11ß-HSD1 inhibition does not affect murine tumour angiogenesis but may exert a selective effect on tumour growth by modulating inflammation and fibrosis.

Glucocorticoids inhibit angiogenesis by activating the glucocorticoid receptor. Inhibition of the glucocorticoid-activating enzyme 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1) reduces tissue-specific glucocorticoid action and promotes angiogenesis in murine models of myocardial infarction. Angiogenesis is important in the growth of some solid tumours. This study used murine models of squamous cell carcinoma (SCC) and pancreatic ductal adenocarcinoma (PDAC) to test the hypothesis that 11ß-HSD1 inhibition promotes angiogenesis and subsequent tumour growth. SCC or PDAC cells were injected into female FVB/N or C57BL6/J mice fed either standard diet, or diet containing the 11ß-HSD1 inhibitor UE2316. SCC tumours grew more rapidly in UE2316-treated mice, reaching a larger (P<0.01) final volume (0.158 ± 0.037 cm3) than in control mice (0.051 ± 0.007 cm3). However, PDAC tumour growth was unaffected. Immunofluorescent analysis of SCC tumours did not show differences in vessel density (CD31/alpha-smooth muscle actin) or cell proliferation (Ki67) after 11ß-HSD1 inhibition, and immunohistochemistry of SCC tumours did not show changes in inflammatory cell (CD3- or F4/80-positive) infiltration. In culture, the growth/viability (assessed by live cell imaging) of SCC cells was not affected by UE2316 or corticosterone. Second Harmonic Generation microscopy showed that UE2316 reduced Type I collagen (P<0.001), whilst RNA-sequencing revealed that multiple factors involved in the innate immune/inflammatory response were reduced in UE2316-treated SCC tumours. 11ß-HSD1 inhibition increases SCC tumour growth, likely via suppression of inflammatory/immune cell signalling and extracellular matrix deposition, but does not promote tumour angiogenesis or growth of all solid tumours.

A dual role for the RNA helicase DHX34 in NMD and pre-mRNA splicing and its function in hematopoietic differentiation.

The DExD/H-box RNA helicase DHX34 is a nonsense-mediated decay (NMD) factor that together with core NMD factors coregulates NMD targets in nematodes and in vertebrates. Here, we show that DHX34 is also associated with the human spliceosomal catalytic C complex. Mapping of DHX34 endogenous binding sites using cross-linking immunoprecipitation (CLIP) revealed that DHX34 is preferentially associated with pre-mRNAs and locates at exon-intron boundaries. Accordingly, we observed that DHX34 regulates a large number of alternative splicing (AS) events in mammalian cells in culture, establishing a dual role for DHX34 in both NMD and pre-mRNA splicing. We previously showed that germline DHX34 mutations associated to familial myelodysplasia (MDS)/acute myeloid leukemia (AML) predisposition abrogate its activity in NMD. Interestingly, we observe now that DHX34 regulates the splicing of pre-mRNAs that have been linked to AML/MDS predisposition. This is consistent with silencing experiments in hematopoietic stem/progenitor cells (HSPCs) showing that loss of DHX34 results in differentiation blockade of both erythroid and myeloid lineages, which is a hallmark of AML development. Altogether, these data unveil new cellular functions of DHX34 and suggest that alterations in the levels and/or activity of DHX34 could contribute to human disease.

Geographic variation in the frequency and potency of postoperative opioid prescriptions for extremity fracture surgery. A retrospective cohort study.

