Orthopaedic Manifestations of Neurofibromatosis Type I.

Neurofibromatosis type 1 (NF1) is a congenital disease which is caused by mutations in the NF1 gene on chromosome 17, resulting in an altered function of the neurofibromin protein. Owing to the ubiquitous expression of this protein, this syndrome is associated with pathology in many organ systems of the body, especially the central and peripheral nervous, musculoskeletal, and integumentary systems. This review outlines the common sequelae related to a diagnosis of NF1 and the common treatment approach to each.

Concurrent and long-term associations between the endometrial microbiota and endometrial transcriptome in postpartum dairy cows.

BACKGROUND: Fertility in dairy cows depends on ovarian cyclicity and on uterine involution. Ovarian cyclicity and uterine involution are delayed when there is uterine dysbiosis (overgrowth of pathogenic bacteria). Fertility in dairy cows may involve a mechanism through which the uterine microbiota affects ovarian cyclicity as well as the transcriptome of the endometrium within the involuting uterus. The hypothesis was that the transcriptome of the endometrium in postpartum cows would be associated with the cyclicity status of the cow as well as the microbiota during uterine involution. The endometrium of first lactation dairy cows was sampled at 1, 5, and 9 weeks postpartum. All cows were allowed to return to cyclicity without intervention until week 5 and treated with an ovulation synchronization protocol so that sampling at week 9 was on day 13 of the estrous cycle. The endometrial microbiota was measured by 16S rRNA gene sequencing and principal component analysis. The endometrial transcriptome was measured by mRNA sequencing, differential gene expression analysis, and Ingenuity Pathway Analysis. RESULTS: The endometrial microbiota changed from week 1 to week 5 but the week 5 and week 9 microbiota were similar. The endometrial transcriptome differed for cows that were either cycling or not cycling at week 5 and cyclicity status depended in part on the endometrial microbiota. Compared with cows cycling at week 5, there were large changes in the transcriptome of cows that progressed from non-cycling at week 5 to cycling at week 9. There was evidence for concurrent and longer-term associations between the endometrial microbiota and transcriptome. The week 1 endometrial microbiota had the greatest effect on the subsequent endometrial transcriptome and this effect was greatest at week 5 and diminished by week 9. CONCLUSIONS: The cumulative response of the endometrial transcriptome to the microbiota represented the combination of past microbial exposure and current microbial exposure. The endometrial transcriptome in postpartum cows, therefore, depended on the immediate and longer-term effects of the uterine microbiota that acted directly on the uterus. There may also be an indirect mechanism through which the microbiome affects the transcriptome through the restoration of ovarian cyclicity postpartum.

Structural Variability of EspG Chaperones from Mycobacterial ESX-1, ESX-3, and ESX-5 Type VII Secretion Systems.

Type VII secretion systems (ESX) are responsible for transport of multiple proteins in mycobacteria. How different ESX systems achieve specific secretion of cognate substrates remains elusive. In the ESX systems, the cytoplasmic chaperone EspG forms complexes with heterodimeric PE-PPE substrates that are secreted from the cells or remain associated with the cell surface. Here we report the crystal structure of the EspG1 chaperone from the ESX-1 system determined using a fusion strategy with T4 lysozyme. EspG1 adopts a quasi 2-fold symmetric structure that consists of a central ß-sheet and two α-helical bundles. In addition, we describe the structures of EspG3 chaperones from four different crystal forms. Alternate conformations of the putative PE-PPE binding site are revealed by comparison of the available EspG3 structures. Analysis of EspG1, EspG3, and EspG5 chaperones using small-angle X-ray scattering reveals that EspG1 and EspG3 chaperones form dimers in solution, which we observed in several of our crystal forms. Finally, we propose a model of the ESX-3 specific EspG3-PE5-PPE4 complex based on the small-angle X-ray scattering analysis.

Three-dimensional printing improves osteochondral allograft placement in complex cases.

