Acrometastasis as the Initial Presentation of a KRAS-Positive Colon Cancer

The propensity of colon cancer to metastasize to bones is very low compared to prostate, breast or lung cancer. The reason for this is not yet understood, although an explanation for the osteotropism of certain primaries has been offered by the ‘seed and soil’ concept, suggesting that the bone microenvironment provides a favorable ‘soil’ for metastasis and proliferation of some tumor cells (‘seeds’) [1]. Here, we report an unusual case of colon cancer with metastasis to the finger at initial presentation, and exophytic sclerotic lesions to other bones. The incidence of metastases to fingers/toes (acrometastases) is reported to be only 0.1%, even after including involvement of primary sites other than the colon. The etiology and characteristics of acrometastases are reviewed in this case report.

Prevention of anastrozole induced bone loss with monthly oral ibandronate: Final 5 year results from the ARIBON trial

Purpose

The ARIBON trial is a double blind, randomised, placebo controlled study designed to evaluate the impact of ibandronate on bone mineral density (BMD) in women taking anastrozole for adjuvant treatment of breast cancer.

Methods

131 postmenopausal women with early breast cancer were recruited to the study. Of these, 13 had osteoporosis, 50 osteopenia and 68 normal BMD. Patients with osteoporosis at baseline were treated with monthly oral ibandronate 150 mg for 5 years; osteopenic patients were randomised to receive either ibandronate or placebo for two years and offered open label ibandronate depending upon the results of their 2-year BMD result.

Results

Of the 20 patients with osteopenia who were randomised to ibandronate and evaluable at the 2 year visit, 17/20 were not offered a bisphosphonate and the improvements in BMD accrued during the first 2 years were lost both at the LS (−3.21%) and TH (−5.0%). Of the 16 patients randomised to placebo 8/16 with high rates of bone loss during years 0–2 received ibandronate over the next 3 years with improvements in BMD of +5.01 and +1.19 at the LS and TH respectively. The 8 patients who were not offered a bisphosphonate experienced relatively little change in BMD throughout the 5 years of the study (LS +0.15%, TH −2.72%). BMD increased steadily in the 9/13 patients initially identified as having osteoporosis (LS +9.65%, TH +2.72%).

Conclusions

Monthly oral ibandronate provides an option to clinicians considering use of a bisphosphonate to prevent bone loss during aromatase inhibitor therapy.

SSRIs: bad to the bone?

Selective serotonin reuptake inhibitors are globally popular antidepressants with broad clinical indications. Despite an overall favorable side-effect profile, our examination of 19 studies, one review, and one meta-analysis indicates that these unique antidepressants appear to have negative effects on bone, particularly with regard to bone mineral density and fracture risk. These risks may be enhanced by more serotonergic agents and/or longer exposure to selective serotonin reuptake inhibitors. The magnitude of this relationship is difficult to determine due to the myriad of potential confounds in available studies, but all indicate risk. In additional support of these findings, serotonin receptors have been identified on osteoclasts, osteoblasts, and osteocyte cell lines, suggesting that serotonin may be an important regulatory agent in bone. While no formal recommendations regarding the use of selective serotonin reuptake inhibitors in risk populations are available, caution is advised in individuals with potential risk (i.e., those with osteoporosis or histories of osteoporotic fractures).

A novel blasted and grooved low profile pedicle screw able to resist high compression bending loads

Objective

Polyaxial pedicle screws are a safe, useful adjunct to transpedicular fixation. However, the large screw head size can cause soft tissue irritation, high rod positioning, and facet joint injury. However, the mechanical resistance provided by small and low profile pedicle screws is very limited. We therefore developed a novel, low profile pedicle screw using grooving and blasting treatment that is able to resist a high compression bending load.

Methods

We evaluated the compression bending force to displacement and yield loads for seven different screw head types that differed with regard to their groove intervals and whether or not they had been blasted.

Results

The rank order of screw types that had the greatest compression bending force to displacement was as follows: (1) universal polyaxial, (2) low polyaxial with 0.1mm grooves and blasting, (3) low polyaxial with blasting, (4) low polyaxial with 0.15mm grooves and blasting, (5) low polyaxial with 0.05mm grooves and blasting, (6) low polyaxial with 0.05mm grooves, (7) and low polyaxial. Low polyaxial screws with 0.1mm grooves and blasting had the maximum yield load and highest compression bending force to displacement of all seven polyaxial screw head systems evaluated.

Conclusion

Blasting and grooving treatment of pedicle screw heads resulted in screw heads with a high yield load and compression bending force relative to displacement because of increased friction. Low polyaxial pedicle screws with 0.1 mm grooves treated by blasting have mechanical characteristics similar to those of universal polyaxial pedicle screws.

Experimental study on temperature rise of acoustic radiation force elastography

INTRODUCTION

Acoustic radiation force (ARF) elastography is potentially useful for imaging the elasticity of human tissue. Because a "push wave" that is used to generate ARF is a long burst wave comparable to that used in regular clinical imaging, detailed investigation of its safety is required.

MATERIALS AND METHODS

We focus on the transient temperature rise in the far field, where the beam paths are overlapped. Soft tissue mimicking a phantom and bone samples were exposed to a 2-MHz plane wave for 20 s. The temperature rises in the far field were measured using a thermocouple. The temperature rises at 1 ms, the time required for the displacement measurement, were estimated by fitting the experimental results. The results showed that the thermosensitivity of the bone was 36 times higher than that of the phantom, and the use of a repeated push wave may have exceeded the allowable maximum temperature rise, 1°C, on the bone surface.

CONCLUSION

In conclusion, the imaging area, including the path of the push wave, should be carefully checked and the time interval for consecutive use should be adjusted to prevent thermal risk on the surface of the bone.

Vascular calcification in chronic kidney disease: Pathogenesis and clinical implication

Cardiovascular disease is the leading cause of death among patients with chronic kidney disease (CKD). Vascular calcification (VC) is one of the independent risk factors associated with cardiovascular disease and cardiovascular mortality in both the general population and CKD patients. Earlier evidence revealed substantially higher prevalence of VC in young adults on chronic hemodialysis compared to the general population in the same age range, indicating the influence of CKD-related risk factors on the development of VC. Pathogenesis of VC involves an active, highly organized cellular transformation of vascular smooth muscle cells to bone forming cells evidenced by the presence of bone matrix proteins in the calcified arterial wall. VC occurs in both the intima and the media of arterial wall with medial calcification being more prevalent in CKD. In addition to traditional cardiovascular risks, risk factors specific to CKD such as phosphate retention, excess of calcium, history of dialysis, active vitamin D therapy in high doses and deficiency of calcification inhibitors play important roles in promoting the development of VC. Non-contrast multi-slice computed tomography has often been used to detect coronary artery calcification. Simple plain radiographs of the lateral lumbar spine and pelvis can also detect VC in the abdominal aorta and femoral and iliac arteries. Currently, there is no specific therapy to reverse VC. Reduction of calcium load, lowering phosphate retention using non-calcium containing phosphate binders, and moderate doses of active vitamin D may attenuate progression. Parenteral sodium thiosulfate has also been shown to delay VC progression.

