A bi-radial approach to define the sagittal geometry of the healthy ankle.

BACKGROUND: Previous descriptions of the sagittal geometry of the tibia and talus have involved single radius curves. The purpose of this investigation was to: determine if the sagittal curvature of the medial and lateral sides of the talus and tibia can be described by dividing the condyles into anterior and posterior regions, determine tibiotalar congruency, and categorize the morphological configurations of the talus and tibia. METHODS: Eighteen subjects underwent weightbearing CT scans and the osseous curvature was analyzed. RESULTS: For the talus, the medial anterior radius was smaller than the lateral anterior radius. For the distal tibia, the lateral posterior radius was smaller than the medial posterior radius. Tibiotalar congruency varied by region. The most common geometric configuration was two cones, one anterior and one posterior, pointed in opposite directions. CONCLUSION: The sagittal profiles of the tibia and talus can be more accurately described using a bi-radial approach as compared to a single radius.

Tumor-derived microvesicles: shedding light on novel microenvironment modulators and prospective cancer biomarkers.

Recent advances in the study of tumor-derived microvesicles reveal new insights into the cellular basis of disease progression and the potential to translate this knowledge into innovative approaches for cancer diagnostics and personalized therapy. Tumor-derived microvesicles are heterogeneous membrane-bound sacs that are shed from the surfaces of tumor cells into the extracellular environment. They have been thought to deposit paracrine information and create paths of least resistance, as well as be taken up by cells in the tumor microenvironment to modulate the molecular makeup and behavior of recipient cells. The complexity of their bioactive cargo-which includes proteins, RNA, microRNA, and DNA-suggests multipronged mechanisms by which microvesicles can condition the extracellular milieu to facilitate disease progression. The formation of these shed vesicles likely involves both a redistribution of surface lipids and the vertical trafficking of cargo to sites of microvesicle biogenesis at the cell surface. Current research also suggests that molecular profiling of these structures could unleash their potential as circulating biomarkers as well as platforms for personalized medicine. Thus, new and improved strategies for microvesicle identification, isolation, and capture will have marked implications in point-of-care diagnostics for cancer patients.

Aberrant endocytosis leads to the loss of normal mitotic spindle orientation during epithelial glandular morphogenesis.

Epithelial cells form tissues with many functions, including secretion and environmental separation and protection. Glandular epithelial tissues comprise cysts and tubules that are formed from a polarized, single-epithelial cell layer surrounding a central, fluid-filled lumen. The pathways regulating key processes in epithelial tissue morphogenesis such as mitotic spindle formation are incompletely understood, but are important to investigate, as their dysregulation is a signature of epithelial tumors. Here, we describe a signaling axis that manifests in a defect in mitotic spindle orientation during epithelial growth and cystogenesis. We found that activation of the small GTPase ADP-ribosylation factor 6 (ARF6) results in the sustained internalization of cell-surface components such as the cMet receptor and the cell-adhesion molecule E-cadherin. The spindle orientation defect arising from elevated levels of ARF6-GTP required an increase in cMet endocytosis, but was independent of E-cadherin internalization or elevated extracellular signal-regulated kinase (ERK) activity resulting from internalized receptor signaling on endosomes. Misorientation of the mitotic spindle resulted in the development of epithelial cysts with structural abnormalities, the most conspicuous of which was the presence of multiple intercellular lumens. Abnormal mitotic spindle orientation was necessary but insufficient to disrupt glandular development, as blocking the strong prosurvival signal resulting from ERK hyperactivation yielded structurally normal cysts despite continued manifestation of spindle orientation defects. Our findings highlight a previously unknown link between ARF6 activation, cMet receptor internalization, and mitotic spindle orientation during epithelial glandular morphogenesis.

Tumor-derived microvesicles in the tumor microenvironment: How vesicle heterogeneity can shape the future of a rapidly expanding field.

