Overcoming Barriers: A Comprehensive Review of Chronic Pain Management and Accessibility Challenges in Rural America.

In the United States (U.S.), chronic pain poses substantial challenges in rural areas where access to effective pain management can be limited. Our literature review examines chronic pain management in rural U.S. settings, identifying key issues and disparities. A comprehensive search of PubMed, Web of Science, and Google Scholar identified high-quality studies published between 2000 and 2024 on chronic pain management in the rural U.S. Data were categorized into thematic areas, including epidemiology, management challenges, current strategies, research gaps, and future directions. Key findings reveal that rural populations have a significantly higher prevalence of chronic pain and are more likely to experience severe pain. Economic and systemic barriers include a shortage of pain specialists, limited access to nonpharmacologic treatments, and inadequate insurance coverage. Rural patients are also less likely to engage in beneficial modalities like physical therapy and psychological support due to geographic isolation. Additionally, rural healthcare providers more often fulfill multiple medical roles, leading to burnout and decreased quality of care. Innovative approaches such as telehealth and integrated care models show the potential to improve access and outcomes. Our review highlights the need for increased telehealth utilization, enhanced provider education, and targeted interventions to address the specific pain needs of rural populations.

Implementation of Vertical Split Flow Model for Patient Throughput at a Community Hospital Emergency Department.

BACKGROUND: Hospitals have implemented innovative strategies to address overcrowding by optimizing patient flow through the emergency department (ED). Vertical split flow refers to the concept of assigning patients to vertical chairs instead of horizontal beds based on patient acuity. OBJECTIVE: Evaluate the impact of vertical split flow implementation on ED Emergency Severity Index (ESI) level 3, patient length of stay, and throughput at a community hospital. METHODS: Retrospective cohort study of all ESI level 3 patients presenting to a community hospital ED over a 3-month period prior to and after vertical split flow implementation between 2018 and 2019. RESULTS: In total, data were collected from 10,638 patient visits: 5262 and 5376 patient visits pre- and postintervention, respectively. There was a significant reduction in mean overall length of stay when ESI-3 patients were triaged with vertical split flow (251 min vs 283 min, p < 0.001). CONCLUSIONS: Community hospital ED implementation of vertical split flow for ESI level 3 patients was associated with a significant reduction in overall length of stay and improved throughput. This model provides a solution to increase the number of patients that can be simultaneously cared for in the ED without increasing staffing or physical space.

Handheld Point-of-Care Ultrasound: Safety Considerations for Creating Guidelines.

BACKGROUND: Compared to traditional ultrasound machines, emerging handheld point-of-care-ultrasound (HPOCUS) systems exhibit superior portability and affordability. Thus, they have been increasingly embraced in the intensive care setting. However, there is scarce data on patient safety and current regulatory body guidelines are lacking. Here, we critically appraise the literature with a focus on the merits, concerns, and framework of existing POCUS guidelines. Subsequently, we provide recommendations for future regulatory guidelines. METHODS: A comprehensive literature review was conducted using the PubMed database employing the key words "point-of-care/handheld/portable ultrasound" and "guidelines" alone, in combination, and using thesaurus terms. Eligible articles were scrutinized for description of potential benefits and concerns of HPOCUS, especially from a patient safety perspective, as well as currently existing POCUS practice guidelines. Data was extracted, reported thematically using a narrative synthesis approach, then subsequently used to guide our proposed guidelines. RESULTS: The most widely reported benefits of HPOCUS include superior portability, affordability, imaging, facilitation of expedited diagnosis and management, and integration with medical workplace flow. However, major barriers to adoption include device security/patient confidentiality and patient safety. Furthermore, except for a policy published by the American College of Emergency Physicians (ACEP) in 2018, there are few other national regulatory guidelines pertaining to handheld POCUS. In light of this, we propose a framework for HPOCUS guideline development to address these and other concerns. Such guidelines include training and credentialing, bioengineering approval, and strategic integration with electronic medical record systems. CONCLUSION: HPOCUS can be a powerful tool for expedited diagnosis and management guidance. However, there is limited data regarding patient safety and current regulatory body guidelines are lacking. Our assessment illuminates that there remain many unsolved problems about HPOCUS, and in turn, we propose guidelines to address safe regulation and implementation.

