Association of CYP2C19 Polymorphism With Proton Pump Inhibitors Effectiveness and With Fractures in Real-Life: Retrospective Cohort Study.

Symptom refractoriness of patients treated with proton pump inhibitors (PPIs) might be explained by polymorphism in CYP2C19. This is a retrospective cohort study in which we used the computerized database of Clalit Health Services to compose a cohort from cancer case-control studies' participants that had been genotyped, and that have been dispensed PPI (January 1, 2002 to November 10, 2020). We retrieved demographic and clinical variables on date of PPI initiation (cohort entry), and studies' questionnaires-reported consumption of foods/beverages known to increase peptic-related symptoms. Primary outcome was an abdominal pain diagnosis; secondary outcome was a composite of abdominal pain, visit to a gastroenterology clinic, change to another PPI, PPI dose increase, or metoclopramide prescription, reflecting symptoms persistence/recurrence; in a 2-year follow-up. We also evaluated the association between genetic groups and hip/wrist/spine fractures, in a long-term follow-up. Of 3,326 PPI initiators, there were 66 (2.0%), 739 (22.2%), 1394 (41.9%), 947 (28.5%), and 180 (5.4%) CYP2C19 poor, intermediate, normal, rapid, and ultra-rapid metabolizers, respectively. Being a poor metabolizer was associated with lower risk for the primary outcome, hazard ratio (HR) = 0.50 (95% confidence interval (CI) 0.27-0.91), HR = 0.52 (95% CI 0.28-0.94); and for the secondary outcome, HR = 0.57 (95% CI 0.38-0.86), HR = 0.58 (95% CI 0.39-0.87), in univariate and multivariable cox regression analyses, respectively. In long-term follow-up with 20,142 person-years of follow-up: 7.6% (5 cases) within the poor metabolizers group, and 11.6%, 12.9%, 12.8%, and 11.1% in the normal, intermediate, rapid, and ultra-rapid metabolizers groups, respectively, had a new fracture (nonsignificant). We conclude that CYP2C19 poor metabolizer status is associated with higher effectiveness of PPIs, and is not associated with higher risk for fractures.

Fractures due to Aromatase Inhibitor Therapy for Breast Cancer: A Real-World Analysis of FAERS Data in the Past 15 Years.

INTRODUCTION: The adverse effect of fractures by different aromatase inhibitor (AI) drugs has not been thoroughly assessed in real-world studies. OBJECTIVE: To assess the adverse events of fractures of real-world breast cancer patients caused by AI therapy through the Food and Drug Administration Adverse Event Reporting System (FAERS) database. METHODS: The FAERS data from January 2004 to December 2018 were sorted out and analyzed for correlations between fractures and AI use. Disproportionate analysis and Bayesian analysis were adopted to quantify the signal, the association between the AIs and fractures. The onset time and outcome of fractures after different AI regimens were also compared. RESULTS: Out of 23,064 adverse reports, 657 fracture reports (2.85%) were analyzed. Anastrozole showed a positive association with 4 detection methods, while letrozole and exemestane did so with 2. More exemestane-related reports (44.62%) resulted in initial or prolonged hospitalization than anastrozole (30.12%, p = 0.013) and letrozole (29.43%, p = 0.006). The fracture onset time showed no significant difference among anastrozole, letrozole, and exemestane (median onset time: 46.95, 34.25, and 40.58 months, respectively; p = 0.236). CONCLUSIONS: Anastrozole should be prescribed with more medical care. Analysis of FAERS data identified fracture risk tendencies with AI regimens, which supported continuous monitoring, risk evaluations, and further comparative studies.

Coordinating Tissue Regeneration Through Transforming Growth Factor-ß Activated Kinase 1 Inactivation and Reactivation.

Aberrant wound healing presents as inappropriate or insufficient tissue formation. Using a model of musculoskeletal injury, we demonstrate that loss of transforming growth factor-ß activated kinase 1 (TAK1) signaling reduces inappropriate tissue formation (heterotopic ossification) through reduced cellular differentiation. Upon identifying increased proliferation with loss of TAK1 signaling, we considered a regenerative approach to address insufficient tissue production through coordinated inactivation of TAK1 to promote cellular proliferation, followed by reactivation to elicit differentiation and extracellular matrix production. Although the current regenerative medicine paradigm is centered on the effects of drug treatment ("drug on"), the impact of drug withdrawal ("drug off") implicit in these regimens is unknown. Because current TAK1 inhibitors are unable to phenocopy genetic Tak1 loss, we introduce the dual-inducible COmbinational Sequential Inversion ENgineering (COSIEN) mouse model. The COSIEN mouse model, which allows us to study the response to targeted drug treatment ("drug on") and subsequent withdrawal ("drug off") through genetic modification, was used here to inactivate and reactivate Tak1 with the purpose of augmenting tissue regeneration in a calvarial defect model. Our study reveals the importance of both the "drug on" (Cre-mediated inactivation) and "drug off" (Flp-mediated reactivation) states during regenerative therapy using a mouse model with broad utility to study targeted therapies for disease. Stem Cells 2019;37:766-778.