Osteoblasts in bone physiology-mini review

Bone structural integrity and shape are maintained by removal of old matrix by osteoclasts and in-situ synthesis of new bone by osteoblasts. These cells comprise the basic multicellular unit (BMU). Bone mass maintenance is determined by the net anabolic activity of the BMU, when the matrix elaboration of the osteoblasts equals or exceeds the bone resorption by the osteoclasts. The normal function of the BMU causes a continuous remodeling process of the bone, with deposition of bony matrix (osteoid) along the vectors of the generated force by gravity and attached muscle activity. The osteoblasts are derived from mesenchymal stem cells (MSCs). Circulating hormones and locally produced cytokines and growth factors modulate the replication and differentiation of osteoclast and osteoblast progenitors. The appropriate number of the osteoblasts in the BMU is determined by the differentiation of the precursor bone-marrow stem cells into mature osteoblasts, their proliferation with subsequent maturation into metabolically active osteocytes, and osteoblast degradation by apoptosis. Thus, the two crucial points to target when planning to control the osteoblast population are the processes of cell proliferation and apoptosis, which are regulated by cellular hedgehog and Wnt pathways that involve humoral and mechanical stimulations. Osteoblasts regulate both bone matrix synthesis and mineralization directly by their own synthetic activities, and bone resorption indirectly by its paracrinic effects on osteoclasts. The overall synthetic and regulatory activities of osteoblasts govern bone tissue integrity and shape.

Tissue engineering using human mineralized bone xenograft and bone marrow mesenchymal stem cells allograft in healing of tibial fracture of experimental rabbit model

BACKGROUND

Bone healing and its reconstruction in fractures, especially in long bones are of particular importance in regenerative medicine. This study compares the bone healing rate after a human xenograft of mineralized bone and together with an allograft of bone marrow mesenchymal stem cells (MSCs) in an experimental tibial bone fracture rabbit model.

METHODS

In fall 2009, twenty New Zealand white rabbits were randomly divided into 2 equal groups. In both groups, a 5 mm segmental defect was created in the right tibia. In group A, a scaffold pin was seeded with allogenic rabbit MSCs and was placed in the defect area and in group B, the defect was filled with an unseeded pin human mineralized bone xenograft. An untreated defect was induced in the left tibia of all animals serving as the control. After 4-8 weeks, the segmental defects were histologically evaluated and also by a compressive test.

RESULTS

In groups A and B, healing and formation of new bony tissue were significantly more than the control group and with a significant less inflammation.

CONCLUSION

Tissue engineering of mineralized bone xenograft and MSCs allograft may be significant steps in bone healing and regenerative medicine.

Assessment of axial bone rigidity in rats with metabolic diseases using CT-based structural rigidity analysis

Objectives

This study aims to assess the correlation of CT-based structural rigidity analysis with mechanically determined axial rigidity in normal and metabolically diseased rat bone.

Methods

A total of 30 rats were divided equally into normal, ovariectomized, and partially nephrectomized groups. Cortical and trabecular bone segments from each animal underwent micro-CT to assess their average and minimum axial rigidities using structural rigidity analysis. Following imaging, all specimens were subjected to uniaxial compression and assessment of mechanically-derived axial rigidity.

Results

The average structural rigidity-based axial rigidity was well correlated with the average mechanically-derived axial rigidity results (R² = 0.74). This correlation improved significantly (p < 0.0001) when the CT-based Structural Rigidity Analysis (CTRA) minimum axial rigidity was correlated to the mechanically-derived minimum axial rigidity results (R² = 0.84). Tests of slopes in the mixed model regression analysis indicated a significantly steeper slope for the average axial rigidity compared with the minimum axial rigidity (p = 0.028) and a significant difference in the intercepts (p = 0.022). The CTRA average and minimum axial rigidities were correlated with the mechanically-derived average and minimum axial rigidities using paired t-test analysis (p = 0.37 and p = 0.18, respectively).

Conclusions

In summary, the results of this study suggest that structural rigidity analysis of micro-CT data can be used to accurately and quantitatively measure the axial rigidity of bones with metabolic pathologies in an experimental rat model. It appears that minimum axial rigidity is a better model for measuring bone rigidity than average axial rigidity.

TGF-β and BMP signaling in osteoblast differentiation and bone formation

Transforming growth factor-beta (TGF-β)/bone morphogenic protein (BMP) signaling is involved in a vast majority of cellular processes and is fundamentally important throughout life. TGF-β/BMPs have widely recognized roles in bone formation during mammalian development and exhibit versatile regulatory functions in the body. Signaling transduction by TGF-β/BMPs is specifically through both canonical Smad-dependent pathways (TGF-β/BMP ligands, receptors and Smads) and non-canonical Smad-independent signaling pathway (e.g. p38 mitogen-activated protein kinase pathway, MAPK). Following TGF-β/BMP induction, both the Smad and p38 MAPK pathways converge at the Runx2 gene to control mesenchymal precursor cell differentiation. The coordinated activity of Runx2 and TGF-β/BMP-activated Smads is critical for formation of the skeleton. Recent advances in molecular and genetic studies using gene targeting in mice enable a better understanding of TGF-β/BMP signaling in bone and in the signaling networks underlying osteoblast differentiation and bone formation. This review summarizes the recent advances in our understanding of TGF-β/BMP signaling in bone from studies of genetic mouse models and human diseases caused by the disruption of TGF-β/BMP signaling. This review also highlights the different modes of cross-talk between TGF-β/BMP signaling and the signaling pathways of MAPK, Wnt, Hedgehog, Notch, and FGF in osteoblast differentiation and bone formation.

Arterial damage accompanying supracondylar fractures of the humerus

BACKGROUND

Arterial damage is sometimes associated with supracondylar fractures of the humerus. Diagnosis and careful management of the fracture and arterial repair is crucial.

OBJECTIVES

The aim of this study was to determine the prevalence and outcome of supracondylar fractures of the humerus with signs and symptoms of limb ischemia, before and after arterial decompression or arterial reconstruction.

MATERIALS AND METHODS

From September 2004 to July 2010, 225 consecutive patients with supracondylar fracture of the humerus were prospectively recruited.

RESULTS

From among 75 cases with Gartland type III fractures, 22 were found to have vascular injury.. Of the 22 cases with vascular injury, 7 patients underwent arterial reconstruction. The other 15 received arterial decompression. All patients had a satisfactory outcome.

CONCLUSIONS

A high level of suspicion and careful clinical evaluation leading to an early diagnosis and management of vascular injury accompanying supracondylar fracture is very important to prevent unnecessary sequelae ranging from limb claudication, and compartment syndrome to more severe complications like Volkmann's contracture and even limb loss.

Intra-abdominal heterotopic ossification of the peritoneum following traumatic splenic rupture

Intra-abdominal heterotopic ossification is extremely rare with only approximately 30 cases having been reported. While most reported cases have involved the mesentery, ossification of the peritoneum is even rarer. The pathogenesis remains undetermined but is generally considered a reactive process in response to various stimuli. Histologically, it is composed of a peripheral area with bone formation and a central area of reactive hypercellular fibrous tissue. We report a rare case of intra-abdominal heterotopic ossification of the parietal peritoneum following traumatic splenic rupture.

