Efficacy of a Mediterranean diet supplemented with fatty fish in ameliorating inflammation in paediatric asthma: a randomised controlled trial.

BACKGROUND: Childhood asthma is the most common respiratory disorder worldwide, being associated with increased morbidity and a decreased quality of life. Omega-3 fatty acids have anti-inflammatory and immunomodulating properties; however, their efficacy in asthma is controversial. The present study aimed to examine the efficacy of a Mediterranean diet supplemented with a high omega-3 'fatty' fish intake in Greek asthmatic children. METHODS: A single-centred, 6-month, parallel randomised controlled trial compared the consumption of a Mediterranean diet supplemented with two meals of 150 g of cooked fatty fish weekly (intervention) with the usual diet (control) with respect to pulmonary function in children (aged 5-12 years) with mild asthma. Pulmonary function was assessed using spirometry and bronchial inflammation by fractional exhaled nitric oxide analysis. RESULTS: Sixty-four children (52% male, 48% female) successfully completed the trial. Fatty fish intake increased in the intervention group from 17 g day-1 at baseline to 46 g day-1 at 6 months (P < 0.001). In the unadjusted analysis, the effect of the intervention was of borderline significance (P = 0.06, ß = -11.93; 95% confidence interval = -24.32 to 0.46). However, after adjusting for age, sex, body mass index and regular physical activity, a significant effect was observed (P = 0.04, ß = -14.15 ppb; 95% confidence interval = -27.39 to -0.91). No difference was observed for spirometry, asthma control and quality of life scores. CONCLUSIONS: A Mediterranean diet supplemented with two fatty fish meals per week might be a potential strategy for reducing airway inflammation in childhood asthma. Future robust clinical trials are warranted to replicate and corroborate these findings.

Discarding IVF embryos: reporting on global practices.

PURPOSE: To provide a global scale report on a representative sample of the clinical embryology community depicting the practice of discarding supernumerary IVF embryos. METHODS: A web-based questionnaire titled "Anonymous questionnaire on embryo disposal practices" was designed in order to ensure anonymous participation of practicing clinical embryologists around the world. RESULTS: During a data collection period of 8 months, 703 filled-in questionnaires from 65 countries were acquired. According to the data acquired, the majority of practitioners, dispose of embryos by placing them directly in a trash can strictly dedicated for embryo disposal for both fresh and frozen cycles (39% and 36.7% respectively). Moreover, 66.4% of practitioners discard the embryos separately-case by case-at different time points during the day. Over half of embryologists (54%) wait until day 6 to discard the surplus embryos, while 65.5% do not implement a specially allocated incubator space as a designated waiting area prior to disposal. The majority of 63.1% reported that this is a witnessed procedure. The vast majority of embryologists (93%) do not employ different protocols for different groups of patients. Nonetheless, 17.8% reported the request to perform a ceremony for these embryos. Assessing the embryologists' perspective, 59.5% of participants stated that the embryology practice would benefit from a universally accepted and practiced protocol. CONCLUSION(S): This study uniquely provides insight into global embryo disposal practices and trends. Results highlight the divergence between reported practices, while indicating the significance on standardization of practice, with embryologists acknowledging the need for a universally accepted protocol implementation.

Should the flexibility enabled by performing a day-4 embryo transfer remain as a valid option in the IVF laboratory? A systematic review and network meta-analysis.

PURPOSE: The present systematic review and network meta-analysis aims to uniquely bring to literature data supporting the true place of the alternative practice of day-4 embryo transfer (D4 ET) in an IVF laboratory, beyond the one-dimensional option of facilitating a highly demanding program. METHODS: A systematic search was conducted in the databases of PubMed/Medline, Embase, and Cochrane Central Library, resulting to six prospective along with nine retrospective cohort studies meeting eligibility criteria for inclusion. A comparison of D4 ET with day-2 (D2), day-3 (D3), and day-5 (D5) ET, respectively, was performed employing R statistics. RESULTS: The sourced results indicate no statistically significant difference regarding clinical pregnancy rates, and ongoing pregnancy/live birth rates stemming from the comparison of D4 with D2, D4 with D3, and D4 with D5 ET, respectively. Additionally, no statistically significant difference could be established in respect to cancelation, and miscarriage rates, following the comparison of D4 with D3 and D4 with D5 ET. Interestingly, we report statistically significant lower preterm birth rates associated with D4 ET, in contrast with D5 ET (RR, 0.19; 95% CI, 0.05-0.67; p value = 0.01). CONCLUSIONS: The aforementioned results may serve as advocates buttressing the option of D4 ET as a valid candidate in the ET decision-making process. Possible limitations of the current study are the publication bias stemming from the retrospective nature of certain included studies, along with various deviations among studies' design, referring to number and quality of transferred embryos, or different culture conditions referring to studies of previous decades.

