Pannexins in the musculoskeletal system: new targets for development and disease progression

During cell differentiation, growth, and development, cells can respond to extracellular stimuli through communication channels. Pannexin (Panx) family and connexin (Cx) family are two important types of channel-forming proteins. Panx family contains three members (Panx1-3) and is expressed widely in bone, cartilage and muscle. Although there is no sequence homology between Panx family and Cx family, they exhibit similar configurations and functions. Similar to Cxs, the key roles of Panxs in the maintenance of physiological functions of the musculoskeletal system and disease progression were gradually revealed later. Here, we seek to elucidate the structure of Panxs and their roles in regulating processes such as osteogenesis, chondrogenesis, and muscle growth. We also focus on the comparison between Cx and Panx. As a new key target, Panxs expression imbalance and dysfunction in muscle and the therapeutic potentials of Panxs in joint diseases are also discussed.

Hepatocellular carcinoma and musculoskeletal system: A narrative literature review

Musculoskeletal alterations in hepatocellular carcinoma (HCC) are less common than liver-related complications. However, they can significantly impact the quality of life and overall prognosis of patients with HCC. The main obstacle in the clinical assessment of HCC-induced musculoskeletal alterations is related to effective and timely diagnosis because these complications are often asymptomatic and unapparent during routine clinical evaluations. This narrative literature review aimed to provide a comprehensive overview of the contemporary literature related to the changes in the musculoskeletal system in patients with HCC, focusing on its clinical implications and underlying etiopathogenetic mechanisms. Osteolytic bone metastases are the most common skeletal alterations associated with HCC, which could be associated with an increased risk of low-trauma bone fracture. Moreover, previous studies reported that osteopenia, sarcopenia, and myosteatosis are associated with poor clinical outcomes in patients with HCC. Even though low bone mineral density and sarcopenia are consistently reported as reliable predictors of pretransplantation and post-transplantation mortality in HCC patients, these complications are frequently overlooked in the clinical management of patients with HCC. Taken together, contemporary literature suggests that a multidisciplinary approach is essential for early recognition and clinical management of HCC-associated musculoskeletal alterations to improve patient prognosis. Further research into the mechanisms and treatment options for musculoskeletal complications is warranted to enhance our understanding and clinical management of this aspect of HCC.

Oral analgesic for musculoskeletal injuries in children: A systematic review and network meta-analysis

OBJECTIVE

Pain in pediatric musculoskeletal (MSK) injuries can lead to increased anxiety, fear, and avoidance of medical care, making analgesic management critical. Therefore, we evaluated analgesic efficacy and adverse effects to select the optimal analgesic agent in pediatric patients with MSK injuries.

METHODS

Four databases were searched from inception to March 2023 for peer-reviewed, open randomized controlled trials (RCTs). Inclusion criteria were: (1) trials with RCT design, (2) children aged 1 month-18 years with MSK injury, (3) outpatient setting, (4) interventions and control, (5) primary outcome of pain score at 60 and 120 min and secondary outcome of adverse effects, and (6) full-text and peer-reviewed articles. Two reviewers screened, extracted data, and assessed the risk of bias. A frequentist random-effects network meta-analysis (NMA) was performed. Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation working group approach.

RESULTS

We included eight trials comprising 1645 children. Ibuprofen was significantly associated with pain reduction at 120 min, compared with acetaminophen (SMD 0.31 [95% CI 0.11-0.51]; moderate certainty) and opioids (SMD 0.34 [95% CI 0.20-0.48]; moderate certainty). Compared with opioids alone, ibuprofen-opioid combination was significantly associated with pain reduction at 120 min (SMD 0.19 [95% CI 0.03-0.35]). No significant differences were found in pain interventions at 60 min. Ibuprofen had statistically fewer adverse events than opioids (RR, 0.54 [95% CI 0.33-0.90]; moderate certainty) and ibuprofen with opioids (RR 0.47 [95% CI 0.25-0.89]; moderate certainty). In terms of limitations, the eight RCTs included had relatively small sample sizes; only two were high-quality RCTs.

CONCLUSIONS

Our NMA found ibuprofen to be the most effective and least adverse analgesic in pediatric patients with MSK injuries.

Primary Soft-Tissue Lymphomas: MRI Features Help Discriminate From Other Soft-Tissue Tumors

OBJECTIVES

MRI presentation of extra-nodal soft-tissue lymphomas (STLs) is scarcely reported and lacks of comparison with other soft-tissue tumors (STTs) including sarcomas (STS). Yet, suggesting this diagnosis on MRI would considerably reduce diagnostic intervals. Our aim was to investigate if conventional MRI could discriminate STLs from other STTs.

METHODS

MRIs of STL patients were compared with those of patients addressed to a sarcoma reference center for the diagnosis of a STT. MRI characteristics depicting the tumor (size, signal, habitats, shape, surrounding tissues) were reported. Uni- and multivariate associations with STL diagnosis were evaluated in the entire cohort, and in the subgroups of benign and malignant STTs patients. Diagnostic performances of MRI features combinations were tested.

RESULTS

We included 39 patients with STLs (median age: 69 years) and 368 patients with other STTs (122 benign STTs and 246 STS; median age: 58 years). Six MRI features were independent predictors of STL compared to all other STTs: intermediate SI on T1-WI, homogeneous enhancement (without necrotic areas), no blood signal, no fibrotic signal, no peritumoral enhancement and lack of abnormal intra- and peritumoral vasculature (p-value range: <0.0001-0.0163). Their simultaneous presence had a sensitivity of 0.88 (0.71-0.96) and a specificity of 0.88 (0.84-0.91). Other relevant MRI features were: no fat signal to discriminate against STS (p = 0.0409), the infiltrative growth pattern and the vessel and nerve encasement to discriminate against benign STTs (p = 0.0016 and 0.0011, respectively).

CONCLUSION

Our research demonstrates that conventional MRI can help discriminating STLs from other STTs. Indeed, radiologists can help suggesting the possible diagnosis of STL, which could speed-up the subsequent proper histopathological analysis in light of MRI findings.

In sickness and in health: The functional role of extracellular vesicles in physiology and pathology in vivo: Part II: Pathology: Part II: Pathology

It is clear from Part I of this series that extracellular vesicles (EVs) play a critical role in maintaining the homeostasis of most, if not all, normal physiological systems. However, the majority of our knowledge about EV signalling has come from studying them in disease. Indeed, EVs have consistently been associated with propagating disease pathophysiology. The analysis of EVs in biofluids, obtained in the clinic, has been an essential of the work to improve our understanding of their role in disease. However, to interfere with EV signalling for therapeutic gain, a more fundamental understanding of the mechanisms by which they contribute to pathogenic processes is required. Only by discovering how the EV populations in different biofluids change-size, number, and physicochemical composition-in clinical samples, may we then begin to unravel their functional roles in translational models in vitro and in vivo, which can then feedback to the clinic. In Part II of this review series, the functional role of EVs in pathology and disease will be discussed, with a focus on in vivo evidence and their potential to be used as both biomarkers and points of therapeutic intervention.

Treatment of skeletal and non-skeletal alterations of Mucopolysaccharidosis type IVA by AAV-mediated gene therapy

Mucopolysaccharidosis type IVA (MPSIVA) or Morquio A disease, a lysosomal storage disorder, is caused by N-acetylgalactosamine-6-sulfate sulfatase (GALNS) deficiency, resulting in keratan sulfate (KS) and chondroitin-6-sulfate accumulation. Patients develop severe skeletal dysplasia, early cartilage deterioration and life-threatening heart and tracheal complications. There is no cure and enzyme replacement therapy cannot correct skeletal abnormalities. Here, using CRISPR/Cas9 technology, we generate the first MPSIVA rat model recapitulating all skeletal and non-skeletal alterations experienced by patients. Treatment of MPSIVA rats with adeno-associated viral vector serotype 9 encoding Galns (AAV9-Galns) results in widespread transduction of bones, cartilage and peripheral tissues. This led to long-term (1 year) increase of GALNS activity and whole-body correction of KS levels, thus preventing body size reduction and severe alterations of bones, teeth, joints, trachea and heart. This study demonstrates the potential of AAV9-Galns gene therapy to correct the disabling MPSIVA pathology, providing strong rationale for future clinical translation to MPSIVA patients.

Fatty infiltration in cervical flexors and extensors in patients with degenerative cervical myelopathy using a multi-muscle segmentation model

Background

In patients with degenerative cervical myelopathy (DCM) that have spinal cord compression and sensorimotor deficits, surgical decompression is often performed. However, there is heterogeneity in clinical presentation and post-surgical functional recovery.