Vitamin D deficiency enhances expression of autophagy-regulating miR-142-3p in mouse and "involved" IBD patient intestinal tissues.

Vitamin D deficiency is an environmental factor involved in the pathogenesis of inflammatory bowel disease (IBD); however, the mechanisms surrounding its role remain unclear. Previous studies conducted in an intestinal epithelial-specific vitamin D receptor (VDR) knockout model suggest that a lack of vitamin D signaling causes a reduction in intestinal autophagy. A potential link between vitamin D deficiency and dysregulated autophagy is microRNA (miR)-142-3p, which suppresses autophagy. In this study, we found that wild-type C57BL/6 mice fed a vitamin D-deficient diet for 5 wk had increased miR-142-3p expression in ileal tissues compared with mice that were fed a matched control diet. Interestingly, there was no difference in expression of key autophagy markers ATG16L1 and LC3II in the ileum whole tissue. However, Paneth cells of vitamin D-deficient mice were morphologically abnormal and had an accumulation of the autophagy adaptor protein p62, which was not present in the total crypt epithelium. These findings suggest that Paneth cells exhibit early markers of autophagy dysregulation within the intestinal epithelium in response to vitamin D deficiency and enhanced miR-142-3p expression. Finally, we demonstrated that treatment-naïve IBD patients with low levels of vitamin D have an increase in miR-142-3p expression in colonic tissues procured from "involved" areas of the disease. Taken together, our findings demonstrate that insufficient vitamin D levels alter expression of autophagy-regulating miR-142-3p in intestinal tissues of mice and patients with IBD, providing insight into the mechanisms by which vitamin D deficiency modulates IBD pathogenesis.NEW & NOTEWORTHY Vitamin D deficiency has a role in IBD pathogenesis, and although the mechanisms surrounding its role remain unclear, it has been suggested that autophagy dysregulation is involved. Here, we show increased ileal expression of autophagy-suppressing miR-142-3p in mice that were fed a vitamin D-deficient diet and in "involved" colonic biopsies from pediatric IBD patients with low vitamin D. miR-142-3p serves as a potential mechanism mediating vitamin D deficiency and reduced autophagy.

Characteristics and Frequency of Children With Severe Obstructive Sleep Apnea Undergoing Elective Polysomnography.

OBJECTIVE: To determine the prevalence and demographics features of pediatric patients with severe obstructive sleep apnea (OSA) who would not undergo preoperative polysomnography (PSG) under current American Academy of Otolaryngology (AAO) guidelines. STUDY DESIGN: In this retrospective cohort study, we identified patients from the electronic medical record who underwent elective polysomnography for evaluation of sleep-disordered breathing between 2012 and 2018. SETTING: Urban tertiary safety net hospital. SUBJECTS AND METHODS: A total of 456 patients with a mean (SD) age of 5.7 (3.2) years (263 male, 193 female). Demographic factors (age, sex, race, language, insurance status) and clinical findings (symptom severity, tonsil size) were recorded. The data were analyzed by univariate analysis. RESULTS: Of 456 patients identified, 66 (14.5%) were found to have severe OSA. African American patients had 3.7 times the odds of severe OSA compared to white patients (95% CI, 1.2-10.8). Patients aged 2 to 3 years had 2.2 times the odds of severe OSA compared to patients aged 4 to 6 years (95% CI, 1.2-4.0). Sex, ethnicity, language, and insurance type were not significantly associated with severity of OSA. The presence of apneic episodes and tonsil size were not found to be statistically significant. CONCLUSION: Up to 14.5% of healthy pediatric patients with sleep-disordered breathing may have severe OSA; young age and African American race are statistically significant predictors. Clinical findings, such as tonsil size and symptom severity, were not found to be statistically significant predictors.

Obstructive Sleep Apnea in Children With Down Syndrome: Screening and Effect of Guidelines.