Information transmission from tumor cells to non-tumor cells in the surrounding microenvironment via microvesicles is a more recently studied form of intercellular signaling that can have a marked impact on the tumor microenvironment. Tumor-derived microvesicles (TMVs) are packed with information including signaling proteins and nucleic acids, and can be taken up by target cells, enabling paracrine signaling. While previous research has focused on how vesicles released from pathologic cells differ from normal cells, the heterogeneity that exists within the TMV population itself is not fully characterized, and only beginning to be appreciated. In this review, we summarize current understanding of the biogenesis and roles of shed TMVs in the tumor microenvironment, and speculate on the consequences for tumor cell signaling in light of the hypothesis that there exists variance within the TMV population. The analysis of differential signaling upon cell-TMV interactions provides insights into potential mechanisms of intercellular communication.

Current situation of osteogenesis imperfecta in Spain: results from a Delphi study.

BACKGROUND: Osteogenesis imperfecta (OI) is a rare disease characterized by low bone mass and bone fragility, associated with an increased risk of fractures, and skeletal and extra-skeletal symptoms that results in an impairment of health-related quality of life of OI patients. Since published studies on OI in Spain are limited, this study aimed to determine the epidemiology, assessed the disease burden, management and unmet needs of OI patients in Spain. Thirty-four experts in the management of patients with osteogenesis imperfecta completed two rounds of online consultation and reported real-life experience and data from Spanish hospitals. Delphi study questionnaires were based on literature review. A working group of nationally recognized clinical experts supported the development of the study questionnaires and the final validation of results. RESULTS: The estimated prevalence of patients diagnosed with OI in Spain is 0.56:10,000 inhabitants (95%CI: 0.54-0.59), which represents that, approximately, 2,669 OI patients are currently managed in Spanish hospitals. It is estimated that approximately 269 new patients would be diagnosed with OI each year in Spain, representing an estimated incidence of 0.06 (95%CI: 0.05-0.06) per 10,000 inhabitants per year. Clinical management of OI in Spain is performed by a range of medical specialists; however, multidisciplinary care is not fully implemented. The absence of an approved curative treatment or a treatment to reduce the clinical features of the disease remains the main unmet need. CONCLUSIONS: This study provides a snapshot of the current situation of patients with OI in Spain reported by clinical experts. The results provide an estimation of the epidemiology of the disease, and complement the available evidence on disease burden, clinical management, and unmet needs of these patients in Spain.

Setrusumab for the Treatment of Osteogenesis Imperfecta: 12-Month Results from the Phase 2b Asteroid Study.

Osteogenesis imperfecta (OI) is a rare genetic disorder commonly caused by variants of the type I collagen genes COL1A1 and COL1A2. OI is associated with increased bone fragility, bone deformities, bone pain, and reduced growth. Setrusumab, a neutralizing antibody to sclerostin, increased areal bone mineral density (aBMD) in a 21-week phase 2a dose escalation study. The phase 2b Asteroid (NCT03118570) study evaluated the efficacy and safety of setrusumab in adults. Adults with a clinical diagnosis of OI type I, III, or IV, a pathogenic variant in COL1A1/A2, and a recent fragility fracture were randomized 1:1:1:1 to receive 2, 8, or 20 mg/kg setrusumab doses or placebo by monthly intravenous infusion during a 12-month treatment period. Participants initially randomized to the placebo group were subsequently reassigned to receive setrusumab 20 mg/kg open label. Therefore, only results from the 2, 8, and 20 mg/kg double-blind groups are presented herein. The primary endpoint of Asteroid was change in distal radial trabecular vBMD from baseline at Month 12, supported by changes in high-resolution peripheral quantitative computed tomography micro finite element-derived bone strength. A total of 110 adults were enrolled with similar baseline characteristics across treatment groups. At 12 months, there was a significant increase in mean (SE) failure load in the 20 mg/kg group (3.17% [1.26%]) and stiffness in the 8 (3.06% [1.70%]) and 20 mg/kg (3.19% [1.29%]) groups from baseline. There were no changes in radial trabecula vBMD (p > 0.05). Gains in failure load and stiffness were similar across OI types. There were no significant differences in annualized fracture rates between doses. Two adults in the 20 mg/kg group experienced related serious adverse reactions. Asteroid demonstrated a beneficial effect of setrusumab on estimates of bone strength across the different types of OI and provides the basis for additional phase 3 evaluation.