Prevalence and risk factors for fragility fracture in systemic mastocytosis.

OBJECTIVES: Systemic mastocytosis (SM) is characterized by the accumulation of mast cells in tissues other than the skin. Bone involvement although frequent has not been thoroughly evaluated. Primary objective was to determine risk factors associated with fragility fractures (FF) in SM. Secondary objectives were to evaluate the ability of bone marrow tryptase (BMT) level to identify patients with FF, and to describe bone involvement in SM. METHODS: We analyzed retrospectively all consecutive patients seen in our expert center, with a diagnosis of SM according to the 2001 WHO criteria, and with complete bone assessment. We collected data about lifetime fractures, types of cutaneous manifestations, degranulation symptoms, blood and BMT levels, bone mineral density assessed by densitometry and KIT mutation. We performed a univariate analysis investigating the factors associated with FF and then a logistic multivariable regression analysis. We assessed the ability of bone marrow tryptase to identify patients with FF. RESULTS: Eighty-nine patients with SM were included. Thirty-six patients (40.4%) suffered from osteoporosis and twenty-five (28.1%) experienced lifetime FF. Univariate analysis identified age at diagnosis and disease onset, presence of telangiectasia macularis eruptiva perstans, digestive symptoms, mast cells activation symptoms, elevated BMT, low femoral and lumbar BMD, as associated with FF. Multivariate analysis identified elevated BMT, low femoral T score and older age at diagnosis as independently associated with FF. CONCLUSIONS: Low femoral T-score, BMT level, and older age at diagnosis are markers associated with FF in SM. BMT may represent an important biomarker to predict FF in SM patients.

Kinetic characteristics of myosin ATPase in dog skeletal muscles after shin bone fracture.

Kinetic characteristics of myosin from dog anterior tibial and gastrocnemius muscles after shin bone fracture were studied. Myosin affinity for ATP increased in muscles of the injured and contralateral limbs.

Acidic pH environments increase the expression of cathepsin B in osteoblasts: the significance of ER stress in bone physiology.

Hypoxia, inflammation, and acidity occur after bone fracture. To simplify the fracture model, we tested the effects of acidity in osteoblasts. We tested three osteoblast cell lines, MG63, MC3T3E1, and HOS cells, with MG63 cells showing much higher sensitivity to acidic pH. In physiologically acidic surroundings, pH 7.2, the endoplasmic reticulum stress response was measured through the expression of unfolded protein response proteins. Acidic surroundings time-dependently increased IL-6 secretion. Cathepsin B, a marker of the inflammation and angiogenic processes that occur after bone fracture, also increased. Thus, acidity can cause ER stress, increase IL-6, and increases cathepsin B expression in osteoblasts.

Case report: multiple fractures in a patient with mutations of TWIST1 and TNSALP.

Hypophosphatasia is a rare inherited disorder characterized by defective skeletal mineralization and low alkaline phosphatase activities in the serum. The genetic cause of hypophosphatasia is believed related to inactivating mutations in the TNSALP gene, encoding tissue-nonspecific alkaline phosphatase. Another rare inheritable disease, Saethre-Chotzen syndrome, leads to premature fusion of the cranial sutures caused by heterozygous mutations of the human TWIST1 gene. Because the two disorders apparently are not genetically related (only reported individually) yet both involve defective skeletal formation, we believe it is important to report our findings on a patient harboring mutations of TNSALP and TWIST1.

Ultrasound induces hypoxia-inducible factor-1 activation and inducible nitric-oxide synthase expression through the integrin/integrin-linked kinase/Akt/mammalian target of rapamycin pathway in osteoblasts.

