Cryopreservation of Human Adipose-Derived Stem Cells for Use in Ex Vivo Regional Gene Therapy for Bone Repair.

The development of an ex vivo regional gene therapy clinical pathway using adipose-derived stem cells (ASCs) may require cryopreservation for cell culture, storage, and transport prior to clinical use. ASCs isolated from five donors were transduced with a lentiviral vector containing BMP-2. Three groups were assessed: transduction without cell freezing (group 1), freezing of cells for 3 weeks followed by transduction (group 2), and cell transduction prior to freezing (group 3). Nontransduced cells were used as a control. The cluster of differentiation (CD) marker profiles, cell number, BMP-2 production, and osteogenic potential were measured. The CD marker profile (CD44, CD73, CD90, and CD105) was unchanged after cryopreservation. Cell number was equivalent among cryopreservation protocols in transduced and nontransduced cells. There was a trend toward decreased BMP-2 production in group 3 compared to groups 1 and 2. Osteogenic potential based on Alizarin red concentration was higher in group 2 compared to group 3, with no difference compared to group 1. Freezing ASCs prior to transduction with a lentiviral vector containing BMP-2 has no detrimental effect on cell number, BMP-2 production, osteogenic potential, or immunophenotype. Transduction prior to freezing, however, may limit the BMP-2 production and potential osteogenic differentiation of the ASCs.

A Strategic Plan for Increasing Scholarly Activity Among Medical Students, Residents, and Faculty.

BACKGROUND: Scholarly activity among students, residents, and faculty provides the foundation for medical education. However, a decline in the number of physician-scientists has been acknowledged during the past few decades. As a result, institutions have attempted to increase research activity among students and residents through a variety of means. This study describes a replicative model for medical institutions to increase their research enterprises among medical students, residents, and faculty. METHODS: Des Moines University College of Podiatric Medicine and Surgery (DMU-CPMS) developed a Strategic Research Plan (SRP) to increase scholarly activity in the college. The SRP outlined an innovative model to increase research activity, including creating a Director of Research position, modifying the existing curriculum toward an evidence-based focus, increasing extracurricular research opportunities, and fostering collaborative research efforts among students, residents, and faculty. RESULTS: After SRP implementation, an increase in scholarly activity was observed. In the 6 years before implementing the SRP, DMU-CPMS published 11 manuscripts. In the 6 years after initiating the SRP, manuscript publications increased to 50. During this same period, podium presentations at scientific meetings increased from 6 to 40, and students listed as lead author increased from 0 to 16. CONCLUSIONS: The SRP provides a replicative model for medical institutions seeking to increase their research enterprises through collaboration among students, residents, and faculty. To our knowledge, this is the first study to demonstrate a research plan aimed at increasing scholarly activity among a comprehensive scope of individuals in medical education.

In vitro evaluation of a lentiviral two-step transcriptional amplification system using GAL4FF transactivator for gene therapy applications in bone repair.

In this study, we developed a lentiviral two-step transcriptional amplification (TSTA) system expressing bone morphogenetic protein-2 (BMP-2) under the control of a GAL4FF transactivator to enhance gene expression and limit toxicity for bone repair applications. To this end human MSCs, isolated from bone marrow or adipose tissue, were transduced overnight with a LV-TSTA system (GAL4FF or GAL4vp16) expressing BMP-2 or GFP and evaluated in vitro for transduction efficiency, mean fluorescence intensity, cell viability, and BMP-2 production. FACS analysis of GFP-transduced MSCs confirmed successful transduction with the GAL4FF+GFP vector. Moreover, ELISA demonstrated abundant BMP-2 production by GAL4FF+BMP2-transduced human MSCs over a period of 8 weeks, with minimal cytotoxicity at all time points. Compared to GAL4vp16, GAL4FF was superior with respect to BMP production at 1, 2, 4, 6, and 8 weeks in BMSCs. In ASCs, GAL4FF was still associated with higher BMP-2 production at weeks 2-8, but this difference was not as prominent as in BMSCs. To our knowledge, this is the first report of GAL4FF-mediated BMP-2 production by human BMSCs and ASCs. Compared to the standard GAL4vp16TSTA vector, GAL4FF was associated with lower cytotoxicity and higher in vitro gene expression in both BMSCs and ASCs.

Gene Therapy for Bone Repair Using Human Cells: Superior Osteogenic Potential of Bone Morphogenetic Protein 2-Transduced Mesenchymal Stem Cells Derived from Adipose Tissue Compared to Bone Marrow.