The use of three-dimensional (3D) printing has seen a vast expansion over recent years, with an increased application for its use in orthopaedics. This report details the use of 3D printing technology to aid in the treatment of a medial femoral condyle osteochondral defect in a 26-year-old female who had previously undergone a failed autograft procedure. A preoperative computed tomography scan of the knee and chondral defect was used to generate a 3D printed, one-to-one scale replica of the distal femur. This replica was then used to size a patient-specific allograft plug for the osteochondral transplantation procedure. The patient recovered well, and 1 year postoperatively the allograft was well incorporated into the medial femoral condyle and healed. This report illustrates the advantages of using a 3D printed model to allow for tactile feedback and improved visualization that will allow for improved understanding of complex surgical procedures.Level of evidence V.

Structures of EccB1 and EccD1 from the core complex of the mycobacterial ESX-1 type VII secretion system.

BACKGROUND: The ESX-1 type VII secretion system is an important determinant of virulence in pathogenic mycobacteria, including Mycobacterium tuberculosis. This complicated molecular machine secretes folded proteins through the mycobacterial cell envelope to subvert the host immune response. Despite its important role in disease very little is known about the molecular architecture of the ESX-1 secretion system. RESULTS: This study characterizes the structures of the soluble domains of two conserved core ESX-1 components - EccB1 and EccD1. The periplasmic domain of EccB1 consists of 4 repeat domains and a central domain, which together form a quasi 2-fold symmetrical structure. The repeat domains of EccB1 are structurally similar to a known peptidoglycan binding protein suggesting a role in anchoring the ESX-1 system within the periplasmic space. The cytoplasmic domain of EccD1has a ubiquitin-like fold and forms a dimer with a negatively charged groove. CONCLUSIONS: These structures represent a major step towards resolving the molecular architecture of the entire ESX-1 assembly and may contribute to ESX-1 targeted tuberculosis intervention strategies.

Deficits in Glenohumeral Passive Range of Motion Increase Risk of Shoulder Injury in Professional Baseball Pitchers: A Prospective Study.

BACKGROUND: Shoulder injuries from repetitive baseball pitching continue to be a serious, common problem. PURPOSE: To determine whether passive range of motion of the glenohumeral joint was predictive of shoulder injury or shoulder surgery in professional baseball pitchers. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Passive range of motion of the glenohumeral joint was assessed with a bubble goniometer during spring training for all major and minor league pitchers of a single professional baseball organization over a period of 8 successive seasons (2005-2012). Investigators performed a total of 505 examinations on 296 professional pitchers. Glenohumeral external and internal rotation was assessed with the pitcher supine and the arm abducted to 90° in the scapular plane with the scapula stabilized anteriorly at the coracoid process. Total rotation was defined as the sum of internal and external glenohumeral rotation. Passive shoulder flexion was measured with the pitcher supine and the lateral border of the scapula manually stabilized. After examination, shoulder injuries and injury durations were recorded by each pitcher's respective baseball organization and reported to the league as an injury transaction as each player was placed on the disabled list. RESULTS: Highly significant side-to-side differences were noted within subjects for each range of motion measurement. There were 75 shoulder injuries and 20 surgeries recorded among 51 pitchers, resulting in 5570 total days on the disabled list. Glenohumeral internal rotation deficit, total rotation deficit, and flexion deficit were not significantly related to shoulder injury or surgery. Pitchers with insufficient external rotation (<5° greater external rotation in the throwing shoulder) were 2.2 times more likely to be placed on the disabled list for a shoulder injury (P = .014; 95% CI, 1.2-4.1) and were 4.0 times more likely to require shoulder surgery (P = .009; 95% CI, 1.5-12.6). CONCLUSION: Insufficient shoulder external rotation on the throwing side increased the likelihood of shoulder injury and shoulder surgery. Sports medicine clinicians should be aware of these findings and develop a preventive plan that addresses this study's findings to reduce pitchers' risk of shoulder injury and surgery.

Structure of EspB, a secreted substrate of the ESX-1 secretion system of Mycobacterium tuberculosis.