Osteogenesis imperfecta, or OI, is a rare disorder affecting patients' bones causing pain and an increased chance of the bone breaking. Setrusumab is a possible treatment for OI being studied in a clinical trial called Asteroid. The goal of Asteroid was to determine which dose of setrusumab helped adults with OI the most: 2, 8, or 20 mg/kg. Researchers looked at the density of patients' bones and estimated how strong their bones were before setrusumab and again after 12 months of treatment to see how they improved with treatment. Researchers could compare these improvements to see which dose of setrusumab helped patients the most. Patients on the highest dose of setrusumab (20 mg/kg) experienced improvements in the density of their arm bones (radius) and leg bones (tibia) after 12 months. The strength of these bones also improved. The density of other bones including the spine, hip, and the overall skeleton (total body) also improved with treatment. Of patients who had side effects after receiving setrusumab, most were mild or moderate intensity. Overall, setrusumab improved the bones of patients with OI with no serious safety concerns. More studies will include even more patients to see how setrusumab can improve their bones.

Tumor-Derived Extracellular Vesicles: Multifunctional Entities in the Tumor Microenvironment.

Tumor cells release extracellular vesicles (EVs) that can function as mediators of intercellular communication in the tumor microenvironment. EVs contain a host of bioactive cargo, including membrane, cytosolic, and nuclear proteins, in addition to noncoding RNAs, other RNA types, and double-stranded DNA fragments. These shed vesicles may deposit paracrine information and can also be taken up by stromal cells, causing the recipient cells to undergo phenotypic changes that profoundly impact diverse facets of cancer progression. For example, this unique form of cellular cross talk helps condition the premetastatic niche, facilitates evasion of the immune response, and promotes invasive and metastatic activity. These findings, coupled with those demonstrating that the number and content of EVs produced by tumors can vary depending on their tumor of origin, disease stage, or response to therapy, have raised the exciting possibility that EVs can be used for risk stratification, diagnostic, and even prognostic purposes. We summarize recent developments and the current knowledge of EV cargoes, their impact on disease progression, and implementation of EV-based liquid biopsies as tumor biomarkers.

The patient clinical journey and socioeconomic impact of osteogenesis imperfecta: a systematic scoping review.

BACKGROUND: Osteogenesis imperfecta (OI) is a rare heritable connective tissue disorder primarily characterised by skeletal deformity and fragility, and an array of secondary features. The purpose of this review was to capture and quantify the published evidence relating specifically to the clinical, humanistic, and economic impact of OI on individuals, their families, and wider society. METHODS: A systematic scoping review of 11 databases (MEDLINE, MEDLINE in-progress, EMBASE, CENTRAL, PsycINFO, NHS EED, CEA Registry, PEDE, ScHARRHUd, Orphanet and Google Scholar), supplemented by hand searches of grey literature, was conducted to identify OI literature published 1st January 1995-18th December 2021. Searches were restricted to English language but without geographical limitations. The quality of included records was assessed using the AGREE II checklist and an adapted version of the JBI cross-sectional study checklist. RESULTS: Of the identified 7,850 records, 271 records of 245 unique studies met the inclusion criteria; overall, 168 included records examined clinical aspects of OI, 67 provided humanistic data, 6 reported on the economic impact of OI, and 30 provided data on mixed outcomes. Bone conditions, anthropometric measurements, oral conditions, diagnostic techniques, use of pharmacotherapy, and physical functioning of adults and children with OI were well described. However, few records included current care practice, diagnosis and monitoring, interactions with the healthcare system, or transition of care across life stages. Limited data on wider health concerns beyond bone health, how these concerns may impact health-related quality of life, in particular that of adult men and other family members, were identified. Few records described fatigue in children or adults. Markedly few records provided data on the socioeconomic impact of OI on patients and their caregivers, and associated costs to healthcare systems, and wider society. Most included records had qualitative limitations. CONCLUSION: Despite the rarity of OI, the volume of recently published literature highlights the breadth of interest in the OI field from the research community. However, significant data gaps describing the experience of OI for individuals, their families, and wider society warrant further research to capture and quantify the full impact of OI.

Microvesicles: mediators of extracellular communication during cancer progression.

