduct more research into SM-22 to determine the protein’s functional role, which could lead the way to future molecular-targeted therapies.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, 700,000 Americans have IC; 90 percent are women. IC is one of the chronic pelvic pain disorders, defined by recurring discomfort or pain in the bladder and surrounding pelvic region.

Also contributing to this research were Thu-Suong Van Le, Uukio Hayashi, Shachi Tyagi and Naoki Yoshimura, all from Pitt.

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Liver donations from extended criteria donors on the increase

Patients who received livers from hepatitis B virus (HBV) core antibody (HBcAb) positive (indicates prior exposure to hepatitis B) and/or hepatitis C virus (HCV) positive donors had similar graft and patient survival compared to patients who received HBcAb negative or HCV negative livers, according to a study by Pitt’s Thomas E. Starzl Transplantation Institute.

The research findings were presented at the sixth annual American Transplant Congress, the joint scientific meeting of the American Society of Transplant Surgeons and the American Society of Transplantation.

To help alleviate the shortage of organs, there has been an increase in the transplantation of livers obtained from extended criteria donors, such as organs from HBcAb positive and HCV positive donors.

In the Pitt study, the researchers conducted a seven-year review of liver transplant recipients who received HBV positive and HCV positive organs between 1997 and 2004.

The patients were divided into three groups. Group one consisted of 28 patients who received both HBcAb positive and HCV positive livers; the second group consisted of 58 patients who received HBcAb positive livers, and the third group consisted of 34 patients who received HCV positive livers. Patient and graft survival and recurrence of the HBV and HCV infections were compared between the various groups of patients.

Michael E. de Vera, assistant professor of surgery at the Thomas E. Starzl Transplantation Institute and lead author of the study, concluded that the use of HBV and/or HCV positive livers for organ donation is safe. HBV recurrence is minimal with the use of HBV prophylaxis and HCV recurrence is similar to that of HCV patients who receive HCV negative livers.

“These findings substantiate the practice of transplanting HBcAb positive and/or HCV positive livers. When selected properly for transplantation, these organs are often of good quality, and so long as they are transplanted to the appropriate recipients, long-term results are comparable to patients who receive livers from HBV- or HCV-negative donors,” according to Amadeo Marcos, chief, clinical transplantation at the Thomas E. Starzl Transplantation Institute.

Collaborators included Kusum Tom, Paulo Fontes, Wallish Marsh, Bijan Eghtesad and Paul Lignoski from the Center for Organ Recovery and Education.

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Public confused & influenced by journal articles on health care

The general public may not be reading the Archives of General Psychiatry or the New England Journal of Medicine, but they are basing important health care decisions and lifestyle changes on the research findings that these and other journals publish, particularly when such findings concern risk factors.

Moreover, these scientific reports frequently are interpreted by clinicians, policy makers and the news media as calls to action, only later to be refuted or questioned by conflicting studies that may even claim serious and harmful consequences from those actions.

“What is a risk? What is a risk factor? Are all risk factors equal? What is the threshold for true clinical significance?” David J. Kupfer, Thomas P. Detre Professor and chairman of psychiatry at the School of Medicine, asked his colleagues at the American Psychiatric Association annual meeting.

“The general public can’t be expected to understand these questions, let alone know the answers. Yet, ultimately, they are the ones who are most affected by journal articles that include words like ‘risk’ that even some of us working in research are not accurately defining.”

Researchers must be more rigorous in how they design and conduct clinical studies as well as be more mindful of the language they use to describe their findings in the scientific literature or in writing reviews of other research, asserted Kupfer.

Kupfer is co-author of the recently published “To Your Health: How to Understand What Research Tells Us About Risk.”

According to Kupfer, a look at the past year’s newspaper headlines about antidepressants being linked to increased risk of suicide in children and adolescents exemplifies how research influences society and yet can paint a confusing picture.

“In truth, these studies, which received much attention from the press, overestimated the risk and underestimated the benefit of prescribing antidepressants to children and teens. But clinicians and parents alike were at a loss to understand their meaning.

“How do we sort out these contradictions?” asked Kupfer. “We have a responsibility to the general public, who on a daily basis hear about new findings or ways to reduce risks of disease that are extrapolated from a study and then reported by the media.”