Mycobacterium tuberculosis secretes multiple virulence factors during infection via the general Sec and Tat pathways, and via specialized ESX secretion systems, also referred to as type VII secretion systems. The ESX-1 secretion system is an important virulence determinant because deletion of ESX-1 leads to attenuation of M. tuberculosis. ESX-1 secreted protein B (EspB) contains putative PE (Pro-Glu) and PPE (Pro-Pro-Glu) domains, and a C-terminal domain, which is processed by MycP1 protease during secretion. We determined the crystal structure of PE-PPE domains of EspB, which represents an all-helical, elongated molecule closely resembling the structure of the PE25-PPE41 heterodimer despite limited sequence similarity. Also, we determined the structure of full-length EspB, which does not have interpretable electron density for the C-terminal domain confirming that it is largely disordered. Comparative analysis of EspB in cell lysate and culture filtrates of M. tuberculosis revealed that mature secreted EspB forms oligomers. Electron microscopy analysis showed that the N-terminal fragment of EspB forms donut-shaped particles. These data provide a rationale for the future investigation of EspB's role in M. tuberculosis pathogenesis.

Visualization and reduction of a mensical capsular junction tear in the knee: an arthroscopic surgical technique.

Meniscal injuries commonly occur concomitantly with anterior cruciate ligament (ACL) injuries. Although many types of meniscal injuries have been described in the literature, there has not been much focus on meniscal capsular junction (MCJ) tears. This lack of attention is concerning given that, in a survey of 67 orthopedic surgeons, 88% indicated that MCJ tears could be a source of chronic pain. In addition, we reviewed 781 ACL reconstructions at our clinic and found a 12.3% incidence of MCJ tear with primary ACL injury and a 23.6% incidence of MCJ tear with revision ACL reconstruction. In this article, we describe an arthroscopic repair technique for MCJ tears at the posterior aspect of the medial meniscus root. The repair uses an accessory posterior medial portal. The technique can also be used for significant posterior medial capsular tears.

Structure of the Mycobacterium tuberculosis type VII secretion system chaperone EspG5 in complex with PE25-PPE41 dimer.

The growth or virulence of Mycobacterium tuberculosis bacilli depends on homologous type VII secretion systems, ESX-1, ESX-3 and ESX-5, which export a number of protein effectors across membranes to the bacterial surface and environment. PE and PPE proteins represent two large families of highly polymorphic proteins that are secreted by these ESX systems. Recently, it was shown that these proteins require system-specific cytoplasmic chaperones for secretion. Here, we report the crystal structure of M. tuberculosis ESX-5-secreted PE25-PPE41 heterodimer in complex with the cytoplasmic chaperone EspG(5). EspG(5) represents a novel fold that is unrelated to previously characterized secretion chaperones. Functional analysis of the EspG(5) -binding region uncovered a hydrophobic patch on PPE41 that promotes dimer aggregation, and the chaperone effectively abolishes this process. We show that PPE41 contains a characteristic chaperone-binding sequence, the hh motif, which is highly conserved among ESX-1-, ESX-3- and ESX-5-specific PPE proteins. Disrupting the interaction between EspG(5) and three different PPE target proteins by introducing different point mutations generally affected protein secretion. We further demonstrate that the EspG(5) chaperone plays an important role in the ESX secretion mechanism by keeping aggregation-prone PE-PPE proteins in their soluble state.

Pentapeptide boronic acid inhibitors of Mycobacterium tuberculosis MycP1 protease.

Mycosin protease-1 (MycP1) cleaves ESX secretion-associated protein B (EspB) that is a virulence factor of Mycobacterium tuberculosis, and accommodates an octapeptide, AVKAASLG, as a short peptide substrate. Because peptidoboronic acids are known inhibitors of serine proteases, the synthesis and binding of a boronic acid analog of the pentapeptide cleavage product, AVKAA, was studied using MycP1 variants from Mycobacterium thermoresistible (MycP1mth), Mycobacterium smegmatis (MycP1msm) and M. tuberculosis (MycP1mtu). We synthesized the boropentapeptide, HAlaValLysAlaAlaB(OH)2 (1) and the analogous pinanediol PD-protected HAlaValLysAlaAlaBO2(PD) (2) using an Fmoc/Boc peptide strategy. The pinanediol boropentapeptide 2 displayed IC50 values 121.6±25.3 µM for MycP1mth, 93.2±37.3 µM for MycP1msm and 37.9±5.2 µM for MycP1mtu. Such relatively strong binding creates a chance for crystalizing the complex with 2 and finding the structure of the unknown MycP1 catalytic site that would potentially facilitate the development of new anti-tuberculosis drugs.

Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: a prospective study.

BACKGROUND: Injuries to the elbow joint in baseball pitchers appear common. There appears to be a correlation between shoulder range of motion and elbow injuries. PURPOSE: To prospectively determine whether decreased ROM of the throwing shoulder is correlated with the onset of elbow injuries in professional baseball pitchers. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: For 8 consecutive years (2005-2012), passive range of motion of both the throwing and nonthrowing shoulders of all major and minor league pitchers within a single professional baseball organization were measured by using a bubble goniometer during spring training. In total, 505 examinations were conducted on 296 pitchers. Glenohumeral external rotation and internal rotation were assessed in the supine position with the arm at 90° of abduction and in the plane of the scapula. The scapula was stabilized per methods previously established. Total rotation was defined as the sum of external rotation and internal rotation. Passive shoulder flexion was assessed with the subject supine and the scapula stabilized per methods previously established. Elbow injuries and days missed because of elbow injuries were assessed and recorded by the medical staff of the team. Throwing and nonthrowing shoulder measurements were compared by using Student t tests; 1-tailed Fisher exact tests were performed to identify significant associations between shoulder motion and elbow injury. Nominal logistic regression was performed to determine the odds of elbow injury. RESULTS: Significant differences were noted during side-to-side comparisons within subjects. There were 49 elbow injuries and 8 surgeries in 38 players, accounting for a total of 2551 days missed. Neither glenohumeral internal rotation deficit nor external rotation insufficiency was correlated with elbow injuries. Pitchers with deficits of >5° in total rotation in their throwing shoulders had a 2.6 times greater risk for injury. Pitchers with deficit of ≥5° in flexion of the throwing shoulder had a 2.8 times greater risk for injury. CONCLUSION: Bilateral differences in shoulder total rotation and flexion had a significant effect on the risk for elbow injuries in pitchers. Clinicians need to be aware of these findings and plan preventive programs that address these issues in hopes of reducing elbow injuries.

Novel mycosin protease MycP1 inhibitors identified by virtual screening and 4D fingerprints.

The rise of drug-resistant Mycobacterium tuberculosis lends urgency to the need for new drugs for the treatment of tuberculosis (TB). The identification of a serine protease, mycosin protease-1 (MycP1), as the crucial agent in hydrolyzing the virulence factor, ESX-secretion-associated protein B (EspB), potentially opens the door to new tuberculosis treatment options. Using the crystal structure of mycobacterial MycP1 in the apo form, we performed an iterative ligand- and structure-based virtual screening (VS) strategy to identify novel, nonpeptide, small-molecule inhibitors against MycP1 protease. Screening of ∼485,000 ligands from databases at the Genomics Research Institute (GRI) at the University of Cincinnati and the National Cancer Institute (NCI) using our VS approach, which integrated a pharmacophore model and consensus molecular shape patterns of active ligands (4D fingerprints), identified 81 putative inhibitors, and in vitro testing subsequently confirmed two of them as active inhibitors. Thereafter, the lead structures of each VS round were used to generate a new 4D fingerprint that enabled virtual rescreening of the chemical libraries. Finally, the iterative process identified a number of diverse scaffolds as lead compounds that were tested and found to have micromolar IC50 values against the MycP1 target. This study validated the efficiency of the SABRE 4D fingerprints as a means of identifying novel lead compounds in each screening round of the databases. Together, these results underscored the value of using a combination of in silico iterative ligand- and structure-based virtual screening of chemical libraries with experimental validation for the identification of promising structural scaffolds, such as the MycP1 inhibitors.

Crystal structure of the N-terminal domain of EccA1 ATPase from the ESX-1 secretion system of Mycobacterium tuberculosis.