Agarose cell block technique as a complementary method in the diagnosis of fungal osteomyelitis in a dog

A 7-year-old Labrador Retriever female dog presenting left forelimb lameness for one day was admitted to the Veterinary Hospital (UNESP-Botucatu) for clinical evaluation. Several tests, including blood and image analysis, microbiological culture and cytology of lytic areas of affected bone were made in order to establish a diagnosis. Serum biochemical profile revealed increased levels of liver enzymes, plasma globulin, creatine kinase (CK) and calcium. Hemogram revealed anemia and leukocytosis; left humerus image analysis revealed an osteolytic lesion and cytology revealed a suppurative periostitis. Differential diagnosis was a nonspecific infectious inflammatory process or osteosarcoma. Since it was not possible to achieve a definitive diagnosis and there was a highly suspicious for an infectious agent, an agarose cell block of the bone marrow fine-needle aspiration was made. The cytological examination of cell block presented similar findings as described previously. However, additional stains including periodic acid-Schiff (PAS) were positive for fungal hyphae, which rendered a diagnosis of fungal osteomyelitis due to Aspergillus spp. This case report illustrates an uncommon cause of osteomyelitis for breed that was diagnosed by an underused method in veterinary medicine.

Extracorporeal human bone-like tissue generation

Objectives

The need for bone tissue supplementation exists in a wide range of clinical conditions involving surgical reconstruction in limbs, the spine and skull. The bone supplementation materials currently used include autografts, allografts and inorganic matrix components; but these pose potentially serious side-effects. In particular the availability of the autografts is usually limited and their harvesting causes surgical morbidity. Therefore for the purpose of supplementation of autologous bone graft, we have developed a method for autologous extracorporeal bone generation.

Methods

Human osteoblast-like cells were seeded on porous granules of tricalcium phosphate and incubated in osteogenic media while exposed to mechanical stimulation by vibration in the infrasonic range of frequencies. The generated tissue was examined microscopically following haematoxylin eosin, trichrome and immunohistochemical staining.

Results

Following 14 days of incubation the generated tissue showed histological characteristics of bone-like material due to the characteristic eosinophilic staining, a positive staining for collagen trichrome and a positive specific staining for osteocalcin and collagen 1. Macroscopically, this tissue appeared in aggregates of between 0.5 cm and 2 cm.

Conclusions

We present evidence that the interaction of the cellular, inorganic and mechanical components in vitro can rapidly generate three-dimensional bone-like tissue that might be used as an autologous bone graft.

Dynamic contrast-enhanced MR imaging findings of bone metastasis in patients with prostate cancer

AIM: To evaluate the dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) findings of bone metastasis in prostate cancer patients.

METHODS: Sixteen men with a diagnosis of metastatic prostate cancer to bones were examined with DCE-MRI at 1.5 Tesla. The mean contrast agent concentration vs time curves for bone metastasis and normal bone were calculated and K^trans and ve values were estimated and compared.

RESULTS: An early significant enhancement (wash-out: n = 6, plateau: n = 8 and persistent: n = 2) was detected in all bone metastases (n = 16). Bone metastasis from prostate cancer showed significant enhancement and high K^trans and ve values compared to normal bone which does not enhance in the elderly population. The mean K^trans was 0.101/min and 0.0051/min (P < 0.001), the mean ve was 0.141 and 0.0038 (P < 0.001), for bone metastases and normal bone, respectively.

CONCLUSION: DCE-MRI and its quantitative perfusion parameters may have a role in improving the detection of skeletal metastasis in prostate cancer patients.

Fibrodysplasia ossificans progressiva: report of a case and review of articles

Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder, characterized by painful swelling of muscles and connective tissue in the early years of life, consequently leading to ossification at a mean age of 4-5 years. We report FOP in a 2-year-old boy with palpable masses in the frontal and lower cervical paraspinal and left periscapular muscles.He was born with hallux valgus. Despite this hallmark, he was referred to the hospital with the primary diagnosis of hematoma, but further investigation indicated FOP. The patient was discharged from the hospital with non steroidal anti-inflammatory drugs (NSAID) and education of the parents. The importance of this case was that in spite of the early occurrence of the typical presentation of FOP for more than one year and the fact that the patient's mother was a physician who had consulted with many specialists, the diagnosis had been missed.This indicates that the general physicians, radiologists and other specialists' awareness and knowledge of FOP is insufficient.

Bizarre Parosteal Osteochondromatous Proliferation: Nora's Lesion

The purpose of this study was to review the imaging and anatomopathologic findings and to discuss the main differential diagnosis of bizarre parosteal osteochondromatous proliferation (BPOP) or Nora's lesion, a rare benign surface lesion of the bone. Histologically confirmed plain radiographs, ultrasound, CT and MRI images of four patients with BPOP were obtained and retrospectively reviewed. Three cases involving the hand and one involving the foot are reported. On plain radiographs, BPOP is a wellmarginated, calcified or ossified mass arising directly from the cortical surface of the underlying bone. Ultrasound images show a low echoic peripheral cap around the lesion. CT images show the wide base of the lesion. On MRI, BPOP was of a low signal on T1, enhancing following gadolinium administration. Underlying bone and adjacent surrounding soft tissues were normal.

Skin, bone and muscle collagen extraction from the trash fish, leather jacket (Odonus niger) and their characterization

Acid soluble (ASC) and pepsin soluble (PSC) collagens were extracted from the skin, bone and muscle of a trash fish, leather jacket (Odonus niger) by three different extraction methods. Method I gave 46-50% yield for ASC, Method II gave 49-58% yield for both ASC and PSC and Method III gave 64-71% yield for PSC. The addition of pepsin had increased the yield by 30-45%. The yields of collagen from skin and bone were higher than muscle. SDS-PAGE pattern revealed that skin and bone collagen as Type I collagen with a typical (α1)2α2 chains and muscle collagen as Type V collagen with a typical α1α3α2 chains. Td values of bone and muscle collagen were high (30-32 °C) compared to skin collagen (27-28 °C). The higher imino acids (190 residues/1,000 residues) were found responsible for the higher Td values. The trash fish, leather jacket can therefore be exploited effectively for collagen as it has got good thermal properties for pharmaceutical and biomedical applications.

Comparative evaluation of bovine porous bone mineral

BACKGROUND

The aim of the present clinical study was to compare the efficacy of bovine porous bone mineral (BPBM) with and without platelet-rich plasma (PRP) for the treatment of periodontal intrabony defects.

MATERIALS AND METHODS

Twenty eight identical bilateral periodontal intrabony defects were selected from 14 chronic periodontitis patients. The subjects were randomly assigned to test group (BPBM+PRP) or the control group (BPBM). The clinical, radiographic, and intrasurgical (re-entry) measurements were made at baseline and at 9 months postoperatively.