Previous studies have shown low rates of screening for obstructive sleep apnea in children with Down syndrome (DS), a high-prevalence population. Our study investigated the impact of the 2011 American Academy of Pediatrics guidelines, which recommends screening for obstructive sleep apnea with polysomnogram by age 4 years. We conducted a retrospective chart review of patients 0 to 18 years of age with DS seen at a medical center between 2006 and 2016. Polysomnogram screening frequency was investigated and compared pre- and post-guideline publication. A total of 136 participants were identified. Thirty-two percent (44/136) of children with DS were referred for polysomnogram, all of whom had symptoms. Although overall referral frequency was unaffected, completion frequency by age 18 years improved after publication (30% [21/69] vs 19% [13/67]; P < .05). Notably, polysomnogram completion frequency by age 4 years improved after guidelines publication compared with prior (25% [17/69] vs 0% [0/67]; P < .0001).

Sustained Improvement in Type 2 Diabetes Mellitus is Common After Treatment of Hepatitis C Virus With Direct-acting Antiviral Therapy.

GOALS: To determine whether diabetic patients with hepatitis C virus (HCV) treated with direct-acting antiviral agents have improved diabetes, accounting for change in both hemoglobin A1c (HbA1c) and diabetes medications, and whether any improvement was sustained. BACKGROUND: HCV infection is associated with an increased risk of diabetes, with improvement in glycemic control after eradication. There remains uncertainty about the durability and magnitude of this effect. STUDY: HbA1c and diabetes medications were recorded at 6-month intervals for 1.5 years pretreatment and posttreatment for 122 patients. Subjects were classified as having improved diabetes if there was a decrease in HbA1c≥0.5% with no increase in diabetes medications or a decrease in diabetes medications with a stable HbA1c. RESULTS: HbA1c at the nearest time point before treatment was 8.4%±1.9%, compared with 7.8%±1.7% after treatment, a mean difference of 0.6% [95% CI (0.2, 0.9), P<0.01]. A linear mixed effects model incorporating each subject's repeated measurements over time also demonstrated a reduction after treatment of 0.5% [95% CI, (0.3, 0.8), P<0.001]. Accounting for both HbA1c and diabetes medications, 42 of 122 (34%) had an improvement in diabetes after HCV treatment, and 20 of 28 (71%) of these subjects sustained improvement at 1.5 years follow-up. Prescription of insulin was associated with improved diabetes. CONCLUSIONS: Treatment of HCV with direct-acting antiviral agents was associated with improved diabetes in a significant portion of patients with an average reduction in HbA1c of clinically significant magnitude. Among responders, this effect was sustained over 1.5 years of follow-up.

The vacuolated morphology of chordoma cells is dependent on cytokeratin intermediate filaments.

Notochordal cells (NCs), characterized by their vacuolated morphology and coexpression of cytokeratin and vimentin intermediate filaments (IFs), form the immature nucleus pulposus (NP) of the intervertebral disc. As humans age, NCs give way to mature NP cells, which do not possess a vacuolated morphology and typically only express vimentin IFs. In light of their concomitant loss, we investigated the relationship between cytosolic vacuoles and cytokeratin IFs, specifically those containing cytokeratin-8 proteins, using a human chordoma cell line as a model for NCs. We demonstrate that the chemical disruption of IFs with acrylamide, F-actin with cytochalasin-D, and microtubules with nocodazole all result in a significant (p < 0.001) decrease in vacuolation. However, vacuole loss was the greatest in acrylamide-treated cells. Examination of the individual roles of vimentin and cytokeratin-8 IFs in the existence of vacuoles was accomplished using small interfering RNA-mediated RNA interference to knock down either vimentin or cytokeratin-8 expression. Reduction of cytokeratin-8 expression was associated with a less-vacuolated cell morphology. These data demonstrate that cytokeratin-8 IFs are involved in stabilizing vacuoles and that their diminished expression could play a role in the loss of vacuolation in NCs during aging. A better understanding of the NCs may assist in preservation of this cell type for NP maintenance and regeneration.

Correction to: Deformability of Human Mesenchymal Stem Cells Is Dependent on Vimentin Intermediate Filaments.