Objectives

Primary: a) to assess differences in muscle fat infiltration (MFI) in patients with DCM versus controls, b) to assess association between MFI and clinical disability. Secondary: to assess association between MFI pre-surgery and post-surgical functional recovery.

Study design

Cross-sectional case control study.

Methods

Eighteen patients with DCM (58.6 ± 14.2 years, 10 M/8F) and 25 controls (52.6 ± 11.8 years, 13M/12 F) underwent 3D Dixon fat-water imaging. A convolutional neural network (CNN) was used to segment cervical muscles (MFSS- multifidus and semispinalis cervicis, LC- longus capitis/colli) and quantify MFI. Modified Japanese Orthopedic Association (mJOA) and Nurick were collected.

Results

Patients with DCM had significantly higher MFI in MFSS (20.63 ± 5.43 vs 17.04 ± 5.24, p = 0.043) and LC (18.74 ± 6.7 vs 13.66 ± 4.91, p = 0.021) than controls. Patients with increased MFI in LC and MFSS had higher disability (LC: Nurick (Spearman’s ρ = 0.436, p = 0.003) and mJOA (ρ = -0.399, p = 0.008)). Increased MFI in LC pre-surgery was associated with post-surgical improvement in Nurick (ρ = -0.664, p = 0.026) and mJOA (ρ = -0.603, p = 0.049).

Conclusion

In DCM, increased muscle adiposity is significantly associated with sensorimotor deficits, clinical disability, and functional recovery after surgery. Accurate and time efficient evaluation of fat infiltration in cervical muscles may be conducted through implementation of CNN models.

Hypergravity as a gravitational therapy mitigates the effects of knee osteoarthritis on the musculoskeletal system in a murine model

Insights into the effects of osteoarthritis (OA) and physical interventions on the musculoskeletal system are limited. Our goal was to analyze musculoskeletal changes in OA mice and test the efficacy of 8-week exposure to hypergravity, as a replacement of physical activity. 16-week-old male (C57BL/6J) mice allocated to sham control and OA groups not centrifuged (Ctrl 1g and OA 1g, respectively) or centrifuged at 2g acceleration (Ctrl 2g and OA 2g). OA 1g displayed decreased trabecular bone in the proximal tibia metaphysis and increased osteoclastic activity and local TNFα gene expression, all entirely prevented by 2g gravitational therapy. However, while cortical bone of tibia midshaft was preserved in OA 1g (vs. ctrl), it is thinner in OA 2g (vs. OA 1g). In the hind limb, OA at 1g increased fibers with lipid droplets by 48% in the tibialis anterior, a fact fully prevented by 2g. In Ctrl, 2g increased soleus, tibialis anterior and gastrocnemius masses. In the soleus of both Ctrl and OA, 2g induced larger fibers and a switch from type-II to type-I fiber. Catabolic (myostatin and its receptor activin RIIb and visfatine) and anabolic (FNDC5) genes dramatically increased in Ctrl 2g and OA 2g (p<0.01 vs 1g). Nevertheless, the overexpression of FNDC5 (and follistatine) was smaller in OA 2g than in Ctrl 2g. Thus, hypergravity in OA mice produced positive effects for trabecular bone and muscle typology, similar to resistance exercises, but negative effects for cortical bone.

Classifying and diagnosing systemic lupus erythematosus in the 21st century

The EULAR/ACR 2019 classification criteria for SLE constitute a current and optimized clinical approach to SLE classification. Classification is still not based on molecular approaches and the results from large studies using polyomics may be interpreted as demonstrating the relevance of the genetic and environmental background rather than splitting SLE into several entities. In fact, an association study within the EULAR/ACR classification criteria project found associations between manifestations only within organ domains. This independency of various organ manifestations argues for SLE as one disease entity. The current review article will therefore concentrate on the clinical and immunological manifestations of SLE and on what we have already learned in this century. Moreover, the structure and essential rules of the EULAR/ACR 2019 classification criteria will be discussed. While classification and diagnosis are distinct concepts, which have to remain clearly separated, information derived from the process towards the classification criteria is also useful for diagnostic purposes. Therefore this article also tries to delineate what classification can teach us for diagnosis, covering a wide variety of SLE manifestations.

Role of Scx+/Sox9+ cells as potential progenitor cells for postnatal supraspinatus enthesis formation and healing after injury in mice

A multipotent cell population co-expressing a basic-helix-loop-helix transcription factor scleraxis (Scx) and SRY-box 9 (Sox9) has been shown to contribute to the establishment of entheses (tendon attachment sites) during mouse embryonic development. The present study aimed to investigate the involvement of Scx+/Sox9+ cells in the postnatal formation of fibrocartilaginous entheses and in the healing process after injury, using ScxGFP transgenic mice. We demonstrate that Scx+/Sox9+ cells are localized in layers at the insertion site during the postnatal formation of fibrocartilaginous entheses of supraspinatus tendon until postnatal 3 weeks. Further, these cells were rarely seen at postnatal 6 weeks, when mature fibrocartilaginous entheses were formed. Furthermore, we investigated the involvement of Scx+/Sox9+ cells in the healing process after supraspinatus tendon enthesis injury, comparing the responses of 20- and 3-week-old mice. In the healing process of 20-week-old mice with disorganized fibrovascular tissue in response to injury, a small number of Scx+/Sox9+ cells transiently appeared from 1 week after injury, but they were rarely seen at 4 weeks after injury. Meanwhile, in 3-week-old mice, a thin layer of fibrocartilaginous tissue with calcification was formed at healing enthesis at 4 weeks after injury. From 1 to 2 weeks after injury, more Scx+/Sox9+ cells, widely distributed at the injured site, were seen compared with the 20-week-old mice. At 4 weeks after injury, these cells were located near the surface of the recreated fibrocartilaginous layer. This spatiotemporal localization pattern of Scx+/Sox9+ cells at the injured enthesis in our 3-week-old mouse model was similar to that in postnatal fibrocartilaginous enthesis formation. These findings indicate that Scx+/Sox9+ cells may have a role as entheseal progenitor-like cells during postnatal maturation of fibrocartilaginous entheses and healing after injury in a manner similar to that seen in embryonic development.

The utility of fine-needle aspiration: how FNA has affected our musculoskeletal oncology practice

Fine-needle aspiration (FNA) has been a widely accepted practice in the diagnosis of head and neck, thyroid, lung, pancreas, and many other visceral sites. This has not been the case with the diagnosis of primary bone and soft tissue lesions. FNA has been an important part of our orthopaedic oncology practice for 18 years. Our ability to efficiently and effectively care for patients dramatically improved when FNA became an option for obtaining a tissue diagnosis. We discuss the advantages and disadvantages of a pathologist-driven FNA service in orthopaedic oncology.

Echography analysis of musculoskeletal, heart and liver alterations associated with endothelial dysfunction in obese rats

BACKGROUND

Modern imaging plays a central role in the care of obese patients, and there is an integral focus on its use and accessibility in individuals who have alterations of various in various organs. The objective in this study was to perform an echographic analysis of musculoskeletal system disorders, endothelial dysfunction and the left ventricle (LV) in obese rats.

METHODS

Sprague Dawley rats (250 ± 5 g) were obtained and divided into two groups: the control (C) group was fed with a standard diet, and the obese (Ob) group was fed hyper caloric diet with a high fructose-fat content for 4 months. Body weight, cholesterol, triglycerides, glucose, inflammatory cytokines and adhesion molecules (ICAM-1, VCAM-1) were measured. Additionally, two-dimensional echocardiography, abdominal ultrasound and musculoskeletal system studies were performed in the lower extremities.

RESULTS

The body weight in the Ob group was increased compared to that in the control group, (p < 0.001); in addition, increased glucose, cholesterol and triglyceride concentrations (p < 0.05) as well as increased levels of the adhesion molecules ICAM-1 and, VCAM-1 (p < 0.01) were found in the Ob group vs the C group. On ultrasound, 75% of the Ob group presented fatty liver and distal joint abnormalities.

CONCLUSION

Obese rats exhibit endothelial dysfunction and musculoskeletal changes, also, fatty liver and articular cysts in the posterior region of the distal lower- extremity joints.