RESULTS

Both treatment modalities resulted in significant reduction in probing depth and gain in clinical attachment level as compared to baseline values. The probing depth reduction was 6.20±1.40 mm in BPBM and 6.60±1.43 mm for the BPBM/PRP-treated sites. The gain in clinical attachment level observed was 4.16±1.05 mm for BPBM and 4.70±0.76 mm for the BPBM/PRP group. Radiographically, there was a significant defect fill (3.83±1.01 mm) for the BPBM group and (4.04±1.77 mm) in the BPBM/PRP group. Similar trend was observed between the two groups in relation to intrasurgical parameters.

CONCLUSIONS

The combination therapy (BPBM+PRP) showed more favorable clinical outcome in the treatment of intrabony defects than the BPBM alone group, although the mean difference between the two groups was statistically nonsignificant.

Cell communication and tissue engineering

Gap junction intercellular communication (GJIC) is ubiquitous in the majority of cells and is indispensable for proper development and function of most tissues. The loss of gap junction mediated cell to cell communication leads to compromised development in many tissues and organs, and also facilitates tumorigenesis and autonomous cell behavior in cancerous cells. Because cells embedded in an extracellular matrix constantly interact through gap junctions to coordinate normal tissue functions and homeostasis, our group hypothesized that increasing cell to cell communication, via genetically engineering cells to overexpress gap junction proteins, could improve cell signaling and increase differentiation in interior regions of engineered tissue equivalents. In a recent paper,1 we presented a platform to regenerate full 3D equivalents of engineered tissue, providing a strategy to overcome a barrier in regenerative medicine. These findings suggest that both targeted delivery and cell-based strategies can be used as treatments to enhance communication in 3D living tissue.2 In this addendum, we address the effects of extracellular calcium (Ca(2+) (e)) on intracellular calcium (Ca(2+) (i)), GJIC and osteogenic differentiation under conditions in which bone marrow stromal cells (BMSCs) also exhibit higher cell-to-cell communication. As a key secondary messenger in many biological processes, the levels of Ca(2+) (e) and Ca(2+) (i) play a role in cell differentiation and may be a tunable signal in tissue regeneration. Higher cell-to-cell communication was achieved by both genetically engineering cells to overexpress connexin 43 (Cx43) and by a high density cell seeding technique, denoted micromass seeding (MM). The results presented in this addendum show that the intensity and duration of a second messenger, like calcium, can be augmented in a platform that enables higher cell-to-cell communication. The ability to modulate calcium signaling, combined with our previous approaches to modulate GJIC, may have an impact on tissue regeneration and therapies for communication incompetent cells, such as those associated with heart disease and certain types of cancer.

Image-guided musculoskeletal biopsies

Image-guided musculoskeletal (MSK) biopsies are safe and effective procedures that yield diagnostic accuracies up to 97%. When performed in conjunction with a multidisciplinary team, they provide crucial information that will affect patient care and outcome. Computed tomography and ultrasound are the main modalities used to carry out MSK biopsies, and various needles and techniques are available to help the radiologist perform these procedures safely.

Schwannoma causing resorption of zygomatic arch

Schwannoma (also known as neurilemmoma, peripheral glioma and peripheral nerve sheath tumor) is a common, histologically distinctive, benign, usually encapsulated, peripheral nerve tumor of Schwann cell origin. Schwannomas can appear anywhere in the body, but are more frequently reported in the head and neck with an incidence of 25-48% in maxillofacial region. Resorption of bones due to schwannoma is rarely noticed in maxillofacial region. We hereby present a case report of schwannoma in a 35-year-old female, causing resorption of zygomatic arch along with review of literature.

Osteoimmunology - Unleashing the concepts

Osteoimmunology is an emerging field of research dedicated to the relationship between the immune processes and the bone metabolism of various inflammatory bone diseases. The regulatory mechanisms governing the osteoclast and osteoblast are critical for understanding the health and disease of the skeletal system. These interactions are either by cell to cell contact or by the secretion of immune regulatory mediators like cytokines and chemokines by immune cells that are governed by the RANKL (TRANCE)-RANK- OPG axis. TRANCE-RANK signaling has served as a cornerstone of osteoimmunology research. There is increased recognition of the importance of the inflammatory and immune responses in the pathogenesis of periodontal disease. Thus, this field has provided a framework for studying the mechanisms underlying periodontal destruction. As bone homeostasis is mainly regulated by both the immune and endocrine systems, there emerged osteoimmunoendocrinology where adipokines take the lead. This review focuses on the underlying concepts of osteoimmunology, its relation to Periodontics.

Implications of bone-only metastases in breast cancer: favorable preference with excellent outcomes of hormone receptor positive breast cancer

Purpose

The aim of the current study was to determine the incidence, clinical presentation, and treatment outcomes of "bone-only metastases" in patients with breast cancer and to analyze the impact of hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status on prognosis.

Materials and Methods

Between 1994 and 2007, of 968 patients with metastatic breast cancer who underwent palliative management at Samsung Medical Center, 565 (57%) relapsed with distant metastases. Of the 968, 146 (15%) had bone-only metastases during a median follow-up period of 75 months. Among the 146 patients with bone-only metastases, 122 (84%) were relapsed patients after curative surgery and 24 (26%) were initially metastatic cases.

Results

The median time from primary surgery to bone-only metastases of the 122 patients was 37 months (95% confidence interval [CI], 27 to 46 months). Bone-only metastases were more common in the HR-positive group than in the other subtypes (85% for HR+; 8.2% for HER2+; 6.8% for triple negative. Among all 146 patients, 75 (51%) were treated with hormone therapy. The median post-relapse progression-free survival was 15 months (95%CI, 13 to 17 months). The median overall survival was much longer in the HR+ patients than the HER2+ and triple negative breast cancer patients with marginal statistical significance (65 vs. 40 vs. 40 months, p=0.077).

Conclusion

Breast cancer patients with "bone-only metastases" had excellent clinical outcomes. Further study is now warranted to reveal the underlying biology that regulates the behavior of this indolent tumor, as it should identify 'favorable tumor characteristics' in addition to 'favorable preferential metastatic site.'

Freezing of rat tibiae at -20°c does not affect the mechanical properties of intramedullary bone/implant-interface: brief report

Background:

The effects of freezing-thawing cycles on intramedullary bone-implant interfaces have been studied in a rat model in mechanical pull-out tests.

Implants:

Twenty TiAl6V4 rods (Ø 0.8 mm, length 10 mm) implanted in rat tibiae

Methods:

10 rats underwent bilateral tibial implantation of titanium rods. At eight weeks, the animals were sacrificed and tibiae harvested for biomechanical testing. Eight tibiae were frozen and stored at -20°C for 14 days, the remaining eight were evaluated immediately post-harvest. Pull-out tests were used to determine maximum force and interfacial shear strength.

Results:

There were no significant differences between fresh and those of the frozen-thawed group in maximum force or in interfacial shear strength.

Conclusion:

Frozen Storage of rat tibiae containing implants at -20° C has no effects on the biomechanical properties of Bone/ Implant interface.

Imaging appearance of bone tumors of the maxillofacial region

This paper reviews the imaging appearance of benign and malignant bone tumors of the maxillofacial region. A benign bone tumor commonly appears as a well circumscribed lesion. The matrix of the tumor may be calcified or sclerotic. Malignancies often display aggressive characteristics such as cortical breakthrough, bone destruction, a permeative pattern and associated soft-tissue masses. Computed tomography scan is an excellent imaging modality for accurate localization of the lesion, characterization of the tumor matrix and detection of associated osseous changes such as bone remodeling, destruction or periosteal reaction. Magnetic resonance imaging is of limited value in the evaluation of maxillofacial bone tumors.

