Comparison of Moseley and Rotterdam straight-line graphs in predicting leg lengths and leg-length discrepancy at maturity.

PURPOSE: One method of predicting leg-length discrepancy at maturity is the Moseley straight-line graph. Beumer et al developed an alternative graph, using a more modern Dutch population. The purpose of this study was to compare the prediction accuracy of these two graphs in a cohort of patients treated at our institution using epiphysiodesis. METHODS: We identified 76 patients treated using epiphysiodesis for leg-length discrepancy who were followed to maturity and had adequate preoperative radiographic assessment for straight-line graph construction. We compared predicted long leg length (after epiphysiodesis), short leg length, and residual leg-length discrepancy to actual outcome for both methods, using both chronological and skeletal ages. RESULTS: Both methods were more accurate using skeletal age rather than chronological age. The Rotterdam graph showed modest improved accuracy compared to the Moseley graph in developmental aetiologies and in Hispanic patients. Using a difference of one centimetre in prediction error as clinically relevant (long leg [after epiphysiodesis], short leg, and leg-length discrepancy in each of the 76 patients, 228 predictions), we found comparable predictions in 171, more accurate prediction using the Rotterdam in 32, and using the Moseley in 25 predictions. CONCLUSIONS: Straight-line graphs provide a generally more accurate prediction of leg lengths at maturity by virtue of multiple preoperative evaluations. The Rotterdam straight-line graph was equal to or superior to the Moseley graph in most patients in this cohort. Use of skeletal age resulted in more accurate predictions than chronological age. Clinicians should remain familiar with the concept and use of the straight-line graph. LEVEL OF EVIDENCE: III, case-control study.

An electronic patient-reported outcomes measurement system in paediatric orthopaedics.

PURPOSE: The purpose of the study was to evaluate the reliability, review differences and assess patient satisfaction of electronic patient-reported outcome measures (PROMs) compared with paper PROMs. METHODS: Participants between 12 and 19 years of age with a knee-related primary complaint were randomized into two groups. Group 1 completed paper PROMs followed by electronic, while Group 2 received the electronic followed by paper. PROMs included the Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery (HSS) Pediatric Functional Activity Brief Scale (HSS Pedi-FABS), Tegner Activity Level Scale, Visual Analogue Scale (VAS), PedsQL Teen and a satisfaction survey. RESULTS: In all, 87 participants were enrolled with one excluded due to incomplete PROMs. Of the 86 participants, 54 were female and 32 were male with an average age of 14.3 years (12 to 18). A high degree of reliability was found when comparing the paper and electronic versions of the Pedi-IKDC (0.946; p < 0.001), HSS Pedi-FABS (0.923; p < 0.001), PedsQL Teen (0.894; p < 0.001), Tegner Activity Level Scale before injury (0.848; p < 0.001) and the Tegner Activity Level Scale after (0.930; p < 0.001). Differences were noted between the VAS scores, with paper scores being significantly higher than electronic (5.3 versus 4.6; p < 0.001). While not significant, a trend was noted in which electronic PROMs took, overall, less time than paper (10.0 mins versus 11.2 mins; p = 0.096).Of all participants, 69.8% preferred the electronic PROMs, 67.4% felt they were faster, 93.0% stated they would complete forms at home prior to appointments and 91.8% were not concerned about the safety/privacy of electronic forms. CONCLUSION: PROMs captured electronically were reliable when compared with paper. Electronic PROMs may be quicker, will not require manual scoring and are preferred by patients. LEVEL OF EVIDENCE: II.

Percutaneous heel cord release for clubfoot: a retrospective, multicentre cost analysis.

PURPOSE: The Ponseti method of treatment is the standard of care for idiopathic clubfoot. Following serial casting, percutaneous tendo-Achilles tenotomy (TAT) is performed to correct residual equinus. This procedure can be performed in either the outpatient clinic or the operating room. The purpose of this study was to evaluate the expense of this procedure by examining hospital charges in both settings. METHODS: We retrospectively reviewed charts of 382 idiopathic clubfoot patients with a mean age of 2.4 months (0.6 to 26.6) treated with the Ponseti method at three institutions. Patients were divided into three groups depending on the setting for the TAT procedure: 140 patients in the outpatient clinic (CL), 219 in the operating room with discharge following the procedure (OR) and 23 in the operating room with admission to hospital for observation (OR+). Medical records were reviewed to analyze age, deformity, perioperative complications and specific time spent in each setting. Hospital charges for all three groups were standardized to one institution's charge structure. RESULTS: Charges among the three groups undergoing TAT (CL, OR, OR+) were found to be significantly different ($3840.60 versus $7962.30 versus $9110.00, respectively; p ≤ 0.001), and remained significant when separating unilateral and bilateral deformities (p < 0.001). There were nine total perioperative complications (six returns to the ER and three unexpected admissions to the hospital): five (2.3%) in the OR group, four (17.4%) in the OR+ group and none in the CL group. The OR+ group statistically had a higher rate of complications compared with the other two groups (p = 0.006). The total event time of the CL group was significantly shorter compared with the OR and OR+ groups (129.1, 171.7 and 1571.6 minutes respectively; p < 0.001). CONCLUSION: Hospital charges and total event time were significantly less when percutaneous TAT was performed in the outpatient clinic compared with the operating room. In addition, performing the procedure in clinic was associated with the lowest rate of complications. LEVEL OF EVIDENCE: Therapeutic, Level III.