Introduction: There is increasing evidence that the prescription opioid crisis is spreading internationally. However, there is scarce literature comparing contemporary prescribing practices between units in different countries, particularly in the context of this evolving international problem. We sought to determine the patterns of postoperative opioid prescribing in three hospitals from geographically distinct regions. Methods: This is a retrospective cohort study involving patients from three hospitals: XXX, Maine, USA; XXX, Scotland; and XXX, Australia. The health records, surgical details, and frequency and potency of discharge prescriptions were analyzed for 350 patients receiving surgery for isolated wrist or ankle fractures. Regression analysis was used to identify independent predictors of prescription opioid provision. Results: Following ankle fracture surgery, Aberdeen patients (OR 6.0, 95% CI 3.0-11.5) and Adelaide patients (11.8, 95% CI 4.1-39.6) were significantly more likely to receive a prescription for opioids than those in Augusta (p < 0.001). For distal radius fractures, this was also the case (Aberdeen OR 21.2, 95% CI 7.2-79.3, Adelaide OR 21.6, 95% CI 7.3-81.3). For both fracture groups, the potency of prescription provided (measured in morphine milligram equivalents) was not significantly different. When opioids were included in the discharge prescription, Adelaide prescribers favored strong opioids, Aberdeen prescribers selected weak opioids, and prescribers in Augusta chose an even distribution of both types (p < 0.001). Multivariate analysis demonstrated that the odds of receiving prescription opioids were significantly influenced by geographic location and decreased by advancing patient age. Conclusions: Geographic location is a key factor influencing the provision of postoperative opioids. We found no association with fracture type, patient demographic factors or intra-operative practices. Prescriber culture is likely an influential determinant of postoperative opioid provision. Emphasis on patient and prescriber education regarding the risks of prescription opioids and their potential long-term sequelae is key if we wish to change modifiable prescriber behavior.

RNA splicing is a key mediator of tumour cell plasticity and a therapeutic vulnerability in colorectal cancer.

Tumour cell plasticity is a major barrier to the efficacy of targeted cancer therapies but the mechanisms that mediate it are poorly understood. Here, we identify dysregulated RNA splicing as a key driver of tumour cell dedifferentiation in colorectal cancer (CRC). We find that Apc-deficient CRC cells have dysregulated RNA splicing machinery and exhibit global rewiring of RNA splicing. We show that the splicing factor SRSF1 controls the plasticity of tumour cells by controlling Kras splicing and is required for CRC invasion in a mouse model of carcinogenesis. SRSF1 expression maintains stemness in human CRC organoids and correlates with cancer stem cell marker expression in human tumours. Crucially, partial genetic downregulation of Srsf1 does not detrimentally affect normal tissue homeostasis, demonstrating that tumour cell plasticity can be differentially targeted. Thus, our findings link dysregulation of the RNA splicing machinery and control of tumour cell plasticity.

Opioid Prescription Following Wrist and Ankle Fracture Fixation in Scotland-Tradition Prevails.

The American 'opioid crisis' is rapidly spreading internationally. Perioperative opioid use increases the risk of long-term opioid use. We review opioid use following wrist and ankle fracture fixation across Scotland, establishing prescribing patterns and associations with patient, injury, or perioperative factors. Six Scottish orthopedic units contributed. A total of 598 patients were included. Patient demographics were similar across all sites. There was variation in anesthetic practice, length of stay, and AO fracture type (p < 0.01). For wrist fractures, 85.6% of patients received a discharge opioid prescription; 5.0% contained a strong opioid. There was no significant variation across the six units in prescribing practice. For ankle fractures, 82.7% of patients received a discharge opioid prescription; 17% contained a strong opioid. Dundee and Edinburgh used more strong opioids; Inverness and Paisley gave the least opioids overall (p < 0.01). Younger patient age, location, and length of stay were independent predictors of increased prescription on binary regression. Despite variability in perioperative practices, discharge opioid analgesic prescription remains overwhelmingly consistent. We believe that the biggest influence lies with the prescriber-institutional 'standard practice'. Education of these prescribing clinicians regarding the risk profile of opioids is key to reducing their use following surgery, thus lowering long-term opioid dependence.

RAC1B modulates intestinal tumourigenesis via modulation of WNT and EGFR signalling pathways.

Current therapeutic options for treating colorectal cancer have little clinical efficacy and acquired resistance during treatment is common, even following patient stratification. Understanding the mechanisms that promote therapy resistance may lead to the development of novel therapeutic options that complement existing treatments and improve patient outcome. Here, we identify RAC1B as an important mediator of colorectal tumourigenesis and a potential target for enhancing the efficacy of EGFR inhibitor treatment. We find that high RAC1B expression in human colorectal cancer is associated with aggressive disease and poor prognosis and deletion of Rac1b in a mouse colorectal cancer model reduces tumourigenesis. We demonstrate that RAC1B interacts with, and is required for efficient activation of the EGFR signalling pathway. Moreover, RAC1B inhibition sensitises cetuximab resistant human tumour organoids to the effects of EGFR inhibition, outlining a potential therapeutic target for improving the clinical efficacy of EGFR inhibitors in colorectal cancer.