IL-6 is associated to IGF-1Ec upregulation and Ec peptide secretion, from prostate tumors.

BACKGROUND: Ec peptide (PEc), resulting from the proteolytic cleavage of the IGF-1Ec isoform, is involved in prostate cancer progression and metastasis, whereas in muscle tissue, it is associated with the mobilization of satellite cells prior to repair. Our aim is to determine the physiological conditions associated to the IGF-1Ec upregulation and PEc secretion in prostate tumors, as well as, the effect of tumor PEc on tumor repair. METHODS: IGF-1 (mature and isoforms) expression was examined by qRT-PCR, both in prostate cancer cells co-incubated with cells of the immune response (IR) and in tumors. PEc secretion was determined by Multiple Reaction Monitoring. The effect of PEc, on mesenchymal stem cell (MSC) mobilization and repair, was examined using migration and invasion assays, FISH and immunohistochemistry (IHC). The JAK/STAT signaling pathway leading to the IGF1-Ec expression was examined by western blot analysis. Determination of the expression and localization of IL-6 and IGF-1Ec in prostate tumors was examined by qRT-PCR and by IHC. RESULTS: We documented that IL-6 secreted by IR cells activates the JAK2 and STAT3 pathway through IL-6 receptor in cancer cells, leading to the IGF-1Ec upregulation and PEc secretion, as well as to the IL-6 expression and secretion. The resulting PEc, apart from its oncogenic role, also mobilizes MSCs towards the tumor, thus promoting tumor repair. CONCLUSIONS: IL-6 leads to the PEc secretion from prostate cancer cells. Apart from its oncogenic role, PEc is also involved in the mobilization of MSCs resulting in tumor repair.

Cadherin-11 mRNA transcripts are frequently found in rheumatoid arthritis peripheral blood and correlate with established polyarthritis.

Rheumatoid arthritis (RA) synovial fibroblasts hyperexpress the mesenchymal cadherin-11, which is involved also in tumor invasion/metastasis, whereas anti-cadherin-11 therapeutics prevent and reduce experimental arthritis. To test the hypothesis that cadherin-11 is aberrantly expressed in RA peripheral blood, 100 patients (15 studied serially) and 70 healthy controls were analyzed by real-time reverse transcription-PCR. Cadherin-11 mRNA transcripts were detected in 69.2% of moderately/severely active RA, versus 31.8% of remaining patients (p=0.001), versus 17.1% of controls (p<0.0001). Notably, cadherin-11 positivity correlated significantly and independently only with established (>1year) polyarthritis (>4 swollen tender joints), by multivariate logistic regression analysis including various possible clinical/laboratory factors. Rare cells of undefined nature, detected by flow cytometry following CD45(-) enrichment, strongly expressed surface cadherin-11 (estimated 10-50cells/ml of blood) in 5/6 patients with polyarticular established disease versus 1/6 patients with early RA. Studies on the potential pathogenic role of circulating cells expressing cadherin-11 in RA are warranted.

Epigenetic regulation on gene expression induced by physical exercise.

It is well established that physical exercise modulates the function of many physiological systems, such as the musculoskeletal, the cardiovascular and the nervous system, by inducing various adaptations to the increased mechanical load and/or metabolic stress of exercise. Many of these changes occur through epigenetic alterations to DNA, such as histone modifications, DNA methylations, expression of microRNAs and changes of the chromatin structure. All these epigenetic alterations may have clinical relevance, thus playing an important role in the prevention and confrontation of neurophysiological disorders, metabolic syndrome, cardiovascular diseases and cancer. Herein we review the known epigenetic modifications induced by physical exercise in various physiological systems and pathologies, and discuss their potential clinical implications.

The quarrel between iatromechanists and animists about the cause of cancer: lymph's role in oncogenesis.