It has been shown that ultrasound (US) stimulation accelerates fracture healing in the animal models and clinical studies. Nitric oxide (NO) is a crucial early mediator in mechanically induced bone formation. Here we found that US stimulation increased NO formation and the protein level of inducible nitric-oxide synthase (iNOS). US-mediated iNOS expression was attenuated by anti-integrin alpha5beta1 or beta1 antibodies but not anti-integrin alphavbeta3 or beta3 antibodies or focal adhesion kinase mutant. Integrin-linked kinase (ILK) inhibitor (KP-392), Akt inhibitor (1L-6-hydroxymethyl-chiro-inositol-2-[(R)-2-O-methyl-3-O-octadecylcarbonate]) or mammalian target of rapamycin (mTOR) inhibitor (rapamycin) also inhibited the potentiating action of US. US stimulation increased the kinase activity of ILK and phosphorylation of Akt and mTOR. Furthermore, US stimulation also increased the stability and activity of HIF-1 protein. The binding of HIF-1alpha to the HRE elements on the iNOS promoter was enhanced by US stimulation. Moreover, the use of pharmacological inhibitors or genetic inhibition revealed that both ILK/Akt and mTOR signaling pathway were potentially required for US-induced HIF-1alpha activation and subsequent iNOS up-regulation. Taken together, our results provide evidence that US stimulation up-regulates iNOS expression in osteoblasts by an HIF-1alpha-dependent mechanism involving the activation of ILK/Akt and mTOR pathways via integrin receptor.

Fractures of the sternum: the influence of non-invasive cardiac monitoring on management.

Management of sternal fractures often involves a protracted hospital stay. This is often based on serial electrocardiography (ECG) and cardiac enzyme measurement (AST, CK, LDH). This retrospective study examined all cases of sternal fracture presenting to our institution between October 1998 and February 2003. Seventy-two cases were identified, 52 of which had isolated sternal fractures. Of these, 11 (21%) patients had an elevation in all cardiac enzymes. Twenty-three (44%) had an increase in some but not all. A single patient with ECG changes had no elevation in cardiac enzymes. Those patients with elevated cardiac enzymes had a significantly longer stay of 5.5 days compared with 3.7 days (P < 0.05). No adverse outcome was recorded in either group. We conclude that ECG and estimation of cardiac enzymes in these patients are of limited benefit and, when abnormal, appear to be associated with a significantly protracted and probably unnecessary hospitalisation.

Matrix metalloproteinases and failed fracture healing.

During fracture healing and the resulting formation of new bone, an extensive amount of extracellular matrix is synthesized which subsequently undergoes enzymatic remodeling and then mineralization. The remodeling process of mostly collagenous molecules is largely attributable to matrix metalloproteinases (MMPs). A variety of members of this protease family and its respective inhibitors - termed tissue inhibitors of matrix metalloproteinases (TIMP) - have been found to be closely related to the fracture healing process. Delays in bone healing or even nonunion could be related to the concentrations of these enzymes or their behavior over time. In this study, serum samples were prospectively collected from patients who had undergone surgical treatment for limb fracture. Serum probes from 15 patients with nonunion of fractures 4 months after surgery have been compared to 15 matched patients with normal bone healing. Postoperative time courses of serum concentrations of MMP-1/-2/-3/-8/-9/-13 as well as TIMP-1/-2 were analyzed using commercially available enzyme immunoassays. Comparison between both collectives revealed significantly elevated serum concentrations of proMMP-1 in the nonunion group at 2 and 24 weeks after surgery. Similar findings were found for MMP-8 at 2, 4 and 8 weeks. At 1 week after surgery, TIMP-1 serum concentrations were significantly lower in nonunion patients when compared to patients with normal bone repair. We have been able to show for the first time the course of serum concentrations of MMPs and TIMPs during normal and delayed fracture healing. Characteristic time courses of systemic MMP- and TIMP-levels could be a reflection of local enzyme regulatory mechanisms during fracture healing. An altered balance of the MMP/TIMP system in favor of proteolytic activity as shown in our investigation may be involved in the pathophysiological processes leading to fracture nonunion.

[Biochemical wound monitoring. PMN elastase in different healing stages after trauma surgery-orthopedic interventions]. / Biochemisches Wundmonitoring. Die PMN-Elastase bei unterschiedlichen Heilungsverläufen nach unfallchirurgisch-orthopädischen Eingriffen.

Laboratory parameters are of proven value in the diagnosis of early postsurgical infections, since clinical aspects cannot always be clearly defined. Neutrophil granulocytes (PMN) are major inflammatory cells taking effect following ingestion and degradation of foreign material, such as bacteria and cell debris, for example after mechanical trauma. In patients who had undergone surgery we monitored the course of plasma PMN elastase in uncomplicated wound healing (n = 22), in uncomplicated wound healing associated with secondary infections (n = 6), and in defective wound healing (manifestation of a bacterial wound infection: n = 3; wound infection already manifest at the time of entry on study: n = 11). Surgical trauma was accompanied by an increase in PMN elastase and C-reactive protein (CRP) in all patients studied, reaching a maximum within the first 3 postsurgical days. When a bacterial wound infection became manifest during the course of healing there was a highly significant difference on the 4th postsurgical day (p < 0.01) compared with the group with uncomplicated healing. Since PMN elastase can now be determined automatically with an autoanalyser and a commercial kit and its discriminatory time point is as soon as 4-5 days after surgery, it is suggested that this marker should be determined routinely together with CRP in traumatology.