Kupfer believes that to advance medical science and promote public health, research must be both flawless and accurately presented.

In order to generate more reliable and meaningful findings, Kupfer urges researchers to be more precise in defining, understanding and evaluating types of risk factors, including their statistical and clinical significance, and to be more discerning of others’ published results that may form the basis of their own research or be cited in their own publications.

“If we are rigorous in organizing, conducting, presenting and evaluating scientific research — specifically psychiatric research — then we are taking important steps in fitting this research into the larger framework of discovering the causes and ways to prevent diseases and disorders. We are responsible for the quality of the studies that we conduct and for the interpretation of our studies to the media, the general public and our colleagues. These new standards are aimed at raising the bar and will ultimately encourage well-designed and correctly interpreted research that will help in our shared goal of advancing science,” Kupfer said.

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“Wet” electron technology potentially could produce clean fuel

The task of transporting electrical charges between metal-oxide and water phases is critical in such technologies as catalysis, sensors and electrochemistry. In a paper published recently in the journal Science, University researchers report that “wet” electrons afford the lowest energy pathway for transporting electrons between solid and liquid states.

In this paper, Hrvoje Petek, professor of physics and co-director of Pitt’s Institute of NanoScience and Engineering, and Kenneth Jordan, professor and chair of the Department of Chemistry, extend Jordan’s previous work on the structure of electrons in small water clusters, which was named one of the top 10 breakthroughs of 2004 by Science.

Wet electrons, which occur on metal oxide surfaces, represent a transition point for electrons between solid and liquid states of matter.

A tiny amount of water from the atmosphere sticks to the surfaces of the oxides and forms hydroxide molecules, which then act like “molecular-scale Velcro,” said Petek. In the presence of energy, their positively charged hydrogen atoms attract negatively charged electrons. Those so-called “wet” electrons then determine how other molecules interact with the surfaces of metal oxides.

The researchers gave the electrons sufficient energy to achieve the wet state by directing short bursts of laser light at titanium dioxide. Titanium dioxide was used because it is a photocatalyst: Exposure to light excites its electrons, which split water molecules into hydrogen and oxygen. Because of this potential for making hydrogen from water, it is possible that titanium dioxide could be used to make a clean fuel — but the process remains inefficient, said Petek. “If we could find out how to make it more efficient by observing how electrons interact with hydrogen atoms, it would have a huge economic impact,” he added.

Petek’s research also could illuminate the interaction between protons and electrons in such biological processes as photosynthesis, in which light energy is converted to chemical energy through correlated transport of protons and electrons, which Petek calls similar to a wet electron system “on a fundamental level.”

Petek plans to continue research on the properties of other oxide materials. In the recent paper, the researchers note that conditions exist to support similar states on all oxide surfaces in contact with water or with a humid atmosphere.

The paper’s other authors are Ken Onda, Bin Li and Jin Zhao of Pitt’s Department of Physics and Astronomy, and Jinlong Yang, a professor at the University of Science and Technology of China.

This research was supported by the U.S. Department of Defense multidisciplinary university research initiative program, the New Energy and Industrial Technology Development Organization (Japan) and the National Science Foundation.

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Gene therapy trial for arthritis shows approach is safe, feasible

Gene therapy for arthritis and other non-terminal, debilitating conditions and diseases is both feasible and safe, report researchers who conducted the world’s first such test on the approach in patients with advanced rheumatoid arthritis.

The results, published in this week’s online edition of the Proceedings of the National Academy of Sciences (PNAS), indicate that introducing a new gene has the potential to block the destructive inflammation process that takes place within arthritic joints.

The clinical trial, which was conducted at Pitt between 1996 and 1999, involved nine women who had genetically modified cells injected into their arthritic knuckles. It marked the first time a gene was introduced into a human joint. The researchers say their results showing that successful gene transfer can target joint inflammation open the door to the development of improved gene-based therapies for both rheumatoid and the more common osteoarthritis, which together affect about 66 million people in the United States.