Various tumor-mimicking lesions in the musculoskeletal system: causes and diagnostic approach

Tumor-mimicking lesions in the musculoskeletal system can be defined as lesions mistaken as tumors due to the presence of palpation upon physical examination or a tumor-like appearance upon radiological examination. Moreover, tumor-mimicking lesions show diverse etiologies and anatomic locations. We illustrated the various tumor-mimicking lesions involving bone and soft tissue. In this review, the tumor-mimicking lesions were classified into those based on clinical examination and those based on radiological examination in musculoskeletal radiology. Awareness of the various causes of tumor-mimicking lesions, correctly obtaining clinical information, and the proper selection of imaging modality are important for the differentiation of tumor-mimicking lesions from true neoplasms.

A comparative evaluation of decalcified freeze dried bone allograft, hydroxyapatite and their combination in osseous defects of the jaws

OBJECTIVES

To evaluate decalcified freeze dried allograft or hydroxyapatite and a combination of both as bone autograft substitutes in the healing of osseous jaw defects.

MATERIALS AND METHODS

24 patients participated in the study which involved the filling of osseous defects in the maxilla/mandible with decalcified freeze dried bone allograft (DFDBA) or hydroxyapatite (HA) or a combined graft composed of these two in equal proportions.

RESULTS

Bone formation occurred as early as 4 weeks in the DFDBA and combination groups and 12 weeks in the HA group which was verified by radiographs, Dentascans (DentaScan® Software Program, General Electric, USA) and bone scintigraphy.

CONCLUSION

Both these materials can be used as bone graft substitutes in smaller defects although their suitability in large defects is yet to be studied.

Epithelioid hemangioma involving three contiguous bones: a case report with a review of the literature

An epithelioid hemangioma involving three contiguous bones in continuity has, to the best of our knowledge, not been reported in the literature. A case of a 48-year-old man presented with radiating pain to the lower thoracic region for two years. A radiograph and CT scan revealed both permeative osteolytic and multiple trabeculated lesions involving the left posterior part of the 10th rib as well as the 9th and 10th vertebral bodies in continuity and was misled as a malignant or infectious lesion. The histopathology and immuno-histochemistry of the lesion confirmed the diagnosis of an epithelioid hemangioma. The lesion was still stable as of three years after surgery.

Skeletal and chronological ages in American adolescents: current findings in skeletal maturation

PURPOSE

This study was designed to assess the relationship between skeletal and chronological ages among current American adolescents using the Greulich and Pyle atlas for skeletal age determination.

MATERIALS AND METHODS

We used the Greulich and Pyle atlas to prospectively determine skeletal age in a group of 138 otherwise healthy American adolescents from 12 to 18 years of age. 62 males and 76 females were enrolled in this cohort. Paired Student t-tests were used to statistically compare the skeletal and chronological ages in this population. Subgroup analysis examined the effect of gender on differences between chronologic age and skeletal age.

RESULTS

For the entire cohort, mean skeletal age was significantly greater than chronological age (mean 0.80 years, P < 0.01). In 29 cases (21%) the skeletal age was at least 2 years greater than the chronologic age. Among females, such cases with marked discrepancy occurred exclusively in those chronologically between 12 and 15 years of age (P < 0.01). Males demonstrated a 2-year or greater discrepancy more commonly than females (26 vs. 17%). In males, 2-year discrepancies were equally likely across chronologic ages (P = 0.82).

CONCLUSIONS

Current American adolescents are significantly more mature by skeletal age, as determined by the Greulich and Pyle method, than their chronological age would suggest. The skeletal ages of females are most likely to markedly exceed chronologic age between the ages of 12-15 years.

Study of papillary carcinoma of thyroid with uncommon sites of metastasis

Papillary carcinoma of thyroid (PCT) is the most common type of thyroid malignancy and metastasis to cervical lymph nodes is very common [1]. Blood borne metastases from PCT are less frequent than with the other thyroid carcinomas [2]. Uncommon sites include lungs, bone, atrium, cerebrum, kidney, skin [3].We report four cases of papillary carcinoma with uncommon sites of metastasis.One showed tumor emboli of 2.5 cm in internal jugular vein, one had tumor deposit in metacarpal bone and lung, one had a subcutaneous tumor deposit and one was a micropapillary carcinoma with metastasis axillary nodes. All these four cases were classical PCT.

Circling behavior developed in Dmp1 null mice is due to bone defects in the vestibular apparatus

With age, there is a progressive loss of body balance function. Yet, the potential influence of osteoporosis on body balance is largely unknown. Dentin matrix protein 1 (DMP1) is highly expressed in bone and required for phosphate homeostasis and mineralization. Dmp1 null mice display striking defects in bone structure. In this study we reported circling behavior and hyper reaction to touching in Dmp1 null mice. Our histology, tartrate resistant acid phosphatase (TRAP) staining and µCT data showed dramatic changes, such as an expansion of poorly mineralized matrices, in the Dmp1 null porous bony structure in the vestibular apparatus. The targeted re-expression of DMP1 in the Dmp1 null bone fully rescued not only the bone phenotype, but also circling behavior and hyper reaction. Furthermore, X-gal stain and DMP1 immunohistochemistry assay showed that DMP1 was not expressed in neuron cells or balance related cells in the inner ear, suggesting that a defect in the bony labyrinth of the internal ear is indirectly responsible for the circling behavior and/or hyper reaction to touching. Finally, discovery of DMP1 lacZ signal in pericyte-like cells may suggest a new function of DMP1 in angiogenesis.

FDG PET for the Detection of Bone Metastases: Sensitivity, Specificity and Comparison with Other Imaging Modalities

A literature review was performed of studies reporting sensitivity and specificity of [18F]fluorodeoxyglucose (FDG) PET from January 1, 2000 to January 1, 2010. PET was found to have higher sensitivity for the detection of osseous metastases when compared to CT, skeletal scintigraphy, whole body MRI and combined conventional imaging modalities. A potential exception is when comparing PET with bone scan in the setting of blastic metastases. PET may be a better indicator of active bony metastases. The efficacy of PET can be increased with fused anatomic imaging.

Engipore acts on human bone marrow stem cells

OBJECTIVES

Porous HA scaffolds are promising materials for tissue engineering because they offer a tridimensional support and serve as template for cell proliferation and at last tissue formation. Engipore provide a natural 3D scaffold with organic fibrous material in bone. However, how this material alters osteoblast activity to promote bone formation is poorly understood.

MATERIALS AND METHODS

To study how Engipore can induce osteoblast differentiation in mesenchymal stem cells, the expression levels of bone related genes and mesenchymal stem cells marker were analyzed.

RESULTS

Engipore causes a significant induction of osteoblast transcriptional factors like SP7 and RUNX2 and of the bone-related gene osteocalcin (BGLAP). The expression of CD105 was not significantly changed in stem cells treated with Engipore with respect to untreated cells, while SSP1 (osteopontin) was significantly down expressed thus reducing osteoclast activity.

