Editorial Commentary: Go Ahead and Repair That Shoulder Rotator Cuff Tear in Your Obese Patient: Just Be Prepared to Admit Them.

Arthroscopic rotator cuff repair in the obese patient offers functional outcomes and rates of complications comparable to those seen in nonobese patients. Future prospective studies with better methodology, as well as including larger numbers of severely obese patients with a body mass index of 40 or greater, will help to further elucidate if obesity truly affects outcomes in rotator cuff repair. In the meantime, be sure to consider admission of your obese rotator cuff repair patients.

Editorial Commentary: Animal Trials Using Stem Cells to Enhance Anterior Cruciate Ligament Treatment Are Interesting. But, Why Not More About Us Humans?

Although hampered by heterogeneous studies with low methodologic quality and high risk for bias, the current literature demonstrates the potential for enhanced healing of anterior cruciate ligament injuries during the early phase using adult stem cells in animal trials. There are only 2 published controlled clinical trials on the subject matter, and they have small sample sizes, undefined cell numbers, and unstandardized selection criteria and surgical techniques. There is a clear need for studies with higher levels of evidence that would include long-term, larger animal studies ultimately leading to improved clinical trials.

Research Pearls: How Do We Establish the Level of Evidence?

Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used. Unfortunately, study quality is not assessed by the assigned hierarchy level. LOE and EBM have increased the number of investigations published with better levels of evidence. As authors, reviewers, editors, and publishers, we desire a system that is consistent, effective, and reliable. Fortunately, the system has proven to have all of those attributes with good interobserver and intra-observer values. The increase in investigations with higher LOEs allows for more frequent use of EBM.

My Kind of Town (Chicago Is): Content Collections Optimize Learning Related to the 2018 AANA Annual Meeting.

The 2018 Arthroscopy Association of North America Annual Meeting represents an opportunity to deepen one's understanding of a wide variety of topics. Arthroscopy journal readers have diverse practices and interests, and the meeting is designed to accommodate individual needs. The constructivist learning theory provides that scholars learn in many different ways. Thus, to enrich your learning experience, selected recently published Arthroscopy articles are suggested to supplement material presented at the meeting. The articles are collated on our web site in Content Collections, to allow meeting participants to prepare and to allow those unable to attend to remain engaged. We offer suggestions and encourage readers to customize their own learning experience.

Editorial Commentary: The Time Has Come to Try Intra-articular Platelet-Rich Plasma Injections for Your Patients With Symptomatic Knee Osteoarthritis.

Platelet-rich plasma injections, in a systematic review and meta-analysis of 10 Level I randomized control trials, were found to provide more pain relief and better functional outcomes than hyaluronic acid in patients with knee osteoarthritis at 12 months after injection. The time has come for those of us who have not yet tried platelet-rich plasma injections in our patients with symptomatic knee osteoarthritis to do so.

Sommelier Suggestions: The Arthroscopy Association of North America Annual Meeting Inspires a Content Collection Worth Tasting.

The 2017 Arthroscopy Association of North America Annual Meeting Program inspires a Content Collection of Arthroscopy journal articles worthy of review. A foundation of a credible podium presentation is the published medical literature. Your Editors thus suggest recent publications that seem particularly relevant in the context of the 2017 annual meeting. Consider these articles as one would a suggestion for a good glass of wine to complement a delicious meal.

Editorial Commentary: Posterior Cruciate Ligament Reconstruction--Do Not Abandon the C-Arm Quite Yet.

Accurate tibial tunnel placement using the arthroscopically-assisted anatomic fovea landmark technique in transtibial posterior cruciate ligament reconstruction is possible without the use of fluoroscopic imaging. However, until a prospective, randomized controlled trial comparing the C-arm and anatomic fovea landmark techniques is completed, abandonment of the C-arm in posterior cruciate ligament reconstruction cannot be recommended.

Editorial Commentary: Intra-articular Corticosteroid Injection at the Time of Knee Arthroscopy Is Not Recommended.