While the Pitt study used the same vector as a more recent French trial for X-linked severe combined immunodeficiency (X-SCID) in which three children later developed leukemia, the researchers point out that this is the only similarity between the two trials. In the arthritis trial, the transduced cells were removed after one week during routine joint replacement surgery. The authors report no clinical side effects up to five years after the procedure.

“Our primary objective was proving the safety of gene therapy. Once we learned of the adverse events in the X-SCID trial, we decided it was best to extend follow-up of our patients to five years so that there’d be little question about long-term safety,” explained Christopher Evans, the study’s lead author, now at Brigham and Women’s Hospital and Harvard Medical School.

In rheumatoid arthritis, immune system cells called macrophages and lymphocytes colonize the lining of joints where they release proteins called cytokines that modulate communication between the immune cells and synovial cells, the cells that line the joint. As the researchers discovered in earlier animal studies, synovial cells have a receptor on their surface that’s a perfect fit for a particular cytokine, interleukin-1, or IL-1. Like a switch, when IL-1 binds to this receptor, the cell unleashes additional biochemical agents, which in turn cause more local inflammation. As inflammation builds, patients experience progressively worse pain and stiffness in their affected joints.

To block this process, the team sought a way to prevent the main actor, IL-1, from binding to the synovial cells, and hence, setting off the destructive chain reaction that follows. In essence, they needed a way to plug up the receptor and found such a device in a gene encoding the IL-1 receptor antagonist, or IL-1 Ra.

Because it was the first trial of its kind and safety was a key concern, the protocol was designed so that the gene would be delivered to cells that had previously been removed from patients and then, after gene transfer, reintroduced several weeks later after intensive screening and determination of gene expression.

“Given that gene therapy was so new and we were dealing with an otherwise healthy patient population, the ex vivo protocol was the most appropriate approach to take at the time,” stated Paul Robbins, professor of molecular genetics and biochemistry and orthopaedic surgery at Pitt’s School of Medicine, who was the study’s co-principal investigator and then director of the University of Pittsburgh’s Viral Vector Core Facility.

According to their results, joints treated with the genetically modified cells exhibited high levels of IL-1 Ra, indicating successful gene transfer. Clusters of cells that expressed large amounts of the gene were present at the surface of the synovial tissue and produced significantly less of the inflammation-provoking IL-6 and PGE 2 than cells within joints that were not treated with the gene.

The nine women enrolled in the trial were between 49 and 73 years of age and had been living with rheumatoid arthritis for between 10 and 26 years. Each was scheduled for joint replacement surgery involving the four knuckles on one of their hands and one additional joint. In the weeks prior to joint replacement surgery, synovial tissue was removed from the additional joint that required surgery. Cells from the tissue were then cultured for several weeks, after which time half the cells had the IL-1 Ra gene inserted and half remained untreated. Six to seven weeks later, following extensive laboratory screening of the genetically modified cells, patients returned to the clinic, where the cells were injected into four knuckles in a double-blind fashion, with two knuckles receiving the gene-modified cells, and two knuckles receiving injections of cells with no added gene. One week later, at the time of the patient’s previously scheduled surgery, the four knuckles were removed for study and replaced with artificial joints.

In their animal studies that preceded the clinical trial, the researchers had noted that a small percentage of injected cells could escape to other tissues within one week. But with five years follow-up, the authors have seen no evidence that these genetically modified cells have caused any adverse events in their nine patients.

Although the ex vivo approach did prove safe and was able to confer gene expression within arthritic joints, the authors contend that it also was tedious, time-consuming and expensive. At this point they would advocate a more direct in vivo approach — introducing the gene directly to affected tissue — using as the vector an adeno-associated virus (AAV) instead of the vector used in the trial reported in PNAS. AAV appears to have a good safety profile and, in animals, facilitates more extended gene expression. Investigators hope to conduct additional trials in both osteoarthritis and rheumatoid arthritis using AAV to transport the gene.

Other study authors are James H. Herndon, also now at Harvard; Steven C. Ghivizzani, now at the University of Florida; Mary Chester Wasko, Molly Vogt, Theresa L. Whiteside, Elaine Elder and Simon C. Watkins, all from Pitt; Matthew M. Tomaino, now at University of Rochester Medical School; and Richard Kang and Thomas A. Muzzonigro, both now in private practice.