Microvesicles are generated by the outward budding and fission of membrane vesicles from the cell surface. Recent studies suggest that microvesicle shedding is a highly regulated process that occurs in a spectrum of cell types and, more frequently, in tumor cells. Microvesicles have been widely detected in various biological fluids including peripheral blood, urine and ascitic fluids, and their function and composition depend on the cells from which they originate. By facilitating the horizontal transfer of bioactive molecules such as proteins, RNAs and microRNAs, they are now thought to have vital roles in tumor invasion and metastases, inflammation, coagulation, and stem-cell renewal and expansion. This Commentary summarizes recent literature on the properties and biogenesis of microvesicles and their potential role in cancer progression.

Acute-Onset Footdrop Caused by Intraneural Ganglion Cyst of the Common Peroneal Nerve: The Effects of Extraneural Pressure Gradients on Cyst Propagation.

Ganglion cysts are relatively common entities, but intraneural ganglia within peripheral nerves are rare and poorly understood. We present a case of a 51-year-old man who presented with acute left dropfoot. Initial magnetic resonance imaging (MRI) was misinterpreted as common peroneal neuritis consistent with a traction injury corroborated by the patient's history. However, after surgical decompression and external neurolysis were performed, the patient's symptoms worsened. Repeated MRI revealed an intraneural ganglion cyst of the common peroneal nerve with connection to the superior tibiofibular joint by means of its anterior recurrent branch that was evident retrospectively on preoperative MRI. It is crucial to carefully inspect atypical cases to further recognize and appreciate the dynamic aspect of this disease or "roller-coaster" phenomenon. Intraneural ganglion cysts rely heavily on intraneural and extraneural pressure gradients for propagation, which can be drawn from the expanded work of the unifying articular theory. This report emphasizes the importance of understanding the pathoanatomical and hydraulic factors to appropriately identify and treat intraneural ganglion cysts. Increased recognition of this pathologic entity as a differential diagnosis for acute onset dropfoot is also highlighted.

Recruitment of DNA to tumor-derived microvesicles.

The shedding of extracellular vesicles (EVs) represents an important but understudied means of cell-cell communication in cancer. Among the currently described classes of EVs, tumor-derived microvesicles (TMVs) comprise a class of vesicles released directly from the cell surface. TMVs contain abundant cargo, including functional proteins and miRNA, which can be transferred to and alter the behavior of recipient cells. Here, we document that a fraction of extracellular double-stranded DNA (dsDNA) is enclosed within TMVs and protected from nuclease degradation. dsDNA inclusion in TMVs is regulated by ARF6 cycling and occurs with the cytosolic DNA sensor, cGAS, but independent of amphisome or micronuclei components. Our studies suggest that dsDNA is trafficked to TMVs via a mechanism distinct from the multivesicular body-dependent secretion reported for the extracellular release of cytosolic DNA. Furthermore, TMV dsDNA can be transferred to recipient cells with consequences to recipient cell behavior, reinforcing its relevance in mediating cell-cell communication.

Mutation of conserved tryptophan residues at the dimer interface of Staphylococcus aureus nitric oxide synthase.

Nitric oxide synthases (NOSs) share two invariant tryptophan residues within a conserved helical lariat that is part of the pterin-binding site and dimer interface. We mutated Staphylococcus aureus NOS Trp-314 (to alanine, phenylalanine, tyrosine and histidine) and Trp-316 (to alanine, phenylalanine and tyrosine) and characterized the effects of mutation on heme environment, quaternary structure, enzymatic activity, and substrate affinity. With arginine present, all saNOS variants bound heme with native thiolate ligation, formed high spin ferric complexes and were dimeric. All variants catalyze the peroxide-dependent oxidation of N-hydroxy-l-arginine, at rates from 10% to 55% of wild type activity. Arginine-free proteins are dimeric with the exception of W314A. Arginine affinity for all variants decreases with increasing temperature between 15 and 42 °C but is precipitous for position-314 variants. Previous structural and biophysical characterization of NOS oxygenase domains demonstrated that the protein can exist in either a tight or loose conformation, with the former corresponding to the active state of the protein. In the position-314 variants it is likely that the loose conformation is favoured, owing to the loss of a hydrogen bond between the indole side chain and the polypeptide backbone of the helical lariat.