Ex vivo regional gene therapy strategies using animal mesenchymal stem cells genetically modified to overexpress osteoinductive growth factors have been successfully used in a variety of animal models to induce both heterotopic and orthotopic bone formation. However, in order to adapt regional gene therapy for clinical applications, it is essential to assess the osteogenic capacity of transduced human cells and choose the cell type that demonstrates the best clinical potential. Bone-marrow stem cells (BMSC) and adipose-derived stem cells (ASC) were selected in this study for in vitro evaluation, before and after transduction with a lentiviral two-step transcriptional amplification system (TSTA) overexpressing bone morphogenetic protein 2 (BMP-2; LV-TSTA-BMP-2) or green fluorescent protein (GFP; LV-TSTA-GFP). Cell growth, transduction efficiency, BMP-2 production, and osteogenic capacity were assessed. The study demonstrated that BMSC were characterized by a slower cell growth compared to ASC. Fluorescence-activated cell sorting analysis of GFP-transduced cells confirmed successful transduction with the vector and revealed an overall higher but not statistically significant transduction efficiency in ASC versus BMSC (90.2 ± 4.06% vs. 80.4 ± 8.51%, respectively; p = 0.146). Enzyme-linked immunosorbent assay confirmed abundant BMP-2 production by both cell types transduced with LV-TSTA-BMP-2, with BMP-2 production being significantly higher in ASC versus BMSC (239.5 ± 116.55 ng vs. 70.86 ± 24.7 ng; p = 0.001). Quantitative analysis of extracellular deposition of calcium (Alizarin red) and alkaline phosphatase activity showed that BMP-2-transduced cells had a higher osteogenic differentiation capacity compared to non-transduced cells. When comparing the two cell types, ASC/LV-TSTA-BMP-2 demonstrated a significantly higher mineralization potential compared to BMSC/LV-TSTA-BMP-2 7 days post transduction (p = 0.014). In conclusion, this study demonstrates that transduction with LV-TSTA-BMP-2 can significantly enhance the osteogenic potential of both human BMSC and ASC. BMP-2-treated ASC exhibited higher BMP-2 production and greater osteogenic differentiation capacity compared to BMP-2-treated BMSC. These results, along with the fact that liposuction is an easy procedure with lower donor-site morbidity compared to BM aspiration, indicate that adipose tissue might be a preferable source of MSCs to develop a regional gene therapy approach to treat difficult bone-repair scenarios.

Charcot Collapse: Does Collapse Pattern Dictate Osseous Metabolism?

Charcot fracture pattern (FP) and Charcot dislocation pattern (DP) are 2 distinct collapse patterns identified in Charcot neuroarthropathy of the foot and ankle. These patterns are believed to demonstrate relative differences in central bone mineral density (BMD), which has been theoretically extrapolated to describe local BMD. To assess variation in local bone composition of FP and DP patients, 10 patients, 5 DP and 5 FP were recruited. The patient's age, body mass index (BMI), radiographs, central BMD, local BMD, sRANKL (soluble receptor activator nuclear factor kappa-beta ligand), sRAGE (soluble receptors of advanced glycated end-products), and osteocalcin were measured to determined bone metabolic status and density. Central BMD was determined using DEXA (dual-energy X-ray absorptiometry) scans of the hip. peripheral BMD was determined using scans at the level of the ankle mortise and Chopart's joint, depending on the location of collapse. These scans were then compared with controls. Central and peripheral DEXA scans were significantly reduced in the FP ( P = .002 and P < .0001) when compared with healthy controls. Additionally, FP patients demonstrated statistically significant elevations in sRANKL ( P = .05) and sRAGE ( P = .002) when compared with DP. No significant difference was seen in osteocalcin ( P = 0.22); however, elevated values compared with normal reference ranges suggest increase bone production. These elevations combined with an osteoporotic profile may indicate difficulty of FP patients in repairing micro fracture. Results from this study emphasize the increased risk of nonunion during FP reconstruction, and highlight the variation in bone composition in these 2 Charcot subtypes. LEVELS OF EVIDENCE: Level III.

Relationship Between Academic Performance and Student Self-Assessment of Clinical Performance in the College of Podiatric Medicine and Surgery.