This erratum is to correct the following: (1) in the Western Blotting subsection under the Materials and Methods section, the concentration of protein from each sample loaded into Criterion Tris-HCl gels was incorrectly stated as 155 µg of protein. The correct value is 9.7 µg; (2) in Fig. 1b, the bar graph showed incorrect values for semi-quantitation of Western blots. Figure 1 has been updated with a corrected graph in Fig. 1b only.

A Biomechanical Comparison of Allograft Tendons for Ligament Reconstruction.

BACKGROUND: Allograft tendons are frequently used for ligament reconstruction about the knee, but they entail availability and cost challenges. The identification of other tissues that demonstrate equivalent performance to preferred tendons would improve limitations. Hypothesis/Purpose: We compared the biomechanical properties of 4 soft tissue allograft tendons: tibialis anterior (TA), tibialis posterior (TP), peroneus longus (PL), and semitendinosus (ST). We hypothesized that allograft properties would be similar when standardized by the looped diameter. STUDY DESIGN: Controlled laboratory study. METHODS: This study consisted of 2 arms evaluating large and small looped-diameter grafts: experiment A consisted of TA, TP, and PL tendons (n = 47 each) with larger looped diameters of 9.0 to 9.5 mm, and experiment B consisted of TA, TP, PL, and ST tendons (n = 53 each) with smaller looped diameters of 7.0 to 7.5 mm. Each specimen underwent mechanical testing to measure the modulus of elasticity (E), ultimate tensile force (UTF), maximal elongation at failure, ultimate tensile stress (UTS), and ultimate tensile strain (UTε). RESULTS: Experiment A: No significant differences were noted among tendons for UTF, maximal elongation at failure, and UTϵ. UTS was significantly higher for the PL (54 MPa) compared with the TA (44 MPa) and TP (43 MPa) tendons. E was significantly higher for the PL (501 MPa) compared with the TP (416 MPa) tendons. Equivalence testing showed that the TP and PL tendon properties were equivalent or superior to those of the TA tendons for all outcomes. Experiment B: All groups exhibited a similar E. UTF was again highest in the PL tendons (2294 N) but was significantly different from only the ST tendons (1915 N). UTϵ was significantly higher for the ST (0.22) compared with the TA (0.19) and TP (0.19) tendons. Equivalence testing showed that the TA, TP, and PL tendon properties were equivalent or superior to those of the ST tendons. CONCLUSION: Compared with TA tendons, TP and PL tendons of a given looped diameter exhibited noninferior initial biomechanical strength and stiffness characteristics. ST tendons were mostly similar to TA tendons but exhibited a significantly higher elongation/UTϵ and smaller cross-sectional area. For smaller looped-diameter grafts, all tissues were noninferior to ST tendons. In contrast to previous findings, PL tendons proved to be equally strong. CLINICAL RELEVANCE: The results of this study should encourage surgeons to use these soft tissue allografts interchangeably, which is important as the number of ligament reconstructions performed with allografts continues to rise.

When Should We Change Drill Bits? A Mechanical Comparison of New, Reprocessed, and Damaged Bits.

OBJECTIVES: We assessed how reprocessed and damaged drill bits perform relative-to-new drill bits in terms of drilling force required, heat generated at near and far cortices, and number of usable passes. METHODS: Nine pairs of nonosteoporotic human cadaveric femora were tested using 3 types of 3.2-mm drill bits (new, reprocessed, and damaged) in 3 investigations (force, temperature, and multiple usable passes). Operating room conditions were simulated. Force and temperature data were collected for each type. The multiple pass investigation measured only force. RESULTS: New and reprocessed drill bits performed similarly regarding force required and heat generated; both outperformed damaged bits. New and reprocessed bits had a similar number of usable passes in ideal conditions. Damaged bits required nearly 2.6 times as much force to maintain drilling rate. CONCLUSIONS: Reprocessed drill bits seem to be a viable alternative to new drill bits for fracture treatment surgery in terms of force required, heat generated, and number of usable passes. Drill bits that are damaged intraoperatively should be replaced. In ideal conditions, new and reprocessed drill bits can be used for multiple consecutive cases. CLINICAL RELEVANCE: Reprocessed drill bits may be as effective as new drill bits, representing potential cost savings for institutions. Both types can be considered for reuse.