Plasma bone-specific alkaline phosphatase as an indicator of osteoblastic activity.

The total plasma alkaline phosphatase level has long been recognised as an indicator of osteoblastic activity, but lack of specificity makes it an insensitive index of the progress of disease and the response to treatment. Selective precipitation by wheatgerm lectin allows measurement of the plasma bone-specific alkaline phosphatase. We measured the plasma levels of this isoenzyme in 170 normal Chinese adolescents and adults, in 49 adults with fractures of a long bone, in 15 patients with osteosarcoma and in 38 patients with osteolytic metastases. The enzyme activity was also determined in 39 patients with liver disease. Of the patients with fractures, 94% had increased plasma activity during the healing process. The level was also increased in those with osteosarcoma but not in those with osteolytic bone metastases. There was no significant increase in activity in the patients with liver disease. We conclude that the plasma bone-specific alkaline phosphatase activity is a sensitive and reliable measure of osteoblastic activity.

[The function of enzymes for the antioxidative protection of the bone marrow cells in rats during irradiation, bone fracture and combined radiation injury]. / Sostoianie fermentov antiokislitel'noi zashchity kletok kostnogo mozga krys pri obluchenii, perelome kosti i kombinirovannoi radiatsionnoi travme.

The activity of superoxide dismutase, glutathione peroxidase, glutathione reductase and glutathione: dehydroascorbate oxidoreductase is lower in the bone marrow than in the liver. The changes in the cellular antioxidative enzymatic system during leg bones fracture and X-ray irradiation are more pronounced in the rat bone marrow, as compared to the liver. The data obtained are in keeping with selective bone-marrow radiosensitivity and with the effect of exogenous superoxide dismutase and glutathione as radioprotectors.

Enzyme histochemical study on bone tumors.

A total of 19 cases with bone tumors, including six osteosarcomas. three giant cell tumors of bone, one malignant fibrous histiocytoma, four nonossifying fibromas, four chondromas and one chondrosarcoma, were examined as to enzyme histochemistry; the enzymes consisted of alkaline phosphatase (ALPase), acid phosphatase (ACPase), nonspecific esterase (NSE), adenosine triphosphatase (ATPase), 5'-nucleotidase (5'-Nucl) and beta-glucuronidase (beta-Gl). Osteosarcoma was strongly positive for ALPase followed by 5'-Nucl. Giant cell tumor, malignant fibrous histiocytoma and nonossifying fibroma showed enzyme histochemistry similar to each other: multinucleated giant cells and round cells in these tumors were strongly positive for ACPase, NSE, ATPase and 5'-Nucl simulating osteoclasts and histiocytes, whereas spindle cells were positive for ATPase and 5'-Nucl in their cytoplasm and weakly positive for ACPase. Chondroma and chondrosarcoma were focally positive for ACPase and NSE; the ACPase was sensitive to tartaric acid treatment. These observations showed that ALPase activity is very characteristic to osteosarcoma, and is useful for its diagnosis. From enzyme histochemistry, giant cell tumor, malignant fibrous histiocytoma and nonossifying fibroma can be regarded as a histiocyte-derived tumor of bone in contrast to osteosarcoma and cartilaginous tumors.

Morphological and biochemical studies during differentiation and calcification of fracture callus cartilage.

Differentiation and calcification of cartilage of a fracture callus morphologically, ultrastructurally, and histochemically resembles cartilage of growing epiphyseal plate. The fracture callus includes the various cartilage cell types found in the epiphyseal plate. Proliferating and hypertrophic cartilage had higher activities of cytochrome oxidase, alkaline phosphatase and glutamate aspartate transaminase than fibrocartilage. Enzymes controlling glycogen synthesis and glycolysis had higher levels of activity in fibrocartilage than in hypertrophic cartilage. Lysosomal enzymes, catalase, 6-phospho-gluconic acid and glucose 6-phosphate dehydrogenase were uniformly distributed. Alkaline phosphatase was associated with extracellular vesicles found in hypertrophic cartilage. EM dense granules were found in mitochondria in hypertrophic cartilage. There was an increase of total lipids in hypertropic and calcified cartilage as compared to resting cartilage.