Current advances and research in ultrasound imaging to the assessment and management of musculoskeletal disorders

Currently evidence-based practice has given scientific weight to the physical therapist profession; it is essential that all medical professional and physical therapists know the usefulness of new tools that optimize the effectiveness of their interventions and allow the growing of the scientific knowledge base. The use of ultrasound imaging (USI) by physiotherapists has evolved in recent years, consolidating as an increasingly standardized technique, low cost compared to other imaging techniques, quickly of execution, feasible and reliable tool. USI offers a wide range of opportunities in clinical practice as well as in different research areas. Therefore, ultrasound has been currently used as a diagnostic tool by physicians and in recent years there has been an expansion of the use of ultrasound equipment by non-physicians professionals such as physical therapist or physical trainers, who incorporates USI as a means of assessing musculoskeletal system architecture and composition, musculoskeletal changes in dysfunction, pain or injury conditions, as an interventional technique assisting echo-guided procedures or using the visual real-time information as a biofeedback in control motor approaches, as guiding tool in clinical decisions as well as to improve the understanding of tissue adaptations to exercise or movement. The purpose of this article is to review and provide an overview about the currently research of the USI applications and their benefits for the diagnosis and management in individuals with musculoskeletal conditions.

Piezo2 expressed in proprioceptive neurons is essential for skeletal integrity

In humans, mutations in the PIEZO2 gene, which encodes for a mechanosensitive ion channel, were found to result in skeletal abnormalities including scoliosis and hip dysplasia. Here, we show in mice that loss of Piezo2 expression in the proprioceptive system recapitulates several human skeletal abnormalities. While loss of Piezo2 in chondrogenic or osteogenic lineages does not lead to human-like skeletal abnormalities, its loss in proprioceptive neurons leads to spine malalignment and hip dysplasia. To validate the non-autonomous role of proprioception in hip joint morphogenesis, we studied this process in mice mutant for proprioceptive system regulators Runx3 or Egr3. Loss of Runx3 in the peripheral nervous system, but not in skeletal lineages, leads to similar joint abnormalities, as does Egr3 loss of function. These findings expand the range of known regulatory roles of the proprioception system on the skeleton and provide a central component of the underlying molecular mechanism, namely Piezo2.

Biomechanical factors during common agricultural activities: Results of on-farm exposure assessments using direct measurement methods

Agricultural work is associated with increased risk of adverse musculoskeletal health outcomes. The purpose of this study was to quantify exposure to biomechanical factors among a sample (n = 55) of farmers in the Midwest region of the U.S. while they performed a variety of routine agricultural activities, and to compare exposure levels between these activities. Surface electromyography was used to estimate activity levels of the erector spinae, upper trapezius, forearm flexor, and forearm extensor muscle groups. Simultaneously, inertial sensors were used to measure kinematics of the trunk, upper arm, and wrist. In general, lower muscle activity levels, less extreme postures, and slower movement speeds were observed during activities that involved primarily the use of agricultural machinery in comparison to manual activities, suggesting a potential advantage of mechanization relative to musculoskeletal health. Median wrist movement speeds exceeding recently proposed exposure thresholds were also observed during many manual activities, such as milking animals and repairing equipment. Upper arm postures and movement speeds did not appear to confer excessive risk for shoulder-related outcomes (on the whole), but interpretation of the results is limited by a sampling approach that may not have captured the full extent of exposure variation. Not surprisingly, substantial variation in exposure levels were observed within each agricultural activity, which is related to substantial variation in the equipment, tools, and work practices used by participants. Ultimately, the results of this study contribute to an emerging literature in which the physical demands of routine agricultural work have been described on the basis of sensor-based measurements rather than more common self-report or observation-based approaches.

Skeletal evidence for violent trauma from the bronze age Qijia culture (2,300-1,500 BCE), Gansu Province, China

This research explores how social and environmental factors may have contributed to conflict during the early Bronze Age in Northwest China by analyzing violent trauma on human skeletal remains from a cemetery of the Qijia culture (2300-1500 BCE). The Qijia culture existed during a period of dramatic social, technological, and environmental change, though minimal research has been conducted on how these factors may have contributed to violence within the area of the Qijia and other contemporaneous material cultures. An osteological assessment was conducted on 361 individuals (n = 241 adults, n = 120 non-adults) that were excavated from the Mogou site, Lintan County, Gansu, China. Injuries indicative of violence, including sharp- and blunt-force trauma that was sustained ante- or peri-mortem, were identified, and the patterns of trauma were analysed. Violent injuries were found on 8.58% (n = 31/361) of individuals, primarily adult males. No evidence of trauma was found on infants or children. Cranial trauma was found on 11.8% (n = 23/195) of the adult individuals examined. Of these, 43.5% (n = 10/23) presented with severe peri-mortem craniofacial trauma. The high rate of perimortem injuries and their locations indicate lethal intent. This lethality, in addition to the fact that individuals with trauma were predominantly male, suggest intergroup violence such as raiding, warfare, or feuding. Both social and environmental factors may have contributed to this conflict in the TaoRiver Valley, though future systematic archaeological and paleoenvironmental data will be needed to disentangle the many potential causal factors.

[Pathologies of the musculoskeletal system in diabetes mellitus]

Diabetes mellitus causes several micro- (nephropathy, neuropathy and retinopathy) and macro-vascular (coronary insufficiency, stroke, lower limb arteriopathy) complications. Some complications are less widely known, particularly the ones involving the musculoskeletal system. Even though diabetes is not specifically linked to these complications, it increases both their incidence and severity. The objective of this paper is to review the main musculoskeletal complications associated to diabetes. It describes the pathophysiology, symptomatology and treatments of these complications.

Effectiveness of physical and cognitive-behavioural intervention programmes for chronic musculoskeletal pain in adults: A systematic review and meta-analysis of randomised controlled trials

This systematic review and meta-analysis aimed to examine the effects of physical exercise cum cognitive-behavioural therapy (CBT) on alleviating pain intensity, functional disabilities, and mood/mental symptoms in those suffering with chronic musculoskeletal pain. MEDLINE, EMBASE, PubMEd, PsycINFO and CINAHL were searched to identify relevant randomised controlled trials from inception to 31 December 2018. The inclusion criteria were: (a) adults ≥18 years old with chronic musculoskeletal pain ≥3 months, (b) randomised controlled design, (c) a treatment arm consisting of physical intervention and CBT combined, (d) the comparison arm being waitlist, usual care or other non-pharmacological interventions such as physical exercise or CBT alone, and (e) outcomes including pain intensity, pain-related functional disabilities (primary outcomes), or mood/mental symptoms (secondary outcome). The exclusion criteria were: (a) the presence of comorbid mental illnesses other than depression and anxiety and (b) non-English publication. The search resulted in 1696 records and 18 articles were selected for review. Results varied greatly across studies, with most studies reporting null or small effects but a few studies reporting very large effects up to 2-year follow-up. Pooled effect sizes (Hedges’ g) were ~1.00 for pain intensity and functional disability, but no effect was found for mood/mental symptoms. The effects were mainly driven by several studies reporting unusually large differences between the exercise cum CBT intervention and exercise alone. When these outliers were removed, the effect on pain intensity disappeared at post-intervention while a weak effect (g = 0.21) favouring the combined intervention remained at follow-up assessment. More consistent effects were observed for functional disability, though the effects were small (g = 0.26 and 0.37 at post-intervention and follow-up respectively). More importantly, the value of adding CBT to exercise interventions is questionable, as consistent benefits were not seen. The clinical implications and directions for future research are discussed.

Orthopaedic phenotyping of NGLY1 deficiency using an international, family-led disease registry

BACKGROUND

NGLY1 deficiency is a rare autosomal recessive disorder caused by loss in enzymatic function of NGLY1, a peptide N-glycanase that has been shown to play a role in endoplasmic reticulum associated degradation (ERAD). ERAD dysfunction has been implicated in other well-described proteinopathies, such as Alzheimer's disease, Parkinson's disease, and Huntington's disease. The classical clinical tetrad includes developmental delay, hypolacrima, transiently elevated transaminases, and hyperkinetic movement disorders. The musculoskeletal system is also commonly affected, but the orthopaedic phenotype has been incompletely characterized. Best practices for orthopaedic clinical care have not been elucidated and considerable variability has resulted from this lack of evidence base. Our study surveyed patients enrolled in an international registry for NGLY1 deficiency in order to characterize the orthopaedic manifestations, sequelae, and management.