In the 17th century, iatromechanists based to the solidist theory for the lymphatic system and lymph established a new speculation for the essential role of lymph in oncogenesis, while animists gave their own views in relation to the cause of cancer. Gradually, with the rise of pathological anatomy, new more rational theories have emerged.

An alternative method for measuring total respiratory resistance during quiet breathing: a feasibility and validation study.

OBJECTIVE: Determining the respiratory system's mechanical properties with minimal patient effort has been an important field of investigation addressing patients unable to perform pulmonary function testing and in light of the preventive measures due to the recent pandemic. The current study aimed to present an alternative method for total respiratory resistance measurement during tidal breathing, compare it with airway resistance (Raw), measured by body plethysmography, and validate the procedure in three groups of subjects with normal, constrictive and obstructive respiratory patterns in spirometry. PATIENTS AND METHODS: We developed an alternative method of assessing total respiratory resistance during quiet breathing. After manufacturing the appropriate hardware apparatus, we applied a steady extrinsic resistance (ΔR) for 100-200 m/s during tidal breathing. Α theoretical mathematical model allowed measurement of total respiratory resistance (Rtot) during inspiration (Rin) and expiration (Rex). To validate the method, 15 individuals were enrolled and assigned to the normal, obstructive and restrictive groups based on their spirometry patterns. All groups participated in two sets of measurements, the plethysmographic and novel method. Finally, respiratory resistance measurements were compared between groups and methods. RESULTS: The method was successfully developed, and Rtot measurements were recorded in five normal subjects and in five obstructive and restrictive subjects. Mean Rin and mean Rex were 4.99 cm H2O/L/sec and 4.42 cm H2O/L/sec in the healthy, 4.87 cm H2O/L/sec, and 6.63 cm H2O/L/sec in the obstructive and 5.97 cm H2O/L/sec and 4.12 cm H2O/L/sec in the restrictive group, respectively. Rex was notably higher than Rin in the obstructive group and was positively correlated with Raw (p<0.005, r=0.47). CONCLUSIONS: This method provides the theoretical background for a plausible alternative tool for accessing a mechanical parameter of the respiratory system, which is easy to perform and requires only passive patient cooperation while enabling rough differentiation between obstructive and restrictive disorders. The model's feasibility potential in a real-life setting was studied in a small sample, and additional implementation and validation of the method in a larger population are guaranteed.

The impact of endocrine disruptors on endocrine targets.

Endocrine disruption represents one of the most controversial environmental issues of our époque. So far, many substances, both natural and artificial, have been recognized to interfere with endocrine signaling pathways. In intact laboratory animals, this interaction has been documented to generate adverse health outcomes by impairing normal functions. With regard to humans, evidence is limited and inconsistent to clearly establish a causal inference, however, accumulating data incriminate endocrine disrupting chemicals to reproductive disorders and disturbed thyroid homeostasis. Recently, as a result of animal models and preliminary human studies, a new area of interest has arisen concerning the implication of endocrine disruptors in the etiology of obesity and diabetes, the two major, life-threatening, epidemics of modern world. This article reviews the evidence linking endocrine disrupting chemicals to a broad spectrum of clinical perturbations from reproduction and thyroid to metabolic regulation.

Evaluating the value of day 0 of an ICSI cycle on indicating laboratory outcome.

A number of oocyte characteristics have been associated with fertilization, implantation and live-birth rates, albeit without reaching a consensus. This study aims to delineate possible associations between oocyte characteristics, oocyte behavior during intracytoplasmic sperm injection (ICSI), fertilization potential, and laboratory outcomes. Four-hundred and seventy-seven patients, yielding 3452 oocytes, were enrolled in this prospective observational study from 2015 to 2018. Οoplasm granularity was associated with poor embryo quality and higher probabilities of post-ICSI oocytes and embryos discarded in any developmental stage and never selected for embryo transfer or cryopreservation (p < 0.001). Both sudden or difficult ooplasm aspiration, and high or lack of resistance during ICSI were associated with either a poor Zygote-Score or fertilization failure (p < 0.001). Sudden or difficult ooplasm aspiration and high resistance during ICSI penetration were positively associated with resulting to a post-ICSI oocyte or embryo that would be selected for discard. Evaluation of oocyte characteristics and oocyte behavior during ICSI may provide early information regarding laboratory and cycle outcomes. Particularly, ooplasm granularity, and fragmentation of polar body, along with sudden or difficult ooplasm aspiration and high or lack of resistance during ICSI penetration may hinder the outcome of an ICSI cycle. The associations presented herein may contribute towards development of a grading system or a prediction model. Taking into account information on oocytes and ICSI behavior may effectively assist in enhancing IVF outcome rates.