CONCLUSIONS

The obtained results can be relevant to better understand the molecular mechanism of bone regeneration.

Fine needle aspiration diagnosis of Rosai-Dorfman disease in an osteolytic lesion of bone

Sinus histiocytosis with massive lymphadenopathy (SHML) or Rosai-Dorfman disease (RDD) is an uncommon but well-defined benign self-limited clinicopathological entity. It mainly involves lymph nodes. Extranodal involvement is seen in up to 43% of cases, with the most common location in the head and neck region. Primary RDD occurring in the bone is rare with only twelve cases reported in the literature to date, all diagnosed on histology except one by fine needle aspiration (FNA) cytology. We report a case of RDD diagnosed by FNA cytology in a 28 year-old female presented as an osteolytic lesion of superior pubic ramus where the differential diagnosis included a sarcoma and lymphoma. Based on the cytologic findings, a diagnosis of a RDD was considered during the rapid FNA on site with no clinical history provided. The diagnosis of RDD was further confirmed by immunohistochemical stains and histology diagnosis. Our findings show that even in the absence of a clinical history, FNA is a less invasive and a very reliable tool for the diagnosis of SHML (RDD).

RANKL inhibition improves bone properties in a mouse model of osteogenesis imperfecta

Recently, a new class of agents targeting the receptor activator of nuclear factor-kappaB ligand (RANKL) pathway has been developed for the treatment of osteoporosis and other bone diseases. In the current study, inhibition of the RANKL pathway was evaluated to assess effects on "bone quality" and fracture incidence in an animal model of osteogenesis imperfect (OI), the oim/oim mouse. Juvenile oim/oim ( approximately 6 weeks old) and wildtype (+/+) mice were treated with either a RANKL inhibitor (RANK-Fc) or saline. After treatment, bone density increased significantly in the femurs of both genotypes. Femoral length decreased with RANK-Fc in +/+ mice. Geometric measurements at mid-diaphysis in the oim/oim groups showed increases in the ML periosteal and endosteal diameters and AP cortical thickness in the treated groups. Within +/+ groups, ML cortical thickness and ML femoral periosteal diameter were significantly increased with RANK-Fc. Biomechanical testing revealed increased stiffness in oim/oim and +/+ mice. Total strain was increased with treatment in the +/+ mice. Histologically, RANKL inhibition resulted in retained growth plate cartilage in both genotypes. The average number of fractures sustained by RANK-Fc-treated oim/oim mice was not significantly decreased compared to saline treated oim/oim mice. This preclinical study demonstrated that RANKL inhibition at the current dose improved density and some geometric and biomechanical properties of oim/oim bone, but it did not decrease fracture incidence. Further studies that address commencement of therapy at earlier time points are needed to determine whether this mode of therapy will be clinically useful in OI.

Clinical Usefulness of (18)F-fluoride Bone PET

PURPOSE

(18)F-fluoride bone positron emission tomography (PET) has been reported as a useful bone imaging modality. However, no clinical bone PET study had been performed previously in Korea. The authors investigated the usefulness of (18)F-fluoride bone PET in Korean patients with malignant or benign bone disease.

METHODS

Eighteen consecutive patients (eight women, ten men; mean age, 55 ± 12 years) who had undergone (18)F-fluoride bone PET for the evaluation of bone metastasis (n = 13) or benign bone lesions (n = 5) were included. The interpretation of bone lesions on (18)F-fluoride bone PET was determined by consensus of two nuclear medicine physicians, and final results were confirmed using combination of all imaging studies and/or clinical follow-up. The analysis was performed on the basis of lesion group.

RESULTS

Thirteen patients with malignant disease had 15 lesion groups, among which seven were confirmed as metastatic bone lesions and eight were confirmed as non-metastatic lesions. (18)F-fluoride bone PET correctly identified six of seven metastatic lesions (sensitivity, 86%), and seven of eight non-metastatic lesions (specificity, 88%). On the other hand, five patients with benign conditions had five bone lesion groups; four were confirmed as benign bone diseases and the other one was confirmed as not a bone lesion. (18)F-fluoride bone PET showed correct results in all the five lesion groups.

CONCLUSIONS

(18)F-fluoride bone PET showed promising potential for bone imaging in Korean patients with malignant diseases as well as with various benign bone conditions. Therefore, further studies are required on the diagnostic performance and cost-effectiveness of (18)F-fluoride bone PET.

Circulating insulin-like growth factor binding protein-4 (IGFBP-4) is not regulated by parathyroid hormone and vitamin D in vivo: evidence from children with rickets

OBJECTIVE

Insulin-like growth factor binding protein-4 (IGFBP-4), inhibits IGF actions under a variety of experimental conditions. Parathyroid hormone (PTH), 1.25-hydroxy(OH)vitamin D, IGF-I, IGF-II and transforming growth factor (TGF)-b are the major regulators of IGFBP-4 production in vitro. However, little is known about the in vivo regulation of circulating IGFBP-4 in humans.

METHODS

We measured serum concentrations of calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), PTH, vitamin D, IGF-I, IGFBP-3, and IGFBP-4 in infants (n=22) with nutritional rickets before and after treatment of rickets with vitamin D (300 000 U single dose po).

RESULTS

The mean±SD age of the patients was 1.3±1.6 years (range 0.2-3). Serum Ca and P increased, whereas ALP and PTH decreased after treatment (Ca from 6.6±1.4 to 9.5±1.6 mg/dL, P from 3.9±1.4 to 5.4±0.8 mg/dL, ALP from 2590±2630 to 1072±776 IU/mL and PTH from 407±248 to 27.4±20.8 ng/dL, respectively). Vitamin D levels were low (7.8±2.5 ng/mL) and increased after treatment (18.1±4.0 ng/mL, p<0.001). Serum IGF-I and IGFBP-3 levels both increased after treatment (IGF-I: 13.5±12.2 vs. 23.7±14.2 ng/mL, p<0.001 and IGFBP-3: 1108±544 vs. 1652±424 ng/mL, p<0.001). However, serum IGFBP-4 levels did not change significantly after treatment (18.8±8.0 vs. 21.5±4.8 ng/mL). No correlation between PTH and IGF-I, IGFBP-3 or IGFBP-4 was detected. Significant correlations were observed between PTH and ALP (r=0.53, p<0.05), and between IGF-I and IGFBP-3 (r=0.46, p<0.05).

CONCLUSION

The results demonstrate that contrary to in vivo studies, circulating IGFBP-4 levels are not influenced by secondary hyperparathyroidism in vitamin D deficiency rickets since IGFBP-4 levels did not change after normalization of PTH with vitamin D treatment.

A quantitative analysis of the structure of human sternum

An extensive study of the human sternum has been carried out to obtain estimates of the omnidirectional path-length distributions and structural parameters for trabeculation and marrow spaces. Data for sternum samples have been collected, using an object plane scanning microscope. These data have been used to produce the omnidirectional path-length distributions and values of structural parameters for the whole sternum. For a typical adult man the mean trabecular and marrow space path lengths are 224 and 1364 μm, respectively. The percentage bone volume is 13.8 and the surface to volume ratio is 190 cm. Data on the structural variations within the whole sternum are presented. They show a percentage difference in bone volume between the manubrium and the body of sternum of about 36%.