Pervasive lesion segregation shapes cancer genome evolution.

Cancers arise through the acquisition of oncogenic mutations and grow by clonal expansion1,2. Here we reveal that most mutagenic DNA lesions are not resolved into a mutated DNA base pair within a single cell cycle. Instead, DNA lesions segregate, unrepaired, into daughter cells for multiple cell generations, resulting in the chromosome-scale phasing of subsequent mutations. We characterize this process in mutagen-induced mouse liver tumours and show that DNA replication across persisting lesions can produce multiple alternative alleles in successive cell divisions, thereby generating both multiallelic and combinatorial genetic diversity. The phasing of lesions enables accurate measurement of strand-biased repair processes, quantification of oncogenic selection and fine mapping of sister-chromatid-exchange events. Finally, we demonstrate that lesion segregation is a unifying property of exogenous mutagens, including UV light and chemotherapy agents in human cells and tumours, which has profound implications for the evolution and adaptation of cancer genomes.

Conserved temporal ordering of promoter activation implicates common mechanisms governing the immediate early response across cell types and stimuli.

The promoters of immediate early genes (IEGs) are rapidly activated in response to an external stimulus. These genes, also known as primary response genes, have been identified in a range of cell types, under diverse extracellular signals and using varying experimental protocols. Whereas genomic dissection on a case-by-case basis has not resulted in a comprehensive catalogue of IEGs, a rigorous meta-analysis of eight genome-wide FANTOM5 CAGE (cap analysis of gene expression) time course datasets reveals successive waves of promoter activation in IEGs, recapitulating known relationships between cell types and stimuli: we obtain a set of 57 (42 protein-coding) candidate IEGs possessing promoters that consistently drive a rapid but transient increase in expression over time. These genes show significant enrichment for known IEGs reported previously, pathways associated with the immediate early response, and include a number of non-coding RNAs with roles in proliferation and differentiation. Surprisingly, we also find strong conservation of the ordering of activation for these genes, such that 77 pairwise promoter activation orderings are conserved. Using the leverage of comprehensive CAGE time series data across cell types, we also document the extensive alternative promoter usage by such genes, which is likely to have been a barrier to their discovery until now. The common activation ordering of the core set of early-responding genes we identify may indicate conserved underlying regulatory mechanisms. By contrast, the considerably larger number of transiently activated genes that are specific to each cell type and stimulus illustrates the breadth of the primary response.

An evaluation of the Herscovici classification for fractures of the medial malleolus.

BACKGROUND: Despite its use in the literature, the application of the Herscovici classification system for medial malleolus fractures has not been evaluated. METHODS: We aimed to determine the reliability and accuracy of the Herscovici classification. The blinded radiographs of 130 patients were independently classified by four orthopaedic trauma surgeons. We held a consensus meeting where observers agreed on a final classification and this served as our reference standard. We used weighted kappa (κ) coefficients of agreement. RESULTS: Twenty-four fractures (18%) were deemed unclassifiable. The classification system demonstrated moderate inter-observer reliability (κ=0.54, 95% CI 0.40-0.68) but substantial reproducibility (κ=0.64, 95% CI 0.51-0.79). Accuracy, when compared with the reference standard, was κ=0.54 (95% CI 0.40-0.66). CONCLUSIONS: The obliquity of the fracture line, and fracture extension, created difficulty in classification in 26% of cases. 18% of our cases could not be classified by majority decision. Our results emphasise the challenges faced in classifying these fractures. Future work should focus on refining the Herscovici classification.

The primary health care of transgender adults.

Gender dysphoria is associated with significant health disparity. Gender services perform specialised activities such as diagnosis, endocrine management and liaison with surgical services. Although providing these specialised transition services appears to be safe and improves well-being, significant health disparity remains. Engaging primary care providers is an important part of any strategy to improve the health care of transgender people. The relationships between gender dysphoria and a range of primary care issues such as mental health, cardiovascular disease and cancer are explored.

Transcription factor Wilms' tumor 1 regulates developmental RNAs through 3' UTR interaction.