In vitro analysis of post-fatigue reverse-torque values at the dental abutment/implant interface for a unitarian abutment design.

PURPOSE: This study analyzed baseline and post-fatigue reverse-torque values (RTVs) for a specific brand control abutment relative to a third party compatible abutment. The purpose of this study was to compare the abutments' fatigue resistance to simulated function, using RTVs as an indication of residual preload at the implant/abutment interface. MATERIALS AND METHODS: Forty Straumann tissue-level implants were mounted in resin and divided into four groups (n = 10). Forty abutments were seated, 20 control and 20 third-party abutments, according to manufacturer guidelines. Ten abutments from each manufacturer were evaluated for RTV without fatigue loading, using a calibrated digital torque gauge to provide a baseline RTVs. Fatigue loading was carried out on the remaining ten specimens from each manufacturer according to ISO 14801 guidelines. A moving-magnet linear motor was used to load one specimen per sequence, alternating from 10 to 200 N at 15 Hz for 5×10(6) cycles. RTV was recorded post-fatigue loading. The results were subjected to two-sample t-testing and two-way ANOVA. Scanning electron microphotography was carried out on three specimens from both manufacturers at baseline and post-fatigue cycling to visualize thread geometry and the abutment/implant interface. RESULTS: The data indicated that mean post-fatigue RTV observed for the control group was significantly higher than the third-party group (RTV 42.65 ± 6.70 N vs. 36.25 ± 2.63 N, p= 0.0161). Visual differences at the macro/microscopic level were also apparent for thread geometry, with third-party abutments demonstrating considerably greater variation in geometrical architecture than control specimens. CONCLUSIONS: Within the limitations of this in vitro model, the effect of component manufacturer resulted in a significantly higher RTV in the control group (two-way ANOVA, p= 0.0032) indicating greater residual preload; however, there was no significant decrease in post-fatigue RTV for either manufacturer compared to baseline.

The ins and outs of microvesicles.

Microvesicles are a heterogeneous group of membrane-enclosed vesicles that are released from cells into the extracellular space by the outward budding and pinching of the plasma membrane. These vesicles are loaded with multiple selectively sorted proteins and nucleic acids. Although interest in the clinical potential of microvesicles is increasing, there is only limited understanding of different types of microvesicles and the mechanisms involved in their formation. Here, we describe what is presently known about this expanding and complex field of research focusing on the mechanism of biogenesis, cargo loading, and release of microvesicles.

Inhibition of N-Nitrosamine Formation in Drug Products: A Model Study.

Nitrosamines, in the absence of toxicological data, are regarded as potential mutagens and need to be controlled at nanogram levels in drug products. Recent high profile product withdrawals have increased regulatory scrutiny of nitrosamine formation assessments for marketed products and for new drug applications. Formation of nitrosamine in drug product is possible when nitrite and vulnerable amines are present. Nitrite is often present as an impurity in excipients at ppm levels, whereas vulnerable amines, if present, stem mainly from the drug substance or its major impurities. In the event a drug product were to contain a major source of vulnerable amines (such as a moiety in the drug substance), it would be desirable to have an inhibitor which could be added to the formulation to minimize nitrosamine formation.  This work demonstrates, for the first time, that the inhibition of nitrosamine formation in oral solid dosage forms is indeed feasible with suitable inhibitors. Five inhibitors investigated (ascorbic acid, sodium ascorbate, α-tocopherol, caffeic acid, and ferulic acid) showed >80% inhibition when spiked at ∼1 wt% level. This work has also shown the potential use of amino acids (glycine, lysine, histidine) as inhibitors of nitrosamine formation in solution.

Breaking Bad: Extracellular Vesicles Provoke Tumorigenic Responses Under Oxygen Deprivation.

Intercellular communication is vital to tumor progression. In this issue of Developmental Cell, Bertolini et al. (2020) describe how small extracellular vesicles released from hypoxic mammary tumor cells facilitate intercellular communication, leading to alterations in mitochondrial dynamics and acquisition of invasive phenotypes in normal epithelial cells.