In a population of Medicare patients undergoing knee arthroscopy, a significant increase in the incidence of postoperative infection at 3 and 6 months was found in patients who received an intra-articular corticosteroid injection at the time of knee arthroscopy compared with a matched control group that did not receive an injection. Intra-articular corticosteroid injection at the time of knee arthroscopy is not recommended.

Derivation of human primordial germ cell-like cells in an embryonic-like culture.

Primordial germ cells (PGCs) are the embryonic precursors of sperm and eggs. They transmit genetic and epigenetic information across generations. Given the prominent role of germline defects in diseases such as infertility, detailed understanding of human PGC (hPGC) development has important implications in reproductive medicine and studying human evolution. Yet, hPGC specification remains an elusive process. Here, we report the induction of hPGC-like cells (hPGCLCs) in a bioengineered human pluripotent stem cell (hPSC) culture that mimics peri-implantation human development. In this culture, amniotic ectoderm-like cells (AMLCs), derived from hPSCs, induce hPGCLC specification from hPSCs through paracrine signaling downstream of ISL1. Our data further show functional roles of NODAL, WNT, and BMP signaling in hPGCLC induction. hPGCLCs are successfully derived from eight non-obstructive azoospermia (NOA) participant-derived hPSC lines using this biomimetic platform, demonstrating its promise for screening applications.

Long-term engraftment and maturation of autologous iPSC-derived cardiomyocytes in two rhesus macaques.

Cellular therapies with cardiomyocytes produced from induced pluripotent stem cells (iPSC-CMs) offer a potential route to cardiac regeneration as a treatment for chronic ischemic heart disease. Here, we report successful long-term engraftment and in vivo maturation of autologous iPSC-CMs in two rhesus macaques with small, subclinical chronic myocardial infarctions, all without immunosuppression. Longitudinal positron emission tomography imaging using the sodium/iodide symporter (NIS) reporter gene revealed stable grafts for over 6 and 12 months, with no teratoma formation. Histological analyses suggested capability of the transplanted iPSC-CMs to mature and integrate with endogenous myocardium, with no sign of immune cell infiltration or rejection. By contrast, allogeneic iPSC-CMs were rejected within 8 weeks of transplantation. This study provides the longest-term safety and maturation data to date in any large animal model, addresses concerns regarding neoantigen immunoreactivity of autologous iPSC therapies, and suggests that autologous iPSC-CMs would similarly engraft and mature in human hearts.

Reconstituted ovaries self-assemble without an ovarian surface epithelium.

Three-dimensional (3D) stem cell models of the ovary have the potential to benefit women's reproductive health research. One such model, the reconstituted ovary (rOvary) self-assembles with pluripotent stem cell-derived germ cells creating a 3D ovarian mimic competent to support the differentiation of functional oocytes inside follicles. In this study, we evaluated the cellular composition of the rOvary revealing the capacity to generate multiple follicles surrounded by NR2F2+ stroma cells. However, the rOvary does not develop a surface epithelium, the source of second-wave pre-granulosa cells, or steroidogenic theca. Therefore, the rOvary models represent the self-assembly of activated follicles in a pre-pubertal ovary poised but not yet competent for hormone production.

EED is required for mouse primordial germ cell differentiation in the embryonic gonad.

Development of primordial germ cells (PGCs) is required for reproduction. During PGC development in mammals, major epigenetic remodeling occurs, which is hypothesized to establish an epigenetic landscape for sex-specific germ cell differentiation and gametogenesis. In order to address the role of embryonic ectoderm development (EED) and histone 3 lysine 27 trimethylation (H3K27me3) in this process, we created an EED conditional knockout mouse and show that EED is essential for regulating the timing of sex-specific PGC differentiation in both ovaries and testes, as well as X chromosome dosage decompensation in testes. Integrating chromatin and whole genome bisulfite sequencing of epiblast and PGCs, we identified a poised repressive signature of H3K27me3/DNA methylation that we propose is established in the epiblast where EED and DNMT1 interact. Thus, EED joins DNMT1 in regulating the timing of sex-specific PGC differentiation during the critical window when the gonadal niche cells specialize into an ovary or testis.