PerioGlas® Acts on Human Stem Cells Isolated from Peripheral Blood

BACKGROUND

PerioGlas® (PG) is an alloplastic material used for grafting periodontal osseous defects since 1995. In animal models, it has been proven that PG achieves histologically good repair of sur-gically created defects. In clinical trials, PG was effective as an adjunct to conventional surgery in the treatment of intrabony defects. Because the molecular events due to PG that are able to alter osteob-last activity to promote bone formation are poorly understood, we investigated the expression of os-teoblastic related genes in mesenchymal stem cells exposed to PG.

METHODS

The expression levels of bone related genes like RUNX2, SP7, SPP1, COL1A1, COL3A1, BGLAP, ALPL, and FOSL1 and mesenchymal stem cells marker (CD105) were analyzed, using real time reverse transcription-polymerase chain reaction. Pearson's chi-square (χ(2)) test was used to detect markers with significant differences in gene expression.

RESULTS

PG caused induction of osteoblast transcriptional factor (like RUNX2), bone related genes osteopontin (SPP1), osteocalcin (BGLAP) and alkaline phosphatase (ALPL). All had statistical sig-nificant P values (< 0.05).

CONCLUSION

PG has a differentiation effect on mesenchymal stem cells derived from peripheral blood. The obtained results can be relevant to better understanding of the molecular mechanism of bone regeneration and as a model for comparing other materials with similar clinical effects.

Ultrasound diagnosis of either an occult or missed fracture of an extremity in pediatric-aged children

OBJECTIVE

To report and assess the usefulness of ultrasound (US) findings for occult fractures of growing bones.

MATERIALS AND METHODS

For six years, US scans were performed in children younger than 15 years who were referred with trauma-related local pain and swelling of the extremities. As a routine US examination, the soft tissue, bones, and adjacent joints were examined in the area of discomfort, in addition to the asymptomatic contralateral extremity for comparison. Twenty-five occult fractures in 25 children (age range, five months-15 years; average age, 7.7 years) were confirmed by initial and follow-up radiograms, additional imaging studies, and clinical observation longer than three weeks.

RESULTS

The most common site of occult fractures was the elbow (n = 9, 36%), followed by the knee (n = 7, 28%), ischium (n = 4, 16%), distal fibula (n = 3, 12%), proximal femur (n = 1, 4%), and humeral shaft (n = 1, 4%). On the retrograde review of the routine radiographs, 13 out of the 25 cases showed no bone abnormalities except for various soft tissue swelling. For the US findings, cortical discontinuity (direct sign of a fracture) was clearly visualized in 23 cases (92%) and was questionable in two (8%). As auxiliary US findings (indirect signs of a fracture), step-off deformities, tiny avulsed bone fragments, double-line appearance of cortical margins, and diffuse irregularity of the bone surfaces were identified.

CONCLUSION

Performing US for soft tissue and bone surfaces with pain and swelling, with or without trauma history in the extremities, is important for diagnosing occult or missed fractures of immature bones in pediatric-aged children.

Rationale for one stage exchange of infected hip replacement using uncemented implants and antibiotic impregnated bone graft

Infection of a total hip replacement (THR) is considered a devastating complication, necessitating its complete removal and thorough debridement of the site. It is undoubted that one stage exchange, if successful, would provide the best benefit both for the patient and the society. Still the fear of re-infection dominates the surgeons decisions and in the majority of cases directs them to multiple stage protocols. However, there is no scientifically based argument for that practice. Successful eradication of infection with two stage procedures is reported to average 80% to 98%. On the other hand a literature review of Jackson and Schmalzried (CORR 2000) summarizing the results of 1,299 infected hip replacements treated with direct exchange (almost exclusively using antibiotic loaded cement), reports of 1,077 (83%) having been successful. The comparable results suggest, that the major factor for a successful outcome with traditional approaches may be found in the quality of surgical debridement and dead space management. Failures in all protocols seem to be caused by small fragments of bacterial colonies remaining after debridement, whereas neither systemic antibiotics nor antibiotic loaded bone cement (PMMA) have been able to improve the situation significantly. Reasons for failure may be found in the limited sensitivity of traditional bacterial culturing and reduced antibiotic susceptibility of involved pathogens, especially considering biofilm formation. Whenever a new prosthesis is implanted into a previously infected site the surgeon must be aware of increased risk of failure, both in single or two stage revisions. Eventual removal therefore should be easy with low risk of additional damage to the bony substance. On the other hand it should also have potential of a good long term result in case of success. Cemented revisions generally show inferior long term results compared to uncemented techniques; the addition of antibiotics to cement reduces its biomechanical properties. Efficient cementing techniques will result in tight bonding with the underlying bone, making eventual removal time consuming and possibly associated with further damage to the osseous structures. All these issues are likely to make uncemented revisions more desirable. Allograft bone may be impregnated with high loads of antibiotics using special incubation techniques. The storage capacities and pharmacological kinetics of the resulting antibiotic bone compound (ABC) are more advantageous than the ones of antibiotic loaded cement. ABC provides local concentrations exceeding those of cement by more than a 100fold and efficient release is prolonged for several weeks. The same time they are likely to restore bone stock, which usually is compromised after removal of an infected endoprosthesis. ABC may be combined with uncemented implants for improved long term results and easy removal in case of a failure. Specifications of appropriate designs are outlined. Based on these considerations new protocols for one stage exchange of infected TJR have been established. Bone voids surrounding the implants may be filled with antibiotic impregnated bone graft; uncemented implants may be fixed in original bone. Recent studies indicate an overall success rate of more than 90% without any adverse side effects. Incorporation of allografts appears as after grafting with unimpregnated bone grafts. Antibiotic loaded bone graft seems to provide sufficient local antibiosis for protection against colonisation of uncemented implants, the eluted amounts of antibiotics are likely to eliminate biofilm remnants, dead space management is more complete and defects may be reconstructed efficiently. Uncemented implants provide improved long term results in case of success and facilitated re-revision in case of failure. One stage revision using ABC together with uncemented implants such should be at least comparably save as multiple stage procedures, taking advantage of the obvious benefits for patients and economy.

Advanced Glycation End-products and Bone Fractures

Bone does not turn over uniformly, and becomes susceptible to post-translational modification by non-enzymatic glycation (NEG). NEG of bone causes the formation of advanced glycation end-products (AGEs) and this process is accelerated with aging, diabetes and antiresorptive postmenopausal osteoporosis therapy. Due to the elevated incidence of fracture associated with aging and diabetes, several studies have attempted to measure and evaluate AGEs as biomarkers for fracture risk. Here current methods of estimating AGEs in bone by liquid chromatography and fluorometric assay are summarized and the relationships between AGEs and fracture properties at whole bone, apparent tissue and matrix levels are discussed.