Wilms' tumor 1 (WT1) is essential for the development and homeostasis of multiple mesodermal tissues. Despite evidence for post-transcriptional roles, no endogenous WT1 target RNAs exist. Using RNA immunoprecipitation and UV cross-linking, we show that WT1 binds preferentially to 3' untranslated regions (UTRs) of developmental targets. These target mRNAs are down-regulated upon WT1 depletion in cell culture and developing kidney mesenchyme. Wt1 deletion leads to rapid turnover of specific mRNAs. WT1 regulates reporter gene expression through interaction with 3' UTR-binding sites. Combining experimental and computational analyses, we propose that WT1 influences key developmental and disease processes in part through regulating mRNA turnover.

WT1 expression in breast cancer disrupts the epithelial/mesenchymal balance of tumour cells and correlates with the metabolic response to docetaxel.

WT1 is a transcription factor which regulates the epithelial-mesenchymal balance during embryonic development and, if mutated, can lead to the formation of Wilms' tumour, the most common paediatric kidney cancer. Its expression has also been reported in several adult tumour types, including breast cancer, and usually correlates with poor outcome. However, published data is inconsistent and the role of WT1 in this malignancy remains unclear. Here we provide a complete study of WT1 expression across different breast cancer subtypes as well as isoform specific expression analysis. Using in vitro cell lines, clinical samples and publicly available gene expression datasets, we demonstrate that WT1 plays a role in regulating the epithelial-mesenchymal balance of breast cancer cells and that WT1-expressing tumours are mainly associated with a mesenchymal phenotype. WT1 gene expression also correlates with CYP3A4 levels and is associated with poorer response to taxane treatment. Our work is the first to demonstrate that the known association between WT1 expression in breast cancer and poor prognosis is potentially due to cancer-related epithelial-to-mesenchymal transition (EMT) and poor chemotherapy response.

Medium-term patient-reported outcomes after total hip replacement for displaced hip fractures.

INTRODUCTION: The aim of the present study was to define the medium-term outcomes following total hip replacement (THR) for hip fracture. METHODS: We prospectively followed up 92 patients who underwent THR for a displaced hip fracture over a 3-year period between 2007 and 2010. These patients were followed up at 5 years using the Oxford Hip Score, Short-Form 12 (SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously reported at 2 years to determine any significant differences. RESULTS: Mean follow-up was at 5.4 years with a mean age at follow-up of 76.5 years. Seventy-four patients (80%) responded. Patients reported excellent functional outcomes and satisfaction (mean Oxford Hip Score 40.3; SF-12 Physical Health Composite Score 44.0; SF-12 Mental Health Composite Score 46.2; mean satisfaction 90%). The rates of dislocation (2%), deep infection (2%) and revision (3%) were comparable to those quoted for elective THR. When compared with 2-year follow-up, there were no statistically significant adverse changes in outcome parameters. CONCLUSIONS: Medium-term outcomes for THR after hip fracture in fit older patients are excellent, and these results demonstrate that the early proven benefits of this surgery are sustained into the midterm.

Patient satisfaction from two studies of collaborative doctor-pharmacist prescribing in Australia.

BACKGROUND: Pharmacist prescribing has been introduced in several countries and is a possible future role for pharmacy in Australia. OBJECTIVE: To assess whether patient satisfaction with the pharmacist as a prescriber, and patient experiences in two settings of collaborative doctor-pharmacist prescribing may be barriers to implementation of pharmacist prescribing. DESIGN: Surveys containing closed questions, and Likert scale responses, were completed in both settings to investigate patient satisfaction after each consultation. A further survey investigating attitudes towards pharmacist prescribing, after multiple consultations, was completed in the sexual health clinic. SETTING AND PARTICIPANTS: A surgical pre-admission clinic (PAC) in a tertiary hospital and an outpatient sexual health clinic at a university hospital. Two hundred patients scheduled for elective surgery, and 17 patients diagnosed with HIV infection, respectively, recruited to the pharmacist prescribing arm of two collaborative doctor-pharmacist prescribing studies. RESULTS: Consultation satisfaction response rates in PAC and the sexual health clinic were 182/200 (91%) and 29/34 (85%), respectively. In the sexual health clinic, the attitudes towards pharmacist prescribing survey response rate were 14/17 (82%). Consultation satisfaction was high in both studies, most patients (98% and 97%, respectively) agreed they were satisfied with the consultation. In the sexual health clinic, all patients (14/14) agreed that they trusted the pharmacist's ability to prescribe, care was as good as usual care, and they would recommend seeing a pharmacist prescriber to friends. DISCUSSION AND CONCLUSION: Most of the patients had a high satisfaction with pharmacist prescriber consultations, and a positive outlook on the collaborative model of care in the sexual health clinic.