Changes in the mechanical properties of human quadriceps muscle after eccentric exercise.

Muscular adaptation which occurs following eccentric exercise-induced muscle damage has been associated with changes in the mechanical properties of muscle manifested as a shift in the length-tension relationship towards longer muscle lengths. However, it is not clear whether this shift is a long term adaptation to eccentric exercise. The purpose of this study was to investigate functional adaptations to skeletal muscle damage in humans, tracking such responses several days into muscle recovery. Ten healthy young men performed an eccentric exercise protocol involving the quadriceps muscle and functional measurements were performed before and on days 1, 2, 5, 8, 12 and 16 post-exercise. Blood samples were also withdrawn before and at 6 h, and 2 days, 5 days and 16 days post-exercise. The exercise protocol resulted in muscle damage, indicated by changes in clinical markers including increased serum creatine kinase activity and muscle soreness compared to pre-exercise levels (p<0.05-0.001). An acute, but not sustained shift in the quadriceps isokinetic and isometric angle-torque curves towards longer muscle lengths was observed post-exercise (p<0.05). It was speculated that the functional adaptations following eccentric exercise might be affected by the short resting and functional length of the quadriceps muscle, relative to its optimum. More studies are needed to confirm the hypothesis that a sustained shift in the muscle's length-tension relationship, as an adaptation after lengthening contraction-induced damage, is muscle specific.

Expression of IGF-1 isoforms after exercise-induced muscle damage in humans: characterization of the MGF E peptide actions in vitro.

Different insulin-like growth factor-1 (IGF-1) isoforms, namely IGF-1Ea, IGF-1Eb and IGF-1Ec (MGF), have been proposed to have various functions in muscle repair and growth. To gain insight into the potentially differential actions of IGF-1 isoforms in the regulation of muscle regeneration, we assessed the time course of their expressions at both mRNA and protein levels after exercise-induced muscle damage in humans. In addition, we characterized mature IGF-1 and synthetic MGF E peptide signalling in C2C12 myoblast-like cells in vitro. Ten healthy male volunteers were subjected to exercise-induced muscle damage and biopsy samples were taken from the exercised muscles before and 6 h, 2, 5 and 16 days post exercise. Muscle damage was documented by specific functional and biochemical responses post exercise. PCR-based analyses of muscle biopsy samples revealed a rapid and transient up-regulation of MGF mRNA expression which was followed by a prolonged increase of IGF-1Ea and IGF-1Eb mRNA expression (p<0.05). Patterns similar to those for mRNA expression were detected for MGF and IGF-1Ea expression at the protein level. The action of synthetic MGF E peptide differed from that of mature IGF-1 since its proliferative effect on C2C12 myoblast-like cells was not blocked by an anti-IGF-1 receptor neutralizing antibody and it did not phosphorylate Akt. Therefore, we conclude that the differential expression profile of IGF-1 isoforms in vivo and the possible IGF-1R - independent MGF E peptide signalling in skeletal muscle-like cells in vitro support the notion that tissue-specific mRNA expression of MGF isoform produces mature IGF-1 and MGF E peptides which possibly act as distinct mitogens in skeletal muscle regeneration.

The role of urokinase-type plasminogen activator (uPA) and transforming growth factor beta 1 (TGFbeta1) in muscle regeneration.

Skeletal muscle regeneration is a highly synchronized process involving the activation of various cellular and molecular events, coordinating inflammation and regeneration processes which are crucial for the beneficial outcome of tissue remodeling. Fibrosis, a failure of tissue remodeling, is initiated with muscle regeneration; however, it is the result of an excessive inflammatory response, representing an imbalance between enhanced production and deposition and impaired degradation of extracellular matrix (ECM) components of the muscle. Therefore, factors influencing the relative degree of muscle fiber regeneration as compared to the amount of scar formation have a critical role in functional muscle remodeling. Herein we have focused on the role of urokinase-type plasminogen activator (uPA) and transforming growth factor beta 1 (TGF/1) in ECM degradation and reconstitution in muscles.