Menin mediates epigenetic regulation via histone H3 lysine 9 methylation.

Menin, encoded by the multiple endocrine neoplasia type 1 (MEN1) gene, is a tumor suppressor that leads to multiple endocrine tumors upon loss of its function. Menin functions as a transcriptional activator by tethering MLL complex to mediate histone H3 K4 methylation. It also functions as a repressor. However, the molecular mechanism of how menin contributes to the opposite outcome in gene expression is largely unknown. Here, we investigated the role of menin in the epigenetic regulation of transcription mediated by histone covalent modification. We show that the global methylation level of histone H3 K9, as well as H3 K4, was decreased in Men1(-/-) MEF cells. Consistently, menin was able to interact with the suppressor of variegation 3-9 homolog family protein, SUV39H1, to mediate H3 K9 methylation. This interaction decreased when patient-derived MEN1 mutation was introduced into the SUV39H1-interaction domain. We show that menin mediated different chromatin changes depending on target genes. Chromatin immunoprecipitation studies showed that menin directly associated with the GBX2 promoter and menin-dependent recruitment of SUV39H1 was essential for chromatin remodeling and transcriptional regulation. These results provide a molecular basis of how menin functions as a transcriptional repressor and suggest that menin-dependent integration of H3 K9 methylation might play an important role in preventing tumors.

Determinants of undercarboxylated and carboxylated osteocalcin concentrations in type 1 diabetes.

UNLABELLED: To determine whether undercarboxylated osteocalcin (UC-OC) or gamma-carboxyglutamic-carboxylated-type osteocalcin (GLA-OC) concentrations deviate from normal in type 1 diabetes (T1D), serum levels were compared between 115 subjects with T1D and 55 age-matched healthy controls. UC-OC and GLA-OC concentrations were similar between groups; however, in T1D, UC-OC correlated positively with markers of insulin exposure, either endogenously produced or exogenously administered. INTRODUCTION: A study was conducted to determine whether dysregulation of circulating concentrations of UC-OC or GLA-OC occurs in patients with type 1 diabetes, a condition of insulin deficiency without insulin resistance. METHODS: We measured serum concentrations of UC-OC and GLA-OC in 115 subjects with T1D, ages 14-40 years, and in 55 age-matched healthy control subjects. Relationships between UC-OC and GLA-OC concentrations and patient characteristics (gender and age), indices of glycemic control (hemoglobin A1c (HbA1c), fasting plasma glucose, C-peptide concentration, 3-day average glucose measured by a continuous glucose sensor, total daily insulin dose) and circulating indices of skeletal homeostasis (total calcium, 25-OH vitamin D, parathyroid hormone, insulin-like growth factor 1 (IGF-1), type 1 collagen degradation fragments (CTX), adiponectin, leptin) were examined. Between group differences in the concentrations of UC-OC and GLA-OC were the main outcome measures. RESULTS: Although adiponectin levels were higher in the T1D group, between-group comparisons did not reveal statistically significant differences in concentration of UC-OC, GLA-OC, CTX or leptin between the T1D and control populations. Instead, by multivariate regression modeling, UC-OC was correlated with younger age (p < 0.001), higher CTX (p < 0.001), lower HbA1c (p = 0.013), and higher IGF-1 (p = 0.086). Moreover, within the T1D subgroup, UC-OC was positively correlated with C-peptide/glucose ratio (reflecting endogenous insulin secretion), with IGF-1 (reflecting intra-portal insulin sufficiency), and with total daily insulin dose. CONCLUSIONS: In T1D, UC-OC appears to correlate positively with markers of insulin exposure, either endogenously produced or exogenously administered.