RESULTS

Our findings, encompassing the largest cohort for NGLY1 deficiency to date, detail levels of motor milestone achievement; physical exam findings; fracture rates/distribution; frequency of motor skill regression; non-pharmacologic and non-procedural interventions; pharmacologic therapies; and procedural interventions experienced by 29 participants. Regarding the orthopaedic phenotype, at time of survey response, we found that over 40% of patients experienced motor skill regression from their peak. Over 80% of patients had at least one orthopaedic diagnosis, and nearly two-thirds of the total had two or more. More than half of patients older than 6 years had sustained a fracture. Related to orthopaedic non-medical management, we found that 93 and 79% of patients had utilized physical therapy and non-operative orthoses, respectively. In turn, the vast majority took at least one medication (including for bone health and antispasmodic therapy). Finally, nearly half of patients had undergone an invasive procedure. Of those older than 6 years, two-thirds had one or more procedures. Stratification of these analyses by sex revealed distinctive differences in disease natural history and clinical management course.

CONCLUSIONS

These findings describing the orthopaedic natural history and standard of care in patients with NGLY1 deficiency can facilitate diagnosis, inform prognosis, and guide treatment recommendations in an evidence-based manner. Furthermore, the methodology is notable for its partnership with a disease-specific advocacy organization and may be generalizable to other rare disease populations. This study fills a void in the existing literature for this population and this methodology offers a precedent upon which future studies for rare diseases can build.

Effects of disease-afflicted and aging neurons on the musculoskeletal system

The musculoskeletal system includes skeletal muscles, bones and innervating axons from neurons in the central and peripheral nervous systems. Together, they form the largest structure in the body. They also initiate and coordinate locomotion, provide structural stability, and contribute to metabolism and homeostasis. Because of these functions, much effort has been devoted to ascertaining the impact of acute and chronic stress, such as disease, injury and aging, on the musculoskeletal system. This review will examine the role of the nervous system in the deleterious changes that accrue in skeletal muscles and bones during the progression of neurologic diseases and with advancing age.

Individually tailored whole-body vibration training to reduce symptoms of chemotherapy-induced peripheral neuropathy: study protocol of a randomised controlled trial-VANISH

INTRODUCTION

Chemotherapy-induced peripheral neuropathy (CIPN) is a prevalent and clinically meaningful side effect of cancer treatment. CIPN is induced by neurotoxic agents, causing severe sensory and/or motor deficits, resulting in disability and poor recovery, reducing patients' quality of life and limiting medical therapy. To date, effective treatment options are lacking. Whole-body vibration (WBV) training can attenuate motor and sensory deficits. We are conducting a two-armed, multicentre, assessor-blinded, randomised controlled trial, to investigate the effects of WBV on relevant symptoms of CIPN and determine the training characteristics.

METHODS AND ANALYSIS

In this ongoing study, 44 patients who have completed therapy in the past 3 months, with a neurologically confirmed CIPN are assessed before and after a 12-week intervention and follow-up. The intervention group receives WBV twice a week. Exercises are individually tailored according to the initially determined optimal neuromuscular response. The control group receives care as usual.Primary endpoint is the patient reported reduction of CIPN-related symptoms (Functional Assessment of Cancer Therapy/Gynaecology Oncology Group-Neurotoxicity). Secondary endpoints are compound muscle action potentials, distal motor latency, conduction velocity, F-waves from the tibial and peroneal nerve, antidromic sensory nerve conduction studies of the sural nerve, normalised electromyographic activity, peripheral deep sensitivity, proprioception, balance, pain, the feasibility of training settings, quality of life and the level of physical activity.

AIM, ETHICS AND DISSEMINATION

The study was approved by both responsible ethics committees. (1) Our results may contribute to a better understanding of the effects of WBV on motor and sensory functions and (2) may provide information whether WBV at the most effective setting, is feasible for neuropathic patients. (3) Our results may also contribute to improve supportive care in oncology, thereby enhancing quality of life and enabling the optimal medical therapy. All results will be published in international peer-reviewed journals as well as a manual for clinical practice.

TRIAL REGISTRATION NUMBER

NCT03032718.

Iron deficiency anemia, population health and frailty in a modern Portuguese skeletal sample

Introduction

Portugal underwent significant political, demographic and epidemiological transitions during the 20^th century resulting in migration to urban areas with subsequent overcrowding and issues with water sanitation. This study investigates population health during these transitions and interprets results within a framework of recent history and present-day public health information. We investigate skeletal evidence for anemia (cribra orbitalia and porotic hyperostosis) as indicators of stress and frailty–i.e., whether the lesions contribute to susceptibility for disease or increased risk of death.

Methods

The presence and severity of skeletal lesions were compared against known sex and cause of death data to investigate potential heterogeneity in frailty and the relationship between lesions and risk of dying over time. Additionally, we tested for the presence of selective mortality in our data (i.e., whether or not the sample is biased for individuals with higher frailty). Our sample derives from a large, documented, modern Portuguese collection from Lisbon and is the first study of its kind using a documented collection. The collection represents primarily middle-class individuals.

Results and conclusions

Analyses indicated that porotic hyperostosis became more common and severe over time, while cribra orbitalia severity increased over time. Neither process was linked to cause of death. However, there was a significant relationship to sex; males exhibited a higher prevalence and severity of lesions and increased mortality. A Gompertz function showed decreased survivorship in early life but increased survivorship over age 60. Using comorbidities of anemia, we were unable to detect selective mortality–i.e., in our sample, lesions do not represent a sign of poor health or increased frailty and are not significantly linked with a decreased mean age-at-death. However, lesion prevalence and severity do reflect the socioeconomic processes in urban Lisbon during the 1800s and 1900s and the possibility of water-borne parasites as the contributing factor for iron deficiency anemia.

The overlooked primary: bladder cancer metastases on dry bone. A study of the 20th century CAL Milano Cemetery Skeletal Collection

OBJECTIVE

The aim of this article is to provide additional documentation of bone metastases to help anthropologists recognize the condition and potentially suggest the diagnosis of bladder carcinoma in differential diagnosis.

MATERIALS AND METHODS

Thirteen individuals clinically diagnosed with bladder carcinoma from the 20^th century Milano Cemetery Skeletal Collection were macroscopically studied to document bone metastases in bladder cancer.

RESULTS

Bone metastases were found through macroscopic observation in three individuals or 23% of the study sample. Metastases were mostly of a mixed nature (45%), although both osteoblastic (13%) and osteolytic (9%) also occurred. In particular, mixed and osteoblastic metastases exhibited different distribution patterns, even when affecting the same bones. The vertebrae (24.7%), skull (12.9%), ribs (11.7%), proximal humeri (7.8%), pelvis (5.2%), proximal femora (2.6%), sacrum (1.3%) and sternum (1.3%) were the most commonly affected. Osteolytic lesions included coalescing superficial pits or lesions perforating the bone cortex. Proliferative lesions manifested as spongiosclerosis or periosteal new bone. Mixed metastases were osteolytic lesions exposing a thickened trabecular bone or coalescent porosity with reactive new bone.

CONCLUSIONS

Bladder carcinoma metastases were mostly mixed, exhibiting periosteal reactions, perforations of bone cortex, spongiosclerosis and coalescing porosity.

SIGNIFICANCE

Bladder carcinoma is rarely considered in the differential diagnosis of the primary organ. This study reports the macroscopic aspect of bone metastases in bladder carcinoma and may help anthropologists diagnose the condition in skeletons.

LIMITATIONS

Absence of evidence is not evidence of absence; some lesions may have been hidden from macroscopic observation and therefore missed.

FURTHER RESEARCH

Radiographic analysis and comparison with other neoplasms should provide additional details for the diagnosis of bladder cancer bone metastases.

Imaging the Pediatric Athlete: Acute and Stress Skeletal Injuries

Sports-related traumatic injuries in children have increased in tandem with participation in higher level activities. The developing musculoskeletal structures in children are susceptible to unique injuries that vary with location and the stage of skeletal maturation. The imaging evaluation of sports injuries in children presents several unique challenges. The purpose of this article is to educate the reader on injuries unique to the skeletally immature athlete with focus on their imaging evaluation and diagnosis.