EccA1 is an important component of the type VII secretion system (T7SS) that is responsible for transport of virulence factors in pathogenic mycobacteria. EccA1 has an N-terminal domain of unknown function and a C-terminal AAA+ (ATPases associated with various cellular activities) domain. Here we report the crystal structure of the N-terminal domain of EccA1 from Mycobacterium tuberculosis, which shows an arrangement of six tetratricopeptide repeats that may mediate interactions of EccA1 with secreted substrates. Furthermore, the size and shape of the N-terminal domain suggest its orientation in the context of a hexamer model of full-length EccA1.

Understanding specificity of the mycosin proteases in ESX/type VII secretion by structural and functional analysis.

Mycobacteria use specialized ESX secretion systems to transport proteins across their cell membranes in order to manipulate their environment. In pathogenic Mycobacterium tuberculosis there are five paralogous ESX secretion systems, named ESX-1 through ESX-5. Each system includes a subtilisin-like protease (mycosin or MycP) as a core component essential for secretion. Here we report crystal structures of MycP1 and MycP3, the mycosins expressed by the ESX-1 and ESX-3 systems, respectively. In both mycosins the putative propeptide wraps around the catalytic domain and does not occlude the active site. The extensive contacts between the putative propeptide and catalytic domain, which include a disulfide bond, suggest that the N-terminal extension is an integral part of the active mycosin. The catalytic residues of MycP1 and MycP3 are located in a deep active site groove in contrast with an exposed active site in majority of subtilisins. We show that MycP1 specifically cleaves ESX-1 secretion-associated protein B (EspB) in vitro at residues Ala358 and Ala386. We also systematically characterize the specificity of MycP1 using peptide libraries, and show that it has evolved a narrow specificity relative to other subtilisins. Finally, comparison of the MycP1 and MycP3 structures suggest that both enzymes have stringent and different specificity profiles that result from the structurally distinct active site pockets, which could explain the system specific functioning of these proteases.

Assembly of the type II secretion system such as found in Vibrio cholerae depends on the novel Pilotin AspS.

The Type II Secretion System (T2SS) is a molecular machine that drives the secretion of fully-folded protein substrates across the bacterial outer membrane. A key element in the machinery is the secretin: an integral, multimeric outer membrane protein that forms the secretion pore. We show that three distinct forms of T2SSs can be distinguished based on the sequence characteristics of their secretin pores. Detailed comparative analysis of two of these, the Klebsiella-type and Vibrio-type, showed them to be further distinguished by the pilotin that mediates their transport and assembly into the outer membrane. We have determined the crystal structure of the novel pilotin AspS from Vibrio cholerae, demonstrating convergent evolution wherein AspS is functionally equivalent and yet structurally unrelated to the pilotins found in Klebsiella and other bacteria. AspS binds to a specific targeting sequence in the Vibrio-type secretins, enhances the kinetics of secretin assembly, and homologs of AspS are found in all species of Vibrio as well those few strains of Escherichia and Shigella that have acquired a Vibrio-type T2SS.

Design and synthesis of inhaled p38 inhibitors for the treatment of chronic obstructive pulmonary disease.

This paper describes the identification and optimization of a novel series of DFG-out binding p38 inhibitors as inhaled agents for the treatment of chronic obstructive pulmonary disease. Structure based drug design and "inhalation by design" principles have been applied to the optimization of the lead series exemplied by compound 1a. Analogues have been designed to be potent and selective for p38, with an emphasis on slow enzyme dissociation kinetics to deliver prolonged lung p38 inhibition. Pharmacokinetic properties were tuned with high intrinsic clearance and low oral bioavailability in mind, to minimize systemic exposure and reduce systemically driven adverse events. High CYP mediated clearance and glucuronidation were targeted to achieve high intrinsic clearance coupled with multiple routes of clearance to minimize drug-drug interactions. Furthermore, pharmaceutical properties such as stability, crystallinity, and solubility were considered to ensure compatibility with a dry powder inhaler. 1ab (PF-03715455) was subsequently identified as a clinical candidate from this series with efficacy and safety profiles confirming its potential as an inhaled agent for the treatment of COPD.