Resuscitative Long-Bone Sonography for the Clinician: Usefulness and Pitfalls of Focused Clinical Ultrasound to Detect Long-Bone Fractures During Trauma Resuscitation

Bone has one of the highest acoustic densities (AD) in the human body. Traditionally, bone has been considered to be a hindrance to the use of ultrasound (US), as US waves are reflected by the dense matrix and obscure underlying structures. The intense wave reflection, however, can clearly illustrate the cortical bony anatomy of long bones, making cortical disruption obvious. Ultrasound can be used at the bedside concurrently with the overall trauma resuscitation, and may potentially limit the patient's and treating team's exposure to ionizing radiation, corroborate clinical findings, and augment procedural success. The extended focused assessment with sonography for trauma (EFAST) is an essential tool in the resuscitation of severe torso trauma, frequently demonstrating intra- pericardial and intra-peritoneal fluid, inferring hemo/pneumothoraces, and demonstrating cardiac function. Although it is typically considered as a diagnosis of exclusion, multiple long-bone fractures may be a source of shock and can be quickly confirmed at the bedside with EFAST. Further, the early detection of long-bone fractures can also aid in the early stabilization of severely injured patients. Sonographic evaluation for long-bone fractures may be particularly useful in austere environments where other imaging modalities are limited, such as in the battlefield, developing world, and space. While prospective study has been limited, selected series have demonstrated high accuracy among both physician and para-medical clinicians in detecting long-bone fractures. Pitfalls in this technique include reduced accuracy with the small bones of the hands and feet, as well as great reliance on user experience.

Traumatic Allogenic Bone Implantation

Traumatic allogenic bone implantation is becoming increasingly common in the setting of road trauma and suicide bombings. We present a unique case where a large bony fragment from one individual became embedded in the arm of another person following a "head-on" collision involving two motorbikes. Several management issues are outlined.

Unveiling the bmp13 enigma: redundant morphogen or crucial regulator?

Bone morphogenetic proteins are a diverse group of morphogens with influences not only on bone tissue, as the nomenclature suggests, but on multiple tissues in the body and often at crucial and influential periods in development.

The purpose of this review is to identify and discuss current knowledge of one vertebrate BMP, Bone Morphogenetic Protein 13 (BMP13), from a variety of research fields, in order to clarify BMP13's functional contribution to developing and maintaining healthy tissues, and to identify potential future research directions for this intriguing morphogen. BMP13 is highly evolutionarily conserved (active domain >95%) across diverse species from Zebrafish to humans, suggesting a crucial function. In addition, mutations in BMP13 have recently been associated with Klippel-Feil Syndrome, causative of numerous skeletal and developmental defects including spinal disc fusion. The specific nature of BMP13's crucial function is, however, not yet known.

The literature for BMP13 is focused largely on its activity in the healing of tendon-like tissues, or in comparisons with other BMP family molecules for whom a clear function in embryo development or osteogenic differentiation has been identified. There is a paucity of detailed information regarding BMP13 protein activity, structure or protein processing. Whilst some activity in the stimulation of osteogenic or cartilaginous gene expression has been reported, and BMP13 expression is found in post natal cartilage and tendon tissues, there appears to be a redundancy of function in the BMP family, with several members capable of stimulating similar tissue responses. This review aims to summarise the known or potential role(s) for BMP13 in a variety of biological systems.

Structural basis of growth-related gain and age-related loss of bone strength

If bone strength was the only requirement of skeleton, it could be achieved with bulk, but bone must also be light. During growth, bone modelling and remodelling optimize strength, by depositing bone where it is needed, and minimize mass, by removing it from where it is not. The population variance in bone traits is established before puberty and the position of an individual's bone size and mass tracks in the percentile of origin. Larger cross-sections have a comparably larger marrow cavity, which results in a lower volumetric BMD (vBMD), thereby avoiding bulk. Excavation of a marrow cavity thus minimizes mass and shifts the cortex radially, increasing rigidity. Smaller cross-sections are assembled by excavating a smaller marrow cavity leaving a relatively thicker cortex producing a higher vBMD, avoiding the fragility of slenderness. Variation in cellular activity around the periosteal and endocortical envelopes fashions the diverse shapes of adjacent cross-sections. Advancing age is associated with a decline in periosteal bone formation, a decline in the volume of bone formed by each basic multicellular unit (BMU), continued resorption by each BMU, and high remodelling after menopause. Bone loss in young adulthood has modest structural and biomechanical consequences because the negative BMU balance is driven by reduced bone formation, remodelling is slow and periosteal apposition continues shifting the thinned cortex radially. But after the menopause, increased remodelling, worsening negative BMU balance and a decline in periosteal apposition accelerate cortical thinning and porosity, trabecular thinning and loss of connectivity. Interstitial bone, unexposed to surface remodelling becomes more densely mineralized, has few osteocytes and greater collagen cross-linking, and accumulates microdamage. These changes produce the material and structural abnormalities responsible for bone fragility.

Unusual presentation of large B cell lymphoma- bone and stomach- treated with autologous transplantation

Extranodal presentation of diffuse large B cell lymphoma (DLBL) is frequently observed in the gastrointestinal tract, CNS, bone, testes and liver. However, the simultaneous detection of multiple extranodal involvement at presentation is quite an uncommon occurrence. In this study, we report on a patient with an uncommon presentation of DLBL, and he had symptoms of left knee joint pain and hematemesis, characterized by bone and stomach involvement. Computed tomography and fluorodeoxyglucose-positron emission tomography (FDG-PET) scanning revealed a rapid, extensive spread to the bones and soft tissues. Subsequent histopathological examination verified the bony and gastric CD20-positive DLBL localization. We diagnosed this case as DLBL of stage IV with an international prognostic index of 3, and classified him into the high intermediate risk group. This patient was treated via chemotherapy with an R-CHOP regimen. After achieving a partial response, the patient received autologous peripheral blood stem cell transplantation. The patient attained partial remission, as shown on the FDG-PET scan, and he displayed improvement of his left femur pain.

Dietary variation in arctic foxes (Alopex lagopus)-an analysis of stable carbon isotopes

We used stable carbon isotopes to analyse individual variation in arctic fox diet. We extracted collagen from bones (the lower jaw), and measured stable carbon isotopes. The foxes came from three different localities: Iceland, where both microtines and reindeer are rare; west Greenland, where microtines are absent; and Sweden, where scat analyses showed the primary food to be microtine rodents and reindeer. The Icelandic samples included foxes from both coastal and inland habitats, the Swedish sample came from an inland area, and the Greenland sample from coastal sites. The spatial variation in the isotopic pattern followed a basic division between marine and terrestrial sources of protein. Arctic foxes from inland sites had δ¹³C values of -21.4 (Iceland) and -20.4‰ (Sweden), showing typical terrestrial values. Coastal foxes from Greenland had typical marine values of -14.9‰, whereas coastal foxes from Iceland had intermediate values of -17.7‰. However, there was individual variation within each sample, probably caused by habitat heterogeneity and territoriality among foxes. The variation on a larger scale was related to the availability of different food items. These results were in accordance with other dietary analyses based on scat analyses. This is the first time that stable isotopes have been used to reveal individual dietary patterns. Our study also indicated that isotopic values can be used on a global scale.