Changes in pediatric DXA measures of musculoskeletal outcomes and correlation with quantitative CT following treatment of acute lymphoblastic leukemia

We previously reported significant gains in pQCT measures of tibia trabecular bone mineral density (BMD) and cortical structure following completion of therapy in children and adolescents with acute lymphoblastic leukemia (ALL). The objective of this study was to examine changes in DXA measures used in clinical practice and expressed as Z-scores using robust national reference data. Children and adolescents, ages 5 to 18 years were enrolled within 2 (median 0.8) years of completing ALL therapy. DXA total-body less-head bone mineral content (TBLH-BMC), and spine, total hip, femoral neck, and 1/3rd radius areal BMD (aBMD) were assessed in 45 participants at enrollment and 12-months later. Linear regression models examined correlates of changes in DXA Z-scores. Changes in DXA outcomes were compared to changes in tibia pQCT trabecular and cortical volumetric BMD (vBMD) and cortical area. At enrollment, DXA TBLH-BMC, spine and radius aBMD Z-scores were not significantly reduced in ALL survivors; however, total hip [median -0.74 (IQ range -1.51 to -0.04)] and femoral neck [-0.51 (-1.24 to 0.14)] aBMD Z-scores were lower (both p < 0.01) compared to reference data. DXA Z-scores at all skeletal sites increased over 12 months. Despite improvement, total hip Z-score remained lower at -0.55 (-1.05 to 0.18). The increases in TBLH-BMC, total hip and femoral neck aBMD Z-scores were more pronounced in those enrolled within 6 months of completing ALL therapy, compared to those enrolled at >6 months. Gains in TBLH-BMC, total hip, femoral neck and radius aBMD Z-scores were significantly associated with gains in tibia cortical area Z-scores (R = 0.56 to 0.67, p ≤ 0.001). Changes in TBLH and proximal femur sites were associated with gains in trabecular vBMD Z-scores (R = 0.37 to 0.40; p ≤ 0.01); these associations were not significant when adjusted for gains in cortical area. In summary, gains in DXA measures were most pronounced in total hip and femoral neck following ALL therapy. The gains in all DXA measures, with the exception of lumbar spine, reflected gains in cortical area. Overall, ALL survivors demonstrate skeletal recovery following completion of therapy; a small sub-group continue to demonstrate deficits and benefit from continued observation to ensure improvement over time.

Automated Radiology-Pathology Module Correlation Using a Novel Report Matching Algorithm by Organ System

OBJECTIVES AND RATIONALE

Radiology-pathology correlation is time-consuming and is not feasible in most clinical settings, with the notable exception of breast imaging. The purpose of this study was to determine if an automated radiology-pathology report pairing system could accurately match radiology and pathology reports, thus creating a feedback loop allowing for more frequent and timely radiology-pathology correlation.

METHODS

An experienced radiologist created a matching matrix of radiology and pathology reports. These matching rules were then exported to a novel comprehensive radiology-pathology module. All distinct radiology-pathology pairings at our institution from January 1, 2016 to July 1, 2016 were included (n = 8999). The appropriateness of each radiology-pathology report pairing was scored as either "correlative" or "non-correlative." Pathology reports relating to anatomy imaged in the specific imaging study were deemed correlative, whereas pathology reports describing anatomy not imaged with the particular study were denoted non-correlative.

RESULTS

Overall, there was 88.3% correlation (accuracy) of the radiology and pathology reports (n = 8999). Subset analysis demonstrated that computed tomography (CT) abdomen/pelvis, CT head/neck/face, CT chest, musculoskeletal CT (excluding spine), mammography, magnetic resonance imaging (MRI) abdomen/pelvis, MRI brain, musculoskeletal MRI (excluding spine), breast MRI, positron emission tomography (PET), breast ultrasound, and head/neck ultrasound all demonstrated greater than 91% correlation. When further stratified by imaging modality, CT, MRI, mammography, and PET demonstrated excellent correlation (greater than 96.3%). Ultrasound and non-PET nuclear medicine studies demonstrated poorer correlation (80%).

CONCLUSION

There is excellent correlation of radiology imaging reports and appropriate pathology reports when matched by organ system. Rapid, appropriate radiology-pathology report pairings provide an excellent opportunity to close feedback loop to the interpreting radiologist.

CT checklist and scoring system for the assessment of soft tissue preservation in human mummies: application to catacomb mummies from Palermo, Sicily

In this study we applied the recently developed "Checklist and Scoring System for the Assessment of Soft Tissue Preservation in Human Mummies" to catacomb mummies from Palermo, Sicily. Data from twenty-three full-body computed tomography (CT) examinations were available. These consisted of seventeen adults and six children dating from the late 18th to the late 19th centuries AD. Seventeen of these mummies were anthropogenically mummified, and six spontaneously. Based on the checklist and scoring system, soft tissue preservation varied between both mummification groups, among mummies with the same type of mummification, and within individual mummies at different anatomical locations. Checkpoints of the main category "A. Soft Tissues of Head and Musculoskeletal System" were clearly more frequent than checkpoints of the main category "B. Organs and Organ Systems". Among the anthropogenic mummies, intra-arterial filling achieved the highest preservation status of organs and organ systems. Despite the small sample size, the statistical evaluation showed significant differences between mummification types, with the highest soft tissue preservation found in anthropogenic mummies. Application of the "Checklist" allowed a standardized assessment and documentation of the soft tissue preservation of these mummies. The "Scoring System" facilitated a comparison among mummification groups and mummies by means of numeric values.

Engineering Stem and Stromal Cell Therapies for Musculoskeletal Tissue Repair

Stem cells and tissue-derived stromal cells stimulate the repair of degenerated and injured tissues, motivating a growing number of cell-based interventions in the musculoskeletal field. Recent investigations have indicated that these cells are critical for their trophic and immunomodulatory role in controlling endogenous cells. This Review presents recent clinical advances where stem cells and stromal cells have been used to stimulate musculoskeletal tissue repair, including delivery strategies to improve cell viability and retention. Emerging bioengineering strategies are highlighted, particularly toward the development of biomaterials for capturing aspects of the native tissue environment, altering the healing niche, and recruiting endogenous cells.

Examining the effect of self-explanation on cognitive integration of basic and clinical sciences in novices

Several studies have shown that cognitive integration of basic and clinical sciences supports diagnostic reasoning in novices; however, there has been limited exploration of the ways in which educators can translate this model of mental activity into sound instructional strategies. The use of self-explanation during learning has the potential to promote and support the development of integrated knowledge by encouraging novices to elaborate on the causal relationship between clinical features and basic science mechanisms. To explore the effect of this strategy, we compared diagnostic efficacy of teaching students (n = 71) the clinical features of four musculoskeletal pathologies using either (1) integrated causal basic science descriptions (BaSci group); (2) integrated causal basic science descriptions combined with self-explanation prompts (SE group); (3) basic science mechanisms segregated from the clinical features (SG group). All participants completed a diagnostic accuracy test immediately after learning and 1-week later. The results showed that the BaSci group performed significantly better compared to the SE (p = 0.019) and SG groups (p = 0.004); however, no difference was observed between the SE and SG groups (p = 0.91). We hypothesize that the structure of the self-explanation task may not have supported the development of a holistic conceptual understanding of each disease. These findings suggest that integration strategies need to be carefully structured and applied in ways that support the holistic story created by integrated basic science instruction in order to foster conceptual coherence and to capitalize on the benefits of cognition integration.

Integrating three-dimensional printing and nanotechnology for musculoskeletal regeneration

The field of tissue engineering is advancing steadily, partly due to advancements in rapid prototyping technology. Even with increasing focus, successful complex tissue regeneration of vascularized bone, cartilage and the osteochondral interface remains largely illusive. This review examines current three-dimensional printing techniques and their application towards bone, cartilage and osteochondral regeneration. The importance of, and benefit to, nanomaterial integration is also highlighted with recent published examples. Early-stage successes and challenges of recent studies are discussed, with an outlook to future research in the related areas.

A detailed musculoskeletal study of a fetus with anencephaly and spina bifida (craniorachischisis), and comparison with other cases of human congenital malformations

Few descriptions of the musculoskeletal system of humans with anencephaly or spina bifida exist in the literature. Even less is published about individuals in which both phenomena occur together, i.e. about craniorachischisis. Here we provide a detailed report on the musculoskeletal structures of a fetus with craniorachischisis, as well as comparisons with the few descriptions for anencephaly and with musculoskeletal anomalies found in other congenital malformations. We focused in particular on the comparison with trisomies 13, 18, and 21 because neural tube defects have been associated with such chromosomal defects. Our results showed that many of the defects found in the fetus with craniorachischisis are similar not only to anomalies previously described in the available works on musculoskeletal phenotypes seen in fetuses with anencephaly and spina bifida, but also to a wide range of other different conditions/syndromes including trisomies 13, 18 and 21, and cyclopia. The fact that similar anomalies are seen commonly not only in a wide range of different syndromes, but also as variants of the normal human population and as the 'normal' phenotype of other animals, supports Pere Alberch's unfortunately named idea of a 'logic of monsters'. That is, it supports the idea that development is so constrained that both in 'normal' and abnormal development one sees certain outcomes being produced again and again because ontogenetic constraints only allow a few possible outcomes, thus also leading to cases where the anatomical defects of some organisms are similar to the 'normal' phenotype of other organisms. In fact, this applies not only to specific anomalies but also to general patterns, such as the fact that in pathological conditions affecting different regions of the body, one consistently sees more defects on the upper limbs than on the lower limbs. Such general patterns are, again, seen in the fetus examined for this study, which had 29 muscle anomalies on the right upper limb and 22 muscle anomalies on the left upper limb, vs. seven muscle anomalies on the right lower limb and two on the left lower limb. It is therefore hoped that this work, which is part of our effort to describe and compile information on human musculoskeletal defects found in a wide range of conditions, will contribute not only to a better understanding of craniorachischisis in particular and of human congenital malformations in general, but also to broader discussions on the fields of comparative anatomy, and developmental and evolutionary biology.