Deformability of Human Mesenchymal Stem Cells Is Dependent on Vimentin Intermediate Filaments.

Mesenchymal stem cells (MSCs) are being studied extensively due to their potential as a therapeutic cell source for many load-bearing tissues. Compression of tissues and the subsequent deformation of cells are just one type physical strain MSCs will need to withstand in vivo. Mechanotransduction by MSCs and their mechanical properties are partially controlled by the cytoskeleton, including vimentin intermediate filaments (IFs). Vimentin IF deficiency has been tied to changes in mechanosensing and mechanical properties of cells in some cell types. However, how vimentin IFs contribute to MSC deformability has not been comprehensively studied. Investigating the role of vimentin IFs in MSC mechanosensing and mechanical properties will assist in functional understanding and development of MSC therapies. In this study, we examined vimentin IFs' contribution to MSCs' ability to deform under external deformation using RNA interference. Our results indicate that a deficient vimentin IF network decreases the deformability of MSCs, and that this may be caused by the remaining cytoskeletal network compensating for the vimentin IF network alteration. Our observations introduce another piece of information regarding how vimentin IFs are involved in the complex role the cytoskeleton plays in the mechanical properties of cells.

Biomechanical Comparison of Cadaveric and Commercially Available Synthetic Osteoporotic Bone Analogues in a Locked Plate Fracture Model Under Torsional Loading.

OBJECTIVES: Biomechanical studies of osteoporotic bone have used synthetic models rather than cadaveric samples because of decreased variability, increased availability, and overall ease of the use of synthetic models. We compared the torsional mechanical properties of cadaveric osteoporotic bone with those of currently available synthetic osteoporotic bone analogues. METHODS: We tested 12 osteoporotic cadaveric humeri and 6 specimens each of 6 types of synthetic analogues. A 5-mm fracture gap model and posterior plating technique with 4.5-mm narrow 10-hole locking compression plate were used. Torque was applied to a peak of ±10 N·m for 1000 cycles at 0.3 Hz. Data were continuously collected during cyclical and ramped loading with a servohydraulic materials testing system. RESULTS: Cadaveric bone had a 17% failure rate before completing 1000 cycles. Three osteoporotic bone models had 100% failure (P < 0.05), 2 had 17% failure, and 1 had 0% failure before 1000 cycles. Significant differences in the stiffness of the 3 types of synthetic bone models that survived cyclic loading were noted compared with the cadaveric bone model (P < 0.05). Osteoporotic bone analogues had torsional mechanical properties different from those of osteoporotic cadaveric specimens. CONCLUSIONS: The differences between osteoporotic cadaveric humeri and synthetic osteoporotic bone analogues ranged from profound with complete catastrophic failure after a few cycles to subtler differences in stiffness and strain hardening. These findings suggest that different bone analogue models vary substantially in their torsional mechanical properties and might not be appropriate substitutes for cadaveric bone in biomechanical studies of osteoporotic bone.

Expression and actions of corticotropin-releasing factor/diuretic hormone-like peptide (CDLP) and teneurin C-terminal associated peptide (TCAP) in the vase tunicate, Ciona intestinalis: Antagonism of the feeding response.

Teneurin C-terminal associated peptide (TCAP) is a neuropeptide that bears some structural similarity to the corticotropin-releasing factor (CRF) family of peptides. TCAP and CRF are both implicated in the regulation of stress-related behaviors, as established in rodent models. However, in vertebrates, both TCAP and CRF possess three additional paralogous forms making vertebrate models difficult to assess with respect to TCAP-CRF interaction. As a urochordate, this species possesses single homologs of TCAP and of a CRF/Diuretic-like peptide (CDLP) in the genome, thereby establishing Ciona intestinalis as an excellent model organism to examine the interaction of these peptide systems. However, the lack of C. intestinalis synthetic peptides and specific antisera has complicated experimentation. We, therefore, prepared synthetic versions of CDLP and TCAP to prepare specific antisera and to investigate their bioactivity in this species. To analyze stress-related behaviors, a novel behavioral assay was used to characterize different types of contraction-based behaviors, using buccal opening contractions, cloacal opening contractions, lateral contractions, longitudinal contractions and expulsions. Protein and mRNA expression data indicate that the mature versions of both peptides are present in a number of tissues. With respect to behavioral activity, both TCAP- and CDLP-treated animals had distinct contraction profiles under ambient conditions. Moreover, food stimulation tests revealed that whereas CDLP-treated animals displayed a strong expulsion behavior in response to feeding, TCAP-treated animals did not show this effect. These actions are consistent with previous studies done in vertebrates.