BACKGROUND: Student self-assessment is viewed as an important tool in medical education. We sought to identify the relationship between student academic performance and third-year clinical performance self-assessment. No such study exists in podiatric medical education. METHODS: Third-year podiatric medical students from the classes of 2012 through 2014 completed a self-assessment of their performance for each of five broad clinical podiatric medical domains (Professionalism, Medicine, Radiology, Surgery, and Biomechanics/Orthopedics). The assessment was completed after students finished the first 12 weeks of their third-year clinical rotations (PRE) and a second time at the conclusion of the third year (POST). The mean self-assessment score for PRE and POST surveys for all combined domains was determined for each student. This mean was compared with the student's 3-year cumulative grade point average (GPA). Students' clinical experiences for the year were essentially identical. RESULTS: No statistically significant correlation was identified between cumulative GPA and the PRE and POST clinical self-assessments or with the change between PRE and POST assessments based on the Pearson correlation test for each class separately or on the pooled data. CONCLUSIONS: Published studies in allopathic medical education have shown that students with lower GPAs tend to rate their clinical performance higher in initial clinical performance self-assessment. Our results show that student academic performance was not correlated with clinical performance self-assessment. These findings may be due to the explicit description of successful clinical competency completion, the orientation students receive before the start of clinical training, and the continuous feedback received from clinical preceptors.

A retrospective review of the effect of metatarsus adductus on healing time in the fifth metatarsal jones fracture.

PURPOSE: The fifth metatarsal Jones fracture is a unique injury. Previous studies have identified possible biomechanical risk factors related to this fracture, as well as potential subsequent effects on bone healing complications. The purpose of this retrospective study was to determine the effect of metatarsus adductus (MAA) on bone healing in patients following intramedullary screw fixation of the Jones fracture. METHODS: This study reviewed 14 Jones fractures that underwent intramedullary screw fixation. Serial radiographs taken approximately every two weeks were evaluated to determine bone healing time (BHT). Weight-bearing antero-posterior radiographs were used to determine the MAA using standard osseous landmarks. RESULTS: There was a strong positive correlation between MAA and BHT. Moderate correlations were also found between age and BHT and between age and MAA. A prediction algorithm derived from the regression model shows that 63.2% of the variability in the Jones fracture healing time (BHT) can be predicted by a minimum of 22.7 days increased by an average of 1.23 days for each degree of MAA. CONCLUSION: This study suggests healing time in Jones fractures to be highly related to the MAA following intramedullary screw fixation. The ability to predict osseous union of Jones fracture offers advantages such as patient expectations as well as individualized rehabilitation programs.

Undergraduate GPAs, MCAT scores, and academic performance the first 2 years in podiatric medical school at Des Moines University.

BACKGROUND: This study was performed to determine the relationship between undergraduate academic performance and total Medical College Admission Test score and academic performance in the podiatric medical program at Des Moines University. The allopathic and osteopathic medical professions have published educational research examining this relationship. To our knowledge, no such educational research has been published for podiatric medical education. METHODS: The undergraduate cumulative and science grade point averages and total Medical College Admission Test scores of four podiatric medical classes (2007-2010, N = 169) were compared with their academic performance in the first 2 years of podiatric medical school using pairwise Pearson product moment correlations and multiple regression analysis. RESULTS: Significant low to moderate positive correlations were identified between undergraduate cumulative and science grade point averages and student academic performance in years 1 and 2 of podiatric medical school for each of the four classes (except one) and the pooled data. There was no significant correlation between Medical College Admission Test score and academic performance in years 1 and 2 (except one) and the pooled data. CONCLUSIONS: These results identify undergraduate cumulative grade point average as the strongest cognitive admissions variable in predicting academic performance in the podiatric medicine program at Des Moines University, followed by undergraduate science grade point average. These results also suggest limitations of the total Medical College Admission Test score in predicting academic performance. Information from this study can be used in the admissions process and to monitor student progress.

A biomechanical analysis of the effects of low-Dye taping on arch deformation during gait.

BACKGROUND: The low-Dye technique serves to limit hindfoot pronation and medial arch collapse. Few studies exist that investigate the effects on medial arch deformation from a biomechanical perspective. METHODS: Kinematic data was collected using a Motion Analysis System. Foot function of 21 healthy adults was assessed during the stance phase of gait. Subjects were evaluated prior to and immediately following the low-Dye tape application, as well as at 48 h. Foot deformation was assessed during the stance phase of gait using the calcaneus, navicular and 1st metatarsal head markers to calculate the medial longitudinal arch angle (MLA) and the dynamic arch height index (dAHI). Paired t-tests were used to assess low-Dye tape effectiveness. RESULTS: There was a significant 19.3% reduction in MLA immediately after application of the tape. However only 4.01% reduction remained in deformation after 48 h. The MLA deformation findings were consistent with the AHI change, showing a significant change in the arch deformation between Pre and Post0 low-Dye taping. The effects were short-lived. CONCLUSIONS: There are measurable changes to medial arch height and amount of arch height deformation during gait following low-Dye taping. Although changes were present immediately after application, results were diminished 48 h after application.