Pathological findings in the red fox (Vulpes vulpes), stone marten (Martes foina) and raccoon dog (Nyctereutes procyonoides), with special emphasis on infectious and zoonotic agents in Northern Germany

Anthropogenic landscape changes contributed to the reduction of availability of habitats to wild animals. Hence, the presence of wild terrestrial carnivores in urban and peri-urban sites has increased considerably over the years implying an increased risk of interspecies spillover of infectious diseases and the transmission of zoonoses. The present study provides a detailed characterisation of the health status of the red fox (Vulpes vulpes), stone marten (Martes foina) and raccoon dog (Nyctereutes procyonoides) in their natural rural and peri-urban habitats in Schleswig-Holstein, Germany between November 2013 and January 2016 with focus on zoonoses and infectious diseases that are potentially threatening to other wildlife or domestic animal species. 79 red foxes, 17 stone martens and 10 raccoon dogs were collected from traps or hunts. In order to detect morphological changes and potential infectious diseases, necropsy and pathohistological work-up was performed. Additionally, in selected animals immunohistochemistry (influenza A virus, parvovirus, feline leukemia virus, Borna disease virus, tick-borne encephalitis, canine adenovirus, Neospora caninum, Toxoplasma gondii and Listeria monocytogenes), next-generation sequencing, polymerase chain reaction (fox circovirus) and serum-neutralisation analysis (canine distemper virus) were performed. Furthermore, all animals were screened for fox rabies virus (immunofluorescence), canine distemper virus (immunohistochemistry) and Aujeszky's disease (virus cultivation). The most important findings included encephalitis (n = 16) and pneumonia (n = 20). None of the investigations revealed a specific cause for the observed morphological alterations except for one animal with an elevated serum titer of 1:160 for canine distemper. Animals displayed macroscopically and/or histopathologically detectable infections with parasites, including Taenia sp., Toxocara sp. and Alaria alata. In summary, wildlife predators carry zoonotic parasitic disease and suffer from inflammatory diseases of yet unknown etiology, possibly bearing infectious potential for other animal species and humans. This study highlights the value of monitoring terrestrial wildlife following the "One Health" notion, to estimate the incidence and the possible spread of zoonotic pathogens and to avoid animal to animal spillover as well as transmission to humans.

Pre-Vaccination Care-Seeking in Females Reporting Severe Adverse Reactions to HPV Vaccine. A Registry Based Case-Control Study

BACKGROUND

Since 2013 the number of suspected adverse reactions to the quadrivalent human papillomavirus (HPV) vaccine reported to the Danish Medicines Agency (DMA) has increased. Due to the resulting public concerns about vaccine safety, the coverage of HPV vaccinations in the childhood vaccination programme has declined. The aim of the present study was to determine health care-seeking prior to the first HPV vaccination among females who suspected adverse reactions to HPV vaccine.

METHODS

In this registry-based case-control study, we included as cases vaccinated females with reports to the DMA of suspected severe adverse reactions. We selected controls without reports of adverse reactions from the Danish vaccination registry and matched by year of vaccination, age of vaccination, and municipality, and obtained from the Danish National Patient Registry and The National Health Insurance Service Register the history of health care usage two years prior to the first vaccine. We analysed the data by logistic regression while adjusting for the matching variables.

RESULTS

The study included 316 cases who received first HPV vaccine between 2006 and 2014. Age range of cases was 11 to 52 years, with a peak at 12 years, corresponding to the recommended age at vaccination, and another peak at 19 to 28 years, corresponding to a catch-up programme targeting young women. Compared with 163,910 controls, cases had increased care-seeking in the two years before receiving the first HPV vaccine. A multivariable model showed higher use of telephone/email consultations (OR 1.9; 95% CI 1.2-3.2), physiotherapy (OR 2.1; 95% CI 1.6-2.8) and psychologist/psychiatrist (OR 1.9; 95% CI 1.3-2.7). Cases were more likely to have a diagnosis in the ICD-10 chapters of diseases of the digestive system (OR 1.6; 95% CI 1.0-2.4), of the musculoskeletal system (OR 1.6; 95% CI 1.1-2.2), symptoms or signs not classified elsewhere (OR 1.8; 95% CI 1.3-2.5) as well as injuries (OR 1.5; 95% CI 1.2-1.9).

CONCLUSION

Before receiving the first HPV vaccination, females who suspected adverse reactions has symptoms and a health care-seeking pattern that is different from the matched population. Pre-vaccination morbidity should be taken into account in the evaluation of vaccine safety signals.

Decoding the Regulatory Landscape of Ageing in Musculoskeletal Engineered Tissues Using Genome-Wide DNA Methylation and RNASeq

Mesenchymal stem cells (MSC) are capable of multipotent differentiation into connective tissues and as such are an attractive source for autologous cell-based regenerative medicine and tissue engineering. Epigenetic mechanisms, like DNA methylation, contribute to the changes in gene expression in ageing. However there was a lack of sufficient knowledge of the role that differential methylation plays during chondrogenic, osteogenic and tenogenic differentiation from ageing MSCs. This study undertook genome level determination of the effects of DNA methylation on expression in engineered tissues from chronologically aged MSCs. We compiled unique DNA methylation signatures from chondrogenic, osteogenic, and tenogenic engineered tissues derived from young; n = 4 (21.8 years ± 2.4 SD) and old; n = 4 (65.5 years±8.3SD) human MSCs donors using the Illumina HumanMethylation 450 Beadchip arrays and compared these to gene expression by RNA sequencing. Unique and common signatures of global DNA methylation were identified. There were 201, 67 and 32 chondrogenic, osteogenic and tenogenic age-related DE protein-coding genes respectively. Findings inferred the nature of the transcript networks was predominantly for 'cell death and survival', 'cell morphology', and 'cell growth and proliferation'. Further studies are required to validate if this gene expression effect translates to cell events. Alternative splicing (AS) was dysregulated in ageing with 119, 21 and 9 differential splicing events identified in chondrogenic, osteogenic and tenogenic respectively, and enrichment in genes associated principally with metabolic processes. Gene ontology analysis of differentially methylated loci indicated age-related enrichment for all engineered tissue types in 'skeletal system morphogenesis', 'regulation of cell proliferation' and 'regulation of transcription' suggesting that dynamic epigenetic modifications may occur in genes associated with shared and distinct pathways dependent upon engineered tissue type. An altered phenotype in engineered tissues was observed with ageing at numerous levels. These changes represent novel insights into the ageing process, with implications for stem cell therapies in older patients. In addition we have identified a number of tissue-dependant pathways, which warrant further studies.

The Clinical and Economic Impacts of Skeletal-Related Events Among Medicare Enrollees With Prostate Cancer Metastatic to Bone

BACKGROUND

Approximately 40% of men diagnosed with metastatic prostate cancer experience one or more skeletal-related events (SREs), defined as a pathological fracture, spinal cord compression, or surgery or radiotherapy to the bone. Accurate assessment of their effect on survival, health care resource utilization (HCRU), and cost may elucidate the value of interventions to prevent SREs.

MATERIALS AND METHODS

Men older than age 65 years with prostate cancer and bone metastasis diagnosed between 2004 and 2009 were identified from linked Surveillance Epidemiology and End Results-Medicare records. Hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk for death associated with SREs were calculated by using Cox regression. HCRU and costs (in 2013 U.S. dollars) were evaluated in a propensity score-matched cohort by using Poisson regression and Kaplan-Meier sample average estimators, respectively.