Biomechanical and Cost Comparisons of Near-Far and Pin-Bar Constructs.

Orthopedic dogma states that external fixator stiffness is improved by placing 1 pin close to the fracture and 1 as distant as possible ("near-far"). This fixator construct is thought to be less expensive than placing pins a shorter distance apart and using "pin-bar" clamps that attach pins to outriggers. The authors therefore hypothesized that the near-far construct is stiffer and less expensive. They compared mechanical stiffness and costs of near-far and pin-bar constructs commonly used for temporary external fixation of femoral shaft fractures. Their testing model simulated femoral shaft fractures in damage control situations. Fourth-generation synthetic femora (n=18) were used. The near-far construct had 2 pins that were 106 mm apart, placed 25 mm from the gap on each side of the fracture. The pin-bar construct pins were 55 mm apart, placed 40 mm from the gap. Mechanical testing was performed on a material test system machine. Stiffness was determined in the linear portion of the load-displacement curve for both constructs in 4 modes: axial compression, torsional loading, frontal plane 3-point bending, and sagittal plane 3-point bending. Costs were determined from a 2012 price guide. Compared with the near-far construct, the pin-bar construct had stiffness increased by 58% in axial compression (P<.05) and by 52% in torsional loading (P<.05). The pin-bar construct increased cost by 11%. In contrast to the authors' hypothesis and existing orthopedic dogma, the near-far construct was less stiff than the pin-bar construct and was similarly priced. Use of the pin-bar construct is mechanically and economically reasonable. [Orthopedics. 2017; 40(2):e238-e241.].

Ultrasonic Structural Health Monitoring to Assess the Integrity of Spinal Growing Rods In Vitro.

BACKGROUND: Rod fracture is a common complication of growing rods and can result in loss of correction, patient discomfort, and unplanned revision surgery. The ability to quantitate rod integrity at each lengthening would be advantageous to avoid this complication. We investigate the feasibility of applying structural health monitoring to evaluate the integrity of growing rods in vitro. METHODS: Single-rod titanium 4.5-mm growing rod constructs (n = 9), one screw proximally and one distally connected by in-line connectors, were assembled with pedicle screws fixed in polyethylene blocks. Proximal and distal ends were loaded and constructs subjected to cyclic axial compression (0-100 N at 1 Hz), with incrementally increasing maximum compressive loads of 10 N every 9k cycles until failure. Four piezoceramic transducers (PZTs) were mounted along the length the constructs to interrogate the integrity of the rods with an ultrasonic, guided lamb wave approach. Every 9k cycles, an 80 V excitatory voltage was applied to a PZT to generate high-frequency vibrations, which, after propagating through the construct, was detected by the remaining PZTs. Amplitude differences between pre- and postload waveform signals were calculated until rod failure. RESULTS: Average construct lifetime was 88,991 ± 13,398 cycles. All constructs failed due to rod fracture within 21 mm (mean = 15 ± 4.5 mm) of a screw or connector. Amplitude differences between pre- and postload increased in a stepwise fashion as constructs were cycled. Compared to baseline, we found a 1.8 ± 0.6-fold increase in amplitude 18k cycles before failure, a 2.2 ± 1.0-fold increase in amplitude 9k cycles before failure, and a 2.75 ± 1.5-fold increase in amplitude immediately before rod fracture. CONCLUSION: We describe a potential method for assessing the structural integrity of growing rods using ultrasonic structural health monitoring. These preliminary data demonstrate the ability of periodic rod assessment to detect structural changes in cycled growing rods, which appear to correspond to subclinical rod fatigue before rod fracture.

Layered Alginate Constructs: A Platform for Co-culture of Heterogeneous Cell Populations.