Generation of three human induced pluripotent stem cell sublines (UCLAi005-A, UCLAi005-B and UCLAi005-C) for reproductive science research.

We generated three human induced pluripotent stem cell (hiPSC) sublines from human dermal fibroblasts (HDF) (MZT05) generated from a skin biopsy donated from a previously fertile woman. The skin biopsy was broadly consented for generating hiPSC lines for biomedical research, including unique consent specifically for studying human fertility, infertility and germ cell differentiation. hiPSCs were reprogrammed using Sendai virus vectors and were subsequently positive for markers of self-renewal. Pluripotency was further verified using PluriTest analysis and in vitro differentiation was tested using Taqman Real-Time PCR assays. These sublines serve as controls for hiPSC research projects aimed at understanding the cell and molecular regulation of female fertility.

Generation of three human induced pluripotent stem cell sublines (UCLAi004-A, UCLAi004-B, and UCLAi004-C) for reproductive science research.

Three induced pluripotent stem cell sublines (hiPSCs) were generated from human dermal human dermal fibroblasts (HDFs) derived from a human skin punch biopsy. The biopsy was donated from a woman with known infertility due to ovarian failure. The hiPSC sublines were created using Sendai virus vectors and were positive for markers of self-renewal including OCT4, NANOG, TRA-1-81 and SSEA-4. Pluripotency was verified using PluriTest analysis and in vitro differentiation using Taqman Real-Time PCR assays for somatic lineage markers. This participant's monozygotic twin sister also donated a skin-punch biopsy, whose resulting hiPSC lines were published previously as a resource.

Generation of six human induced pluripotent stem cell sublines (MZT01E, MZT01F, MZT01N and MZT02D, MZT02G and MZT02H) for reproductive science research.

Six human induced pluripotent stem cell sublines (hiPSCs) were generated from human dermal fibroblasts (HDFs) derived from skin biopsies donated from monozygotic twin women wherein one woman had proven fertility and her sister was infertile due to ovarian failure. Three hiPSC sublines were created from each twin's HDFs. hiPSCs were reprogrammed using Sendai virus vectors and were subsequently positive for markers of self-renewal including OCT4, NANOG, TRA-1-81 and SSEA-4. Pluripotency was further verified using PluriTest. We show here that the hiPSC lines created from the twins are equivalent in measures of pluripotency and self-renewal, despite their differential diagnosis.

Intrabone transplantation of CD34+ cells with optimized delivery does not enhance engraftment in a rhesus macaque model.

Intrabone (IB) injection of umbilical cord blood has been proposed as a potential mechanism to improve transplant engraftment and prevent graft failure. However, conventional IB techniques produce low retention of transplanted cells in the marrow. To overcome this barrier, we developed an optimized IB (OIB) injection method using low-volume, computer-controlled slow infusion that promotes cellular retention in the marrow. Here, we compare engraftment of CD34+ cells transplanted in a myeloablative rhesus macaque (RM) model using the OIB method compared with IV delivery. RM CD34+ cells obtained by apheresis were split equally for transduction with lentiviral vectors encoding either green fluorescent protein or yellow fluorescent protein reporters. Following conditioning, one marked autologous population of CD34+ cells was injected directly IB using the OIB method and the other was injected via slow IV push into the same animal (n = 3). Daily flow cytometry of blood quantified the proportion of engrafting cells deriving from each source. Marrow retention was examined using positron emission tomography/computed tomography imaging of 89Zirconium (89Zr)-oxine-labeled CD34+ cells. CD34+ cells injected via the OIB method were retained in the marrow and engrafted in all 3 animals. However, OIB-transplanted progenitor cells did not engraft any faster than those delivered IV and contributed significantly less to hematopoiesis than IV-delivered cells at all time points. Rigorous testing of our OIB delivery system in a competitive RM myeloablative transplant model showed no engraftment advantage over conventional IV infusion. Given the increased complexity and potential risks of IB vs IV approaches, our data do not support IB transplantation as a strategy to improve hematopoietic engraftment.