Predictors of Compartment Syndrome After Tibial Fracture.

OBJECTIVES: The aim of our study was to identify the risk factors associated with the development of acute compartment syndrome (ACS) after a fracture of the tibia. DESIGN: Retrospective cohort study. SETTING: Orthopaedic trauma unit, university teaching hospital. PATIENTS: From our trauma database, we identified all patients who sustained an acute tibial diaphyseal fracture over a 13-year period. A retrospective analysis of 1407 patients was performed to record and analyze the OTA fracture classification, open fracture grade according to Gustilo, soft tissue injury classification according to Tscherne, treatment, development of ACS, and other patient demographics including smoking, occupation, and socioeconomic deprivation. MAIN OUTCOME MEASURE: A diagnosis of ACS was made using clinical signs, compartment pressure monitoring, or a combination of the 2. RESULTS: One thousand three hundred eighty-eight patients were included with a mean age of 39 (12-98) years, and 957 (69%) were male. One hundred sixty patients (11.5%) were diagnosed with ACS. On initial analysis, age, male gender, blue-collar occupation, sporting injury, fracture classification, and treatment with intramedullary nails were predictive of ACS (all P < 0.05). Age was the strongest predictor of developing ACS (P < 0.001), with the highest prevalence between 12-19 years and 20-29 years. Occupation (P = 0.01) and implant type (P = 0.004) were the only factors that remained significant after adjusting for age. On further subanalysis, implant type was not predictive when stratified by Tscherne class (P = 0.11). CONCLUSIONS: We have documented the risk factors for the development of ACS after an acute tibial diaphyseal fracture, with youth the strongest predictor. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Transcriptional dynamics reveal critical roles for non-coding RNAs in the immediate-early response.

The immediate-early response mediates cell fate in response to a variety of extracellular stimuli and is dysregulated in many cancers. However, the specificity of the response across stimuli and cell types, and the roles of non-coding RNAs are not well understood. Using a large collection of densely-sampled time series expression data we have examined the induction of the immediate-early response in unparalleled detail, across cell types and stimuli. We exploit cap analysis of gene expression (CAGE) time series datasets to directly measure promoter activities over time. Using a novel analysis method for time series data we identify transcripts with expression patterns that closely resemble the dynamics of known immediate-early genes (IEGs) and this enables a comprehensive comparative study of these genes and their chromatin state. Surprisingly, these data suggest that the earliest transcriptional responses often involve promoters generating non-coding RNAs, many of which are produced in advance of canonical protein-coding IEGs. IEGs are known to be capable of induction without de novo protein synthesis. Consistent with this, we find that the response of both protein-coding and non-coding RNA IEGs can be explained by their transcriptionally poised, permissive chromatin state prior to stimulation. We also explore the function of non-coding RNAs in the attenuation of the immediate early response in a small RNA sequencing dataset matched to the CAGE data: We identify a novel set of microRNAs responsible for the attenuation of the IEG response in an estrogen receptor positive cancer cell line. Our computational statistical method is well suited to meta-analyses as there is no requirement for transcripts to pass thresholds for significant differential expression between time points, and it is agnostic to the number of time points per dataset.

Predictors of poor clinical outcome following hip fracture in middle aged-patients.