RESULTS

Among 3,297 men with prostate cancer metastatic to bone, 40% experienced ≥1 SRE (median follow-up, 19 months). Compared with men who remained SRE-free, men with ≥1 SRE had a twofold higher risk for death (HR, 2.29; 95% CI, 2.09-2.51). Pathological fracture was associated with the highest risk for death (HR, 2.77; 95% CI, 2.38-3.23). Among men with ≥1 SRE, emergency department visits were twice as frequent (95% CI, 1.77-2.28) and hospitalizations were nearly four times as frequent (95% CI, 3.20-4.40). The attributable cost of ≥1 SRE was $21,191 (≥1 SRE: $72,454 [95% CI, $67,362-$76,958]; SRE-free: $51,263 [95% CI, $45,439-$56,100]).

CONCLUSION

Among men with prostate cancer metastatic to bone, experiencing ≥1 SRE is associated with poorer survival, increased HCRU, and increased costs. These negative effects emphasize the importance of SRE prevention in this population.

Sustained impact of a short small group course with systematic feedback in addition to regular clinical clerkship activities on musculoskeletal examination skills--a controlled study

BACKGROUND

The discrepancy between the extensive impact of musculoskeletal complaints and the common deficiencies in musculoskeletal examination skills lead to increased emphasis on structured teaching and assessment. However, studies of single interventions are scarce and little is known about the time-dependent effect of assisted learning in addition to a standard curriculum. We therefore evaluated the immediate and long-term impact of a small group course on musculoskeletal examination skills.

METHODS

All 48 Year 4 medical students of a 6 year curriculum, attending their 8 week clerkship of internal medicine at one University department in Berne, participated in this controlled study. Twenty-seven students were assigned to the intervention of a 6×1 h practical course (4-7 students, interactive hands-on examination of real patients; systematic, detailed feedback to each student by teacher, peers and patients). Twenty-one students took part in the regular clerkship activities only and served as controls. In all students clinical skills (CS, 9 items) were assessed in an Objective Structured Clinical Examination (OSCE) station, including specific musculoskeletal examination skills (MSES, 7 items) and interpersonal skills (IPS, 2 items). Two raters assessed the skills on a 4-point Likert scale at the beginning (T0), the end (T1) and 4-12 months after (T2) the clerkship. Statistical analyses included Friedman test, Wilcoxon rank sum test and Mann-Whitney U test.

RESULTS

At T0 there were no significant differences between the intervention and control group. At T1 and T2 the control group showed no significant changes of CS, MSES and IPS compared to T0. In contrast, the intervention group significantly improved CS, MSES and IPS at T1 (p < 0.001). This enhancement was sustained for CS and MSES (p < 0.05), but not for IPS at T2.

CONCLUSIONS

Year 4 medical students were incapable of improving their musculoskeletal examination skills during regular clinical clerkship activities. However, an additional small group, interactive clinical skills course with feedback from various sources, improved these essential examination skills immediately after the teaching and several months later. We conclude that supplementary specific teaching activities are needed. Even a single, short-lasting targeted module can have a long lasting effect and is worth the additional effort.

Autopsy versus clinical findings in patients with systemic sclerosis in a case series from patients of the EUSTAR database

OBJECTIVES

Subclinical organ pathology occurs regularly in systemic sclerosis (SSc) and affects correct prognosis as well as treatment choices. We aimed to evaluate autopsy data for organ involvement with subsequent correlation to clinical data in order to assess discrepancies in pathological and clinical findings in SSc.

METHODS

A standardised autopsy questionnaire from diseased patients registered in the European Scleroderma Trials and Research group (EUSTAR) cohort was analysed on cause of death and various manifestations in different organ systems. Clinical data obtained from the EUSTAR database of the corresponding patients including cause of death and disease manifestations of lung, heart, kidney, gastrointestinal, skin or musculoskeletal organ involvement were retrospectively analysed and compared to autopsy data.

RESULTS

11 patients (6 women, 5 male) aged between 23 and 84 were included. Cause of death defined by pathologist and clinician were identical in 9/11 cases. In 8 individuals, cause of death was related to heart and lung pathologies. Heart and lung involvement (both 10/11) were the most frequently detected organ involvement at autopsy. Here, myocardial fibrosis occurred in 66% and lung fibrosis in 50% of the patients. Clinically, diastolic function abnormalities (6/11), conduction block (4/11), reduced DCLO (6/11) and dyspnea (8/11) were the most prevalent cardiopulmonary findings. For heart and renal involvement we found higher prevalence in autopsy than by clinical diagnosis. Especially myocardial fibrosis and renal arteriosclerosis were only obtained by autopsy in several individuals.

CONCLUSIONS

Clinical diagnostic procedures are limited in detection of end-organ damage, especially for cardiac involvement. All the more post mortem examinations are needed for quality verification of clinical diagnosis and might help as to better understand the disease processes as well as to improve patient care.

Impact of musculoskeletal ultrasound on clinical practice in paediatric rheumatology

OBJECTIVES

Musculoskeletal ultrasound (MSUS) is an imaging technique increasingly used in paediatric rheumatology. The aim of our study was to evaluate the extent to which MSUS may influence the diagnosis and management decisions in daily clinical practice in paediatric rheumatology.

METHODS

All child patients attending our PR unit over a 3-month period were included. A consultant rheumatologist assessed juvenile patients and weighted the need for MSUS assessment under a Likert scale from 0 (not necessary) to 5 (very necessary) with scanning performed when the Likert score was greater than 0. The rheumatologist completed a questionnaire used to report previous and current diagnosis, therapeutic decisions and disease activity. An assistant rheumatologist who was blinded to the questionnaire carried out the MSUS scanning of selected joints. After MSUS examination, a second questionnaire was completed by the consultant rheumatologist reporting changes in diagnosis and systemic and local treatment, if applicable.

RESULTS

We included 111 patients [73 (65.8%) female]. Fifteen (13.5%) were new patients and 96 (86.5%) follow-up patients. Fifty-one (45.9%) patients were diagnosed with JIA. 65 (58.6%) patients qualified for MSUS. A total of 108 joints from 65 patients were clinically assessed with 93 (86.1%) joints deemed to require complementary MSUS assessment (mean assessed joints 1.4 per patient). Of the 65 patients undergoing MSUS, 38 (58.5%) patients there was a change in diagnosis, therapeutic decisions or both following the MSUS information.

CONCLUSIONS

MSUS may play a significant role in local diagnosis and therapeutic decisions among follow-up JIA patients and could help in the management of rheumatic diseases in children. Further longitudinal studies are needed to confirm the impact of MSUS in paediatric rheumatology.

Musculoskeletal Pathology

The current understanding of pathology as it relates to common diseases of the equine musculoskeletal system is reviewed. Conditions are organized under the fundamental categories of developmental, exercise-induced, infectious, and miscellaneous pathology. The overview of developmental pathology incorporates the new classification system of juvenile osteochondral conditions. Discussion of exercise-induced pathology emphasizes increased understanding of the contribution of cumulative microdamage caused by repetitive cyclic loading. Miscellaneous musculoskeletal pathology focuses on laminitis, which current knowledge indicates should be regarded as a clinical syndrome with a variety of possible distinct mechanisms of structural failure that are outlined in this overview.

Proceedings from the 7th Annual International Society for Musculoskeletal Imaging in Rheumatology (ISEMIR) conference

The International Society for Musculoskeletal Imaging in Rheumatology (ISEMIR) was founded in 2005 with the goal of discussing matters related to imaging in rheumatology, particularly, validation, education, and use in clinical practice and research. Because the field of musculoskeletal (MSK) imaging is rapidly evolving, continuous education in the field is imperative. ISEMIR's international faculty and world-renowned experts presented the newest information as it relates to the use of magnetic resonance imaging (MRI) and ultrasound (US) at the 7th annual ISEMIR meeting which took place on April 12-14, 2014 in Santa Monica, California. Presentations from the meeting can be viewed at www.isemir.org.

[Musculoskeletal system as a target organ of a frailty processes]

Pathology of the musculoskeletal system is widespread in the population and is one of the most common diseases of patients in older age groups. The most significant of them are osteoporosis, osteoarthritis and sarcopenia. All three components separately, of course, lead to lower quality of life. In our work we show the mechanisms of interference of these states at each other, and their combined impact on the musculoskeletal system as a target organ processes senile asthenia. Osteoarthritis, osteoporosis, and sarcopenia, and especially their combination lead to hypomobility. Hypomobility under the influence of external factors is one of the leading syndromes potentiating aggravation processes senile asthenia. Thus, the mechanism of re-entry is triggered, and a vicious circle leading to fatal medical-social and social consequences. It is shown that changes in the musculoskeletal system should be considered as a single aging within senile asthenia, and all used and newly created medical and social rehabilitation and prevention programs should be integrated in nature.