Generation of three human induced pluripotent stem cell sublines (MZT04D, MZT04J, MZT04C) for reproductive science research.

We generated three human induced pluripotent stem cell (hiPSC) sublines from human dermal fibroblasts (HDFs) (MZT04) generated from a skin biopsy donated from a previously fertile woman. The skin biopsy was broadly consented for generating hiPSC lines for biomedical research, including unique consent specifically for studying human fertility, infertility and germ cells. hiPSCs were reprogrammed using Sendai virus vectors and were subsequently positive for markers of self-renewal including OCT4, NANOG, TRA-1-81 and SSEA-4. Pluripotency was further verified using teratomas and PluriTest. These sublines serve as controls for hiPSC research projects aimed at understanding the cell and molecular regulation of female fertility and infertility.

PRDM14 is expressed in germ cell tumors with constitutive overexpression altering human germline differentiation and proliferation.

Germ cell tumors (GCTs) are a heterogeneous group of tumors occurring in gonadal and extragonadal locations. GCTs are hypothesized to arise from primordial germ cells (PGCs), which fail to differentiate. One recently identified susceptibility loci for human GCT is PR (PRDI-BF1 and RIZ) domain proteins 14 (PRDM14). PRDM14 is expressed in early primate PGCs and is repressed as PGCs differentiate. To examine PRDM14 in human GCTs we profiled human GCT cell lines and patient samples and discovered that PRDM14 is expressed in embryonal carcinoma cell lines, embryonal carcinomas, seminomas, intracranial germinomas and yolk sac tumors, but is not expressed in teratomas. To model constitutive overexpression in human PGCs, we generated PGC-like cells (PGCLCs) from human pluripotent stem cells (PSCs) and discovered that elevated expression of PRDM14 does not block early PGC formation. Instead, we show that elevated PRDM14 in PGCLCs causes proliferation and differentiation defects in the germline.

TFAP2C regulates transcription in human naive pluripotency by opening enhancers.

Naive and primed pluripotent human embryonic stem cells bear transcriptional similarity to pre- and post-implantation epiblast and thus constitute a developmental model for understanding the pluripotent stages in human embryo development. To identify new transcription factors that differentially regulate the unique pluripotent stages, we mapped open chromatin using ATAC-seq and found enrichment of the activator protein-2 (AP2) transcription factor binding motif at naive-specific open chromatin. We determined that the AP2 family member TFAP2C is upregulated during primed to naive reversion and becomes widespread at naive-specific enhancers. TFAP2C functions to maintain pluripotency and repress neuroectodermal differentiation during the transition from primed to naive by facilitating the opening of enhancers proximal to pluripotency factors. Additionally, we identify a previously undiscovered naive-specific POU5F1 (OCT4) enhancer enriched for TFAP2C binding. Taken together, TFAP2C establishes and maintains naive human pluripotency and regulates OCT4 expression by mechanisms that are distinct from mouse.

A Chronic Cardiac Ischemia Model in Swine Using an Ameroid Constrictor.

Cardiovascular disease remains the number one cause of mortality in the United States. There are numerous approaches to treating these diseases, but regardless of the approach, an in vivo model is needed to test each treatment. The pig is one of the most used large animal models for cardiovascular disease. Its heart is very similar in anatomy and function to that of a human. The ameroid placement technique creates an ischemic area of the heart, which has many useful applications in studying myocardial infarction. This model has been used for surgical research, pharmaceutical studies, imaging techniques, and cell therapies. There are several ways of inducing an ischemic area in the heart. Each has its advantages and disadvantages, but the placement of an ameroid constrictor remains the most widely used technique. The main advantages to using the ameroid are its prevalence in existing research, its availability in various sizes to accommodate the anatomy and size of the vessel to be constricted, the surgery is a relatively simple procedure, and the post-operative monitoring is minimal, since there are no external devices to maintain. This paper provides a detailed overview of the proper technique for the placement of the ameroid constrictor.