The aim of this study was to investigate morbidity and mortality following hip fractures in middle aged patients. In addition, we aimed to identify risk factors which could be used to predict postoperative complications. All patients aged 40-55 who sustained a hip fracture in Lothian from 2007 to 2008 were identified from a prospective trauma database. The main outcomes were complications and 5-year mortality. Thirty hip fractures were included in the study. Complications occurred in nine (30%) cases. Deep infection was seen in three cases (10%). Mortality was 20% at 5 years, 26 times higher than for the general population. All surviving patients were contacted for risk factor analysis (24). Low energy fractures, alcohol excess, smoking and history of previous fractures were significantly associated with complications (p<0.05). Complications only occurred amongst low energy fractures. Risk factors were further analysed using the WHO FRAX algorithm. No patient with a FRAX score of less than 10 suffered a complication, whereas 50% of patients who had a FRAX score of more than 10 suffered a complication. The results of our study suggest that low energy hip fractures in middle age are due to underlying morbidity and are associated with a high incidence of postoperative complications and mortality. The FRAX score could be used as a simple method of identifying patients in this age group who are at risk of a poor outcome.

Sports-related fractures in South East Scotland: an analysis of 990 fractures.

PURPOSE: To describe the characteristics of all sports related fractures in patients aged ≥ 15 years in South East Scotland in one year. METHODS: Medical records of 990 consecutive patients aged ≥ 15 years who presented to the Orthopaedic Trauma Unit of the Royal Infirmary of Edinburgh with sports-related fractures between 1 July 2007 and 30 June 2008 were reviewed. Acute fractures of the upper limbs, lower limbs, pelvis, and cervical spine were included, but those of the skull, facial bones, and thorax were excluded, as were stress and chronic fractures. RESULTS: The incidence of sports-related fractures was 1.8/1000/year (82% involving men). The median age of patients was 25 (interquartile range, 19-35) years. Sports-related fractures accounted for 24.6% and 5.1% of all fractures in men and women, respectively. Men aged 15 to 19 years were 9 times more likely to have sports-related fractures than women of the same age. The sports-related fractures involved the upper limbs (52.4%), lower limbs (45.4%), and axial skeleton (2.2%). 12 of 49 sports (football, rugby, skiing, snowboarding, 3 cycling disciplines, horse riding, motocross, basketball, martial arts, and ice skating) accounted for 82.8% of all sports-related fractures. Upper limb fractures outnumbered lower limb fractures in all sports, except for horse riding and motocross that the proportions were similar. CONCLUSION: In South East Scotland, most sports related fractures involved the upper limbs.

The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome.

BACKGROUND: The aim of our study was to document the estimated sensitivity and specificity of continuous intracompartmental pressure monitoring for the diagnosis of acute compartment syndrome. METHODS: From our prospective trauma database, we identified all patients who had sustained a tibial diaphyseal fracture over a ten-year period. A retrospective analysis of 1184 patients was performed to record and analyze the documented use of continuous intracompartmental pressure monitoring and the use of fasciotomy. A diagnosis of acute compartment syndrome was made if there was escape of muscles at fasciotomy and/or color change in the muscles or muscle necrosis intraoperatively. A diagnosis of acute compartment syndrome was considered incorrect if it was possible to close the fasciotomy wounds primarily at forty-eight hours. The absence of acute compartment syndrome was confirmed by the absence of neurological abnormality or contracture at the time of the latest follow-up. RESULTS: Of 979 monitored patients identified, 850 fit the inclusion criteria with a mean age of thirty-eight years (range, twelve to ninety-four years), and 598 (70.4%) were male (p < 0.001). A total of 152 patients (17.9%) underwent fasciotomy for the treatment of acute compartment syndrome: 141 had acute compartment syndrome (true positives), six did not have it (false positives), and five underwent fasciotomy despite having a normal differential pressure reading, with subsequent operative findings consistent with acute compartment syndrome (false negatives). Of the 698 patients (82.1%) who did not undergo fasciotomy, 689 had no evidence of any late sequelae of acute compartment syndrome (true negatives) at a mean follow-up time of fifty-nine weeks. The estimated sensitivity of intracompartmental pressure monitoring for suspected acute compartment syndrome was 94%, with an estimated specificity of 98%, an estimated positive predictive value of 93%, and an estimated negative predictive value of 99%. CONCLUSIONS: The estimated sensitivity and specificity of continuous intracompartmental pressure monitoring for the diagnosis of acute compartment syndrome following tibial diaphyseal fracture are high; continuous intracompartmental pressure monitoring should be considered for patients at risk for acute compartment syndrome.