The association of metatarsus adductus to the proximal fifth metatarsal Jones fracture.

This retrospective study aimed to determine if a transverse plane forefoot relationship exists in patients with Jones fractures. Anteroposterior radiographs of 30 acute Jones fractures were compared with radiographs of 30 asymptomatic control subjects. Radiographic metatarsus adductus angle measurements were analyzed with a digital software program. The reliability of the measurements was evaluated with an intra-rater study. An independent t test was used to compare the metatarsus adductus angle between the Jones fracture group and the control group. Radiographic analysis revealed the mean metatarsus adductus angle for the Jones fracture group to be 20.22° (± 6.79°) compared with a mean of 14.27° (± 4.60°) for the control group. This difference between the groups was found to be statistically significant (p < .005). The intraclass reliability coefficient (ICC = 0.9396) confirmed there was no bias in the radiographic measurements. The metatarsus adductus angle in this group of patients with Jones fractures was increased compared with the nonpathologic control group. The Jones fracture mechanism of injury and resultant lateral column overload may be intensified with an increased metatarsus adductus. This relationship should be considered a risk factor for Jones fractures and taken into consideration with respect to bone healing, treatment, and prevention.

Relationship between student academic and clinical performance in podiatric medical education at Des Moines University.

BACKGROUND: This study was performed to determine whether a relationship exists regarding academic achievement between years 1 and 2 of podiatric medical education at Des Moines University. Furthermore, this study evaluates the relationship between academic performance in the first 2 years and clinical performance in year 3. METHODS: The academic records of four classes (2007-2010, N = 164) were examined for grade point averages and clinical performance scores using pairwise Pearson product moment correlations. RESULTS: Significant high correlations existed in academic performance scores between year 1 and year 2 for individual classes and pooled data. Significant low to moderate correlations were found between academic performance and clinical performance scores for individual classes and pooled data. CONCLUSIONS: These results help define the relationship between student academic and clinical performance for podiatric medicine students at Des Moines University and suggest that nonacademic characteristics may play a pivotal role in clinical abilities. These characteristics need to be further identified and developed in the academic curriculum. There may be attributes identified that also benefit the admissions process.

Peripheral and central bone mineral density in Charcot's neuroarthropathy compared in diabetic and nondiabetic populations.

BACKGROUND: This prospective study was performed to compare calcaneal and lumbar bone mineral density (BMD) in individuals with and without diabetes mellitus. We compared bone density with the time from onset of Charcot's neuroarthropathy (CN) in patients with unilateral, nonoperative, reconstructive-stage CN. The final purpose was to investigate the role that sex, age, and serum vitamin D level may have in osseous recovery. METHODS: Thirty-three individuals were divided into three groups: controls and patients with diabetes mellitus with and without CN. Peripheral instantaneous x-ray imaging and dual-energy x-ray absorptiometry were performed. RESULTS: The calcaneal BMD of patients with diabetes mellitus and CN was lower than that of the control group (P < .01) but was not significantly lower than that of patients with diabetes mellitus alone. There was no statistically significant difference in lumbar T-scores between groups. Women demonstrated lower BMD than did men (P = .02), but patients 60 years and older did not demonstrate significantly lower BMD than did patients younger than 60 years (P = .135). A negative linear relationship was demonstrated between time and BMD in patients with CN. CONCLUSIONS: The results of this study suggest that lumbar BMD does not reflect peripheral BMD in patients with diabetes mellitus and reconstructive-stage CN. This study has clinical implications when reconstructive osseous surgery is planned in patients with CN.

Navicular stress reactions in runners: a review of evaluation and management of a competitive athlete.

Navicular stress injuries in athletes can be devastating. Clinical findings are frequently nonspecific until significant progression of the abnormality has occurred. The use of diagnostic imaging techniques early in the discovery period increases the likelihood of establishing an immediate diagnosis and avoids frank fracture of the navicular bone. Delayed diagnosis of navicular stress injuries in athletes can cause dire consequences. The physician must be aware of the injury in establishing a high index of clinical suspicion. The timing and sequencing of diagnostic imaging studies is essential in establishing a diagnosis to manage the patient and minimize time away from competition. This case study examines the history and management of an elite high school track athlete who sustained a navicular stress injury. The timing and use of diagnostic imaging studies is reviewed.