Two critical thinking models-probing questions and conceptualization-adding 4 skillsets to the teacher's armamentarium.

Critical thinking is ubiquitous in patient care. One track for critical thinking develops skillsets emulating the thought process of the master clinician using probing questions and has been offered in treatment planning, literature search, and critique, risk assessment in caries and geriatrics, technology decision-making, EBD, and IPP. This paper offers 2 additional critical thinking skillsets following this emulation model in social work and ethics. Conceptualization, another form of critical thinking, is also ubiquitous in health care, yet almost no literature exists to guide learning and assess performance on conceptualization. This paper introduces for discussion 2 examples of conceptualization-"How and how much does this situation differ from the ideal?" and "How does the student/practitioner conceptualize the outcome prior to the imminent procedure?" -used continually by the practitioner in patient care situations. The result is 4 additional critical thinking skillsets at different stages of development in the armamentarium for the teacher.

Rab11b-mediated integrin recycling promotes brain metastatic adaptation and outgrowth.

Breast cancer brain metastases (BCBM) have a 5-20 year latency and account for 30% of mortality; however, mechanisms governing adaptation to the brain microenvironment remain poorly defined. We combine time-course RNA-sequencing of BCBM development with a Drosophila melanogaster genetic screen, and identify Rab11b as a functional mediator of metastatic adaptation. Proteomic analysis reveals that Rab11b controls the cell surface proteome, recycling proteins required for successful interaction with the microenvironment, including integrin ß1. Rab11b-mediated control of integrin ß1 surface expression allows efficient engagement with the brain ECM, activating mechanotransduction signaling to promote survival. Lipophilic statins prevent membrane association and activity of Rab11b, and we provide proof-of principle that these drugs prevent breast cancer adaptation to the brain microenvironment. Our results identify Rab11b-mediated recycling of integrin ß1 as regulating BCBM, and suggest that the recycleome, recycling-based control of the cell surface proteome, is a previously unknown driver of metastatic adaptation and outgrowth.

Spontaneous Rupture of Multiple Tendons in the Lower Extremity Following the Diagnosis of Lyme Disease.

Over a time frame of less than 1 year, a 23-year-old competitive horseback rider experienced a midsubstance tear of both the tibialis anterior and extensor hallucis longus tendons without inciting injury. It was after the second spontaneous tear that the patient's recent diagnosis of Lyme disease became the likely culprit. Often, patients with chronic Lyme disease present with an elaborate clinical picture that can mimic many more common diagnoses such as septic arthritis, transient synovitis, ligamentous sprain, and various other traumatic injuries. With the pathognomonic erythema migrans rash reported to be present less than 50% of the time in late-stage infections, the diagnosis of Lyme disease can often be difficult, with a high rate of underdiagnosis. It is important that Lyme disease be included in the differential diagnosis of spontaneous tendon pathology, especially for physicians practicing in highly endemic areas. The treatment is relatively simple and successful-especially for an acute infection-and it is important to initiate treatment promptly to prevent disability.

Coordinated Regulation of Intracellular Fascin Distribution Governs Tumor Microvesicle Release and Invasive Cell Capacity.

Tumor cell invasion is one result of the bidirectional interactions occurring between tumor cells and the surrounding milieu. The ability of tumor cells to invade through the extracellular matrix is in part regulated by the formation of a class of protease-loaded extracellular vesicles, called tumor microvesicles (TMVs), which are released directly from the cell surface. Here we show that the actin bundling protein, fascin, redistributes to the cell periphery in a ternary complex with podocalyxin and ezrin, where it promotes TMV release. The peripheral localization of fascin is prompted by the loss of Rab35 signaling, which in turn unleashes ARF6 activation. The result is a mechanism through which Rab35 and ARF6 cooperatively and simultaneously regulate the distribution and localization of fascin and promote oncogenic signaling, which leads to TMV release while inhibiting invadopodium formation. These studies are clinically significant as fascin-loaded TMVs can be detected in bodily fluids and elevated fascin expression coupled with low Rab35 levels correlates with poor overall survival in some cancers.