Soy protein isolate reduces hepatosteatosis in yellow Avy/a mice without altering coat color phenotype.

Agouti (A(vy)/a) mice fed an AIN-93G diet containing the soy isoflavone genistein (GEN) prior to and during pregnancy were reported to shift coat color and body composition phenotypes from obese-yellow towards lean pseudoagouti, suggesting epigenetic programming. Human consumption of purified GEN is rare and soy protein is the primary source of GEN. Virgin a/a female and A(vy)/a male mice were fed AIN-93G diets made with casein (CAS) or soy protein isolate (SPI) (the same approximate GEN levels as in the above mentioned study) for 2 wks prior to mating. A(vy)/a offspring were weaned to the same diets and studied at age 75 d. Coat color distribution did not differ among diets, but SPI-fed, obese A(vy)/a offspring had lower hepatosteatosis (P < 0.05) and increased (P < 0.05) expression of CYP4a 14, a PPARalpha-regulated gene compared to CAS controls. Similarly, weanling male Sprague-Dawley (SD) rats fed SPI had elevated hepatic Acyl Co-A Oxidase (ACO) mRNA levels and increased in vitro binding of PPARalpha to the PPRE promoter response element. In another hepatosteatosis model, adult SD rats fed a high fat/cholesterol diet, SPI reduced (P < 0.05) steatosis. Thus, 1) consumption of diets made with SPI partially protected against hepatosteatosis in yellow mice and in SD rats, and this may involve induction of PPARalpha-regulated genes; and 2) the lifetime (in utero, neonatal and adult) exposure to dietary soy protein did not result in a shift in coat color phenotype of A(vy)/a mice. These findings, when compared with those of previously published studies of A(vy)/a mice, lead us to conclude that: 1) the effects of purified GEN differ from those of SPI when GEN equivalents are closely matched; 2) SPI does not epigenetically regulate the agouti locus to shift the coat color phenotype in the same fashion as GEN alone; and 3) SPI may be beneficial in management of non-alcoholic fatty liver disease.

Surface characterization and chondrogenic differentiation of mesenchymal stromal cells derived from synovium.

BACKGROUND: Synovium is the only tissue that can produce hyaline cartilage in benign conditions, such as synovial chondromatosis and osteoarthritis, suggesting potential advantages in chondrogenesis using mesenchymal stromal cells. We performed surface characterization of cells isolated from the synovium of patients with osteoarthritis after different passages and induced chondrogenic differentiation. METHODS: Using cells obtained from synovium, colony-forming unit fibroblast assay and characterization of cell-surface markers by flow cytometry using 22 different Ab at different passages were performed. Cells were cultured under chondrogenic conditions and evaluated grossly, histologically, immunohistochemically and by [(35)S]sulfate incorporation and reverse transcription-PCR. RESULTS: The positive cell-surface markers of immediately isolated cells were CD10, CD13, CD14, CD34, CD44, CD45, CD49a, CD62e, CD73 and HLA-DR. After the first passage (P), CD14, CD34, CD45, CD62e and HLA-DR disappeared, whereas CD105 and CD166 appeared and CD10, CD13, CD44, CD49a and CD73 showed increased expression levels. The surface marker expression level did not vary much after P1 through to P8. The chondrogenic differentiation potential of cells from the synovium was confirmed using various evaluation methods. DISCUSSION: We have demonstrated that cells from synovium contain a mesenchymal stromal cell population capable of chondrogenic differentiation, which seems to increase with passage under our culture conditions. The cell-surface markers were found to change remarkably after the first passage and then remained stable. The results of this study may be helpful for sorting mesenchymal stromal cells from heterogeneous synovial cells for future studies.

Human CD16 as a lysis receptor mediating direct natural killer cell cytotoxicity.

In addition to their role in peptide antigen presentation, class I MHC proteins also play a critical role in inhibiting natural killer (NK) cytotoxicity through interaction with NK inhibitory receptors. Thus, NK cells are cytotoxic to virus-infected and tumor cells that have lost class I MHC protein expression. However, the nature of the receptors involved in the triggering of lysis of target cells is poorly understood. CD16 (Fcgamma receptor III) has been described as a receptor expressed on NK cells that facilitates antibody-dependent cellular cytotoxicity (ADCC) by binding to the Fc portion of various antibodies. However, we show here that CD16 has a broader function and is directly involved in the lysis of some virus-infected cells and tumor cells, independent of antibody binding. The presence of a putative CD16 ligand on appropriate target cells has also been demonstrated by the use of a CD16-Ig fusion protein.