Many load bearing tissues possess structurally and functionally distinct regions, typically accompanied by different cell phenotypes with differential mechanosensing characteristics. Engineering and analysis of these tissue types remain a challenge. Layered hydrogel constructs provide an opportunity for investigating the interactions among multiple cell populations within single constructs. Alginate hydrogels are both biocompatible and allow for easy isolation of cells after experimentation. Here, we describe a method for the development of small sized dual layered alginate hydrogel discs. This process maintains high cell viability of human mesenchymal stem cells during the formation process and these layered discs can withstand unconfined cyclic compression, commonly used for stimulation of hMSCs undergoing chondrogenesis. These layered constructs can potentially be scaled up to include additional levels, and also be used to segregate cell populations initially after layering. This dual layer alginate hydrogel culture platform can be used for many different applications including engineering and analysis of cells of load bearing tissues and co-cultures of other cell types.

Optical Coherence Tomographic Elastography Reveals Mesoscale Shear Strain Inhomogeneities in the Annulus Fibrosus.

STUDY DESIGN: Basic science study using in vitro tissue testing and imaging to characterize local strains in annulus fibrosus (AF) tissue. OBJECTIVE: To characterize mesoscale strain inhomogeneities between lamellar and inter-/translamellar (ITL) matrix compartments during tissue shear loading. SUMMARY OF BACKGROUND DATA: The intervertebral disc is characterized by significant heterogeneities in tissue structure and plays a critical role in load distribution and force transmission in the spine. In particular, the AF possesses a lamellar architecture interdigitated by a complex network of extracellular matrix components that form a distinct ITL compartment. Currently, there is not a firm understanding of how the lamellar and ITL matrix coordinately support tissue loading. METHODS: AF tissue samples were prepared from frozen porcine lumbar spines and mounted onto custom fixtures of a materials testing system that incorporates optical coherence tomography (OCT) imaging to perform tissue elastography. Tissues were subjected to 20 and 40% nominal shear strain, and OCT images were captured and segmented to identify regions of interest corresponding to lamellar and ITL compartments. Images were analyzed using an optical flow algorithm to quantify local shear strains within each compartment. RESULTS: Using histology and OCT, we first verified our ability to visualize and discriminate the ITL matrix from the lamellar matrix in porcine AF tissues. Local AF strains in the ITL compartment (22.0 ±â€Š13.8, 31.1 ±â€Š16.9 at 20% and 40% applied shear, respectively) were significantly higher than corresponding strains in the surrounding lamellar compartment (12.1 ±â€Š5.6, 15.3 ±â€Š5.2) for all tissue samples (P < 0.05). CONCLUSION: Results from this study demonstrate that the lamellar and ITL compartments of the AF distribute strain unevenly during tissue loading. Specifically, shear strain is significantly higher in the ITL matrix, suggesting that these regions may be more susceptible to tissue damage and more mechanobiologically active. LEVEL OF EVIDENCE: N/A.

Effect of Dynamic Culture and Periodic Compression on Human Mesenchymal Stem Cell Proliferation and Chondrogenesis.

We have recently developed a bioreactor that can apply both shear and compressive forces to engineered tissues in dynamic culture. In our system, alginate hydrogel beads with encapsulated human mesenchymal stem cells (hMSCs) were cultured under different dynamic conditions while subjected to periodic, compressive force. A customized pressure sensor was developed to track the pressure fluctuations when shear forces and compressive forces were applied. Compared to static culture, dynamic culture can maintain a higher cell population throughout the study. With the application of only shear stress, qRT-PCR and immunohistochemistry revealed that hMSCs experienced less chondrogenic differentiation than the static group. The second study showed that chondrogenic differentiation was enhanced by additional mechanical compression. After 14 days, alcian blue staining showed more extracellular matrix formed in the compression group. The upregulation of the positive chondrogenic markers such as Sox 9, aggrecan, and type II collagen were demonstrated by qPCR. Our bioreactor provides a novel approach to apply mechanical forces to engineered cartilage. Results suggest that a combination of dynamic culture with proper mechanical stimulation may promote efficient progenitor cell expansion in vitro, thereby allowing the culture of clinically relevant articular chondrocytes for the treatment of articular cartilage defects.