Admission characteristics and academic performance of podiatric and osteopathic medical students at Des Moines University.

BACKGROUND: Podiatric and osteopathic medical students at Des Moines University take the same basic science medical curriculum. The first course students complete is medical biochemistry. The final common course is the second-year medical pharmacology course. Attrition typically occurs between these academic offerings. We sought to compare admissions data, retention rates, and academic performance between these two groups of medical students for the classes of 2008 to 2011. METHODS: Average admission scores, performance scores for the biochemistry and medical pharmacology courses, and retention rates for the 2008 to 2011 classes were obtained from the registrar and enrollment offices. One-way analysis of variance was used to compare the scores of the two cohorts. Linear regression was used to identify changes across time. RESULTS: The DO students showed significantly better performance than the DPM students in matriculating overall and science grade point averages, total Medical College Admissions Test scores, retention rates, and the medical biochemistry course (P < .01). There was no difference in the performance of the student groups in the medical pharmacology course. The DPM student scores across the four classes increased for both academic courses, whereas the DO student scores remained at the same level for medical biochemistry, at a rate of 0.74% per year (R(2) = 0.50), and pharmacology, at a rate of 0.90% per year (R(2) = 0.49). CONCLUSIONS: Admissions data and initial academic performance of osteopathic medical students were higher than those of podiatric medical students. Once attrition occurred in year 1, the difference in academic performance between these groups of students was no longer statistically significant, and students in both medical programs at that time in the curriculum are equally academically qualified.

Admission characteristics and academic performance of podiatric and osteopathic medical students at Des Moines University.

In this study, the admissions data and initial academic performance of osteopathic medical students were significantly statistically higher than that of podiatric medical students at Des Moines University. Once attrition occurred in year one, the academic performance between these groups of medical students was no longer statistically significant and can be considered comparable. The challenge for podiatric medicine is to increase the applicant-to-seat ratio and admit classes with admissions qualifications similar to other health professions. Until this goal is achieved, the academic aptitude or comparability of two groups of medical students representing different medical professions can be achieved through collaborative curriculum strategies and student outcomes assessment processes.

A comparison of vitamin D levels in nondiabetic and diabetic patient populations.

BACKGROUND: This study was designed to compare the vitamin D levels in a cohort of nondiabetic patients to populations of diabetic patients with and without Charcot neuroarthropathy. METHODS: A total of 41 participants (22 male, 19 female) with a mean +/- SD age of 59 +/- 9.43 years had serum 25-hydroxyvitamin D levels tested. Fifteen participants composed the nondiabetic group; 13, the group with diabetes but without Charcot neuroarthropathy; and 13, the group with both diabetes and Charcot neuroarthropathy. RESULTS: The results of the study showed that the vitamin D levels in both diabetic populations were significantly lower (P < .05) than the nondiabetic population. There was no statistical difference between the group with diabetes but without Charcot foot disease and the group with both diabetes and Charcot neuroarthropathy. CONCLUSIONS: Based on the results of this study, given the importance of vitamin D in bone metabolism and the osseous consequences associated with diabetes, as well as other systems affected by low levels of vitamin D in the diabetic patient, it appears that vitamin D levels should be monitored in diabetic patients.

Chopart's amputation: a 10-year case study.

The purpose of this case study was to review the 10-year outcome of a patient with a history of diabetes, pedal osteomyelitis, and peripheral vascular disease, who underwent a Chopart's amputation of the right foot. Key evaluative elements to consider for long-term success of any amputation include the vascular status of the foot, control of infection, adequate soft tissue coverage, biomechanics associated with amputation, the metabolic challenge of amputation, and the psychosocial consequences linked to loss of a limb. The results of the case study show that Chopart's amputation is an excellent limb salvage surgical option that can achieve beneficial long-term outcomes in properly selected patients.

Elephantiasis nostras verrucosa.

Swelling of the leg is a frequent finding in podiatric medicine. Unless the patient draws notice to the condition or the physician is diligent in asking questions and examining the extremity, the condition may be viewed as minor and given little attention. Swelling of the leg can be a clinical sign of certain systemic diseases, lymphatic and venous disorders, or other miscellaneous causes. Dermatologic consequences linked to many of these causes of swelling are well documented. What is not as well chronicled is a dramatic skin alteration associated with chronic lymphedema. This article provides an overview and a case presentation of the unusual and debilitating skin condition related to chronic lymphedema of the lower extremity known as elephantiasis nostras verrucosa.