In vivo models for heart failure research.

The medical treatment of heart failure (HF) is associated with 50% survival at 5 years, thus being one of the major causes of mortality in Western countries. An understanding of the pathophysiology of HF is essential for the development of novel efficient therapies. Consequently, the use of animal models is indispensable. In addition, the development of new in vivo models of HF is critical for the evaluation of treatments such as gene therapy, mechanical devices and new surgical approaches. However, every animal model has advantages and limitations and none of them is suitable to study all aspects of HF. Besides the technical determinants of a model, species, strain and gender affect the pathophysiology of a given heart pathogenesis and, therefore, have to be considered in each animal model. The most common in vivo models used in cardiology research and in particular in HF remodeling are presented.

Characterization of a rabbit antihuman mechano growth factor (MGF) polyclonal antibody against the last 24 amino acids of the E domain.

The human insulin-like growth factor-1 (IGF-1) gene gives rise to multiple, heterogeneous mRNA transcripts by alternative splicing, thus producing different IGF-1 isoforms. The mechano growth factor (MGF) is an IGF-1 isoform that was found to be markedly up-regulated in exercised or damaged muscle. The specific E domain of the MGF splice variant may act as an independent growth factor. The aim of the present study was to characterize a rabbit antihuman MGF polyclonal antibody. New-Zealand rabbits were immunized by injections of a purified synthetic peptide corresponding to the last 24 amino acids of the human C-terminal of the MGF E domain. Western blotting and immunohistochemical techniques were used to characterize the specificity of the polyclonal anti-MGF antiserum. The anti-MGF antiserum was found to recognize the MGF E-peptide and not the common part of the IGF-1 isoforms, i.e. the mature IGF-1 peptide. Furthermore, it specifically bound to the MGF protein in human skeletal and in rat cardiac muscle, apparently due to the considerable homology between the human and rat MGF E-peptide sequences. Immunostaining analysis showed that this polyclonal anti-MGF antibody was able to detect MGF in human muscle and in rat cardiomyocytes and vessels' smooth muscle cells. We conclude that this rabbit polyclonal anti-human/rat MGF antibody could become a valuable tool in the study of IGF-1 isoforms in human and rat tissues.

Risks in Surrogacy Considering the Embryo: From the Preimplantation to the Gestational and Neonatal Period.

Surrogacy is an assisted reproduction-based approach in which the intended parents assign the gestation and birth to another woman called the surrogate mother. The drivers of surrogacy refer largely to infertility, medical conditions, same-sex couples' parenting, and cases of diversity regarding sexual identity and orientation. Surrogacy consists of a valid option for a variety of conditions or circumstances ranging from medical to social reasons. However, surrogacy may be associated with risks during the preimplantation, prenatal, and neonatal period. It became obvious during the exhaustive literature research that data on surrogacy and its association with factors specific to the IVF practice and the options available were not fully represented. Could it be that surrogacy management adds another level of complexity to the process from the ovarian stimulation, the subsequent IVF cycle, and the techniques employed within the IVF and the Genetic Laboratory to the fetal, perinatal, and neonatal period? This work emphasizes the risks associated with surrogacy with respect to the preimplantation embryo, the fetus, and the infant. Moreover, it further calls for larger studies reporting on surrogacy and comparing the surrogate management to that of the routine IVF patient in order to avoid suboptimal management of a surrogate cycle. This is of particular importance in light of the fact that the surrogate cycle may include not only the surrogate but also the egg donor, sperm donor, and the commissioning couple or single person.

Purification and partial sequencing of the major mitogen for human uterine smooth muscle-like cells in leiomyoma extracts.

We purified the major mitogen for human smooth muscle-like cells in leiomyoma extracts by sequential liquid chromatography on (a) carboxymethyl-Sepharose, (b) heparin-Sepharose columns, (c) cartridges of C18 silica, and (d) linear gradient reverse-phase high performance liquid chromatography. The mitogenic activity of the leiomyoma extract throughout purification was tested by tritiated thymidine incorporation and DNA content in NIH/3T3 fibroblasts and KW human smooth muscle-like cells. Purification of the leiomyoma-derived growth factor (LDGF) for KW smooth muscle-like cells confirmed that its partial NH2-terminal amino acid (aa) sequence (1-20 aa) was identical to 113-132 aa of the human cysteine-rich protein (hCRP). A synthetic peptide which was engineered based on the purified aa sequence, stimulated the proliferation and growth of KW cells. An oligonucleotide probe constructed by the cDNA of the hcrp gene that encodes this aa sequence depicted the expression of 1.9-kb LDGF mRNA in leiomyomas and myometrium. The expression of the LDGF mRNA was three to sixfold higher in leiomyomas compared with adjacent myometrium of women harboring leiomyomas by in situ hybridization analysis. These data suggest that LDGF may participate in the pathophysiology of uterine leiomyomas.