Mechanics of the foot Part 2: A coupled solid-fluid model to investigate blood transport in the pathologic foot

A coupled computational model of the foot consisting of a three-dimensional soft tissue continuum and a one-dimensional (1D) transient blood flow network is presented in this article. The primary aim of the model is to investigate the blood flow in major arteries of the pathologic foot where the soft tissue stiffening occurs. It has been reported in the literature that there could be up to about five-fold increase in the mechanical stiffness of the plantar soft tissues in pathologic (e.g. diabetic) feet compared with healthy ones. The increased stiffness results in higher tissue hydrostatic pressure within the plantar area of the foot when loaded. The hydrostatic pressure acts on the external surface of blood vessels and tend to reduce the flow cross-section area and hence the blood supply. The soft tissue continuum model of the foot was modelled as a tricubic Hermite finite element mesh representing all the muscles, skin and fat of the foot and treated as incompressible with transversely isotropic properties. The details of the mechanical model of soft tissue are presented in the companion paper, Part 1. The deformed state of the soft tissue continuum because of the applied ground reaction force at three foot positions (heel-strike, midstance and toe-off) was obtained by solving the Cauchy equations based on the theory of finite elasticity using the Galerkin finite element method. The geometry of the main arterial network in the foot was represented using a 1D Hermite cubic finite element mesh. The flow model consists of 1D Navier-Stokes equations and a nonlinear constitutive equation to describe vessel radius-transmural pressure relation. The latter was defined as the difference between the fluid and soft tissue hydrostatic pressure. Transient flow governing equations were numerically solved using the two-step Lax-Wendroff finite difference method. The geometry of both the soft tissue continuum and arterial network is anatomically-based and was developed using the data derived from visible human images and magnetic resonance images of a healthy male volunteer. Simulation results reveal that a two-fold increase in tissue stiffness leads to about 28% reduction in blood flow to the affected region.

Mechanics of the foot Part 1: a continuum framework for evaluating soft tissue stiffening in the pathologic foot

Soft tissue stiffening is a common mechanical observation reported in foot pathologies including diabetes mellitus and gout. These material changes influence the spatial distribution of stress and affect blood flow, which is essential to nutrient entry and waste removal. An anatomically-based subject-specific foot model was developed to explore the influence of tissue stiffening on plantar pressure and internal von Mises stress at heel-strike, midstance and toe-off. This work draws on the model database developed for the Physiome project consisting of muscles, bones, soft tissue and other structures such as sensory nerves. The anisotropic structure of soft tissue was embedded in a single continuum as an efficient model for finite soft tissue deformation, and customisation methods were used to capture the unique foot profile. The model was informed by kinetics from an instrumented treadmill and kinematics from motion capture, synchronised together. Foot sole pressure predictions were evaluated against a commercial pressure platform. Key outcomes showed that internal stress can be up to 1.6 times the surface pressure with implications for internal soft tissue damage not observed at the surface. The main nerve branch stimulated during gait was the lateral plantar nerve. This subject-specific modelling framework can play an integral part in therapeutic treatments by informing assistive strategies such as mechanical noise stimulation and orthotics.

Magnetic resonance imaging findings in patients with systemic scleroderma and musculoskeletal symptoms

OBJECTIVE

To explore the role of whole-body magnetic resonance imaging (MRI) in detecting musculoskeletal involvement in patients with systemic scleroderma and musculoskeletal symptoms.

METHODS

Eighteen consecutive patients (8 men, 10 women) with systemic scleroderma (median age 46 years) presenting with musculoskeletal complaints underwent whole-body MRI at 1.5 T. Images were evaluated for abnormal signal intensity and/or thickening of subcutaneous fatty tissue septa, muscular fasciae, intramuscular perifascial septa, muscle signal intensity and articular or tendon sheath synovial abnormalities on STIR and post-gadolinium scans. Additionally, C-reactive protein, creatinine kinase and the modified Rodnan skin score were determined.

RESULTS

MRI indicated evidence of fasciitis, articular synovial inflammation, and subcutaneous thickening in 16 (89 %) patients. MRI findings were compatible with myopathy or myositis in 14 (78 %) patients, tenosynovitis in 11 (61 %) patients and enthesitis in 10 (56 %) patients. Typically, these manifestations were distributed symmetrically and mostly generalised. We only found few correlations with modified Rodnan skin score, C-reactive protein and creatinine kinase.

CONCLUSION

In patients with systemic scleroderma experiencing musculoskeletal symptoms, whole-body MRI is able to detect involvement of muscles, fasciae, joints and entheses more confidently compared with clinical and laboratory parameters.

Safety of weightlifting among women with or at risk for breast cancer-related lymphedema: musculoskeletal injuries and health care use in a weightlifting rehabilitation trial

INTRODUCTION

It has been noted that only 14% of all clinical trials are translated into practice. The objective of this paper is to promote translation of an efficacious rehabilitative exercise program for breast cancer survivors by clarifying for clinicians the safety profile of participants (e.g., rates of musculoskeletal injury and referral to medical professionals), and to use this evidence to make recommendations on the appropriate training of health and fitness staff who would be capable of safely, effectively, and sustainably delivering the program.

METHODS

Breast cancer survivors with and at risk for lymphedema were randomized to twice-weekly weightlifting or standard care for 1 year. An injury survey and health care evaluation were administered after 1 year and in 3-month intervals, respectively.

RESULTS

The cumulative incidence and rate of injury were higher in the weightlifting than in the control group. The injury rates were 2.3 and 0.3 per 1,000 bouts of weightlifting among breast cancer survivors with and at risk for lymphedema, respectively. Among breast cancer survivors with or at risk for lymphedema, 20.9% in the weightlifting group had an encounter with a health care provider that required cessation or dose modification of weightlifting.

CONCLUSION

Despite the demonstrated efficacy of weightlifting, musculoskeletal injuries and other health problems did occur. Therefore, for the successful translation of this rehabilitative intervention into clinical practice, health and fitness professionals working with breast cancer survivors need the knowledge, skills, and abilities that clarify their scope of practice to address these health care needs.

In vivo 1H MRS for musculoskeletal lesion characterization: which factors affect diagnostic accuracy?

In vivo (1)H MRS is a noninvasive imaging technique for the identification of malignancy. Musculoskeletal lesions vary in their composition, causing field inhomogeneity and magnetic susceptibility effects which may be technical and diagnostic challenges for MRS. This study investigated the factors that affect diagnostic accuracy in the use of MRS for the characterization of musculoskeletal neoplasms. During a 7-year period, 210 consecutive patients with musculoskeletal lesions larger than 1.5 cm in diameter were examined. MRS of a single-voxel point-resolved spectroscopy sequence with TE = 135 ms was undertaken using a 1.5-T scanner. Lesions with a choline signal-to-noise ratio larger than 3.0 were considered to be malignant tumors. The diagnostic accuracy was calculated for all lesions and for subgroups on the basis of lesion type (bone and soft tissue), lesion composition (mixed and solid nonsclerotic), lesion size (≤4, >4-10 and >10 cm), MR scanner (MR scanner 1 and 2) and selected voxel size (≤3, >3-8 and >8 cm(3)). Multivariate logistic regressions were performed to estimate the associations between each factor and diagnostic accuracy. The diagnostic accuracy was 73.3% for all lesions. The accuracy was 54.4% for mixed lesions and 80.4% for solid nonsclerotic lesions (p < 0.001). The diagnostic accuracy was lower for larger lesions [86.8% for lesions of ≤4 cm, 71.6% for lesions of >4-10 cm (p = 0.04) and 63.6% for lesions of >10 cm (p = 0.007)]. There was no difference in diagnostic accuracy for bone versus soft-tissue lesions or as a function of MR scanner or voxel size. By the use of multivariate logistic regression, a solid nonsclerotic lesion was 3.15 times (95% confidence interval, 1.59-6.27) more likely than a mixed lesion to have a diagnosis (p = 0.001). MRS can be used to characterize musculoskeletal lesions, particularly solid nonsclerotic lesions.

[Features of bone and muscular diseases in accordance with physical exertion level in workers]

The authors studied changes in development and structure of bone and muscular disorders in industrial workers of Perm area. The workers' examination considered features of physical overload during the working process. The authors revealed developmental peculiarities of bone and muscular system in various occupational groups of metallurgists, oil extractors, machinery building workers. The article shows necessity of interdisciplinary approach and observation of the workers to prevent progression of bone and muscular disorders.