Characteristics of prostate-derived growth factors for cells of the osteoblast phenotype.

We examined the characteristics of mitogens extracted from human benign prostatic hyperplasia and prostatic adenocarcinoma tissue. Although mitogens for fetal rat skin fibroblasts as well as for rat calvarial osteoblasts and osterosarcoma cells were found, distinct entities that acted selectively in cells of the osteoblast phenotype could be obtained by sequential reverse-phase high performance liquid chromatography. Two peptides with apparent molecular weights of 10,000 and 13,000 D were derived from hyperplastic tissue, whereas a single moiety of 10,000 D was obtained from malignant tissue. These entities increased cell numbers and alkaline phosphatase activity in osteoblastlike cells consistent with effects on both growth and differentiation. Prostatic peptides did not stimulate adenylate cyclase in osteosarcoma cells. Mitogenic activity selective for osteoblastlike cells was identified in postpubertal but not prepubertal normal prostate. The results demonstrate the existence of osteoblastic growth factors in prostatic tissue whose presence may accompany postpubertal development.

Type I insulin-like growth factor receptor signaling in skeletal muscle regeneration and hypertrophy.

Skeletal muscle is able not only to increase its mass as an adaptation to mechanical loading generated by and imposed upon muscle but also to regenerate after damage, via its intrinsic regulation of gene transcription. Both cellular processes, muscle regeneration and hypertrophy, are mediated by the activation, proliferation and differentiation of muscle satellite cells and appear to be modulated by the mitotic and myogenic activity of locally produced insulin-like growth factor 1 (IGF-1), which functions in an autocrine/paracrine mode. Differentiation of satellite cells into myoblasts involves the regulation of skeletal muscle-specific proteins belonging to the family of myogenic regulatory factors (MRFs). The endocrine, autocrine and paracrine functions of IGF-1 are mediated through binding to the type I IGF receptor (IGF-1.R), which is a ligand-activated receptor tyrosine kinase. The binding of IGF-1 to IGF-1.R induces its autophosphorylation, which recruits specific cytoplasmic molecules containing the Insulin Receptor Substrate Proteins (IRS). The recruitment of IRS proteins by IGF-1/IGF-1.R binding is a critical level at which the proliferative and differentiative actions of IGF-1 diverge. Specific signaling pathways downstream of IGF-1, potentially involved in the mitogenic and myogenic responses and mediating skeletal muscle protein synthesis and hypertrophy following exercise-induced muscle overloading and damage, are discussed. A potential alternative activation of different signaling pathway(s) via a different receptor remains to be demonstrated.

Regulation of the mGluR5, EAAT1 and GS expression by glucocorticoids in MG-63 osteoblast-like osteosarcoma cells.

INTRODUCTION: Growth factors, cytokines, sex steroid hormones and glucocorticoids have differential and complex effects on skeletal metabolism. Recently, the presence of the glutamatergic (Glu) system in bone cells has provided new evidence for its possible role in bone physiology. Consequently, we have investigated the regulation of certain components of the Glu system by glucocorticoids in MG-63 osteoblast-like osteosarcoma cells, in vitro. MATERIALS AND METHODS: We characterized the effects of dexamethasone on the expression of the mGluR5, EAAT1 and GS, at mRNA and protein level, using relative quantitative RTPCR and Western blot analysis, respectively. RESULTS: We confirmed the induction of GS expression by dexamethasone published previously. In addition, we documented for the first time the expression of the mGluR5 and EAAT1 in MG-63 cells, as well as the ability of dexamethasone to upregulate the expression of the mGluR5 and EAAT1 in the MG-63 cells. CONCLUSIONS: Components of the glutamatergic system may play a role in bone pathophysiology.